Review article Open Access
Nutrition of Patients with Jaw Fracture and After Orthognatik Surgery, Review of the Literature
Bobamuratova DT1*, Boymuradov ShA2, Rakhmonov SB3 and Olimjonov TA4
1PhD Candidate (researcher), Department of Dentistry, Tashkent Medical Academy, Uzbekistan
2PDoctor of medical sciences, Department of Otolaryngology and Dentistry, head of the the maxillofacial surgery department of the Tashkent Medical Academy, Uzbekistan
3PMaster degree student of the department maxillofacial surgery, Tashkent State Dental Institute, Uzbekistan
4Pmaster degree student of the department maxillofacial surgery, Tashkent State Dental Institute, Uzbekistan
*Corresponding author: Bobamuratova DT, PhD Candidate (researcher), Department of Dentistry, Tashkent Medical Academy, Uzbekistan, 100109, Tel: +99897 7105911; E-mail: @
Received: September 11, 2018; Accepted: September 28, 2018; Published: October 12, 2018
Citation: Bobamuratova DT, Boymuradov ShA, Rakhmonov SB, Olimjonov TA (2018) Nutrition of Patients with Jaw Fracture and After Orthognatik Surgery, Review of the Literature. J Dent Oral Disord Ther 6(2): 1-7. DOI: http://dx.doi.org/10.15226/jdodt.2018.00199
Abstract
Nutritional deficiencies occurring during treatment process in patients with jaw fractures will have a negative impact as: reducing of immune indicators in the body, weakening of protective reactions, tendency to complications, and traumatic effects.

This article summarizes the content of scientific studies related to the nutritional status or nutrition of patients with fractures.

Methods: Was conducted a systematic review of randomized controlled trials evaluating the nutritional status of patients with jaw fractures and post-orthodontic surgery during immobilization.

Results: Were identified twenty-seven studies. It is established that during the immobilization period the patient has changes of the trophic status, nutritional insufficiency (malnutrition), explained by weight loss and changes in anthropometric parameters, blood changes (hypoalbuminemia, decrease of hemoglobin of blood).

Oral nutritional supplements or alternative feeding methods improve nutritional status, as many studies have observed (weight and other anthropometric parameters, normalization of biochemical blood parameters,). In addition, according to some authors, decreased the number of complications and reduced the duration of hospitalization and expenditure. It is recommended that nutritional supplements be offered to malnourished patients during this period.

Keywords: Maxillofacial trauma; Mandibular fracture; Jaw fracture; Nutrition; Feeding; Diet; Nutritional assessment; Nutritional status; Intermaxillar fixation; Orthognatik surgery;
Introduction
According to domestic and foreign authors, with maxillofacial injuries, fractures of the lower jaw occur in 70-85% of cases [17,24,38,39]. A nutritional disorder, which inevitably occurs in patients with trauma of the maxillofacial region, has a negative impact on the outcome of treatment.

In surgical patients, the operative insult is followed by a period of catabolism, characterized by release of stress hormones and inflammatory mediators. It is thought that if these physiological processes are unchecked or exaggerated, they will exacerbate the acute inflammatory response and contribute to morbidity. The following operation, surgical patients are vulnerable to the development and consequences of malnutrition, because of the mechanical restrictions imposed by their operations, pain, nausea, and periods.

Intermaxillary Fixation (IMF) is one of the modalities used in the fixation of the mandible to the maxilla after fracture reduction of these bones or any surgery to correct their position as in orthognathic surgery. The Intermaxillary Fixation (IMF) compromises the normal oral intake which leads to a situation similar to starvation or fasting state. This method is a constant stress for the patient, as it complicates speech and chewing. The diet of patients with IMF is restricted on a semisolid and fluid diet which is often inadequate in energy content and in the range of nutrients and this type of diet will not compensate the proteolysis process which occurs in response to trauma. Reducing energy consumption causes weight loss in subsequent changes in the composition of the body and muscles [16,25,31]. In many countries, despite the limitations, intermaxillary fixation is considered an absolute method of immobilization [7]. Conversely, IMF has also been used in obese patients for treatment obesity and diet control, and in these cases, body weight loss ranged 5-6 kg/6 weeks [16,41].

However, patients who underwent orthognathic surgery also get bone trauma and IMF, as a rule, cannot eat properly for 6-8 weeks. It should be noted that during this period it is important to comply with all requirements for nutrition, otherwise, due to deficit of macro- and micronutrients, dehydration can develop unwanted complications [6,7].

