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Causes and mechanism of injuries of the maxillofacial area

Depending on the cause of occurrence, all traumatic injuries are divided into industrial (industrial and agricultural) and non-industrial (domestic, transport, street, sports).

Occupational injury - damage associated with the performance by workers of their work duties in industry or agriculture. Industrial injuries are usually distinguished by industry (coal, metallurgical, etc.). According to E.I. Deryabin (1981), occupational injuries to persons in the Lvov-Volyn coal basin are 2.06 ± 0.7 per 1000 workers. The main reasons were collapses and collapses of rock and roof (41.5%), breakdowns of machines and mechanisms (38.1%), accidental falls and impacts (11.3%), accidents in internal mine transport (9.1%). The most susceptible to occupational injuries were workers in the main underground specialties (miners, longwall workers, fasteners), most often with 5 to 10 years of experience (up to 30%). According to the author, in case of industrial injuries in mines, fractures of the lower jaw occurred in 57%, the middle zone of the face - in 33%, multiple fractures of facial bones - in 10%. Combined injuries were observed in 79.5% of patients. Agricultural injuries are characterized by seasonality, multiple head injuries, lacerations and bruises (inflicted by animals). According to T.M. Lurie, N.M. Aleksandrova (1986) the share of agricultural industrial injuries is 1.2%. Analyzing the causes of injuries, the authors found that they are more often observed due to careless handling of agricultural machines (threshers, etc.) or when struck by animals while working with them.

Domestic injury is damage that is not related to production activities, but occurred during household work or during domestic conflicts. The share of household trauma is presented in Table 16.1.1 (according to the clinic of maxillofacial surgery of the Kyiv Medical Academy of Postgraduate Training named after P.L. Shupik, the Ukrainian Center for Maxillofacial Surgery). It has been noticed that the frequency of household injuries increases in the spring and summer (from April to September). About 90% of household injuries occur as a result of a blow, and only 10% as a result of a fall or other causes. Among the victims, men predominate over women (in a ratio of 4:1, respectively). Domestic injuries are more common between the ages of 20 and 40 (66%).

Street injury - injuries received on the street while walking (a person falls due to poor general health, icy conditions, natural disasters, etc.), not related to transport. About half of the victims are middle-aged, elderly and senile people. This injury is characterized by a mild nature of damage (usually bruises, abrasions, wounds, damage to teeth, nasal bones and zygomatic complex). Transport (road) injury - occurs as a result of road accidents. Characterized by multiplicity and combination of damage. Combined injury is a simultaneous injury to two or more organs belonging to different anatomical and functional systems. The most common type of combination is cranio-facial damage. This is directly related to the commonality of the facial and cerebral skull, which transmits shocks and concussions to the brain. The seasonality of transport injuries was noted (more often in April - September). This injury occurs more often in men than in women (5:1, respectively). According to our observations, injuries most often occur in car and motorcycle accidents; less often they occur in traffic or falling from a bicycle. The early hospitalization of these victims should be noted. On the first day, about 75% of victims are hospitalized, up to 3 days - 22%, and only 3% of patients seek medical help on the 4-10th day after a road traffic accident.

Sports injury - occurs during physical education and sports. There is a seasonality of sports injury. Most common in the winter months (skating, playing hockey, skiing) or summer (playing soccer). Much less often, injuries occur during organized sports games or training. It should be noted that people who have suffered a sports injury do not seek medical help in a timely manner. Thus, only 30% of the victims sought help on the first day, 64% - on the second - third days, 16% - on the 4th - 10th day after the injury.

Basic methods for examining injuries to the maxillofacial area:

External inspection

Palpation, percussion

X-ray examination

X-ray of the vault of the oral cavity (“bite”)

Intraoral contact radiography

X-ray of the lower jaw in direct and oblique projections

X-ray of the skull in direct and oblique projections, etc.

Computed tomography (soft tissue and bone damage)

Magnetic resonance imaging (soft tissue injuries)

Electroodontodiagnostics (determining pulp viability in case of dental damage)

Ultrasound method (for damage to the salivary glands and their ducts)

Complications of injuries to the maxillofacial area

Asphyxia. Mucus, saliva, blood, and foreign bodies (bone fragments, teeth) accumulated in the mouth can be aspirated by victims, especially those who are unconscious in a horizontal position on their back, and cause asphyxia. Therefore, such victims are transported by laying them face down and placing rolled up clothes under their chest, and some kind of solid support under their head, or on their side with their head turned towards the wound. At the first aid stage, a thorough examination of the oral cavity is performed again and blood clots and foreign bodies are removed.

Even more dangerous is asphyxia, which can occur as a result of pressure on the root of the tongue with a broken upper jaw, as well as as a result of retraction of the tongue, which is possible with double fractures of the chin of the lower jaw. In the latter case, asphyxia occurs when the tongue, devoid of attachment points, sinks backward and presses the epiglottis against the wall of the larynx with its root.

Urgent measures to combat asphyxia with a double mental fracture are as follows. Using a piece of gauze, grab the tongue with your fingers and pull it out. The elongated tongue is stitched with a thick thread along the midline at the border of the anterior and middle third of the tongue and tied around the neck.

An even simpler way to secure an extended tongue is to pierce the tongue in the same area with a safety pin and secure it with a gauze strip around the neck.

The hanging upper jaw and the displaced chin fragment of the lower jaw are secured accordingly.

In some cases of increasing asphyxia, when the measures taken do not bring relief, tracheotomy is indicated. To reduce swelling of the tissue at the entrance to the larynx, ice should be applied to the corresponding part of the neck in the first hours, and then inhalation of a 2% sodium bicarbonate solution, and diphenhydramine, suprastin, etc. orally.

Bleeding. There are bleedings from the vessels of the soft tissues of the oral cavity; from the nose and its accessory cavities; from damaged jaws.

Bleeding is possible from shallowly located arteries - the facial, superficial temporal, transverse arteries of the face and from the deep vessels of the face: the lingual artery in case of injury to the lower segment of the face and neck, the maxillary artery in case of injury to the mid-lateral part of the face and damage to the infratemporal or pterygopalatine fossa and the deep temporal artery in case of injury upper lateral part of the face (temporal region).

With injuries to the sublingual and lingual arteries, intraoral bleeding is observed at the bottom of the oral cavity, the buccal artery in the area of ​​the soft tissues of the cheek, the palatine artery in the hard palate, and the pterygoid venous plexus in the area of ​​the maxillary tubercle.

Bleeding that occurs with injuries to the nasal cavities, maxillary and frontal sinuses requires special attention, since due to the ingestion of blood they are not always detected.

Bone bleeding during fractures or wounds of the upper jaw occurs from relatively small vessels. Bleeding when the lower jaw is injured due to damage to the mandibular artery can be quite severe.

Stopping bleeding in the first stages of evacuation is done using pressure bandages and tamponade. Most intraoral bleeding, as well as bleeding from the accessory cavities, can be stopped with layer-by-layer tight tamponade, preferably iodoform gauze. If there is bleeding from the tongue, the wound is sutured tightly.

If bleeding from the nasal cavity is detected, gauze tampons soaked in 5% synthomycin emulsion or petroleum jelly should be inserted into the nasal passages; in extreme cases, posterior tamponade should be performed.

Continued bleeding from the facial, lingual, and especially the maxillary arteries requires ligation of the vessels throughout.

With extensive tissue damage, simultaneous bleeding from several large vessels is possible, for example from the lingual and facial arteries. In such cases, it is advisable to proceed directly to ligation of the external carotid artery, from which all arterial branches of the facial region depart.

Bone bleeding can be stopped by compression or pressure with bone scissors or a bone chisel in the area of ​​the bleeding vessel, as well as tamponade with catgut, fat or fascia. If these measures are unsuccessful, one has to resort to ligation of the afferent vessels of the external carotid artery, and in some cases the common carotid artery, which, of course, is only feasible in a hospital setting.

Shock. Anti-shock measures are carried out in accordance with the rules of emergency surgery.

In case of damage to the maxillofacial area, the main measures for treating shock are as follows: eliminating pain (blocking fracture sites), carrying out transport immobilization, combating asphyxia and blood loss.

Soft tissue injuries

Non-gunshot injuries to soft tissues of the maxillofacial area and neck are often the result of mechanical trauma. According to our data, isolated soft tissue injuries are observed in 16% of patients who sought emergency care at a trauma center. The victims are most often men aged 18 to 37 years. Domestic trauma predominates among the causes. A.P. Agroskin (1986), according to the nature and degree of damage, divides all injuries of the soft tissues of the face into two main groups: 1) isolated injuries of the soft tissues of the face (without violating the integrity of the skin or mucous membrane of the oral cavity - bruises; with violating the integrity of the skin or mucous membrane oral cavity - abrasions, wounds): 2) combined injuries to the soft tissues of the face and bones of the facial skull (without violating the integrity of the skin or mucous membrane of the oral cavity, with violation of the integrity of the skin or mucous membrane of the oral cavity).

Classification of soft tissue injuries of the maxillofacial area. facial injury bleeding asphyxia

Group I. Isolated injuries to soft tissues of the face:

Without violating the integrity of the skin or mucous membranes (bruises);

With a violation of the integrity of the skin of the face or mucous membrane (abrasions, wounds).

Group II. Combined injuries to the soft tissues of the face and bones of the facial skull (with or without disruption of the integrity of the skin of the face and mucous membrane).

The nature of soft tissue damage depends on the force of the impact, the type of traumatic agent and the location of the damage.

They occur when there is a weak blow to the face with a blunt object, which damages the subcutaneous fat, muscles and ligaments without tearing the skin. As a result, a hematoma (bleeding) and post-traumatic edema are formed. The hematoma lasts 12-14 days, gradually changing color from purple to green and yellow.

Occurs when the integrity of the surface layers of the skin is violated, which does not require sutures. It is most often observed in the chin, cheekbone, nose and forehead.

It is formed when the skin is damaged when struck by a sharp or blunt object with sufficient force to disrupt the integrity of the skin.

The wound may be:

Superficial (skin and subcutaneous tissue are damaged);

Deep (with damage to muscles, blood vessels and nerves);

Penetrating into cavities (nose, mouth, paranasal sinuses);

With or without tissue defect;

With (or without) damage to bone tissue;

Cut, stabbed, chopped, torn, lacerated, bruised, bitten, depending on the type and shape of the wounding object and the nature of the tissue damage.

The clinic of injuries to soft tissues of the face depends on the type of injury

Bruises - complaints of pain, swelling, bluish bruising. They arise as a result of damage to subcutaneous fat and muscles without rupture of the skin, which is accompanied by crushing of small-caliber vessels and tissue imbibition with blood.

Abrasions - concern about damage to the skin or mucous membranes. Pain due to a violation of the integrity of the surface layers of the skin (epidermis) or mucous membrane.

Incised wound - the patient complains of trauma to the skin, accompanied by bleeding and pain. There is damage to the entire thickness of the skin or oral mucosa, dissection of blood vessels, fascia, muscles, loose tissue, and nerve trunks.

Puncture wound - complaints of minor soft tissue damage, moderate or heavy bleeding, pain at the site of injury. There is an entrance hole and a wound canal, and profuse bleeding when large vessels are injured.

Chopped wound - the patient notes extensive damage to soft tissues, accompanied by heavy bleeding (possible damage to the bones of the facial skeleton).

Lacerated wound - the presence of a wound with uneven edges (possibly with the presence of flaps and soft tissue defects), severe hemorrhages, moderate or severe bleeding, pain.

Bruised wound - the presence of a wound, hematoma, hemorrhages, the presence of flaps, tissue defects, surrounding tissues are crushed.

A bite wound is the presence of a wound with uneven edges, the formation of flaps with teeth marks on damaged skin or on intact skin, there may be a tissue defect, bleeding, pain.

General complaints

Bruises, abrasions, bruised wounds, bitten wounds, lacerations - there are usually no general complaints.

An incised wound, a puncture wound, a chopped wound - complaints will depend on the severity of the damage: pale skin, dizziness, weakness. Occurs due to blood loss.

History of injury. Injury can be industrial, domestic, transport, sports, street, or while intoxicated. It is necessary to find out the time of injury and the time to see a doctor. If you contact a specialist late or receive incorrect care, the incidence of complications increases.

Life history. It is important to know concomitant or past diseases, bad habits, working and living conditions, which can lead to a decrease in the general and local defenses of the body and impaired tissue regeneration.

General condition. It can be satisfactory, moderate, or severe. Determined by the severity of the damage, which can be combined or extensive.

Local changes in damage to the soft tissues of the face

Bruises - the presence of a bluish-red bruise and swelling of tissues spreading to the surrounding soft tissues, palpation is painful.

Abrasions - the presence of a wound to the surface layer of the skin or mucous membrane of the lips and oral cavity, pinpoint hemorrhages, hyperemia. Most often observed on protruding parts of the face: nose, forehead, cheekbone and chin areas.

An incised wound has cut smooth edges, usually gapes, and is several centimeters long. The length of the wound is several times greater than its depth and width, and bleeds profusely; Palpation of the edges of the wound is painful.

A puncture wound has a small entrance hole, a deep, narrow wound channel, bleeds moderately or profusely, palpation in the wound area is painful, and nosebleeds are possible. The depth of penetration depends on the length of the weapon, the force applied and the absence of obstacles in the path of penetration of the weapon (bone). Heavy bleeding is possible when large vessels are injured, as well as destruction of the thin wall of the maxillary sinus.

A chopped wound is a wide and deep wound that has smooth, raised edges if the wound is caused by a heavy sharp object. At the edges of the wide wound there is bruising, bruising, and additional tears (cracks) at the end of the wound when injured by a blunt object. In the depths of the wound there may be bone fragments and fragments in case of damage to the facial skeleton. There may be severe bleeding from a wound (nose, mouth) with penetrating wounds into the oral cavity, nose, or maxillary sinus.

The lacerated wound has uneven edges, moderate or extensive gaping, there may be flaps when one skin or an entire layer is torn off; hemorrhage into the surrounding tissues and their detachment, palpation of the wound area is painful. This wound is caused by a blunt object and occurs when the physiological ability of the tissue to stretch is exceeded, and can simulate the formation of a defect.

The bruised wound has an irregular shape with frayed edges. Additional breaks (cracks) may extend from the central wound in the form of rays; pronounced hemorrhages along the periphery and edema.

A bite wound has uneven edges and resembles a laceration in nature, often with the formation of flaps or a true tissue defect with the presence of teeth marks. The bleeding is moderate, palpation in the wound area is painful. Most often observed in the area of ​​the nose, lips, ear, cheeks. Traumatic amputation of tissue, part or all of the organ may occur

Differential diagnosis of injuries to soft tissues of the face

Bruises: differentiated from hematoma in blood diseases.

Similar symptoms: the presence of a bluish-red bruise.

Distinctive symptoms: no history of trauma, pain.

Abrasions: differentiated from scratches.

Similar symptoms: violation of the integrity of the surface layers of the skin, mild pain.

Distinctive symptoms: thin linear damage to the superficial layers of the skin.

Incised wound: differentiated from a chopped wound.

Similar symptoms: damage to the skin or mucous membrane and underlying tissues, bleeding, pain.

Distinctive symptoms: extensive damage to soft tissues, hemorrhage into surrounding tissues, deep wound, often accompanied by damage to the facial skeleton.

Laceration: differentiated from a bite wound.

Similar symptoms: the presence of an irregularly shaped wound, loose, uneven, scalloped edges, flaps or soft tissue defects may form, bleeding, pain.

Distinctive symptoms: animal and human teeth are wounding weapons; their imprints can remain on the skin in the form of bruises.

Incised wound: differentiated from a stab wound.

Similar symptoms: damage to the integrity of the skin or mucous membrane, bleeding, pain.

Distinctive symptoms: the presence of a small, sometimes pinpoint entry hole and a long, deep wound channel.

Treatment of facial soft tissue injuries

Emergency care: carried out at the prehospital stage to prevent wound infection and bleeding from small vessels. The skin around the wound is treated with iodine solution, the bleeding is stopped by applying a bandage.

For abrasions, the primary dressing can be performed using a protective film of film-forming preparations applied to the wound. If there is simultaneous bone damage, transport immobilization is applied.

Treatment of a patient in a clinic

Indications: bruises, abrasions, cuts, stabs, lacerations, bruised and bitten wounds of small size, requiring a small excision of its edges and subsequent immediate suturing.

Treatment of a bruise: cold in the first two days, then heat to resolve the hematoma.

Treatment of abrasions: treatment with an antiseptic, heals under the crust.

Treatment of cut, stab, lacerated, bruised, bitten wounds. PSO of the wound is performed.

Under local or general anesthesia, PSO of wounds is performed (the steps are described above) and surgical methods of closing the wound defect are used: the application of early, initially delayed and late sutures, as well as plastic surgery. PST of a wound involves a one-stage primary restoration operation, the widespread use of primary and early delayed skin grafting, and reconstructive operations on blood vessels and nerves.

If it is possible to perform radical PSO, then the wound can be sutured tightly.

Early primary surgical suture is used as the final stage in primary surgical treatment in order to restore the anatomical continuity of tissues, prevent secondary microbial contamination of the wound and create conditions for its healing by primary intention.

With extensive crushed, contaminated and infected wounds, it is not always possible to carry out radical PST of the wound, and therefore it is rational to carry out general antimicrobial therapy for several days, local treatment of wounds with the introduction of gauze swabs with Vishnevsky ointment. If 3-5 days after PSO acute inflammatory phenomena subside significantly, a initially delayed suture can be placed on the wound. A wait-and-see approach is necessary to ensure complete excision of necrotic tissue, as evidenced by the subsidence of acute inflammatory phenomena and the absence of new foci of necrotic tissue. Applying sutures will reduce the likelihood of wound infection and speed up its healing.

If the inflammation subsides slowly, then suturing the wound is postponed for several days until the first granulations begin to appear, necrotic tissue is rejected and the formation of pus stops. At this time, the wound is treated under a gauze swab moistened with a hypertonic solution or Vishnevsky ointment.

