EVALUATION OF THE RESULTS OF COMPLEX THERAPY FOR POST-TRAUMATIC OSTEOMYELITIS IN MANDIBULAR FRACTURES

The most common complication of mandibular fractures is post-traumatic osteomyelitis, which accounts for 10 to 30% of cases. Analysis of the literature and numerous clinical and expert observations show that factors contributing to the development of post-traumatic osteomyelitis include the presence of teeth with foci of chronic infection in the fracture line, late seeking of specialized medical care by patients with mandibular fractures, as well as deficiencies in medical care at various stages of treatment. At the present stage, it is particularly relevant to highlight issues related to the clinical characteristics of mandibular fractures complicated by post-traumatic osteomyelitis, which aggravates the course of the mandibular fracture and leads to an increase in treatment duration, thereby exacerbating the harm caused to human health [Günter V.E., Khodorenko V.N., Chekalkin T.L. et al., 2018]. The term “post-traumatic osteomyelitis” refers to purulent inflammation of all elements of the bone resulting from trauma. It is a nonspecific purulent-necrotic infectious-allergic inflammatory process in the area of the mandibular fracture, accompanied by necrosis of the wound surfaces of the fragments with the formation of sequestra and regeneration of bone tissue. At the same time, post-traumatic osteomyelitis of the mandible represents a qualitatively new form of the inflammatory process, in which necrosis occurs in areas of bone that showed no signs of damage and are located at a certain distance from the fracture line; self-cleaning of the wound and healing without prolonged specialized treatment do not occur. Most researchers associate the induced pathomorphosis of purulent inflammation with both changes in the etiological structure of pathogens and their properties, and with disturbances in the immune status of the body. Currently, the development of inflammation is noted under the influence of resident flora from odontogenic foci and individual pathogens that potentially possess virulence, invasiveness, and toxicity. An expansion of the species spectrum of pathogens has been observed, where resident and pathogenic infections combine with a sequential change in the dominance of aerobic, obligate anaerobic, and facultative anaerobic organisms. However, it should not be forgotten that the development of an infectious-inflammatory process is determined not only by the relationship “microbial pathogen – immunity,” but also by all physiological systems of the body. The very probability of developing an infectious process, the features of the clinical course, and the prognosis largely depend on the factors that determine these relationships [Efimov Yu.V., Efimova E.Yu., Dolgova I.V., 2016]. Taking into account the above information regarding the complicated clinical course of mandibular fractures, the problem of diagnosis and optimization of complex treatment of post-traumatic osteomyelitis of the mandible remains relevant to this day.下颌骨骨折最常见的并发症为创伤后骨髓炎（post-traumatic osteomyelitis），其发生率占病例总数的10%~30%。对现有文献及大量临床与专家观察结果的分析显示，创伤后骨髓炎的发病相关因素包括：骨折线处存在伴有慢性感染病灶的牙齿、下颌骨骨折患者未能及时就诊专科医疗、以及各治疗阶段的医疗照护不足。当前，明确合并创伤后骨髓炎的下颌骨骨折的临床特征具有重要现实意义：此类并发症会加重下颌骨骨折的病程，延长治疗周期，进而加剧对人体健康的损害[Günter V.E.、Khodorenko V.N.、Chekalkin T.L.等，2018]。 “创伤后骨髓炎”一词指由创伤引发的骨骼所有结构的化脓性炎症。该病症是下颌骨骨折区域内的非特异性化脓坏死性感染变态反应性炎症过程，伴随骨折断端创面坏死、死骨片（sequestra）形成及骨组织再生。与此同时，下颌骨创伤后骨髓炎属于一种全新的炎症进程类型：坏死可发生于骨折线以外一定距离、原本无损伤迹象的骨组织区域；且无法通过创面自净与无需长期专科治疗的方式实现愈合。 多数研究者认为，化脓性炎症的继发性病理形态改变，既与病原体的病原学构成及其特性变化有关，也与机体免疫状态紊乱相关。当前研究发现，炎症的发生受牙源性病灶（odontoogenic foci）的常驻菌群以及部分具备潜在毒力、侵袭性与毒性的病原体影响。已有研究观察到病原体物种谱的扩大：常驻菌群与致病性感染相互结合，需氧菌、专性厌氧菌及兼性厌氧菌的优势地位依次发生改变。但需注意，感染性炎症进程的发生不仅取决于“病原体-免疫”的相互作用，还与机体所有生理系统密切相关。感染性进程的发生概率、临床病程特征及预后，在很大程度上取决于调控上述相互作用的各类因素[Efimov Yu.V.、Efimova E.Yu.、Dolgova I.V.，2016]。 鉴于上述关于下颌骨骨折复杂临床病程的研究结论，下颌骨创伤后骨髓炎的诊断与综合治疗优化问题至今仍具有重要研究价值。