Options to support oral nutrition or diet should meet the needs of patients, considering post-traumatic catabolism, blocking the chewing function and lack of function of the gastrointestinal tract [5,17,21,24]. As observations show, on trauma of the face and jaws, especially, penetrating to the oral cavity, the appetite decreases markedly, the taste is perversed, and the painfulness of the food intake procedure is quite natural. All this in the aggregate often causes the patients to refuse to eat or sharply limit themselves in eating [24]. With a prolonged lack of nutrition (with parenteral nutrition), it develops hypoxic damage to the mucosa of the gastrointestinal tract. These patients have intestinal insufficiency, as a rule, malabsorption develops due to a decrease in food intake, although it is during this period that the need for nutrients increases. Therefore, it can be said with certainty that patients with fractures in the maxillofacial area, undoubtedly, need temporary support of nutrition [2,9,14,21,24].

Poor nutrition, often unrecognized and untreated, causes muscular weakness, impaired immunity, and poor wound healing, and are associated with increasing in morbidity, and duration of hospitalization. In malnourished surgical patients, nutrition support improves nutrition status and clinical outcome.

The object of our review is to analyze the studies devoted to the nutritional features of patients with jaw fractures.
Study Materials
As a result of studying the literature, were selected patients with intermaxillary fixation. This also applies to patients after orthognathic surgery, because general and local features are similar to those in patients with jaw fractures in which immobilization lasts for a month. The articles were identified using the computerized search engine PubMed, Elsevier, Cochrane Central, Google scholar, Google search, Research Gate, Ebsco Host, dissercat.com, medical-diss.com and other possible sites with keywords: maxillofacial trauma, mandibular fracture, jaw fracture, intermaxillar fixation, orthognathic surgery and nutrition, feeding, diet, nutritional assessment, nutritional status, and in various combinations of these words in Russian and English. The relevant bibliographic lists were also taken into account. Were selected randomized controlled trials, metaanalyzes, and prospective clinical trials, on the basis of their significance.
Results and Discussion
Has been analyzed the work on the evaluation of malnutrition in the treatment of MFR trauma. The review identified 31 studies that highlight either nutritional status or the effectiveness of oral nutrient use in patients with jaw injuries. In the studies analyzed in this review, the nutritional status or effect of oral nutrients was assessed in patients with jaw fractures and in patients after orthognathic surgery (Table). In studies used the same or similar definitions to assess the nutritional status and risk for nutrition, but the inclusion criteria were different. 17 studies were in the form of an abstract, 11 journal articles and 3 thesis's.
Table 1: Analysis of literature data

Author

Year

Patients

Food

Method of research

Type of received Information

Country where the study was carried out

 

Keisuke Kondo, Norio Horie, et al.

2017

Total 50 patients with mandibular fracture: 25 study groups,

25 patients who were treated by IMF with nutrition support teams (NSTs) intervention (Liquid nutrition), who were used as the primary study group, and 25 patients treated without NST intervention

were measured: body weight, serum markers (albumin Alb, hemoglobin Hb, C-reactive protein CRP), grip strength and body composition parameters (triceps skin fold thickness, mid-arm muscle circumference, body fat, subcutaneous fat, skeletal muscle)

Article

Japan

 

 

 

Christiansen B.

2016

446 patients with jaw fracture

-

loss of body weight ,

Article

USA, Louisiana

change in BMI

 

Ono S, Ishimaru M, et al.

2016

309 patients with an open fracture of the lower jaw

-

Effect of BMI on the incidence of complications, the duration of anesthesia, the duration of hospitalization, costs

abstract

Japan

Bobamuratova DT, Boymuradov Sh.A.

2016

46 patients with a jaw fracture

-

Was noted  body weight loss, depending on the time of year

Article

Uzbekistan

Yazdani J, Hajizadeh S, et al.

2015

60 patients with intermaxillary fixation

-

Anthropometric parameters: weight, BMI, skin - fat fold of the biceps, triceps, submental. region were determined with the help of kaliperometer

Article

Iran

Kayani SG, Ahmed W, et a l.

2015

-

Liquid  diet + "Ensure" nutritional support

loss of body weight

Article

Pakistan

Malichly LA, Ivchenko AP, et al.

2015

48 patients of main gr. with a fracture of the lower jaw,

In the main gr. nutritional support with Nutri Drink

The loss of body weight, changes in anthropometric parameters:  the circumference of shoulders and the thickness of skin fold on  and triceps, the level of hemoglobin, total protein, albumin in the blood

Abstract

Russia

44 patients of control gr.