Sutures placed on a cleaned wound 6-7 days after PSO are called late primary sutures. Suturing a wound that is not completely cleared of necrotic tissue will inevitably lead to its suppuration, which is aimed at sanitation of the wound. The use of a hypertonic solution and Vishnevsky ointment promotes the outflow of exudate from the wound walls, the subsidence of acute inflammation and activates the regeneration of connective tissue, the growth of granulations and the rejection of necrotic tissue.

In cases where the wound cannot be sutured 7 days after PSO due to the presence of inflammatory phenomena, its treatment is continued in the above manner until filled with granulations. In this case, the phenomenon of wound contraction is observed - spontaneous rapprochement of the edges of the wound due to the contraction of myofibrils in the myofibroblasts of the granulation tissue. In this case, sutures are placed on the wound without excising the granulations. These sutures, placed within 8-14 days after PSO, are called early secondary sutures.

Late secondary sutures are applied 3-4 weeks after PSO of the wound. If scar tissue forms in the wound, preventing its edges from approaching, it is necessary to mobilize the tissues surrounding the wound and excise a strip of skin along the edges of the wound 1-2 mm wide.

When suturing wounds on the lateral surface of the face, in the submandibular region, or penetrating wounds, drainage in the form of a rubber strip should be inserted to ensure the outflow of exudate. External layer-by-layer sutures must be applied to create contact between the wound walls along the entire length and drains are introduced for the outflow of wound discharge.

To prevent the development of tetanus, patients must be given antitetanus serum.

Fractures of the lower jaw

Fracture of the lower jaw is damage to the lower jaw with a violation of its integrity.

Classification of mandibular fractures

There are fractures sustained at work and outside of it (industrial and non-industrial injuries). The latter is divided into household, transport, street, sports, etc. Non-occupational injury prevails (more than 90%), among which the leading place is occupied by domestic injury (more than 75%).

The most commonly used classification is B.D. Kabakov and V.A. Malyshev, according to which fractures of the lower jaw are divided into the following types.

By localization.

Fractures of the jaw body:

With the presence of a tooth in the fracture gap;

With a missing tooth in the fracture gap.

Fractures of the jaw branch:

Actually branches;

coronoid process;

Condylar process: base, neck, head.

According to the nature of the fracture.

Without displacement of fragments;

With displacement of fragments;

Linear;

Splintered.

A fracture of the lower jaw occurs due to the impact of a force on it that exceeds the plastic capabilities of the bone tissue. This type of fracture is called traumatic. If the jaw breaks under the influence of a force not exceeding physiological, then the fracture is defined as pathological.

If a fracture occurs at the point of application of force, it is called direct; if at some distance from the point of impact, it is called indirect or reflected.

Depending on the direction of the fracture gap, it is divided into longitudinal, transverse, oblique and zigzag. In addition, it can be coarse and finely fragmented.

Based on the number, single, double and multiple fractures are distinguished. They can be located on one side of the jaw - unilateral or on both sides - bilateral. Single fractures are more common than double ones, multiple ones are less common than single and double ones.

CLINICAL PICTURE OF FRACTURES OF THE LOWER JAW

With fractures of the lower jaw, the complaints of patients are varied and are largely determined by the location of the fracture and its nature.

Patients are concerned about swelling in the perimaxillary tissues, pain in the lower jaw, which intensifies when opening and closing the mouth, and improper closure of the teeth. Biting and chewing food is sharply painful, sometimes impossible. Some patients experience numbness of the skin in the chin and lower lip. If you have a concussion, you may experience dizziness, headache, nausea, and vomiting.

When collecting anamnesis, the doctor must find out when, where and under what circumstances the injury occurred. Based on clinical signs (preservation of consciousness, contact, breathing pattern, pulse, blood pressure level), the general condition of the patient is assessed. Damage to other anatomical areas must be excluded.

During the examination, a violation of the facial configuration is determined due to post-traumatic swelling of soft tissues, hematoma, and displacement of the chin away from the midline. There may be abrasions, bruises, and wounds on the skin of the face.

Palpation of the lower jaw reveals a bony protrusion, a bone defect or a painful point, often in the area of ​​the most pronounced soft tissue swelling or hematoma.

An important diagnostic criterion is a positive load symptom (pain symptom): when pressing on a known undamaged area of ​​the lower jaw in the fracture area, sharp pain appears due to displacement of fragments and irritation of the damaged periosteum.

If, as a result of damage to the jaw and displacement of fragments, a rupture or injury of the lower alveolar nerve occurs, then on the side of the fracture in the skin of the lower lip and chin there will be no pain reaction, which is established using a sharp needle.

To establish a fracture of the condylar process, the volume of movement of the head in the glenoid cavity is studied. To do this, the doctor inserts his fingers into the patient’s external auditory canal on both sides and presses them against the front wall of the latter. The heads are palpated during jaw movement, and the presence or absence of synchronous movement of the heads, insufficient amplitude will indicate a fracture of the condylar process.

During opening and closing of the mouth, a decrease in the amplitude of movement of the lower jaw, pain and displacement of the chin away from the midline (towards the fracture) are determined.

The bite can be disrupted due to the displacement of fragments due to uneven traction of the masticatory muscles. In this case, the teeth of the small fragment will be in contact with the antagonists, and on the larger fragment there will be no contact of the teeth with the antagonists along almost the entire length, except for the molars.

Percussion of a tooth located in a fracture gap can be painful.

A special diagnostic sign of a fracture of the body of the lower jaw is the formation of a hematoma not only in the vestibule of the mouth, but also on the lingual side of the alveolar part. In case of soft tissue bruise, it is determined only from the vestibular side.

Sometimes a lacerated wound of the mucous membrane of the alveolar part is found in the oral cavity, which extends into the interdental space where the fracture gap passes.

An absolutely reliable sign of a fracture is the symptom of mobility of jaw fragments. The doctor fixes the suspected fragments with the fingers of both hands in the area of ​​the base of the jaw and on the side of the teeth. Next, the fragments are carefully rocked “to the point of fracture”, and the integrity of the dental arch is violated due to displacement of the fragments.

In the case of a fracture in the area of ​​the angle, it is more convenient to fix a smaller fragment in the area of ​​the lower jaw branch, placing the first finger of the left hand from the side of the oral cavity on its front edge, and the remaining fingers (outside) on its back edge. The fingers of the right hand grasp the large fragment and displace it as described above.

The clinical picture data must be confirmed by the results of an X-ray examination. Radiographs make it possible to clarify the topical diagnosis of the fracture, the severity of displacement of fragments, the presence of bone fragments, and the relationship of the roots of the teeth to the fracture gap. Usually two x-rays are taken: in frontal and lateral projections, or an orthopantomogram. For fractures of the condylar process, additional information is provided by special placements for the TMJ.

TREATMENT OF PATIENTS WITH FRACTURES OF THE LOWER JAW

The goal of treating patients with fractures of the lower jaw is to create conditions for the fusion of fragments in the correct position in the shortest possible time. In this case, the treatment should ensure complete restoration of the function of the lower jaw. To carry out what was previously said, the doctor must: firstly, carry out reposition and fixation of jaw fragments for the period of consolidation of the fragments (includes removal of the tooth from the fracture line and primary surgical treatment of the wound); secondly, creating the most favorable conditions for the course of reparative regeneration in bone tissue; thirdly, prevention of the development of purulent-inflammatory complications in bone tissue and surrounding soft tissues. Before considering methods of immobilizing fragments for fractures of the lower jaw, I want to express my opinion in relation to the tooth that is located in the fracture gap. There can be a wide variety of options for the location of teeth in relation to the fracture gap (Fig. 18.4.1). To be deleted:

* broken roots and teeth or teeth completely dislocated from the socket;

* periodontitis teeth with periapical chronic inflammatory foci;

* teeth with symptoms of periodontitis or moderate to severe periodontal disease;

* if the exposed root is located in the fracture gap or an impacted tooth that interferes with the tight (correct) juxtaposition of the jaw fragments (a tooth wedged into the fracture gap);

* teeth that are not amenable to conservative treatment and support inflammatory phenomena.

Subsequently, primary surgical treatment of the wound is performed, i.e. delimit the bone wound from the oral cavity. In this way, an open fracture is converted into a closed one. Sutures made of chrome-plated catgut are placed on the mucous membrane. They try to close the hole tightly so that there is less chance of infection of the blood clot and the development of purulent-inflammatory complications.

Temporary immobilization of fragments is carried out at the scene of the incident, in an ambulance, in any non-specialized medical institution by paramedics or doctors, and can also be performed as mutual aid. Temporary immobilization of fragments of the lower jaw is carried out for a minimum period (preferably no more than a few hours, sometimes up to a day) before the victim is admitted to a specialized medical institution.

The main purpose of temporary immobilization is to press the lower jaw against the upper jaw using various bandages or devices. Temporary (transport) immobilization of fragments of the lower jaw includes: * circular bandage parietal-chin bandage; * standard transport bandage (consists of a rigid tire - Entin's sling); * soft chin sling Pomerantseva - Urbanskaya; * intermaxillary ligature binding of teeth with wire

Permanent immobilization of fragments To immobilize fragments of the lower jaw, conservative (orthopedic) and surgical (operative) methods are used. 449 Most often, dental wire splints are used for permanent fixation of fragments of the lower jaw when it is fractured (a conservative method of immobilization). During the First World War, for the treatment of wounded with maxillofacial injuries, S.S. Tigerstedt (dentist of the Russian army, Kiev) in 1915 proposed aluminum dental splints, which are used to this day in the form of a smooth splint - a bracket, a splint with a spacer (spacer bend) and double-jaw splints with hook loops and intermaxillary traction

Osteosynthesis is a surgical method of connecting bone fragments and eliminating their mobility using fixing devices. Indications for osteosynthesis:

* insufficient number of teeth for splinting or absence of teeth in the lower and upper jaws;

* the presence of mobile teeth in patients with periodontal diseases that prevent the use of conservative treatment;

* fractures of the lower jaw in the area of ​​the neck of the condylar process with an irreducible fragment, with dislocation or subluxation (incomplete dislocation) of the head of the jaw;

* interposition - the introduction of tissue (muscles, tendons, bone fragments) between fragments of a broken jaw, preventing reposition and consolidation of fragments;

* comminuted fractures of the lower jaw, if the bone fragment cannot be juxtaposed into the correct position;

* incomparable, as a result of displacement, bone fragments of the lower jaw.

Acute tooth trauma occurs from a simultaneous cause. Often patients do not seek help immediately, but after a long period of time. This makes it difficult to diagnose and treat such lesions. The type of injury depends on the force of the blow, its direction, and the location of application. Age, condition of teeth and periodontal disease are of great importance.

Acute trauma in 32% of cases causes destruction and loss of anterior teeth in children.

In temporary teeth, the most common occurrence is tooth dislocation, fracture, and less commonly, crown fracture. In permanent teeth, the frequency is followed by the breaking off of part of the crown, then dislocation, bruise of the tooth and fracture of the tooth crown. Dental trauma occurs in children of different ages, but temporary teeth are often injured at the age of 1-3 years, and permanent teeth - at 8-9 years.

Bruised tooth. In the first hours, significant pain occurs, which intensifies when biting. Sometimes, as a result of a bruise, a rupture of the vascular bundle occurs, and there may be hemorrhage into the pulp. The condition of the pulps is determined using odontometry, which is carried out 2-3 days after the injury.

Treatment consists of creating peace, achieved by eliminating solid foods from the diet. In young children, the tooth can be excluded from contact by grinding the cutting edge of the antagonist crown. It is not advisable to grind the edges of the crown of a permanent tooth. In case of irreversible damage to the pulp of the affected tooth, trepanation of the crown, removal of the dead pulp and filling of the canal are indicated. If darkening of the crown occurs, it is bleached before filling.

Tooth dislocation. This is a displacement of the tooth in the socket that occurs when a traumatic force is directed laterally or vertically. In normal periodontal condition, significant force is required to displace the tooth. However, with bone resorption, dislocation can occur from hard food and be accompanied by damage to the integrity of the gums. It can be isolated or in combination with a fracture of the tooth root, alveolar process or jaw body.

Complete tooth luxation is characterized by its falling out of the socket.

Incomplete dislocation is a partial displacement of the root from the alveolus, always accompanied by rupture of periodontal fibers over a greater or lesser extent.

Impacted dislocation is manifested by partial or complete displacement of the tooth from the socket towards the body of the jaw, leading to significant destruction of bone tissue.

The patient complains of pain in one tooth or group of teeth, and significant mobility. Accurately indicates the time of occurrence and cause.

First of all, it is necessary to decide on the advisability of preserving such a tooth. The main criterion is the condition of the bone tissue at the root of the tooth. If it is preserved for at least 1/2 the length of the root, it is advisable to preserve the tooth. First, the tooth is placed in its original place (under anesthesia), and then it is kept at rest, excluding its mobility. For this purpose, splinting is carried out (with wire or quick-hardening plastic). Then the condition of the dental pulp should be determined. In some cases, when the root is displaced, the neurovascular bundle ruptures, but sometimes the pulp remains viable. In the first case, with necrosis, the pulp must be removed and the canal sealed; in the second case, the pulp is preserved. To determine the condition of the pulp, its response to electric current is measured. The reaction of the pulp to a current of 2-3 μA indicates its normal state. It should, however, be remembered that in the first 3-5 days after injury, a decrease in pulp excitability may be a response to traumatic exposure. In such cases, it is necessary to check the condition of the pulp over time (repeatedly). Restoration of excitability indicates restoration of a normal state.

If the tooth reacts to a current of 100 μA or more during repeated examination, then this indicates pulp necrosis and the need for its removal. If a tooth is injured, the root may be driven into the jaw, which is always accompanied by rupture of the neurovascular bundle. This condition is accompanied by pain, and the patient points to a “shortened” tooth. In this case, the tooth is fixed in the correct position and the necrotic pulp is immediately removed. It is recommended to remove it as early as possible to prevent decay and staining of the tooth crown in a dark color.

In case of acute injury, there may be a complete dislocation (the tooth is brought in by hand or the fallen tooth is inserted into the socket). Treatment consists of tooth replantation. This operation can be successful with intact periodontal tissues. It is carried out in the following sequence: the tooth is trepanned, the pulp is removed and the canal is filled. Then, after treating the root and socket with antiseptic solutions, the tooth is inserted into place and fixed (in some cases, splinting is not necessary). If there are no complaints of pain, observation and x-ray control are carried out. The tooth root, replanted in the first 15-30 minutes after injury, is only slightly resorbed, and the tooth remains for many years. If replantation is carried out at a later date, then root resorption is radiologically determined within 1 month after replantation. Root resorption progresses, and by the end of the year a significant part of it is resorbed.

Tooth fracture

Crown fracture does not present any diagnostic difficulties. The volume and nature of treatment intervention depend on tissue loss. If part of the crown is broken off without opening the pulp chamber, it is restored using a composite filling material. The exposed dentin is covered with an insulating lining, and then a filling is applied. The best results are achieved when restoring the crown using a cap. If the conditions for fixing the filling are insufficient, then parapulp pins are used.

If a tooth cavity is opened during an injury, the first step is anesthesia and removal of the pulp; if there are no indications and conditions for its preservation, the canal is sealed. In order to improve the conditions for fixing the filling, a pin can be used, which is fixed in the canal. The lost part of the crown is restored with a composite filling material using a cap. In addition, an inlay or an artificial crown can be made.

It should be remembered that the restoration of the broken part of the tooth should be carried out in the coming days after the injury, since in the absence of contact with the antagonist, this tooth moves in a short time and the adjacent teeth tilt towards the defect, which will not allow further prosthetics without prior orthodontic treatment .

Tooth root fracture. Diagnosis depends on the type of fracture and its location, and most importantly, the possibility of preserving and using the root. X-ray examination is decisive in diagnosis.

The most unfavorable are longitudinal, comminuted and diagonal oblique fractures, in which roots cannot be used for support.

With a transverse fracture, much depends on its level. If a transverse fracture occurs at the border of the upper 1/3-1/4 of the root length or in the middle, then the tooth is trepanned, the pulp is removed, the canal is filled, and the fragments are connected with special pins. In case of a transverse fracture in the quarter of the root closest to the apex, it is enough to fill the canal of the larger fragment. The apical part of the root can be left without intervention.

After filling the canals, it is important to restore the correct position of the tooth and avoid injury when closing the jaws.

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CHAPTER 1

GENERAL INFORMATION ABOUT INJURY OF THE MAXILLOFACIAL AREA, STATISTICS, CLASSIFICATION

Patients with injuries to the maxillofacial region make up about 30% of all patients treated in maxillofacial surgery hospitals. The frequency of facial injuries is 0.3 cases per 1000 people, and the proportion of all maxillofacial trauma among injuries with bone damage in the urban population ranges from 3.2 to 8%. According to Yu.I. Bernadsky (2000), the most common are fractures of the facial bones (88.2%), soft tissue injuries - in 9.9%, facial burns - in 1.9%.

There is a predominance of injuries to the maxillofacial area in men compared to women. The number of traumatic injuries increases in the summer and on holidays.

Classification of injuries of the maxillofacial region.

1. Depending on the circumstances of the injury, the following types of traumatic injuries are distinguished: industrial and non-industrial (domestic, transport, street, sports) injuries.

2. According to the mechanism of damage (the nature of the damaging factors) there are:

· mechanical (firearm and non-firearm),

· thermal (burns, frostbite);

· chemical;

· radial;

· combined.

3. Mechanical damage in accordance with the “Classification of damage to the maxillofacial area” is divided depending on:

a) localization (injuries to the soft tissues of the face with damage to the tongue, salivary glands, large nerves, large vessels; injuries to the bones of the lower jaw, upper jaw, cheekbones, nasal bones, two bones or more);

b) the nature of the wound (through, blind, tangential, penetrating and non-penetrating into the oral cavity, maxillary sinuses or nasal cavity);

c) mechanism of damage (gunshot and non-gunshot, open and closed).

There are also: combined lesions, burns and frostbite.

It is necessary to distinguish between the concepts of combined and combined injury.

Combined injury represents damage to at least two anatomical areas by one or more damaging factors.

Combined injuries a is damage caused by exposure to various traumatic agents. In this case, the participation of the radiation factor is possible.

In traumatology there are open and closed damage. Open ones include those in which there is damage to the integumentary tissues of the body (skin and mucous membrane), which usually leads to infection of the damaged tissues. With a closed injury, the skin and mucous membrane remain intact.

The nature of facial injury, clinical course and outcome depend on the type of wounding object, the strength of its impact, the location of the injury, as well as the anatomical and physiological characteristics of the area of ​​injury.

Features of primary surgical treatment of facial wounds.

· early surgical treatment of the wound up to 24 hours from the onset of injury;

· final surgical treatment of the wound in a specialized institution;

· the edges of the wound are not excised, only clearly non-viable tissues are cut off;

· narrow wound channels are not completely dissected;

· foreign bodies are removed from the wound, but no search is undertaken for foreign bodies located in hard-to-reach places;

· wounds penetrating into the oral cavity must be isolated from the oral cavity by applying blind sutures. It is necessary to protect the bone wound from the contents of the oral cavity;

· on wounds of the eyelids, wings of the nose and lips, a primary suture is always applied, regardless of the timing of surgical treatment of the wound.

When suturing wounds on the side of the face, drainage is inserted in the submandibular area.

At wound penetrating the oral cavity First of all, the mucous membrane is sutured, then the muscles and skin.

At lip wounds The muscle is sutured, the first suture is placed on the border of the skin and the red border of the lip.

At damage to the soft tissues of the face, combined with bone trauma, First, the bone wound is treated. In this case, fragments not connected to the periosteum are removed, the fragments are repositioned and immobilized, and the bone wound is isolated from the contents of the oral cavity. Then they begin surgical treatment of soft tissues.

At wounds penetrating the maxillary sinus, perform a revision of the sinus, form an anastomosis with the inferior nasal passage, through which the iodoform tampon is removed from the sinus. After this, surgical treatment of the facial wound is performed with layer-by-layer sutures.

If damaged salivary gland First, sutures are placed on the parenchyma of the gland, then on the capsule, fascia and skin.

If damaged duct conditions should be created for the flow of saliva into the oral cavity. To do this, a rubber drainage is placed at the central end of the duct and discharged into the oral cavity. The drainage is removed on day 14. The central excretory duct can be sewn onto a polyamide catheter. In this case, its central and peripheral sections are compared.

Crushed submandibular salivary gland may be removed during primary surgical treatment of the wound, but the parotid one, due to the complex anatomical relationship with the facial nerve due to injury, cannot be removed.

At large through defects soft tissues of the face, the convergence of the edges of the wound almost always leads to pronounced deformations of the face. Surgical treatment of wounds should be completed by “suturing” them, connecting the skin with the mucous membrane with sutures. Subsequently, plastic closure of the defect is performed.

In case of extensive trauma to the lower third of the face, floor of the mouth, or neck, a tracheostomy is necessary, followed by intubation and primary surgical treatment of the wound.

Wound in the infraorbital region with a large defect, it is not sutured “on its own” parallel to the lower orbital edge, but is eliminated by cutting out additional flaps (triangular, tongue-shaped), which are moved to the site of the defect and fixed with appropriate suture material.

After the initial surgical treatment of the wound, it is necessary to carry out tetanus prophylaxis.

DENTAL INJURIES

Tooth injury– this is a violation of the anatomical integrity of the tooth or the tissues surrounding it, with a change in the position of the tooth in the dentition.

Cause of acute dental injury: fall on hard objects and blow to the face.

Most often, the incisors are susceptible to acute dental trauma, mainly in the upper jaw, especially with prognathism.

Classification of traumatic dental injuries.

I. WHO classification of injuries.

Class I: Tooth contusion with minor structural damage.

Class II. Uncomplicated fracture of the tooth crown.

Class III. Complicated fracture of the tooth crown.

Class IV. Complete fracture of the tooth crown.

Class V. Coronal-root longitudinal fracture.

Class VI. Tooth root fracture.

Class VII. The tooth dislocation is incomplete.

Class VIII. Complete tooth dislocation.

II. Classification of the clinic of pediatric maxillofacial surgery of the Belarusian State Medical University.

1. Tooth bruise.

1.1. with rupture of the neurovascular bundle (NVB).

1.2. without breaking the SNP.

2. Tooth dislocation.

2.1. incomplete dislocation.

2.2. with a rupture of the SNP.

2.3. without breaking the SNP.

2.4. complete dislocation.

2.5. impacted dislocation

3. Tooth fracture.

3.1. tooth crown fracture.

3.1.1. within the enamel.

3.1.2. within dentin (with opening of the tooth cavity, without opening of the tooth cavity).

3.1.3. fracture of the tooth crown.

3.2. tooth root fracture (longitudinal, transverse, oblique, displaced, without displacement).

4. Injury to the tooth germ.

5. Combined tooth trauma (luxation + fracture, etc.)

TOOTH CONTRIBUTION

Bruised tooth - traumatic damage to a tooth, characterized by concussion and/or hemorrhage into the pulp chamber. When a tooth is bruised, the periodontium is first damaged in the form of rupture of part of its fibers, damage to small blood vessels and nerves, mainly in the apical part of the tooth root. In some cases, complete rupture of the neurovascular bundle at its entrance to the apical foramen is possible, which usually leads to the death of the dental pulp due to the cessation of blood circulation in it.

Clinic.

The symptoms of acute traumatic periodontitis are determined: pain in the tooth, aggravated by biting, pain during percussion. Due to swelling of the periodontal tissues, there is a feeling of the tooth “pushing out” of the socket, and its moderate mobility is determined. At the same time, the tooth retains its shape and position in the dentition. Sometimes the crown of a damaged tooth turns pink due to hemorrhage in the tooth pulp.

An X-ray examination is required to rule out a root fracture. If a tooth is bruised, an x-ray can reveal a moderate widening of the periodontal fissure.

· creating conditions for the damaged tooth to rest, removing it from occlusion by grinding the cutting edges of the teeth;

mechanically gentle diet;

· in case of pulp death – extirpation and canal filling.

Pulp viability is controlled using

electroodontic diagnostics over a period of 3-4 weeks, as well as on the basis of clinical signs (darkening of the tooth crown, pain on percussion, the appearance of a fistula on the gum).

TEETH BREAKING

Tooth luxation– traumatic damage to a tooth, as a result of which its connection with the socket is disrupted.

Tooth dislocation occurs most often as a result of a blow to the crown.

tooth More often than others, the front teeth on the upper jaw are dislocated and less often on the lower jaw. Dislocations of premolars and molars most often occur when neighboring teeth are carelessly removed using an elevator.

There are:

incomplete dislocation (extrusion),

complete dislocation (avulsion),

Impacted dislocation (intrusion).

In case of incomplete dislocation, the tooth partially loses its connection with the tooth socket,

becomes mobile and shifts due to rupture of periodontal fibers and disruption of the integrity of the cortical plate of the tooth alveolus.

With complete luxation, the tooth loses connection with the tooth socket due to rupture

of all periodontal tissues, falls out of the socket or is held only by the soft tissues of the gums.

With an impacted dislocation, the tooth is embedded in the spongy

substance of the bone tissue of the alveolar process of the jaw (immersion of the tooth into the socket).

Incomplete tooth dislocations

Clinic. Complaints of pain, tooth mobility, changes in sex

its presence in the dentition, dysfunction of chewing. When examining the oral cavity, incomplete tooth dislocation is characterized by a change in position (displacement) of the crown of the injured tooth in different directions (orally, vestibularly, distally, towards the occlusal plane, etc.). The tooth may be mobile and sharply painful upon percussion, but not displaced beyond the dentition. The gums are swollen and hyperemic, and ruptures are possible. Due to rupture of the circular ligament of the tooth, periodontal tissues and damage to the alveolar wall, pathological dental-gingival pockets and bleeding from them can be determined. When a tooth is dislocated and its crown is displaced orally, the root of the tooth is usually displaced vestibularly, and vice versa. When a tooth moves towards the occlusal plane, it protrudes above the level of neighboring teeth, is mobile and interferes with occlusion. Very often the patient has a concomitant injury to the soft tissues of the lips (bruise, hemorrhage, wound).

In case of incomplete dislocation of a tooth, a widening of the periodontal fissure and some “shortening” of the tooth root are determined radiologically if it is displaced orally or vestibularly.

Treatment of incomplete dislocation.

tooth repositioning;

· fixation with a mouthguard or a smooth splint;

· gentle diet;

· examination after 1 month;

· when it is established that the pulp is dead, extirpate it and fill the canal.

Immobilization or fixation of teeth is carried out in the following ways:

1. Ligature binding of teeth (simple ligature binding, continuous in the form of a figure eight, binding of teeth according to Baronov, Obwegeser, Frigof, etc.). Ligature binding of teeth is indicated, as a rule, in permanent dentition in the presence of stable, adjacent teeth (2-3 on both sides of the dislocated one). For ligature binding of teeth, thin (0.4 mm) soft bronze-aluminum or stainless steel wire is usually used. The disadvantage of these splinting methods is the impossibility of their use in temporary dentition for the reasons stated above. In addition, applying wire ligatures is a rather labor-intensive process. At the same time, this method does not allow sufficiently rigid fixation of dislocated teeth.

2. Bus bracket (wire or tape). A tire is made (bent) from stainless wire from 0.6 to 1.0 mm. thickness or standard steel tape and is fixed to the teeth (2-3 on both sides of the dislocated one) using a thin (0.4 mm) ligature wire. A splint-bracket is indicated in permanent dentition, as a rule, in the presence of a sufficient number of stable adjacent teeth.

Disadvantages: traumatic, labor-intensive and limited use in temporary dentition.

3. Splint-kappa. It is usually made from plastic in one visit, directly in the patient’s mouth after teeth repositioning. Disadvantages: bite separation and difficulty in performing EDI.

4. Teeth-gingival splints. Indicated in any bite in the absence of a sufficient number of supporting teeth, including adjacent teeth. They are made of plastic with reinforced wire, in the laboratory after taking an impression and casting a jaw model.

5. The use of composite materials, with the help of which wire arches or other splinting structures are fixed to the teeth.

Immobilization of dislocated teeth is usually carried out within 1 month (4 weeks). In this case, it is necessary to strictly observe oral hygiene to prevent inflammatory processes and damage to the enamel of splinted teeth.

Complications and outcomes of incomplete dislocation: shortening of the tooth root,

obliteration or expansion of the tooth root canal with the formation of intrapulpar granuloma, stopping the formation and growth of the root, curvature of the tooth root, changes in the periapical tissues in the form of chronic periodontitis, root cyst.

Complete dislocation of teeth.

Complete tooth dislocation (traumatic extraction) occurs after complete rupture of periodontal tissue and the circular ligament of the tooth as a result of a strong blow to the tooth crown. Most often, the frontal teeth on the upper jaw (mainly the central incisors) are affected and less often on the lower jaw.

Clinical picture: upon examination of the oral cavity, there is no tooth in the dentition and there is a hole in the dislocated tooth that is bleeding or filled with a fresh blood clot. There are often concomitant injuries to the soft tissues of the lips (bruises, wounds to the mucous membrane, etc.). When visiting a dentist, dislocated teeth are often brought “in your pocket.” To draw up a treatment plan, you should evaluate the condition of the dislocated tooth (the integrity of the crown and root, the presence of carious cavities, a temporary tooth or a permanent one, etc.).

Treatment of complete dislocation consists of the following stages.

· pulp extirpation and canal filling;

· replantation;

· fixation for 4 weeks with a mouth guard or a smooth splint;

· mechanically gentle diet.

It is necessary to examine the tooth socket and assess its integrity. X-ray, with complete dislocation of the tooth, a free (empty) tooth socket with clear contours is determined. If the socket of a dislocated tooth is destroyed, then the boundaries of the alveoli are not determined radiologically.

Indications for tooth replantation depend on the patient’s age, his

the general condition, the condition of the tooth itself and its socket, whether the tooth is temporary or permanent, whether the root of the tooth is formed or not.

Tooth replantation- this is the return of the tooth to its own socket. Distinguish immediate and delayed tooth replantation. With one-stage replantation, in one visit, the tooth is prepared for replantation, its root canal is filled, and the replantation itself is carried out, followed by splinting it. In case of delayed replantation, the avulsed tooth is washed, immersed in a saline solution with an antibiotic and placed temporarily (until replantation) in the refrigerator. After a few hours or days, the tooth is trepanned, filled, and replanted.

The tooth replantation operation can be divided into the following stages:

1. Preparing the tooth for replantation.

2. Preparing the tooth socket for replantation.

3. The actual replantation of the tooth and its fixation in the socket.

4. Postoperative treatment and monitoring over time.

1-1.5 months after tooth replantation surgery, the following types of tooth engraftment are possible:

1. Healing of the tooth according to the type of primary intention through the periodontium (syndesmosis). This is the most favorable periodontal type of fusion, depending mainly on the preservation of the viability of periodontal tissues. With this type of fusion, the control radiograph shows a uniform width of the periodontal gap.

2. Engraftment of the tooth by the type of synostosis or bone fusion of the tooth root and the wall of the socket. This occurs with the complete death of periodontal tissue and is the least favorable type of fusion (ankylosis of the tooth). In case of ankylosis of the tooth, the periodontal fissure is not visible on the control radiograph.

3. Engraftment of the tooth using a mixed (periodontal-fibrous-osseous) type of fusion of the tooth root and alveolar wall. On a control radiograph with such a fusion, the line of the periodontal fissure alternates with areas of its narrowing or absence.

In the long-term period (several years) after tooth replantation, resorption (resorption) of the root of the replanted tooth may occur.

Surgical methods of treatment.

1. Suspension of the upper jaw to the orbital edge of the frontal bone according to Faltin-Adams.

For a fracture:

· according to the lower type, the upper jaw is fixed to the lower edge of the orbit or to the edge of the pyriform opening;

· according to the middle type - to the zygomatic arch;

· by the upper type – to the zygomatic process of the frontal bone;

Operation stages:

· A wire splint with two hooking loops facing downwards is placed on the upper jaw.

· An intact area of ​​the upper outer edge of the orbit is exposed, in which a hole is made. A thin wire or polyamide thread is passed through it.

· Using a long needle, both ends of the ligature are passed through the thickness of the soft tissues so that they exit into the vestibule of the oral cavity at the level of the first molar.

· After repositioning the fragment into the correct position, the ligature is fixed by the hook of the dental splint.

· This operation is carried out on both sides.

· If it is necessary to correct the bite, apply a splint with hooking loops to the lower jaw and an intermaxillary rubber rod or a parietal-mental sling.

2. Frontomaxillary osteosynthesis according to Chernyatina-Svistunov indicated for fractures of the upper jaw of the middle and upper type.

The fragments are fixed not to the splint, but to the zygomaticalveolar ridge.

3. Fixing fragments of the upper jaw with Kirschner wires according to Makienko.

4. Osteosynthesis of fractures of the upper jaw with titanium mini-plates.

· In case of a fracture of the lower type, osteosynthesis is performed in the area of ​​the zygomatic-alveolar ridge and along the edge of the pyriform opening through intraoral incisions.

· For a mid-type fracture, mini-plates are applied along the zygomatic-alveolar ridge, as well as along the lower edge of the orbit and in the area of ​​the bridge of the nose.

· In case of a fracture of the upper type, osteosynthesis is indicated in the area of ​​the bridge of the nose, the upper outer corner of the orbit and the zygomatic arch.

· To prevent traumatic maxillary sinusitis, an inspection of the maxillary sinus is performed, an anastomosis is applied to the lower nasal meatus, and the defect is closed with local tissues to isolate the oral cavity from the sinus.

FRACTURES OF THE ZYGOMIC BONE AND ZYGOMICAL ARCH

Classification of non-gunshot fractures of the zygomatic bone and arch:

1. Fractures of the zygomatic bone (with and without displacement of fragments).

2. Fractures of the zygomatic arch (with and without displacement of fragments).

Displaced fractures of the zygomatic bone are usually open.

Fractures of the zygomatic arch are most often closed.

Clinic for fractures of the zygomatic bone (zygomatic maxillary complex).

The following symptoms are identified:

· Severe swelling of the eyelids and hemorrhage into the tissue around one eye, which leads to narrowing or closure of the palpebral fissure.

· Bleeding from the nose (from one nostril).

· Limited mouth opening due to blocking of the coronoid process of the lower jaw, displaced by the zygomatic.

· Anesthesia or paresthesia of soft tissues in the area of ​​innervation of the infraorbital nerve on the side of the injury (upper lip, wing of the nose, infraorbital region, etc.).

· Impaired binocular vision (diplopia or double vision) due to displacement of the eyeball.

· Retraction, determined by palpation in the zygomatic region.

· Pain and the “step” symptom upon palpation along the lower orbital edge, the superior outer edge of the orbit, along the zygomatic arch and along the zygomatic-alveolar ridge.

Clinic for zygomatic arch fractures:

· Damage to the soft tissues of the zygomatic area (swelling, wounds, hemorrhages), which are masked by retraction in the zygomatic area.

· Limited mouth opening due to blocking of the coronoid process of the mandible by the displaced zygomatic arch.

· Absence of unilateral lateral movements of the lower jaw.

· Recession, pain and “step” symptom upon palpation in the area of ​​the zygomatic arch.

X-ray examination.

Radiographs of the paranasal sinuses and zygomatic bones are studied in the nasomental (semi-axial) and axial projections.

Defined by:

· violation of the integrity of bone tissue at the junction of the zygomatic bone with other bones of the facial and cerebral skull;

· darkening of the maxillary sinus on one side as a result of hemosinus in fractures of the zygomatic bone.

Treatment.

Patients are treated in a hospital.

For fractures of the zygomatic bone and arch without significant displacement of fragments and dysfunction, conservative treatment is carried out, limiting the intake of solid food.

Indications for repositioning fragments of the zygomatic arch and bone:

· deformation of the face due to retraction of tissues in the zygomatic region,

· impaired sensitivity in the area of ​​innervation of the infraorbital and zygomatic nerve, diplopia,

· violation of movements of the lower jaw.

Fractures of the nasal bones

Occurs when a fall or strong blow to the bridge of the nose. The displacement of bone fragments depends on the strength and direction of the traumatic factor.

Classification.

There are fractures of the nasal bones with displacement and without displacement of bone fragments, as well as impacted fractures of the nasal bones.