 

 

Sheet W, Hassouni MK

2012

25 traumatized patients and 7 obese patients

Comparison between the traumatized and obese patients.

Body weight, 4 sites of skin fold thickness. Laboratory investigations included serum electrolytes Na+1, K+1 and serum albumin levels

Article

Iraq

 

 

Kuvat SV, G ü ven E, et al.

2010

30 orthodontic patients

liquid + semi-liquid diet

using a body composition analyzer determined the change in body weight, fat mass, lean body mass, were determined signs of nutritional deficiency

Article

Turkey

Mekkawy MM, et al.

2010

60 patients with a jaw fracture

dietarian recommendations, ration

assessment of nutritional status using the questionnaire  «Mini Nutritional assessment »/ BMI ,

Article

Egypt

change in hemoglobin level ;
trends of complications, complaints, the intensity of pain

 

 

2009

3 cases after orthognathic surgery

high-calorie, high-protein
liquid

body weight , anthropometric parameters (BMI, shoulders circumference, skin-fat fold of triceps)

Article

Brazil

Giacobbo J, et al.

 

Tegza NV.

2008

69 patients with jaw fracture + 69 patients with inflammatory diseases of MFR

Soft nonchewy diet + patients with injuries - Nutrien OSteo, patients with inflammatory diseases of MFR - Nutrien
Standard

anthropometric (BMI, PSZHO, OMP), biochemical (protein: general, albumen; nitrogen;  lipids: cholesterol, carbohydrates: glucose, urine vitamin:  C, B 1, In 2 ,microelements K , Na , Ca ) ,leucocytes , erythrocytes; Economic effectiveness of treatment

dissertation Candidate of Medical sciences

Russia

Telnikh RY.

2008

100 patients with open traumatic fractures of the lower jaw: 40 patients with traditional scheme of managing; 60 patients + dietary supplements

Biologically active supplement: «Camosten»
(microelements and essential amino acids), "FluGone" anti - inflammatory

clinical (local complications), microbiological (dysbacteriosis), x-ray studies, timing of consolidation of fragments;

dissertation Cand. Of Medical Sciences

Russia

biochem. study. (Ca ++, alkaline phosphatase) in the blood; periods of incapacity for work

 

 

and immunostimulatory drug

 

 

Elamin N.

2006

30 patients with splints

-

loss of body weight;

dissertation of  master degree

Sudan

bioch. parameters (triglycerides, cholesterol, protein), K +, trends of complications and complaints of patients

 

 

El Khatib K, GradelJ.

2005

111 patients with fracture of the lower jaw

81 patients -

the duration of hospitalization, costs, postoperative complications

Abstract

nutrition with a nasogastric tube,

 

 

 

30 patients - oral nutrition

 

Reychter TE.

2002

134 patients with a jaw fracture (66 + 68)

optimization of the soft, nonchewy diet + calcium alginate

evaluation of rations;

Article

Russia

bioch. indicators (protein, creatinine lipids, urea, Ca); timing of consolidation of fragments

 

 

Manus R. e t al.

2000

93 patients with a jaw
fracture

Assessment of the nutritional status of alcoholics and those who consume illegal substances

correlation between alcohol and plasma aspartate aminotransferase, lactate dehydrogenase, ferritin level

Abstract

-

Worrall SF.

1994

22 patients: 18 - with a fracture of  jaw, 4 – ortognathic surgery

-

Body weight, lean mass, total body water with the help of the determination of skin-fat fold; comparison of a group parameters of patients with intermaxillar fixation and fixation with mini-screws

abstract

UK

Antila

1993

17 oral surgical patients with intermaxillary fixation

9 patients received nutritional counseling,  8 +oral supplementation

Body weight and anthropometric  parameters, serum copper, iron, selenium and bromide concentrations

Abstract

Finland

Califano L, et al.

1992

12 patients with a trauma of MFR, 12 patients with a neoplasm of MFR

adequate enteral nutrition

anamnesis; nitrogen balance; water-electrolyte balance; immunne parameters

Abstract

Italy

Saber SK.

1991

-

individualized nutrition

infection;

Abstract

healing of wounds;
general condition

 

Cawood

1985

100 patients with a jaw fracture

-

change in body weight, depending on the method of treatment; comparison of group parameters with intermaxillar fixation and fixation with mini-screws

Abstract

USA

Olejko TD, Fonseca RJ.