All displaced fractures of the nasal bones are open fractures, as they are accompanied by ruptures of the nasal mucosa and profuse nosebleeds.

40% of patients with nasal bone fractures have a traumatic brain injury.

Clinical symptoms of a nasal bone fracture:

· Deformation of the external nose in the form of lateral curvature or saddle-shaped retraction.

· Nosebleed.

· Difficulty in nasal breathing.

· Damage to the skin of the back of the nose.

· Swelling of the eyelids and hemorrhage into the tissue around the eyes (a symptom of glasses).

· Pain, crepitus and mobility of bone fragments, determined by palpation in the dorsum of the nose.

· Displacement of the bone and cartilaginous part of the nasal septum, which is detected during anterior rhinoscopy.

· For the final diagnosis of a fracture, radiography of the nasal bones in direct and lateral projection is indicated.

Treatment.

First aid- stopping bleeding (anterior or posterior tamponade).

Reposition of fragments under local anesthesia using a hemostatic clamp inserted into the upper nasal passage or a special elevator, which is used to lift the displaced bones, forming the contours of the nasal bridge with the index and thumbs of the left hand. The nasal passages are packed.

Application of an external fixation bandage (splint) for fixation of bone fragments for 8-10 days (gauze collodion dressing or plaster).

COMPLICATIONS OF FACIAL INJURIES

The following types of complications of injuries to the maxillofacial area are distinguished:

1. Direct (asphyxia, bleeding, traumatic shock).

2. Immediate complications (wound suppuration, abscess and phlegmon of soft tissues, traumatic osteomyelitis, traumatic maxillary sinusitis, secondary bleeding due to melting of a blood clot, sepsis).

3. Long-term complications (scar deformation of soft tissues, soft tissue defects, edentia and death of the rudiments of permanent teeth, jaw deformation, improperly healed fracture of the jaw, malocclusion, bone tissue defects, pseudarthrosis, delayed jaw growth, ankylosis and other diseases of the temporomandibular joint).

TRAUMATIC SHOCK

Traumatic shock- a general reaction of the body to severe damage, in the pathogenesis of which a central place is occupied by impaired tissue circulation, a decrease in cardiac output, hypovolemia and a drop in peripheral vascular tone. Ischemia occurs in vital organs and systems (heart, brain, kidneys).

Traumatic shock occurs as a result of severe polytrauma, severe bone damage, crushing of soft tissues, extensive burns, combined trauma of the face and internal organs. With such injuries, severe pain occurs, which is the root cause of traumatic shock and disruption of the interrelated functions of the circulatory, respiratory and excretory organs.

During shock, erectile and torpid phases are distinguished. The erectile phase is usually short-lived and is manifested by general anxiety.

The torpid phase is divided into 3 degrees according to the severity of clinical manifestations:

1st degree – mild shock;

2nd degree – severe shock;

3rd degree – terminal condition.

The 1st degree of the torpid phase is characterized by: indifference to the environment, pallor of the skin, pulse 90-110 beats per minute, systolic pressure 100-80 mm. rt. Art., diastolic – 65-55 mm. rt. Art. The volume of circulating blood is reduced by 15-20%.

With 2 degrees of shock, the victim’s condition is severe, the skin is pale with a grayish tint, although consciousness is preserved, indifference to the environment increases, the pupils react poorly to light, reflexes are decreased, the pulse is rapid, and the heart sounds are muffled. Systolic pressure – 70 mm. rt. Art., diastolic – 30-40 mm. rt. Art., is not always caught. The volume of circulating blood is reduced by 35% or more. Breathing is frequent and shallow.

The terminal state is characterized by: loss of consciousness, pale gray skin, covered with sticky sweat, cold. The pupils are dilated and weakly or completely unresponsive to light. Pulse and blood pressure are not determined. Breathing is barely noticeable. The volume of circulating blood is reduced by 35% or more.

Treatment.

Main objectives of treatment:

local and general anesthesia;

stopping bleeding;

· compensation of blood loss and normalization of hemodynamics;

· maintaining external respiration and combating asphyxia and hypoxia;

· temporary or transport immobilization of a jaw fracture, as well as timely surgical intervention;

· correction of metabolic processes;

· satisfying hunger and thirst.

When providing first aid at the scene of an accident, bleeding can be reduced by applying finger pressure to the damaged blood vessel. Effective general anesthesia is achieved by using non-narcotic analgesics (analgin, fentanyl, etc.) or neuroleptanalgesia (droperidol, etc.). Local anesthesia - conduction or infiltration. If there is a risk of asphyxia, subcutaneous administration of morphine (omnopon) is contraindicated. In cases of respiratory depression, victims inhale carbon dioxide and inject ephedrine subcutaneously.

BRONCHOPULMONARY COMPLICATIONS

Bronchopulmonary complications develop as a result of prolonged aspiration of infected oral fluid, bone, blood, and vomit. With gunshot wounds of soft tissues and bones of the face, bronchopulmonary complications occur more often than with injuries to other areas.

Predisposing factors for the development of bronchopulmonary complications:

· constant drooling from the mouth, which, especially in winter, can lead to significant hypothermia of the anterior surface of the chest;

· blood loss;

· dehydration;

· eating disorders;

· weakening of the body's defenses.

The most common complication is aspiration pneumonia. Develops 4-6 days after injury.

Prevention:

· timely provision of specialized assistance;

· antibiotic therapy;

· prevention of aspiration of food during feeding;

· mechanical protection of the chest organs from wetting with saliva;

· breathing exercises.

ASPHYXIA

Asphyxia Clinic. The breathing of victims is accelerated and deep, auxiliary muscles are involved in the act of breathing, and when inhaling, the intercostal spaces and the epigastric region sink. The inhalation is noisy, with a whistle. The victim's face is bluish or pale, the skin becomes gray in color, the lips and nails are cyanotic. The pulse slows down or quickens, and cardiac activity decreases. The blood takes on a dark color. Victims often experience agitation and motor restlessness is replaced by loss of consciousness.

Types of asphyxia in those wounded in the face and jaws and treatment according to G.M. Ivashchenko

Indications for tracheostomy:

· damage to the maxillofacial area in combination with severe traumatic brain injury, causing loss of consciousness and respiratory depression;

· the need for long-term artificial ventilation and systematic drainage of the tracheobronchial tree;

· wounds with separation of the upper and lower jaws, when there is significant aspiration of blood into the respiratory tract and their drainage cannot be ensured through the endotracheal tube;

· after extensive and severe operations (resection of the lower jaw with a one-stage Crail operation, excision of a cancerous tumor of the root of the tongue and floor of the mouth).

In the postoperative period, due to impaired swallowing and a decreased cough reflex, as well as due to a violation of the integrity of the muscles of the floor of the mouth, such patients often experience a retraction of the tongue, blood mixed with saliva constantly flows into the trachea, and a large amount of fluid accumulates in the trachea and bronchi itself. amount of mucus and phlegm.

The following types of tracheostomy are distinguished:

· upper (stoma placement above the isthmus of the thyroid gland);

· medium (stomy through the isthmus of the thyroid gland);

· lower (stoma placement below the isthmus of the thyroid gland);

The lower one is shown only in children, the middle one is practically not performed.

Tracheostomy technique(after V. O. Bjork, 1960).

· The patient lies on his back with a cushion under his shoulder blades and his head thrown back as much as possible.

· An incision of the skin and subcutaneous tissue 2.5-3 cm long is made along the midline of the neck 1.5 cm below the cricoid cartilage.

· The muscles are bluntly separated and the isthmus of the thyroid gland is moved upward or downward, depending on the anatomical features. In the first case, to prevent pressure on the tracheostomy tube, the isthmus capsule is fixed to the upper skin flap.

· In the anterior wall of the trachea, a flap is cut out from the second or from the second and third rings of the trachea, with the base facing downwards. To avoid trauma to the cricoid cartilage with the tracheostomy tube, the first tracheal ring is preserved.

· The top of the flap is fixed to the dermis of the lower skin flap with one catgut suture.

· A tracheostomy cannula of the appropriate diameter with a replaceable inner tube is inserted into the stoma. The diameter of the outer cannula should correspond to the opening in the trachea.

Removal of the tracheostomy tube (decannulation) is usually carried out on the 3-7th day, after making sure that the patient can breathe normally through the glottis, the stoma is then tightened with a strip of adhesive tape. As a rule, it closes on its own after 7-10 days.

Crico-conicotomy indicated for asphyxia, when there is no time left for tracheostomy and intubation is impossible.

Operation technique:

· Rapid dissection (simultaneously with the skin) of the cricoid cartilage and thyroid cricoid ligament.

· The edges of the wound are separated with any instrument suitable for this purpose.

· A narrow cannula is temporarily inserted into the wound and the trachea is drained through it.

BLEEDING

Bleeding is called the leakage of blood from a blood vessel when the integrity of its walls is violated.

Depending on the place where blood flows after an injury, there are:

· interstitial bleeding - blood leaving the vessels, permeating the tissue surrounding the damaged vessel, causes the formation of petechiae, ecchymoses and hematomas;

External bleeding - bleeding onto the surface of the body;

· internal bleeding - the flow of blood into any organ cavity.

According to the source of blood flow from the vessel, they are distinguished arterial, venous, capillary and mixed bleeding.

According to the time factor of blood flow, the following are distinguished:

· primary;

· secondary early (in the first 3 days after injury).

Reasons: cutting through a vessel with a ligature, slipping of the ligature from the vessel, technical errors in hemostasis, improvement of central and peripheral hemodynamics as a result of the patient recovering from a state of circulatory failure;

· secondary late (on the 10-15th day after injury).

Reasons: purulent melting of the blood clot and the vessel wall, disseminated intravascular coagulation syndrome with subsequent hypocoagulation of the blood.

Criteria for assessing the severity of blood loss.

CHAPTER 10 TACTICS OF PROGRAMMED MULTISTAGE SURGICAL TREATMENT OF WOUNDS AND INJURIES (DAMAGE CONTROL SURGERY)

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. THORACOABDOMINAL WOUNDS

CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

Combat injuries of the maxillofacial area amount to gunshot injuries(bullet, shrapnel wounds, MVR, blast injuries), non-gunshot injuries(open and closed mechanical injuries, non-gunshot wounds) and their various combinations.

Injuries to the maxillofacial area are very diverse and cause disruption of important body functions, such as swallowing, breathing, chewing and speech. Gunshot wounds of the jaw during the Great Patriotic War of 1941-1945. accounted for 3.5% of the total number of all injuries ( YES. Entin). In local wars of recent years, the frequency of injuries to the face has increased 1.5-2 times, while the frequency of combined injuries to the face is 4.5-5%, and the proportion of all facial wounds reaches 9% ( N.M. Alexandrov).

18.1. TERMINOLOGY AND CLASSIFICATION OF DAMAGES TO THE MAXILLOFACIAL AREA

Among combat injuries, the most prominent ones are: isolated, multiple and combined injuries (wounds).

Isolated called a trauma (wound) of the maxillofacial area, in which there is one damage.

Multiple trauma (wound) of the maxillofacial area called a trauma (wound), in which there are several damages within the maxillofacial area. Multiple head trauma (wound) is called damage to several parts of the head (frontal area, ENT, organ of vision or brain) as a result of exposure to one or more MS. Simultaneous damage to the maxillofacial area with other anatomical areas of the body (neck, chest, abdomen, pelvis, spine, limbs) is defined as combined injury (wound) of the maxillofacial area.

Gunshot wounds There are some penetrating(in the mouth, nose and paranasal sinuses) and non-penetrating. The nature of the wound channel varies blind, through, tangent injuries . Injuries

MFA include damage to soft tissues, bones of the facial skeleton (upper and lower jaws, alveolar processes and teeth, zygomatic bones), facial organs (tongue, salivary glands), blood vessels, and nerves.

Injuries to the maxillofacial area may be accompanied by the development immediate consequences, i.e. pathological processes developing immediately after damage as a result of disruption of the anatomical structures of the maxillofacial area, of which the most dangerous life-threatening consequences(asphyxia and ongoing bleeding). All these characteristics must be taken into account when making a diagnosis. To correctly construct a diagnosis, a nosological classification is used, which to a certain extent is an algorithm for its formulation (Table 18.1).

Table 18.1. Classification of gunshot wounds and MVR of the maxillofacial area

Non-gunshot wounds of the jaw differ significantly from firearms, since they are usually applied with piercing and cutting objects and do not have areas of primary and secondary necrosis. They become significant when large vessels and nerve trunks (cranial nerves) are damaged by a wounding object, causing life-threatening consequences - the same as with gunshot wounds.

Mechanical injuries of the maxillofacial area depending on the condition of the integumentary tissues there are closed and open, penetrating and non-penetrating. Open injuries are those accompanied by a violation of the integrity of the skin or mucous membrane of the oral cavity, and penetrating injuries are those that communicate with the oral cavity, nose and paranasal sinuses. Fractures of the upper and lower jaw within the dentition are always accompanied by damage to the mucous membrane (attached gum), since in this part there is no submucosal layer, and the mucous membrane is fused with the periosteum.

The maxillofacial area is divided into the middle and lower facial zones.

Middle zone -bounded above by the base of the nose and brow ridges - arc. superciliaris, the posterior edge of the zygomatic bone and the lower edge of the zygomatic arch to a line drawn in front of the external auditory canal, and below - the line of closure of the dentition. The middle zone of the face includes: the nose area, eye sockets, cheekbones, cheek and infraorbital areas.

Injuries to the midface are accompanied by fractures of the nasal bones, damage to the zygomatic-orbital complex and fractures of the upper jaw. The main danger with nasal injuries is continued nosebleeds. Injuries to the zygomatic-orbital complex are usually combined with damage to the walls of the orbit, contusion of the eyeball, and may be accompanied by partial or complete loss of visual function. The second dangerous consequence of injuries to this area is damage to the paranasal sinuses. Due to impaired function of the ciliated epithelium and impaired sinus aeration, post-traumatic sinusitis is a common complication. For adequate diagnosis and treatment of injuries to the zygomatic-orbital complex, the joint work of an oral and maxillofacial surgeon, an otolaryngologist and an ophthalmologist is necessary.

Types of fractures of the upper jaw are presented in Figure 18.1. The most common classification of fractures of the upper jaw

Rice. 18.1. The main types of fractures of the upper jaw according to Lefort: a - Lefort I - craniofacial separation, or upper type of fracture; b - Lefor II - middle type of fracture, c - Lefor III - lower type of fracture

according to Lefort (1900), according to which fractures should be divided into three main types, caused by lines of weakness at the junction of the upper jaw with other bones of the skull. The most severe and difficult to treat are craniofacial separations or the upper type of fracture. This type of damage is combined with a fracture of the bones of the base of the skull and is manifested by the leakage of cerebrospinal fluid from the nose and external auditory canal.

The consequence of fractures of the upper jaw is external bleeding with a high risk of asphyxia due to aspiration of blood into the tracheobronchial tree.

Lower face area - from above it is limited by the line of closure of the dentition, from below - by the body of the hyoid bone and a line drawn along the projection m. mylohyoideus to proc.mastoideus.

Injuries to the lower area of ​​the face may be accompanied by fractures of the lower jaw. Fractures of the lower jaw are divided depending on the nature into single, double, multiple, unilateral or bilateral; by localization: alveolar part, chin and lateral region, angle of the jaw, branch of the jaw (the branch itself, condylar and coronoid process). Isolated fractures usually do not pose major problems in treatment if early adequate reduction and immobilization are performed. Multiple fractures can lead to dislocation asphyxia due to displacement of fragments and retraction of the tongue, obturation

upper respiratory tract thrombus. External bleeding with extensive tissue damage can be intense and lead to massive blood loss and aspiration of blood into the tracheobronchial tree.

Thus, damage to various structures of the maxillofacial area and their consequences are interconnected. They are presented in the form of nosological classification in table. 18.2 and should be taken into account when formulating the diagnosis of a maxillofacial injury.

Examples of diagnoses of injuries to the maxillofacial area.

1. Shrapnel blind wound of soft tissues of the midface on the right.

2. Bullet through wound of the lower area of ​​the face, penetrating into the oral cavity; a fracture of the lower jaw in the area of ​​35-36 and 43-44 teeth and extensive damage and defect of soft tissues. Aspiration of blood into the tracheobronchial tree. Aspiration and dislocation asphyxia. ODN 2nd degree.

3. A bullet through wound of the middle and lower area of ​​the face, penetrating into the oral cavity, with a fracture of the upper jaw in the area of ​​the 14-15 tooth, a fracture of the lower jaw with a defect in the alveolar part and extraction of the 34-36 tooth. Continued external bleeding. Traumatic shock of the first degree.

4. Mine-explosive multiple head wound. TBI. Concussion. Open severe maxillofacial trauma. Extensive damage to soft tissue and bones in the middle and lower areas of the face. Multiple fragmentation wounds penetrating into the maxillary sinuses and oral cavity with fractures of the walls of the maxillary sinuses and the alveolar process of the upper jaw in the area of ​​11-13, 21-23 teeth. Bilateral maxillary hemosinus. Aspiration of blood into the TBD. Dislocation asphyxia. Continued external bleeding. ARF II degree. Acute blood loss. Traumatic shock of the second degree (Fig. 18.2 color illustration).

5. Multiple head trauma. Open severe maxillofacial injury. Fracture of the lower wall of the left orbit with displacement of fragments, mild contusion of the left eyeball. Fracture of the zygomatic arch, anterior and lateral walls of the left maxillary sinus. Fracture of the anterior wall of the maxillary sinus on the right. Bilateral maxillary hemosinus. Multicomminuted fracture of the lower jaw with the formation of a defect in the alveolar region and extraction of 41-43 teeth. Continued external bleeding. Aspiration of blood into the tracheobronchial tree. Traumatic shock of the first degree (Fig. 18.3 color illustration, 18.4).

Rice. 18.4. X-ray of a multiple mandibular fracture

18.2. CLINICAL COURSE AND DIAGNOSTICS OF COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

The clinical course of gunshot wounds of the maxillofacial area differs from the course of similar wounds of other localization in the following main ways: features:

Peculiar, sometimes very pronounced emotional and mental disorders associated with facial disfigurement;

Frequent discrepancy between the type of injury and its severity; frequent multiple nature of injuries within one anatomical area - the “head” (simultaneous damage to the maxillofacial area, brain, ENT organs and organ of vision), which requires the involvement of appropriate specialists in providing assistance; characteristic manifestations of wound infection and shortened healing time of infected facial wounds, which is due to the anatomical and physiological characteristics of the maxillofacial area (rich vascularization, innervation, etc.); the presence of specific secondary RS (teeth); the need for special nutrition and care

these wounded. The symptomatology of wounds and damage to the maxillofacial area is very characteristic, and their diagnosis in most cases is not difficult. Already at inspection In some cases, the wounded person is struck by the pallor of the skin, abundant soaking of the bandage with blood and saliva, shortness of breath and forced positioning, disturbances in chewing, swallowing, breathing and speech. The latter circumstance makes it difficult or even impossible to interview the wounded.

Isolated soft tissue injuries are diagnosed based on visible disorders of the skin of the face and soft tissues of the oral cavity. Damage to the bones of the face, especially the jaws, is diagnosed on the basis of violations of the normal contours of the face and the relationship between the teeth of the upper and lower jaws - malocclusion (Fig. 18.5).

Rice. 18.5. Malocclusion in mandibular fractures

In addition, with jaw fractures, the wounded experience significant pain in the fracture area, which intensifies with the slightest movement of the lower jaw; mobility and displacement of fragments are observed. Displacement of fragments is especially typical for fractures of the lower jaw, and the fragments are displaced so characteristically that this provides grounds for topical diagnosis of the fracture even without an x-ray examination. The displacement always occurs in the direction of traction of the masticatory muscles.

Fractures of the upper jaw are diagnosed by lengthening and flattening of the midface, hemorrhages in the tissue surrounding the eyeball, displacement and mobility of fragments and malocclusion (the latter can only be detected during examination of the oral cavity).

Fractures of the zygomatic bones are recognized by damage to the soft tissue in this area, sometimes by the occurrence of a typical deformation in the form of tissue retraction, as well as by difficulty opening the mouth, which is always observed with these injuries.

Bones faces are palpated in the direction from the forehead to the chin:

Brow ridges;

Lateral edges of the orbits;

Inferior orbital margins;

Elevations of the zygomatic bones;

Zygomatic arches;

Upper jaw;

Nose bones;

Lower jaw.

In addition to the disorders listed above, diagnosed in those wounded in the jaw, it is very important to promptly recognize, especially at the advanced stages of evacuation, the life-threatening consequences of wounds to the face and jaws - bleeding and asphyxia.

Form of asphyxia	Frequency of occurrence,%	Pathogenesis	Help measures
Dislocation		Displacement (relapse) of the tongue, displacement of fragments of the lower jaw	Stitching and fixing the tongue in the correct position, fixing jaw fragments
Obstructive		Closure of the upper part of the breathing tube by a foreign body, blood clot, etc.	Removal of a foreign body, blood clot, and, if impossible, tracheostomy (conicotomy)
Stenotic		Tracheal compression (swelling, neck hematoma)	Tracheostomy (conicotomy)
Valve		Closing the entrance to the larynx with a soft tissue flap	Lifting and suturing the hanging flap or cutting it off
Aspiration		Aspiration of blood and vomit	Suctioning contents from the respiratory tract with a rubber tube inserted into the trachea

Instrumental research methods:

Radiography. To diagnose fractures of the facial skeleton, photographs are taken in several projections.

1. Standard projections (primary x-ray examination):

Photographs of the facial skull in anterior and two lateral projections; - occipitomental projection.

2. Images of the lower jaw (if necessary).

3. Special projections (if the results of the primary study indicate their need):

Photograph of the nasal bones;

Frontal-mental-parietal projection;

Orthopantomography.

Additional Research may be required when providing specialized assistance. They are carried out after stabilization of the wounded person’s condition: CT scan of the bones of the facial skeleton, eye sockets and lower jaw in horizontal and frontal projections; volumetric reconstruction of CT images (DDD mode). In diagnosing the nature of gunshot wounds of the major salivary glands, increasing importance is being attached to Ultrasound - a method widely used in peacetime injury surgery. Videoendoscopy makes it possible not only to identify the source of bleeding, but also to determine the nature of multiple damage to the ethmoidal labyrinth, the walls of the paranasal sinuses (maxillary, frontal sinuses and main sinus), as well as to audit and sanitize them in order to prevent the development of serious infectious complications, such as purulent meningitis and sepsis (Fig. 18.6 color illustration).

18.3. PROVIDING ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

First and first aid. The main task of first aid to those wounded in the face and jaws on the battlefield is to combat the life-threatening consequences of the wound - bleeding and asphyxia. Some of those wounded in the face are severely disfigured. Unconscious, their face covered in blood, they may appear hopeless or even dead. Therefore, paramedics, medical instructors, orderlies and simply military personnel must learn the rule that the severity of a wound to the face is not always determined by the appearance of the wounded person, and if there are even the slightest signs of life, such wounded people must be urgently provided with medical assistance and evacuated from the battlefield.

Bleeding is controlled by applying a pressure bandage. Most often, circular bandages are applied to the face and secured to the vault of the skull (Fig. 18.7).

For isolated wounds of the chin, upper lip or nose, a sling-shaped bandage is applied. For wounds that penetrate the oral cavity, ordinary bandages become saturated with saliva, which can lead to frostbite on the face in the winter. Based on this, at low ambient temperatures, the bandages are insulated with cotton wool. During the hot season, measures are taken to quench thirst. On the field

Rice. 18.7. Application of a circular bandage for facial wounds

During combat, you can use a flask with a piece of bandage placed in the neck.

In case of severe suffocation, it is necessary to free the oral cavity, pharynx and nasal passages from blood, mucus, vomit, and foreign bodies. To prevent asphyxia, all those wounded in the face, especially those who have lost consciousness, are laid face down or on their side - on the side of the wound. In the same position, the wounded are removed from the battlefield. This ensures better outflow of blood and saliva from the oral cavity and prevents them from entering the respiratory tract. In addition to first aid measures first aid includes the introduction of an air duct to the wounded with asphyxia due to loss of consciousness, mechanical ventilation with a manual breathing apparatus or a KI-4 oxygen inhaler.

First medical aid. To stop bleeding, primary pressure bandages are applied or previously applied pressure bandages are corrected. Only those bandages that are heavily soaked in blood or have become loose and do not cover the wound should be replaced. If the pressure bandage is ineffective, tight wound tamponade or ligation of a bleeding vessel in a wound. If you tie up a vessel in the depths

If it is not possible, it is permissible to leave the applied hemostatic clamp in the wound and secure it securely before evacuation.

Bleeding from the terminal branches of the carotid artery (except the lingual) usually stops on its own after applying a pressure bandage. A standard pressure bandage cannot be applied to injuries to the lower jaw and neck organs (risk of asphyxia!). Therefore, in case of profuse bleeding from the floor of the mouth, pharynx or posterior wall of the pharynx into the lumen of the trachea, which is detected by rapidly increasing suffocation and the release of bloody-foamy sputum when coughing, tracheostomy or conicotomy is performed, and then tight tamponade of the oral cavity and pharynx. To better hold the tampon, the jaws are closed and held in this position with a tight bandage.

In case of asphyxia, it is first necessary to find out its cause. In case of dislocation asphyxia, if the applied bandage does not create support for the tongue, insertion of an air duct or the wounded person is placed on his stomach. For other types of asphyxia, it is necessary to do tracheostomy. It is not recommended to apply sutures to the neck skin wound above or below the inserted tracheotomy cannula. Only with large neck wounds or long incisions is it permissible to apply 2-3 situational sutures. If bloody fluid is released from the trachea when coughing, suction should be used. aspirate blood and saliva flowing into the trachea, and pack the oral cavity and pharynx (Fig. 18.8).

It is necessary to first insert a thin, dense probe through the nose into the esophagus in order to give water to the wounded person.

Transport immobilization for wounded people with damage to the maxillofacial area, it is indicated for bone fractures, extensive soft tissue injuries, damage to the temporomandibular joints, damage to the great vessels and nerves, deep burns and frostbite.

For transport immobilization for jaw fractures, standard and improvised bandages are used, which allow the jaws to be fixed and held in this position for a certain time (Fig. 18.9).

Method of applying a chin splint. In case of fractures of the lower jaw, the support for its fragments is the teeth of the upper jaw. In case of fractures of the upper jaw, on the contrary, the lower jaw with teeth fixes its fragments in the optimal position. A standard headband consists of a supporting headband and

hard chin sling. It is applied over a regular cotton-gauze bandage that covers the wound. First, a supporting headband is applied and secured to the cranial vault. Then a lining of several layers of gauze and cotton wool is placed at the bottom of a rigid chin sling, a sling is applied, which is connected to the headband using elastic bands threaded into it in advance. When applying a headband, the elastic bands should be strictly on the sides of the face. The chin sling should only support the jaw fragments. Therefore, one or two elastic bands are put on each side.

To quench thirst and combat dehydration, those wounded in the face and jaw must be given water from a sippy cup with a rubber tube attached to its tip. During drinking, this tube is passed to the root of the tongue or into the cheek pocket to the back teeth.

To prevent wound infection, tetanus toxoid and antibiotics are administered.

Evacuation of the wounded, who are in serious condition or unconscious, is carried out in a prone position, face down or on their side

Rice. 18.8. Tamponade of the mouth and pharynx

Rice. 18.9. Immobilization with a standard Entin-Fialkovsky transport bandage for a wounded maxillofacial area

(on the side of the wound). In case of severe head injuries, not only immobilization is required, but also “depreciation” of it. A wounded person should be evacuated from a wounded area by placing an overcoat or other soft bedding under his head. Those wounded in a moderately severe wounded area are evacuated while sitting. This makes breathing easier and reduces pain in the wound from vehicle impacts. It must be borne in mind that at the time of injury to the maxillofacial area, a number of wounded people receive a concussion or contusion of the brain, therefore, wounded people with a history of prolonged loss of consciousness should be evacuated in a prone position.

Qualified medical care. All maxillofacial wounded people should be examined by a dentist in the dressing room for the seriously wounded with the bandages removed. The need to examine at this stage of evacuation all those wounded in the face and jaw is dictated, firstly, by the fact that the appearance and general condition of the wounded do not correspond to the actual severity of the injury, which can lead to serious complications during evacuation. Secondly, without removing the bandages from this group of wounded it is impossible to carry out evacuation and transport triage, i.e. determine the order of evacuation, type of transportation and place of further treatment.

According to the clinical course of the injury and the volume of damage those wounded in the ChLO are divided into three groups (Balin V.N., Prokhvatilov G.I., Madai D.Yu.): 1. Severely wounded:- wounded with extensive gunshot wounds of the soft tissues and bones of the maxillofacial area with tissue defects penetrating into the oral cavity, nose and paranasal sinuses, with damage to the temporomandibular joint (TMJ), salivary glands, trunk and branches of the external carotid artery and facial nerve; - wounded with extensive penetrating wounds of the eyelids, nose, ears

shells and lips with their defect; - wounded with detachments of parts and organs of the face (nose, lips, ears

shells and chin); - wounded with extensive gunshot wounds of the soft tissues and bone structures of the maxillofacial area, combined with damage to the ENT organs, eyes, penetrating into the cranial cavity and with damage to organs and tissues of other anatomical areas. The wounded of this group need early specialized care in the 1st turn, i.e. they must be evacuated by helicopter to the 1st echelon MVG without providing medical treatment.

2. Wounded moderate severity who received: - isolated injuries without soft tissue and bone defects

structures penetrating the oral cavity, nose and paranasal sinuses;

Isolated through wounds of the eyelids, wings of the nose, lips and ears without tissue defects;

Extensive injuries to the soft tissues of the face and neck without tissue defects and damage to the bones of the facial skeleton, salivary glands, TMJ, external carotid artery and facial nerve;

Gunshot fractures of the facial skeleton without a bone defect;

Isolated injuries of the alveolar process and teeth within 2 or more functional groups of teeth;

Festering hematomas and infected wounds of the maxillofacial area. The wounded of the 2nd group require early specialized care in the second place, or they can undergo standard staged treatment.

3. Lightly wounded who received: - isolated wounds of the maxillofacial area without defects of soft tissues and bones

and damage to the TMJ, major salivary glands, large branches of the external carotid artery and facial nerve, as well as non-penetrating into the oral cavity, nose and paranasal sinuses; - blind wounds of the eyelids, nose, ears and lips without defect

fabrics; - marginal and perforated fractures of the lower jaw without violation

its integrity; - isolated wounds of the alveolar process within

one functional group of teeth; - extensive tissue bruises and facial hematomas. The wounded of the 3rd group are subject to treatment in the VPGLR and evacuation in order of priority.

Help is provided in first of all to those wounded in the ChLO who need it for life reasons - wounded with asphyxia and ongoing external bleeding.

Elimination of asphyxia provides for the release of the respiratory tract from foreign bodies, bone fragments, tissue scraps, and blood; ensuring airway patency; elimination of tongue retraction. If these measures are ineffective, tracheal intubation or tracheostomy is performed. Inhalation in progress

oxygen using oxygen inhalers, and in severe respiratory failure - mechanical ventilation.

Stopping external bleeding carried out in various ways, depending on the type of bleeding, in particular, by applying hemostatic clamps, ligating blood vessels in the wound, and if these measures are not possible, by tightly tamponade of the wound or its suturing with fixation of tampons in the wound cavity with a ligature, carried out around the lower jaw and the mass of bleeding tissue. In case of bleeding from deep wounds of the face, especially the floor of the mouth, ligation of the external carotid artery along. With extensive and multiple wounds of the face, it is not always possible to determine which vessels are damaged and on which side the external carotid artery needs to be ligated. In such a situation, ligation of both external carotid arteries is acceptable, or a tracheotomy and tight tamponade of the oral cavity and pharynx should be performed (Fig. 18.8). The installed tampon is not removed from the oral cavity and pharynx until admission to the stage of specialized care. The wounded person is fed and fluids are administered through a tube inserted into the esophagus through the nose. It should be considered a rule to organize the provision of food and drink in the medical hospital (omedo) for all those wounded in the face and jaw.

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Damage to the maxillofacial area

What are Injuries to the maxillofacial area -

Maxillofacial orthopedics is one of the sections of orthopedic dentistry and includes the clinic, diagnosis and treatment of damage to the maxillofacial area resulting from trauma, wounds, surgical interventions for inflammatory processes, and neoplasms. Orthopedic treatment can be independent or used in combination with surgical methods.

Maxillofacial orthopedics consists of two parts: maxillofacial traumatology and maxillofacial prosthetics. In recent years, maxillofacial traumatology has become predominantly a surgical discipline. Surgical methods for fixing jaw fragments: osteosynthesis for jaw fractures, extraoral methods of fixing fragments of the lower jaw, suspended craniofacial fixation for fractures of the upper jaw, fixation using alloy devices with “shape memory” - have replaced many orthopedic devices.

Advances in facial reconstructive surgery have also influenced the field of maxillofacial prosthetics. The emergence of new methods and improvement of existing methods of skin grafting, bone grafting of the lower jaw, and plastic surgery for congenital cleft lip and palate have significantly changed the indications for orthopedic treatment methods.

Modern ideas about the indications for the use of orthopedic methods for treating injuries of the maxillofacial area are due to the following circumstances.

The history of maxillofacial orthopedics goes back thousands of years. Artificial ears, noses and eyes have been discovered in Egyptian mummies. The ancient Chinese restored lost parts of the nose and ears using wax and various alloys. However, before the 16th century there is no scientific information about maxillofacial orthopedics.

For the first time, facial prostheses and an obturator for closing a palate defect were described by Ambroise Pare (1575).

Pierre Fauchard in 1728 recommended drilling the palate to strengthen dentures. Kingsley (1880) described prosthetic structures for replacing congenital and acquired defects of the palate, nose, and orbit. Claude Martin (1889), in his book on dentures, describes structures for replacing lost parts of the upper and lower jaws. He is the founder of direct prosthetics after resection of the upper jaw.

Modern maxillofacial orthopedics, based on the rehabilitation principles of general traumatology and orthopedics, based on the achievements of clinical dentistry, plays a huge role in the system of providing dental care to the population.

• Tooth dislocations

Tooth luxation is the displacement of a tooth as a result of acute trauma. Tooth dislocation is accompanied by rupture of the periodontium, circular ligament, and gum. There are complete, incomplete and impacted dislocations. The history always contains indications of the specific cause that caused the tooth dislocation: transport, household, sports, work injury, dental interventions.

What provokes / Causes of Injuries to the maxillofacial area:

• Tooth fractures

False joints

The causes leading to the formation of false joints are divided into general and local. Common ones include: malnutrition, vitamin deficiencies, severe, long-term diseases (tuberculosis, systemic blood diseases, endocrine disorders, etc.). In these conditions, the body’s compensatory and adaptive reactions are reduced and reparative regeneration of bone tissue is inhibited.

Among the local causes, the most likely are violations of the treatment technique, soft tissue interposition, bone defect, and complications of the fracture due to chronic bone inflammation.

Contracture of the lower jaw

Contracture of the lower jaw can occur not only as a result of mechanical traumatic damage to the jaw bones, soft tissues of the mouth and face, but also other reasons (ulcerative-necrotic processes in the oral cavity, chronic specific diseases, thermal and chemical burns, frostbite, myositis ossificans, tumors and etc.). Here we consider contracture in connection with trauma to the maxillofacial area, when contractures of the lower jaw arise as a result of improper primary treatment of wounds, prolonged intermaxillary fixation of jaw fragments, and untimely use of physical therapy.

Pathogenesis (what happens?) during Injuries to the maxillofacial area:

• Tooth fractures

Contracture of the lower jaw

The pathogenesis of mandibular contractures can be presented in the form of diagrams. In scheme I, the main pathogenetic link is the reflex-muscular mechanism, and in scheme II, the formation of scar tissue and its negative effects on the function of the lower jaw.

Symptoms of Injuries to the Maxillofacial Area:

The presence or absence of teeth on jaw fragments, the condition of the hard tissues of the teeth, the shape, size, position of the teeth, the condition of the periodontium, the oral mucosa and soft tissues that interact with prosthetic devices are important.