1984

Orthognatik surgery

high-calorie liquid - pre-operative (early) food

Changes in body weight

Abstract

USA

Harju E, Pernu H.

1984

13 patients withorthognathic surgery

-

loss of body weight; complications

Abstract

Finlandiya

Kendell BD, Fonseca RJ, Lee M.

1982

24 patients (12 +12 ) with ortognathic surgery

high-calorie liquid + libitum; blended food

Body weight , protein level

Abstract

USA

 

Rudenko AT.

1982

65 patients

Dry protein mixture

nitrogen urine, vitamin metabolism (C, B1, B2), symptoms of changes in the digestive tract

Article

Russia

Lange H, PodleschI.

1981

40 patients

ordinary diet + Nutro Drip , probe feeding, postoperative 10 - day nutrition

Duration of complications; body weight; protein (albumen), creatinine) K+

Abstract

Germany

Martin Ritzau

1975

33 patients

-

loss of weight ; overweight patients to have a greater loss of weight

Abstract

USA

Byrne J.

1970

5 cases

diet

loss of body weight

Abstract

USA, Chicago

Smith J.

1965

-

balanced, enriched liquid

analysis of micronutrients; complications, diarrhea, changes in the digestive tract organs

Abstract

Califano L, et al.

1992

12 patients with a trauma of MFR, 12 patients with a neoplasm of MFR

Adequate enteral nutrition

anamnesis; nitrogen balance; water-electrolyte balance; immune parameters

Abstract

Italy

In 12 studies, was studied the topological status and nutritional insufficiency was revealed in patients with jaw fractures, that in the process of treatment did not receive specific nutrients. The principle of the endpoint in these studies was weight and anthropometric changes during immobilization or biochemical blood indices [1,3,7,10-12,16,25,27,29,30,33].

A balanced diet containing the optimal number of kilocalories and essential nutrients is important for patients with bone damage to prevent complications, support healing and health. To correct the nutritional insufficiency of these patients, a hypercaloric and enriched diet was proposed [6,9,20-22,24,26,35,45,46]. In patients with splints, the needs were regulated by a dietitian. Dietary recommendations help to improve consumption by changing the intake of food (for example, enriching food, adapting the diet). In some studies, increased energy and / or protein intake was studied, as a result of which the effectiveness of treatment was higher than in the control group [6,9,20-22,26,35,46].

A number of authors evaluated the influence of patented supplements in the form of dry and liquid nutrient mixtures, biologically active additives, which were used as nutritional support in patients with trauma FMA. The goal of food is to ensure the balance of energy, proteins, vitamins and microelements, resulting in a significant improvement in the clinical outcomes of patients with a trauma of MFR. The use of nutritive support or biologically active additives proved to be more effective than standard care [2,4,8,15,17,18,23,28,32].

Many researchers note that patients received support in the simplest way: they used additives for feeding or enteral tubes. El-Khatib et al. compared the result of tube- feeding and oral nutrition. After analyzing the hospitalization duration and frequency of complications, the authors found the advantages of the usual type of nutrition in 111 patients with a jaw fracture after osteosynthesis [13].

Some authors recommend the prescription of nutritional support to surgical patients either before surgery or after surgery due to the severity of existing malnutrition or for the purpose of preventing postoperative complications and reducing the timing of wound healing. Early postoperative nutrition (< 24 hours) significantly affects nutritional status and promotes faster recovery [42-44]. Long-term nutritional support was suggested by Fonseca et al., who recommended pre-operative, high-calorie nutrition to orthognathic patients to prevent weight loss and complications [8].

The most common in patients with jaw injuries is a change in body weight. An assessment of anthropometric indicators trends, such as body mass index, thickness of skin-fat folds of the triceps, biceps, etc., was carried out by many authors. Biochemical parameters, duration of hospitalization, the timing of wound healing or consolidation of fragments, the nature of complications, quality of life and functional status can serve both as criteria for assessing tropholigic status and confirming markers for the effectiveness of nutritional support.