Depending on these characteristics, the design of the orthopedic apparatus and prosthesis changes significantly. The reliability of fixation of fragments and the stability of maxillofacial prostheses, which are the main factors for the favorable outcome of orthopedic treatment, depend on them.

It is advisable to divide the signs of damage to the maxillofacial area into two groups: signs indicating favorable and unfavorable conditions for orthopedic treatment.

The first group includes the following signs: the presence on jaw fragments of teeth with full-fledged periodontium during fractures; the presence of teeth with full periodontium on both sides of the jaw defect; absence of cicatricial changes in the soft tissues of the mouth and perioral area; integrity of the TMJ.

The second group of signs consists of: the absence of teeth on jaw fragments or the presence of teeth with diseased periodontal disease; pronounced cicatricial changes in the soft tissues of the mouth and perioral area (microstomy), lack of a bone base for the prosthetic bed in case of extensive defects of the jaw; pronounced disturbances in the structure and function of the TMJ.

The predominance of signs of the second group narrows the indications for orthopedic treatment and indicates the need for complex interventions: surgical and orthopedic.

When assessing the clinical picture of damage, it is important to pay attention to signs that help establish the type of bite before the damage. This need arises due to the fact that displacement of fragments during jaw fractures can create relationships in the dentition similar to a prognathic, open, cross bite. For example, with a bilateral fracture of the lower jaw, the fragments shift along the length and cause shortening of the branches; the lower jaw moves back and upward with a simultaneous lowering of the chin. In this case, the closure of the dentition will be similar to prognathia and open bite.

Knowing that each type of bite is characterized by its own signs of physiological tooth wear, it is possible to determine the type of bite the victim had before the injury. For example, with an orthognathic bite, wear facets will be on the incisal and vestibular surfaces of the lower incisors, as well as on the palatal surface of the upper incisors. With progeny, on the contrary, there is abrasion of the lingual surface of the lower incisors and the vestibular surface of the upper incisors. A direct bite is characterized by flat wear facets only on the cutting surface of the upper and lower incisors, and with an open bite there will be no wear facets. In addition, anamnestic data can also help to correctly determine the type of bite before damage to the jaws.

• Tooth dislocations

The clinical picture of a dislocation is characterized by swelling of the soft tissues, sometimes rupture around the tooth, displacement, mobility of the tooth, and disruption of occlusal relationships.

Tooth fractures

Fractures of the lower jaw

Of all the bones of the facial skull, the lower jaw is most often damaged (up to 75-78%). Among the causes, traffic accidents come first, followed by domestic, industrial and sports injuries.

The clinical picture of fractures of the lower jaw, in addition to general symptoms (impaired function, pain, facial deformation, occlusion disorder, mobility of the jaw in an unusual place, etc.), has a number of features depending on the type of fracture, the mechanism of displacement of fragments and the condition of the teeth. When diagnosing fractures of the lower jaw, it is important to identify signs indicating the possibility of choosing one or another method of immobilization: conservative, surgical, combined.

The presence of stable teeth on jaw fragments; their slight displacement; localization of the fracture in the area of ​​the angle, ramus, condylar process without displacement of fragments indicates the possibility of using a conservative method of immobilization. In other cases, there are indications for the use of surgical and combined methods of fixation of fragments.

Contracture of the lower jaw

Clinically, unstable and persistent contractures of the jaws are distinguished. According to the degree of mouth opening, contractures are divided into mild (2-3 cm), medium (1-2 cm) and severe (up to 1 cm).

Unstable contractures most often they are reflex-muscular. They occur when jaws are fractured at the attachment points of the muscles that lift the mandible. As a result of irritation of the muscle receptor apparatus by the edges of fragments or decay products of damaged tissue, a sharp increase in muscle tone occurs, which leads to contracture of the lower jaw

Scar contractures, depending on which tissues are affected: skin, mucous membrane or muscle, are called dermatogenic, myogenic or mixed. In addition, contractures are distinguished between temporo-coronal, zygomatic-coronal, zygomatic-maxillary and intermaxillary.

Although the division of contractures into reflex-muscular and cicatricial is justified, in some cases these processes do not exclude each other. Sometimes, with damage to soft tissues and muscles, muscle hypertension turns into persistent scar contracture. Preventing the development of contractures is a very real and concrete measure. It includes:

• preventing the development of rough scars by correct and timely treatment of the wound (maximum approximation of the edges with sutures; for large tissue defects, suturing the edge of the mucous membrane with the edges of the skin is indicated);
• timely immobilization of fragments, if possible, using a single-jaw splint;
• timely intermaxillary fixation of fragments in case of fractures at the sites of muscle attachment in order to prevent muscle hypertension;
• the use of early therapeutic exercises.

Diagnosis of Injuries to the maxillofacial area:

• Tooth dislocations

Diagnosis of tooth dislocation is carried out on the basis of examination, tooth displacement, palpation and x-ray examination.

• Tooth fractures

The most common fractures of the alveolar process of the upper jaw are predominantly localized in the area of ​​the anterior teeth. They are caused by road accidents, impacts, falls.

Diagnosing fractures is not very difficult. Recognition of dentoalveolar damage is carried out on the basis of anamnesis, examination, palpation, and x-ray examination.

During a clinical examination of the patient, it should be remembered that fractures of the alveolar process can be combined with damage to the lips, cheeks, dislocation and fracture of teeth located in the broken area.

Palpation and percussion of each tooth, determining its position and stability make it possible to recognize damage. Electroodontodiagnosis is used to determine damage to the neurovascular bundle of teeth. The final conclusion about the nature of the fracture can be made on the basis of radiological data. It is important to establish the direction of displacement of the fragment. Fragments can be displaced vertically, in the palatine-lingual, vestibular direction, which depends on the direction of the blow.

Treatment of alveolar process fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.

Fractures of the lower jaw

Clinical diagnosis of mandibular fractures is supplemented by radiography. Based on radiographs obtained in anterior and lateral projections, the degree of displacement of fragments, the presence of fragments, and the location of the tooth in the fracture gap are determined.

For fractures of the condylar process, TMJ tomography provides valuable information. The most informative is computed tomography, which allows you to reproduce the detailed structure of the bones of the articular area and accurately identify the relative position of fragments.

Treatment of Injuries to the Maxillofacial Area:

Development surgical treatment methods, especially neoplasms of the maxillofacial area, required widespread use of orthopedic interventions in the surgical and postoperative period. Radical treatment of malignant neoplasms of the maxillofacial region improves survival rates. After surgical interventions, serious consequences remain in the form of extensive defects of the jaws and face. Severe anatomical and functional disorders that disfigure the face cause painful psychological suffering to patients.

Very often, reconstructive surgery alone is ineffective. The tasks of restoring the patient's face, chewing, swallowing functions and returning him to work, as well as to perform other important social functions, as a rule, require the use of orthopedic treatment methods. Therefore, the joint work of dentists - a surgeon and an orthopedist - comes to the fore in the complex of rehabilitation measures.

There are certain contraindications to the use of surgical methods for treating jaw fractures and performing operations on the face. Usually this is the presence in patients of severe blood diseases, the cardiovascular system, an open form of pulmonary tuberculosis, severe psycho-emotional disorders and other factors. In addition, there are injuries for which surgical treatment is impossible or ineffective. For example, in case of defects of the alveolar process or part of the palate, prosthetics are more effective than surgical restoration. In these cases, the use of orthopedic measures as the main and permanent method of treatment was shown.

The timing of restoration operations varies. Despite the tendency of surgeons to perform the operation as early as possible, a certain amount of time must be allowed when the patient is left with an unrepaired defect or deformity while awaiting surgical treatment or plastic surgery. The duration of this period can be from several months to 1 year or more. For example, reconstructive operations for facial defects after tuberculous lupus are recommended to be carried out after permanent elimination of the process, which is approximately 1 year. In such a situation, orthopedic methods are indicated as the main treatment for this period. During the surgical treatment of patients with injuries to the maxillofacial area, auxiliary tasks often arise: creating support for soft tissues, closing the postoperative wound surface, feeding patients, etc. In these cases, the use of the orthopedic method is indicated as one of the auxiliary measures in complex treatment.

Modern biomechanical studies of methods for fixing fragments of the lower jaw have made it possible to establish that dental splints, in comparison with known on-bone and intraosseous devices, are the fixators that most fully meet the conditions of functional stability of bone fragments. Dental splints should be considered as a complex retainer, consisting of an artificial (splint) and natural (tooth) retainer. Their high fixing abilities are explained by the maximum area of ​​contact of the fixator with the bone due to the surface of the roots of the teeth to which the splint is attached. These data are consistent with the successful results of the widespread use of dental splints by dentists in the treatment of jaw fractures. All this is another justification for the indications for the use of orthopedic devices for the treatment of injuries to the maxillofacial area.

Orthopedic devices, their classification, mechanism of action

Treatment of injuries to the maxillofacial area is carried out using conservative, surgical and combined methods.

The main method of conservative treatment is orthopedic devices. With their help, they solve problems of fixation, reposition of fragments, formation of soft tissues and replacement of defects in the maxillofacial area. In accordance with these tasks (functions), devices are divided into fixing, reducing, forming, replacing and combined. In cases where one device performs several functions, they are called combined.

Based on the place of attachment, the devices are divided into intraoral (unimaxillary, bimaxillary and intermaxillary), extraoral, intra-extraoral (maxillary, mandibular).

Based on their design and manufacturing method, orthopedic devices can be divided into standard and individual (non-laboratory and laboratory-made).

Fixing devices

There are many designs of fixing devices. They are the main means of conservative treatment of injuries to the maxillofacial area. Most of them are used in the treatment of jaw fractures and only a few - in bone grafting.

For primary healing of bone fractures, it is necessary to ensure the functional stability of the fragments. The strength of fixation depends on the design of the device and its fixing ability. Considering the orthopedic device as a biotechnical system, it can be divided into two main parts: splinting and actually fixing. The latter ensures the connection of the entire structure of the device with the bone. For example, the splinting part of a dental wire splint consists of a wire bent to the shape of a dental arch and a ligature wire for attaching the wire arch to the teeth. The actual fixing part of the structure is the teeth, which provide connection between the splinting part and the bone. Obviously, the fixing ability of this design will depend on the stability of the connections between the tooth and the bone, the distance of the teeth in relation to the fracture line, the density of the connection of the wire arch to the teeth, the location of the arch on the teeth (at the cutting edge or chewing surface of the teeth, at the equator, at the neck of the teeth) .

With tooth mobility and severe atrophy of the alveolar bone, it is not possible to ensure reliable stability of fragments using dental splints due to the imperfection of the actual fixing part of the device design.

In such cases, the use of periodontal splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of ​​contact of the splinting part in the form of coverage of the gums and alveolar process. In case of complete loss of teeth, the intra-alveolar part (retainer) of the device is absent; the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained. However, the fixing ability of such devices is extremely low.

From a biomechanical point of view, the most optimal design is a soldered wire splint. It is attached to rings or full artificial metal crowns. The good fixing ability of this tire is explained by the reliable, almost motionless connection of all structural elements. The splinting arch is soldered to a ring or to a metal crown, which is fixed to the supporting teeth using phosphate cement. When ligating teeth with an aluminum wire arch, such a reliable connection cannot be achieved. As the splint is used, the tension of the ligature weakens, and the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.

With the introduction of fast-hardening plastics, many different designs of dental splints have appeared. However, in terms of their fixing abilities, they are inferior to soldered splints in a very important parameter - the quality of the connection between the splinting part of the device and the supporting teeth. A gap remains between the surface of the tooth and the plastic, which is a receptacle for food debris and microbes. Long-term use of such tires is contraindicated.

The designs of dental splints are constantly being improved. By introducing actuator loops into a splinting aluminum wire arch, they try to create compression of fragments in the treatment of mandibular fractures.

The real possibility of immobilization with the creation of compression of fragments with a dental splint appeared with the introduction of alloys with a shape “memory” effect. A dental splint on rings or crowns made of wire with thermomechanical “memory” allows not only to strengthen fragments, but also to maintain constant pressure between the ends of the fragments.

Fixing devices used in osteoplastic operations are a dental structure consisting of a system of welded crowns, connecting locking bushings, and rods.

Extraoral apparatuses consist of a chin sling (plaster, plastic, standard or customized) and a head cap (gauze, plaster, standard strips of belt or ribbon). The chin sling is connected to the head cap using a bandage or elastic cord.

Intraoral apparatuses consist of an intraoral part with extraoral levers and a head cap, which are interconnected by elastic traction or rigid fixing devices.

AST. Rehearsal devices

There are one-stage and gradual reposition. One-time reposition is carried out manually, and gradual reposition is carried out using hardware.

In cases where it is not possible to compare the fragments manually, reduction devices are used. The mechanism of their action is based on the principles of traction, pressure on displaced fragments. Reduction devices can be mechanical or functional. Mechanically operating reduction devices consist of 2 parts - supporting and acting. The supporting parts are crowns, mouthguards, rings, base plates, and a head cap.

The active part of the apparatus are devices that develop certain forces: rubber rings, an elastic bracket, screws. In a functionally functioning reduction apparatus, the force of muscle contraction is used to reposition fragments, which is transmitted through guide planes to the fragments, displacing them in the desired direction. A classic example of such a device is the Vankevich tire. With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.

Forming apparatus

These devices are designed to temporarily maintain the shape of the face, create a rigid support, prevent cicatricial changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformation of the prosthetic bed, etc.). Forming devices are used before and during reconstructive surgical interventions.

The design of the devices can be very diverse depending on the area of ​​damage and its anatomical and physiological characteristics. In the design of the forming apparatus, one can distinguish the forming part and the fixing devices.

Replacement devices (prostheses)

Prostheses used in maxillofacial orthopedics can be divided into dentoalveolar, maxillary, facial, and combined. When resection of the jaws, prostheses are used, which are called post-resection. There are immediate, immediate and remote prosthetics. It is legitimate to divide prostheses into surgical and postoperative.

Dental prosthetics is inextricably linked with maxillofacial prosthetics. Achievements in the clinic, materials science, and technology for manufacturing dentures have a positive impact on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid-cast clasp dentures have found application in the design of resection dentures and dentures restoring dentoalveolar defects.

Replacement devices also include orthopedic devices used for palate defects. This is primarily a protective plate - used for palate plastic surgery; obturators - used for congenital and acquired palate defects.

Combined devices

For reposition, fixation, shaping and replacement, a single design that can reliably solve all problems is advisable. An example of such a design is an apparatus consisting of soldered crowns with levers, fixing locking devices and a forming plate.

Dental, dentoalveolar and jaw prostheses, in addition to their replacement function, often serve as a forming apparatus.

The results of orthopedic treatment of maxillofacial injuries largely depend on the reliability of fixation of the devices.

When solving this problem, you should adhere to the following rules:

• use the preserved natural teeth as support as much as possible, connecting them into blocks, using well-known techniques for splinting teeth;
• make maximum use of the retention properties of alveolar processes, bone fragments, soft tissues, skin, cartilage that limit the defect (for example, the cutaneous-cartilaginous part of the lower nasal passage and part of the soft palate, preserved even after total resections of the upper jaw, serve as a good support for strengthening the prosthesis);
• apply surgical methods to strengthen prostheses and devices in the absence of conditions for their fixation in a conservative way;
• use the head and upper body as a support for orthopedic devices if the possibilities of intraoral fixation have been exhausted;
• use external supports (for example, a system of traction of the upper jaw through blocks with the patient in a horizontal position on the bed).

Clasps, rings, crowns, telescopic crowns, mouthguards, ligature binding, springs, magnets, spectacle frames, sling-shaped bandages, and corsets can be used as fixing devices for maxillofacial devices. The correct selection and application of these devices adequately to clinical situations allows us to achieve success in the orthopedic treatment of injuries to the maxillofacial area.

Orthopedic treatment methods for injuries of the maxillofacial area

Dislocations and fractures of teeth

• Tooth dislocations

Treatment of complete dislocation is combined (tooth replantation followed by fixation), and treatment of incomplete dislocation is conservative. In fresh cases of incomplete dislocation, the tooth is set with the fingers and strengthened in the alveolus, fixing it with a dental splint. As a result of untimely reduction of a dislocation or subluxation, the tooth remains in an incorrect position (rotation around an axis, palatoglossal, vestibular position). In such cases, orthodontic intervention is required.

• Tooth fractures

The previously mentioned factors can also cause tooth fractures. In addition, enamel hypoplasia and dental caries often create conditions for tooth fracture. Root fractures can occur from corrosion of metal pins.

Clinical diagnosis includes: anamnesis, examination of the soft tissues of the lips and cheeks, teeth, manual examination of the teeth, alveolar processes. To clarify the diagnosis and draw up a treatment plan, it is necessary to conduct x-ray studies of the alveolar process and electroodontodiagnosis.

Fractures of teeth occur in the area of ​​the crown, root, crown and root; microfractures of cement are distinguished, when sections of cement with attached perforating (Sharpey) fibers peel off from the dentin of the root. The most common fractures of the tooth crown are within the enamel, enamel and dentin with exposure of the pulp. The fracture line can be transverse, oblique and longitudinal. If the fracture line is transverse or oblique, passing closer to the cutting or chewing surface, the fragment is usually lost. In these cases, tooth restoration is indicated by prosthetics with inlays and artificial crowns. When opening the pulp, orthopedic measures are carried out after appropriate therapeutic preparation of the tooth.

For fractures at the neck of the tooth, often resulting from cervical caries, often associated with an artificial crown that does not tightly cover the neck of the tooth, removal of the broken part and restoration using a stump pin insert and an artificial crown are indicated.

A root fracture is clinically manifested by tooth mobility and pain when biting. The fracture line is clearly visible on dental x-rays. Sometimes, in order to trace the fracture line along its entire length, it is necessary to have x-rays obtained in different projections.

The main method of treating root fractures is to strengthen the tooth using a dental splint. Healing of tooth fractures occurs after 1 1/2-2 months. There are 4 types of fracture healing.

Type A: the fragments are closely juxtaposed with each other, healing ends with the mineralization of the tooth root tissue.

Type B: healing occurs with the formation of pseudarthrosis. The gap along the fracture line is filled with connective tissue. The radiograph shows an uncalcified band between the fragments.

Type C: Connective tissue and bone tissue grow between the fragments. The x-ray shows the bone between the fragments.

Type D: the gap between the fragments is filled with granulation tissue: either from the inflamed pulp or from gum tissue. The type of healing depends on the position of the fragments, immobilization of the teeth, and pulp viability.

Fractures of the alveolar ridge

Treatment of alveolar bone fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.

Reposition of the fragment in case of fresh fractures can be carried out manually, in case of old fractures - by the method of bloody reposition or with the help of orthopedic devices. When the fractured alveolar process with teeth is displaced to the palatal side, reposition can be performed using a palatal release plate with a screw. The mechanism of action of the device is to gradually move the fragment due to the pressing force of the screw. The same problem can be solved by using an orthodontic apparatus by pulling the fragment towards the wire arch. In a similar way, it is possible to reposition a vertically displaced fragment.

If the fragment is displaced to the vestibular side, reposition can be carried out using an orthodontic apparatus, in particular a vestibular sliding arch fixed on the molars.

Fixation of the fragment can be carried out with any dental splint: bent, wire, soldered wire on crowns or rings, made of quick-hardening plastic.

Fractures of the body of the upper jaw

Non-gunshot fractures of the upper jaw are described in textbooks on surgical dentistry. Clinical features and treatment principles are given in accordance with Le Fort's classification, based on the location of fractures along lines corresponding to weak points. Orthopedic treatment of fractures of the upper jaw consists of repositioning the upper jaw and immobilizing it with intra-extraoral devices.

In the first type (Le Fort I), when it is possible to manually set the upper jaw into the correct position, intra-extraoral devices supported on the head can be used to immobilize fragments: a solid-bent wire splint (according to Ya. M. Zbarzh), a dentogingival splint with extraoral levers, soldered splint with extraoral levers. The choice of design for the intraoral part of the apparatus depends on the presence of teeth and the condition of the periodontium. If there are a large number of stable teeth, the intraoral part of the device can be made in the form of a wire dental splint, and in the case of multiple absences of teeth or mobility of existing teeth - in the form of a dentogingival splint. In toothless areas of the dentition, the periodontal splint will consist entirely of a plastic base with imprints of antagonist teeth. In case of multiple or complete absence of teeth, surgical treatment methods are indicated.

Orthopedic treatment of a Le Fort type II fracture is carried out in a similar way if the fracture was not displaced.

In the treatment of fractures of the upper jaw with posterior displacement | di there is a need to stretch it anteriorly. In such cases, the design of the apparatus consists of an intraoral part, a head plaster cast with a metal rod located in front of the patient's face. The free end of the rod is curved in the form of a hook at the level of the front teeth. The intraoral part of the device can be either in the form of a dental (bent, soldered) wire splint, or in the form of a dentogingival splint, but regardless of the design, in the anterior section of the splint, in the area of ​​the incisors, a hooking loop is created to connect the intraoral splint with the rod coming from the head bandage .

The extraoral supporting part of the device can be located not only on the head, but also on the torso.

Orthopedic treatment of upper jaw fractures of type Le Fort II, especially Le Fort III, should be carried out very carefully, taking into account the general condition of the patient. At the same time, it is necessary to remember the priority of treatment measures according to vital indications.

Fractures of the lower jaw

The main goal of treating fractures of the lower jaw is to restore its anatomical integrity and function. It is known that the best therapeutic effect is observed with early connection to the function of the damaged organ. This approach involves treating fractures in conditions of lower jaw function, which is achieved by reliable (rigid) fixation of fragments with a single-jaw splint, timely transition from intermaxillary to single-jaw fixation and early therapeutic exercises.

With intermaxillary fixation, due to prolonged immobility of the lower jaw, functional disorders occur in the temporomandibular joint. Depending on the timing of intermaxillary fixation, after removal of the splints, partial or complete restriction of movements of the lower jaw (contracture) is observed. Single-jaw fixation of fragments does not have these disadvantages. Moreover, the function of the lower jaw has a beneficial effect on the healing of fractures, thereby reducing the treatment time for patients.

The description of the advantages of single-jaw fixation does not make them the only way to fix fragments of the lower jaw. There are certain contraindications to them: for example, with fractures of the lower jaw in the area of ​​the angle, when the fracture line passes through the attachment points of the masticatory muscles. In such cases, intermaxillary fixation is indicated, otherwise contracture may occur due to reflex-painful contraction of the masticatory muscles.

At the same time, when using intermaxillary fixation of fragments of the lower jaw, timely transition to a single-jaw splint is important. The timing of the transition depends on the type of fracture, the nature of the displacement of fragments and the intensity of reparative processes and ranges from 10-12 to 20-30 days.

The choice of design of an orthopedic device in each specific case depends on the type of fracture, its clinical characteristics, or is determined by the sequence of therapeutic interventions. For example, in case of a median fracture of the body of the lower jaw with a sufficient number of stable teeth, manual reduction is performed on the fragments and the fragments are fixed using a single-jaw dental splint. The simplest design is a bent wire splint in the form of a smooth bracket, secured to the teeth with ligature wire.

In case of a unilateral lateral fracture of the body of the lower jaw, when a typical displacement of the fragments occurs: upward of the small one under the influence of the masticatory, medial pterygoid, temporal muscles and downward of the large one as a result of traction of the digastric, geniohyoid muscles, the design of the fixing apparatus must be strong. It must resist the pull of these muscles, ensuring the immobility of the fragments during the function of the lower jaw.

This problem is quite satisfactorily solved by the use of a single-jaw soldered wire splint on crowns or rings.

In case of a bilateral lateral fracture, when three fragments are formed, there is a danger of asphyxia due to the retraction of the tongue, which moves back down along with the middle fragment; urgent reposition and fixation of the fragments is required.

When providing first aid, you should remember the need to stretch the tongue and fix it in the forward position with an ordinary pin.

Of the possible options for immobilizing fragments in this type of mandibular fracture, the optimal one is intermaxillary fixation using dental splints: soldered wire splints with hooking loops, bent aluminum splints with hooking loops, Vasiliev standard tape splints, splints with hooking protrusions made of fast-hardening plastic. Their choice depends on specific conditions, availability of material, technological capabilities and other factors.

Fractures in the area of ​​the angle, branches of the jaw and condylar process with slight displacement of fragments can also be treated with the listed devices that provide intermaxillary fixation. In addition to them, other devices are used to treat fractures of this location - with a hinged intermaxillary joint. This design eliminates the horizontal displacement of a large fragment during vertical movements of the lower jaw.

Treatment of multiple fractures of the lower jaw is carried out using a combined method (operative and conservative). The essence of orthopedic measures lies in the reposition of fragments, retention of individual fragments in accordance with the occlusal relationships of the dentition. Reposition of each fragment is carried out separately and only after this the fragments are fixed with a single splint. Fragmentary reduction can be performed using dental splints. To do this, splints are made with hooking loops for each fragment and a splint for the upper row of teeth. Then, using a rubber rod, the fragments are moved to the correct position. After matching, they are connected with a single wire splint and the entire block is fixed to the splint of the upper dentition according to the type of intermaxillary fixation.

Orthopedic treatment of mandibular fractures with a bone defect is carried out using all the main methods of treatment of maxillofacial orthopedics: reposition, fixation, formation and replacement. Their sequential use in the same patient can be carried out with different devices or with one device - a combined multiple action.

When using orthopedic devices that perform one or two functions (reposition, reduction and fixation), there is a need to replace one device with another, which significantly complicates the treatment process. Therefore, it is advisable to use combined-action devices. For fractures of the lower jaw with a bone defect, when there is a sufficient number of stable teeth on the fragments, a mouth guard apparatus is used. It allows for consistent reposition of fragments, their fixation, and formation of soft tissues. The design of the device (I.M. Oksman) is known, with the help of which it is possible to carry out both reposition and fixation of fragments, and replacement of a bone tissue defect. However, this does not mean that single- or dual-function devices have completely lost their significance.

In case of a lateral fracture of the body of the lower jaw with a bone defect and in the presence of supporting teeth on the fragments, the problems of reposition and fixation can be successfully solved using the Kurlyandsky apparatus.

Treatment of mandibular fractures with a bone tissue defect and in the absence of the possibility of constructing tooth-supported devices, it is carried out surgically or in a combined way. Among orthopedic devices, the Vankevich splint has received wide recognition.

In most cases, the outcomes of fracture treatment are favorable. For non-gunshot fractures after 4-5 weeks. the fragments heal, although the fracture gap can be determined X-ray even after 2 months.

To obtain such a favorable outcome, three main conditions must be met:

• accurate anatomical comparison of fragments;
• mechanical stability of the connection of fragments;
• preservation of blood supply to fixed fragments and function of the lower jaw.

If even one of these conditions is violated, the outcome of treatment may be unfavorable in the form of fusion of fragments in the wrong position or complete non-union with the formation of a false joint of the lower jaw.

Prolonged intermaxillary fixation of fragments and other reasons can lead to contracture of the lower jaw.

Improperly healed jaw fractures

The main reason for improper healing of jaw fractures is a violation of the principles of treatment, in particular, incorrect comparison of fragments or their unsatisfactory fixation, as a result of which secondary displacement of the fragments occurs and their fusion in the wrong position.

Morphological picture of healing of incorrectly juxtaposed and poorly fixed fragments has its own characteristics. In this condition of the fracture, cellular activity is much higher, the connection is achieved due to a large influx of fibroblasts appearing in the tissues surrounding the fracture. The resulting fibrous tissue then slowly ossifies and the fibroblasts transform into osteoblasts. Due to the displacement of fragments, the relative position of the cortical layer is disrupted. Its restoration as a single layer is slowing down, since a significant part of the tissue is resorbed and most of it is reformed from the bone.

In case of incorrectly healed fractures, it is reasonable to expect a deeper and longer-lasting restructuring in the dental system, since the direction of the load on the jaw bones changes, pressure and traction are distributed differently. First of all, spongy bone undergoes restructuring. Atrophy of underloaded and hypertrophy of newly loaded bone crossbars occurs. As a result of such restructuring, bone tissue acquires a new architectonics, adapted to new functional conditions. Restructuring also occurs in the area of ​​periodontal tissues. Often, a functional load changing in direction and magnitude can lead to destructive processes in the periodontium.

When jaw fractures heal incorrectly, there is a risk of developing TMJ pathology due to functional overload of its elements.

Incorrectly healed fractures are clinically manifested by deformation of the jaws and disruption of the occlusal relationships of the dentition.

In case of improperly healed fractures with vertical displacement of fragments, signs of an anterior or lateral open bite are observed. Fragments displaced in the horizontal plane in the transversal direction cause the closure of the dentition as a crossbite or a pattern of palatal (lingual) displacement of a group of teeth.

Relatively minor occlusal disorders can be corrected by prosthetics. Vertical discrepancies can be leveled with both fixed and removable prostheses: metal crowns, aligners, removable dentures with a cast occlusal overlay. In case of transversal occlusion disorders and a small number of remaining teeth, a removable denture with a duplicated dentition is used. The closure of the teeth is ensured by artificial teeth, and natural teeth serve only as a support for the prosthesis.

Orthodontic methods can also be used to eliminate occlusal disorders. Hardware, hardware-surgical methods for correcting bite deformities can have a high positive effect in the treatment of improperly healed jaw fractures.

False joints

The morphological picture of healing of a fracture ending in the formation of a false joint differs sharply from that observed with complete healing of fractures. With false joints, signs are clearly visible that indicate low reparative regeneration of bone tissue: the absence of a sufficient number of osteogenic elements in the fracture area, the state of ischemia, the proliferation of scar tissue, etc.

Orthopedic measures for pseudarthrosis as the main method of treatment are used in cases where there are contraindications to bone grafting or it is postponed for a considerable time. Contraindications to osteoplastic surgery are mainly related to the general condition of the body (weakness and exhaustion) and the patient’s refusal to undergo surgery.

The choice of prosthesis design depends on the presence and condition of the remaining teeth, the size and topography of the defect. However, there is a general principle for designing dentures for false joints: making dentures from two halves, corresponding to two fragments, and movably connecting them to each other. This design is due to the fact that a single base leads to overload of supporting tissues and teeth due to multidirectional displacement of each fragment. With a movable connection of the two halves of the prosthesis, the functional overload is reduced.

Many methods have been developed for movably connecting prosthesis bases. The original designs of prostheses were proposed by I.M. Oksman. This is a prosthesis with a single-joint connection and a two-articular connection. The first design is used for low mobility, the second for large displacement of jaw fragments.

Dental prosthetics are mandatory when treating a false joint surgically. In this case, orthopedic treatment is an integral part of complex rehabilitation therapy.

Contracture of the lower jaw

Treatment of contractures is conservative, surgical and combined. Conservative treatment consists of medications, physiotherapeutic methods, therapeutic exercises and mechanotherapy.

Which doctors should you contact if you have injuries to the maxillofacial area:

• Orthopedist
• Maxillofacial surgeon

Is something bothering you? Do you want to know more detailed information about Damage to the maxillofacial area, its causes, symptoms, methods of treatment and prevention, the course of the disease and diet after it? Or do you need an inspection? You can make an appointment with a doctor– clinic Eurolab always at your service! The best doctors will examine you, study external signs and help you identify the disease by symptoms, advise you and provide the necessary assistance and make a diagnosis. You can also call a doctor at home. Clinic Eurolab open for you around the clock.

How to contact the clinic:
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If you have previously performed any research, Be sure to take their results to a doctor for consultation. If the studies have not been performed, we will do everything necessary in our clinic or with our colleagues in other clinics.

At yours? It is necessary to take a very careful approach to your overall health. People don't pay enough attention symptoms of diseases and do not realize that these diseases can be life-threatening. There are many diseases that at first do not manifest themselves in our body, but in the end it turns out that, unfortunately, it is too late to treat them. Each disease has its own specific signs, characteristic external manifestations - the so-called symptoms of the disease. Identifying symptoms is the first step in diagnosing diseases in general. To do this, you just need to do it several times a year. be examined by a doctor, in order not only to prevent a terrible disease, but also to maintain a healthy spirit in the body and the organism as a whole.

If you want to ask a doctor a question, use the online consultation section, perhaps you will find answers to your questions there and read self care tips. If you are interested in reviews about clinics and doctors, try to find the information you need in the section. Also register on the medical portal Eurolab to be constantly aware of the latest news and information updates on the site, which will be automatically sent to you by email.

Other diseases from the group Dental and oral cavity diseases:

Abrasive precancerous cheilitis Manganotti

Abscess in the facial area

Adenophlegmon

Edentia partial or complete

Actinic and meteorological cheilitis

Actinomycosis of the maxillofacial region

Allergic diseases of the oral cavity

Allergic stomatitis

Alveolitis

Anaphylactic shock

Angioedema

Anomalies of development, teething, changes in their color

Anomalies in the size and shape of teeth (macrodentia and microdentia)

Arthrosis of the temporomandibular joint

Atopic cheilitis

Behçet's disease of the mouth

Bowen's disease

Warty precancer

HIV infection in the oral cavity

The effect of acute respiratory viral infections on the oral cavity

Inflammation of the tooth pulp

Inflammatory infiltrate

Dislocations of the lower jaw

Galvanosis

Hematogenous osteomyelitis

Dühring's dermatitis herpetiformis

F KSMU 4/3-04/03

Karaganda State Medical University

Department of Surgical Dentistry

LECTURE

Topic: “Injuries to the maxillofacial area. Classification. Principles of diagnosis and treatment"

Discipline PHS 4302 “Propaedeutics of surgical dentistry”

Specialty 051302 “Dentistry”

Course: 4

Time (duration) 1 hour

Karaganda 2014

Approved at a meeting of the Department of Surgical Dentistry

“____”______ 20___ protocol No. ____

Head of the Department of Surgical Dentistry, Professor _______________ Kurashev A.G.

3. Branches of the lower part:

a) the branches themselves;

b) articular process (base, neck, head);

c) coronoid process;

B. Fractures of the i/h.

a) alveolar process;

b) the body of the jaw without the nasal and zygomatic bones.

c) the jaw with nasal and zygomatic bones;

D. Fractures of the zygomatic bone and zygomatic arch:

a) zygomatic bone with damage to the walls of the maxillary bone

sinuses or without damage;

b) zygomatic bone and zygomatic arch;

c) zygomatic arch;
D. Fractures of the nasal bones:

a) nasal septum in the cartilaginous section;

b) nasal septum in the osteochondral section;

c) nasal bones;

By nature:

A.a) single;

b) double;

d) multiple;

B.a) one-sided;

b) double-sided;

B.a) without displacement of fragments;

b) with displacement of fragments;

D.a) isolated;

b) combined;

1. with traumatic brain injury;

2. with fractures of other bones of the facial skeleton and

other areas of the body;

3. with damage to the soft tissues of the face;

D.a) closed;

b) open;

E. a) penetrating into the oral cavity;

d) do not penetrate the maxillary sinus;

According to the mechanism of damage:

A. Firearms;

B Non-firearm;
II. Combined lesions.
III. Burns.
IV. Frostbite.
II-2. C L A S S I F I C A T I O N E O G N E S T R E L N

WOUND AND DAMAGE OF HUMAN BEINGS -

V O Y O L A S T I.
I. Mechanical damage to the upper, middle, lower and upper

kovy zones of the face.

1. Soft tissue injuries.

2. Injuries to teeth and bones of the maxillofacial area.

By localization:

a) dental injuries;

b) fractures of the lower part;

c) fractures of the h/h;

d) fractures of the zygomatic bone and zygomatic arch;

e) fractures of the nasal bones;

By nature:

A.a) ordinary;

b) double;

c) multiple;

B. a) unilateral;

b) double-sided;

B. a) without displacement of fragments;

b) with displacement of fragments;

D. a) isolated;

Fractures of other bones of the face and other areas of the body

With damage to the soft tissues of the face

E. a) closed;

b) open;

D. a) penetrating into the oral cavity;

b) do not penetrate into the oral cavity;

c) penetrating the maxillary sinus;

d) do not penetrate the maxillary sinus;
According to the mechanism of damage:

A. firearms;

B. non-firearm;
II. Combined.
III.Burns
IV. Frostbite.

CLASSIFICATION OF FIRE SHOOTINGS

DAMAGE TO THE MODEL

O B L A S T I.