In 16 studies, was provided information about the change in body weight in patients with traumas of maxilla facial area [1,3 ,5,11,13,15,16,21,24,26,27,29,31]. Christensen noted an average of 4.8 ± 6.4 kg of body weight loss, according to Worall, this index varied by an average of 4.5 for 6 weeks; E. Harju observed 7.5 ± 3.5 kg of weight loss for the entire period wearing a bimaxillar splint [3,11,30]. Antila et al. reported that body weight loss during the IMF period in patients receiving nutritional counseling with and without oral supplementation was 3.8 ± 2.7% and 6.0 ± 3.8%/4-6 weeks, respectively [4]. In Keisukes’ study, body weight loss with nutrition support teams intervention (1.8 ± 1.5 kg and 3.1 ± 2.3% /3 weeks) was significantly lower than that without intervention (2.7 ± 1.4 kg and 4.6 ± 2.4%/3 weeks) [46].

Worall and Cawood, comparing the nutritional status of patients depending on the method of treatment, found that in patients with bone fixation with miniplates and screws, nutritional insufficiency and weight loss were significantly less [27,30]. The loss of body weight affects both the composition of the body, and the ratio between lean body mass and fatty deposits. Simultaneously with the reduction in body fat, a significant loss of body proteins occurs, which leads to a decrease in muscle mass. S. Kuvat et al. And Keisuke and coauthors with the help of the body composition analyzer revealed a change between lean and fat mass in patients after correction of occlusion surgically and with mandibular fracture [31,46].

Changes in the body mass index as a result of treatment in patients are reported in 9 studies [10,11,12,17,25,31,32]. Other authors for assessing trophological status used anthropometric measurements by assessing the thickness of the skin-fat fold of the triceps, the biceps, the submental region, and the circumference of the shoulder muscles [12,17,32]. It is shown that the effectiveness of nutritional support during the treatment period directly depends on the nature of the intervention [17,32].

A number of authors carried out biochemical studies to assess the insufficiency of macro- and micronutrients [2,4,5,6,7,16,17,22- 24,28,33,46]. As a result, were analyzed the concentration and composition of proteins, lipids, carbohydrates in blood and urine, the level of vitamins and microelements, electrolyte imbalance and a number of enzymes such as aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, etc.

As is known, in the process of bone healing the main role is played by protein and minerals. It has been established that in patients with insufficient nutrition, slow down wound healing and synostosis [9,34]. Has been identified the relationship between nutrition and local status, on which depend the timing of the consolidation of fragments and healing of wounds [18,28].

The frequency and nature of complications in the injured with a jaw fracture with nutritional support was studied in 9 studies [2,3,7,9,13,18,20,26,28]. As the analysis of these studies has shown, specialists make attempts to significantly reduce the risk of complications in the treatment of patients with a fracture of the mandible, using for this purpose different types of diets or nutritional support. Less complications and relief of complaints at an earlier time was observed in the group of patients who received additional nutritional support [2,26].

However, the available randomized controlled trials provide too little information about the cost of such treatment. In total, we found 3 studies in which were studied the financial side and duration of hospitalization [10,13,17]. Thus, N.V. Tegza found that the use of dry nutrient mix is justified from a medical and economic point of view, since it promotes faster activation of patients in the clinic and reduces the cost of their maintenance in a hospital [17].

In another study, was considered the effect of a postoperative type of diet - hospital costs, depending on the frequency of complications [13]. Savings from shortening the duration of hospital stay were assessed by S. Ono et al., who found the relationship between the body mass index and the rate of complications, the duration of anesthesia, the duration of hospitalization, and the cost of treatment in 309 patients with an open fracture of the mandible [10].
Conclusions
i.As shown by the analysis of literature data, intermaxillary fixation and trauma itself have a significant effect on nutritional status and other metabolic indicators, such as body composition, including proteins, fats, carbohydrates, electrolytes, etc.

ii. The authors of many studies included in this review focus on the trophic status and the impact of an alternative strategy for feeding patients with jaw fractures and intermaxillary fixation.

iii. Recently, have been widely used the most modern methods for assessing trophological status, such as bioimpedanceometry, dual-energy X-ray absorptiometry, air plethysmography, MRI or magnetic resonance spectroscopy. Together, these methods make it possible to determine the structure of the body relatively accurately at the elemental, molecular, cellular, tissue levels and at the level of the organism as a whole. With the help of these methods, it is possible to determine the amount of fats, the weight without fat, the content of bone mineral substances, total body water, extracellular water, total adipose tissue and its internal depot (visceral, subcutaneous and intermuscular), skeletal muscles, ectopic fat depot giving information about the metabolic function. The use of technology to evaluate body composition is the most accurate method, but it is most effective when included as one of several important components of the study in assessing nutritional status.

Thus, the study of the nutritional status of the injured with a jaw trauma makes possible to determine the measures for correcting disorders and metabolic indices.
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