1. By type of wounding weapon:

a) bullet;

b) splintered;

c) fraction;

d) secondary projectiles;
2. By the number of wounding shells:

a) single;

b) multiple;
3. According to the nature of the wound channel:

a) blind;

b) through;

c) tangents;

d) traumatic amputations-shots of the face;
4. By localization of damage to the soft tissues of the face, depending on the area of ​​the face, head, neck.
5. According to the nature of soft tissue damage:

a) abrasions;

b) point;

d) gifted;

e) scalped;

f) torn and crushed, etc.

6. According to the location of bone damage:

a) lower jaw;

b) upper jaw;

c) both jaws;

d) zygomatic bone;

e) nasal bones;

e) hyoid bone;

g) combined injuries to several facial bones;

7. According to the nature of bone damage:

a) incomplete fractures (cracks, perforated, marginal);

b) complete fractures (transverse, longitudinal, oblique, impacted, coarsely fragmented, finely fragmented, crushed, with a bone flaw);
8. According to the nature of the direction of the wound channel:

a) segmental;

b) contour;

c) diametrical;

d) rebound;
9. According to the nature of the injury:

a) isolated;

b) combined;

c) multi-regional;

10. In relation to the cavities of the head and neck:

a) non-penetrating;

b) penetrating (into the nasal cavity, paranasal sinuses, pharynx, larynx, esophagus, trachea, several cavities at once);
11. In relation to the organs of the facial area:

a) without damage;

b) with damage to the tongue, hard palate, soft palate,

salivary glands, blood vessels, nerves;

12. By the nature of the damage to the teeth;

a) incomplete fractures;

b) complete fractures;
13. In relation to related areas and bodies;

a) without damage;

b) with damage (TMJ, organs of vision, hearing, brain, spine, etc.).
14. In relation to damage to other areas of the body;

a) without damage;

b) with damage (lower and upper limbs, chest, abdomen, pelvic organs, etc.).
15. According to the severity of the injury;

a) lungs;

b) average;

c) heavy;

d) terminal;

METHODS OF INVESTIGATION OF PATIENTS

S O V R E J E N I A M I ​​C H L O.
I. K l i n c h e s k e.

The examination of any patient must be carried out according to a specific, clearly established system, strictly sequentially. Particular attention should be paid to the nature of complaints, medical history, establishing the causes and circumstances of occurrence

injuries. This consistency and clarity is of particular importance when examining a trauma patient who needs urgent care.

It is necessary to find out the time, place and circumstances of the injury, make a preliminary diagnosis and provide first aid and refer the patient for medical care to a trauma center, clinic, or hospital.

All data from the interview and examination of the patient and the therapeutic measures used must be documented and noted in the direction (especially the administration of anti-tetanus serum).

The examination should include questioning, inspection, palpation and special (instrumental) methods.

Survey. During the interview, they first fill out the passport and front parts of the medical history, and then begin to collect an anamnesis of the disease.

The anamnesis can be collected from the words of the patient, as well as those accompanying him. The patient’s medical documents (referral, accident report, extract from the medical history, etc.) can also be used. One should be especially critical of the medical history of victims who are intoxicated. It is necessary to find out when, where and under what circumstances the injury was received, the nature of the injury (industrial, household, sports, street, agricultural), if possible, clarify the mechanism of injury, the nature of the injuring object, the condition of the patient at the time of the injury. At the same time, the year, month, day, hour (and, if possible, minutes) of injury must be accurately indicated. In special cases, for forensic medical examination data (in case of a domestic injury), it is necessary to indicate the last name, first name, and patronymic of the person who caused the injury or witnesses.

It is necessary to find out whether the patient lost consciousness, whether he remembers what happened (retrograde history), whether there was vomiting, what sensations the patient had that were accompanied by the injury (character and duration of pain, state of breathing, swallowing and speech), whether the character of pain and complaints has changed, What is currently bothering the patient?

time.

Complaints from patients with trauma to the maxillofacial area (if they are conscious) usually boil down to the following: pain in various parts of the face, disturbances in chewing, swallowing, speech, as well as closure of the dentition.

When clarifying all these circumstances, one must strictly observe the rules of medical deontology. If the patient’s condition is serious, the initial survey should be shortened if possible, but all necessary data should be entered into the medical history, as an addition to the medical history on the day the information is received.

All medical and life history data, as well as past illnesses and injuries, must be carefully recorded in the medical history.

O w o t r. During an objective examination, it is first necessary to assess the general condition: the state of consciousness, the cardiovascular system (pulse characteristics and blood pressure) and the respiratory system (breathing frequency and characteristics), internal organs, musculoskeletal system, skin (for this patient must be undressed).

Particular attention should be paid to determining the state of the central nervous system based on the extent of cerebral symptoms.

When starting to examine the area of ​​damage, first of all, the condition of the outer integument is determined: changes in skin color due to abrasions and bruises, facial asymmetry, edema and swelling of soft tissues. If there are burns, their location, nature, and size are noted. All this must be described accurately (indicate dimensions in centimeters).

Changes in bite (the relationship between the upper and lower teeth) are the main symptom of jaw fractures.

During the examination, you should pay attention to the presence of fresh dental defects (the condition of the socket), dislocations and fractures of teeth, the nature, location, size of damage to the mucous membrane and soft tissues of the oral cavity, the condition of the gums in the area of ​​the fracture line.

Examination of the eyes and nose, especially the eyeballs, is mandatory.

When examining the nose, the presence of deformation (curvature, retraction, etc.), impaired nasal breathing, and the nature of discharge from the nasal passages (blood, mucus, cerebrospinal fluid) are determined.

P a l p a t s i . After the examination, palpation begins, which should also be consistent and methodical and begin from a known undamaged area.

Using palpation, the presence of edema or infiltrate, its consistency, boundaries, and the place of greatest pain are determined.

Palpation in front of the tragus, and fingers inserted into the external auditory canals and pressed against their anterior wall, help determine the mobility of the articular head. An empty glenoid cavity may indicate a dislocation or fracture of the head.

You should not try to determine the crepitus of fragments. You can resort to examining the load on the chin, and the patient indicates pain at the fracture site.

When examining the jaw, it is necessary to carefully palpate the entire jaw, identifying painful points at the point of its connection with other bones of the facial skeleton. To clarify the nature of the fracture of the bones of the facial skeleton, the direction and degree of displacement of the fragments, the location of the fracture gap, as well as the relationship between the root tooth and fracture gap, the clinical examination must be supplemented with an x-ray.
II. X-ray

X-ray diagnosis of fractures of the facial bones and possible associated injuries to the bones of the skull are based on the identification of classic symptoms: fracture plane, displacement of fragments, emphysema, hemosinus, as well as changes in the linearity of the image of the structural elements of the facial skeleton in the form of their angular or step-like deformation, disruption of continuity (asymmetry, etc. ).

The main method of X-ray examination for facial trauma is radiography (electroradiography). Images in lateral projections are especially important for determining possible combined injuries to the skull bones, as well as for characterizing the displacement of fragments of the facial bones. Tomography (orthopantomography) and radiography with direct image magnification are of great practical importance for clarifying the diagnosis of injuries to the maxillofacial area.

In recent years, computed tomography has become well used in clinical practice. It is effective in examining the nasal cavity, paranasal sinuses, walls and cavity of the orbit, sphenoid and ethmoid bones, and mandibular joints.

Computed tomography can detect changes in fine bone structures and musculofascial disorders that usually accompany bone lesions that cannot be detected with traditional x-rays and tomography. Computed tomograms clearly show complex injuries to the orbit and ethmoid bone, hematomas, low-contrast and small foreign bodies, wound canal and other changes, which makes it easier to determine the nature of the lesion and plan surgical intervention for trauma to the maxillofacial area.

At the same time, it has been established that computed tomography in a standard projection is not always able to identify a fracture with maximum displacement of fragments in the direction perpendicular to the plane of the examined section.

Damage to the upper part

The main method of X-ray examination for gunshot wounds of the face is radiography or electro-radiography of this area in standard projections, as well as using targeted images and tomography.

COMBINED WOUNDS OF THE FACE AND Neck.

With combined injuries of the face and necks, visible damage and initial clinical manifestations do not always correspond to the severity and volume of true destruction hidden in the depths of the altered tissues. In this case, X-ray examination allows you to most accurately determine the volume and nature of the damage, as well as their location.

III. Laboratory, functional, radioisotonic.

In modern clinical medicine, data obtained using objective diagnostic methods occupy a leading place. A subjective approach in assessing the patient’s condition, although not completely excluded, gives way to accurate, measurable

methods. These include laboratory (including microbiological, functional, radioactive methods of research and diagnostics.
LABORATORY METHODS

and investigation.

Using these methods, it is possible to identify early, not yet clinically diagnosed and subjectively undetectable laboratory research methods that allow you to monitor the progress of the treatment process and predict the outcome of the disease.

BLOOD INVESTIGATION. necessary and important diagnostic method. Hematopoietic organs are very sensitive to pathological influences, including fractures. These changes and the restructuring of the bone tissue itself are a response

whole organism for trauma: Trauma of the maxillofacial area; complicated by significant blood loss; reflected in the clinical blood test.

During fracture healing, biochemical blood tests are very important, including determination of protein, total protein, protein fractions, amino acids and carbohydrate (hexosamines, lactic and other acids, glycogen) metabolism.

These studies are also of great importance in case of complicated fractures; Thus, with traumatic osteomyelitis, in addition to high leukocytosis, ESR and other parameters increase in the blood serum and dysproteinemia is noted, which is expressed in hypoalbuminemia and hyperglobunemia. V.N. Bulyaev and co-author. (1975)

a test for the activity of alkaline phosphatase in blood leukocytes is proposed, which in the initial stages of inflammatory complications changes earlier than leukocytosis appears.

The results of a study of hydroxyproline and an amino acid that is part of collagen are also characteristic.

Determination of the content of neuroamic acids and glycoproteins in serum as indicators of protein metabolism can also be of diagnostic value.

I nvestigation of urine. With uncomplicated isolated trauma of the maxillofacial area, it is rarely possible to detect changes in the urine. However, with extensive trauma, combined fractures, shock, when kidney function is impaired, the amount of urine excreted and its composition may change. With wounds and fractures complicated by the inflammatory process, kidney function is also impaired. The relative density of urine changes, substances that are not found normally (sugar, protein and

etc.), this may be accompanied by bacteriuria, leukocyturria, hematuria. Indicators of the physical and chemical properties of urine are very important. In addition, urine testing can provide significant clues regarding drug absorption.

Microbiological and research. A significant role in the course of the wound process, fracture healing, and the development of purulent-inflammatory complications belongs to the microbial factor. The main source of purulent-inflammatory processes is gram-positive staphylococci and a number of gram-negative aerobes.

It is necessary that the crops be processed no later than 1-2 hours after collecting the material. The material must be collected using special swabs and cotton balls.

Immunological studies.

The complex of examination of the patient includes: determining the number of T-lymphocytes (E-rock) and their reaction to PHA (phytohemagglutinin); determination of the number in lymphocytes and their function on lipolysaccharide (LPS), as well as on the spectrum of immunoglobulin Jg G, Jg M, Jg A

serums; determination of the level of antigenemia by aggregate-aglutination reaction and antibodies to staphylococcal and streptococcal toxins; assessment of neutrophil function by their phagocytic activity; determination of the level of complement components (C3 and C4) by radial immunodiffusion; determination of individual proteins of the inflammatory complex.

F u n c t i a n a l d i a g n o s t i c a . Serves to identify functional disorders and monitor the restoration of lost functions; its task is not only to identify these disorders and the degree of their severity, but also to give these disorders

quantitative characteristics, i.e. objectify observations.

There are many methods for functional diagnostics and monitoring the condition of the masticatory apparatus. Of these, the Gelman test, which can be used to conduct a comparative assessment of the restoration of chewing function. Then masticationography according to Rubinov became widespread worldwide. However, this technique does not always allow an objective assessment of the data obtained.

Functional research methods include tendomechanomyography, proposed by I.S. Rubinov (1954) and modified by V.Yu. Kurlyandsky and S.D. Fedorov (1968). Using special strain gauges, an impulse is obtained, which is amplified by recorders on an oscilloscope.

However, one of the most modern and informative diagnostic methods is electromyography, which allows observations throughout the entire treatment process. The principle of electromyography is based on the ability to record potential fluctuations resulting from the occurrence of

excitation in muscle fibers. In addition, this ability of the muscle to excite allows you to stimulate the muscle with impulses

current. Recording is carried out using an electromyograph, which is based on an oscilloscope.

There is global electromyography, which is carried out using cutaneous electrodes; local, carried out using needle electrodes; stimulation, which allows you to determine the speed of propagation of excitation along the nerve. The clinic uses electromyography in two versions: using cutaneous and needle electrodes. The former are used to record the potentials of muscle groups, the latter to record more local processes.

For injuries of the maxillofacial area, as indicated by A.A. Prokhonchukov et al. (1988), electromyography serves to objectively assess the degree of impairment and, accordingly, restoration of the masticatory muscles.

The tone of the masticatory muscles can be measured using tonometry. Muscle tone is measured in myotones (mt) and examined with an electromyotonometer. The average values ​​of resting tension tone are normally 46 and 80 mt, respectively. When splints are applied, these figures increase.

P o l i r o g r a p h i . an electrochemical method that allows one to determine the trophic capabilities of soft tissues and the level of redox processes in them.

Using the polarographic method, it is possible to measure oxygen tension in tissues (Po2) and determine its average values. The method is based on recording current-voltage curves that reflect the dependence of current on voltage, which in turn depends on the polarization process on the working electrode. This method allows, if necessary, to perform plastic surgery of maxillofacial defects and to select flaps with optimal regenerative capabilities.

An oxygen test is used to determine oxygen tension. It is carried out using an oxygen mask through which the patient inhales oxygen. Against the background of this functional test, colorography is performed. The same method can also determine the volumetric velocity of blood flow. The technique is based on the electrochemical oxidation of hydrogen. In case of soft tissue injuries, if free skin grafts are necessary, it is advisable to use this method to clarify the level of trophic capabilities of the tissues. This can be done by compiling polarographic data and redox determination results.

body potential (ORP). For this determination of ORP, functional tests are used, as in polarography. It is an important indicator that allows us to judge the process of oxygen utilization by tissues.

Another common method of functional research and functional diagnostics is rheography - a method for studying the blood supply to tissues and, consequently, their viability. It is based on recording changes in the complex resistance of tissues when a high current passes through them.

frequencies. Resistance depends on the speed of blood flow and blood filling. Rheographers record these vibrations, which makes it possible to judge the viability of tissues. This is especially important when performing plastic surgery.

In maxillofacial traumatology, rheography can be used to assess the effect of local anesthesia. Since anesthesia causes vasospasm, a decrease in the amplitude of the rheogram can be used to judge the effectiveness of anesthesia. In addition, this method can serve to identify possible vascular disorders in jaw fractures and to clarify the duration of the rehabilitation period, as well as the effectiveness of the treatment.

In addition to rheography, photoplethysmography is used - a relatively new method for studying the degree of blood filling of tissues depending on sound vibrations. Changes in tissue blood supply are recorded using complex electron-optical instruments - photoplethysmographs. They use powerful light sources and lasers. Photoplethysmography uses light transmittance and light reflection.

In recent years, thermal imaging has begun to be used, since it has been proven that a correlation is determined between pathological processes and the temperature of certain areas of body surfaces. Thermal imaging allows you to observe individual parts of the human body in the infrared region of the spectrum. This method is absolutely harmless and has a high diagnostic resolution, especially for vascular lesions.

Ultrasound is also used. By sending oscillation pulses with a frequency of 0.8-20 mHy, it is possible to carry out echolocation and thus get an idea of ​​the state of the tissues, the size of the pathological focus, and the presence of an inflammatory process. Ultrasound is also used for the development of pathological processes in bone tissue, since the speed of its conduction through the bone varies depending on its condition.

According to T.E. Khorkova, T.M. Oleinikov (1980) and others, with fractures and osteomyelitis, a decrease in the speed of ultrasound propagation through the bone is detected.

In particular, with fractures of the lower part, osteometry reveals a sharp decrease in speed on the damaged side.

R a d i o t o p e n d i a g n o s t i c a . To study the dynamics of metabolic processes in bone tissue under the functioning conditions of the body, radioactive isotopes are used, which are sources of gamma studies. In particular, in maxillofacial traumatology they are used for diagnostic monitoring of fracture healing processes, predicting inflammatory complications, as well as for monitoring treatment.

Based on the results of radiometric studies, graphs are constructed that reflect the dynamics of accumulation and removal of the isotope during the healing process of the fracture. The accumulation and elimination curve of the drug is characterized by the presence of two rises in the level of radioactivity.

By 5-7 days, the first rise in radioactivity is determined, and its occurrence is explained by the formation of a new vascular network and the activation of neoplasm processes. The second increase in the radioactivity of the isotope corresponds to 21-24 days from the moment of injury. This peak of radioactivity indicates the beginning of perestroika

primary callus, which is accompanied by an increase in bone tropism for calcium ions.

• 
  Illustrative material

Foley No. 15

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  Literature

Author(s)	Title, type of publication	Number of copies
	MAIN LITERATURE
Kurash, Amangeldi Galymzhanuly.	Bastyn myinny clinic- lyk anatomy: Okulyk/ЄММА; A.G.Kurash.-Karagandy:Kazakhstan-Resey University Baspas. T. 1.- 2006.- 280b. : suret. .-ISBN	94 copies
Kharkov, Leonid Viktorovich.	Surgical dentistry and Maxillofacial surgery for children: Textbook for medical universities/L V. Kharkov, L.N. Yakovenko, I.V. Chekhova; Edited by L.V. Kharkov.-M.: Book plus, 2005.-470s. .-ISBN 5932680156:8160t.	20 copies

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  Security questions (feedback)

1. 
   Methods of surgical treatment:

A. Osteosynthesis with bone suture.

B. Osteosynthesis with Kirschner wires.

B. Osteosynthesis with miniplates.

D. Osteosynthesis with a structure with shape memory effect.