Traditional medicine

Classification of orthopedic devices for the treatment of maxillofacial injuries. Devices used in maxillofacial orthopedics Manufacturing technology of maxillofacial devices

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 (Scheme 4). 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.

Scheme 4
Classification of fixing devices

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, two main parts can be distinguished: 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 (Fig. 237) is represented by 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 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 (Fig. 238). 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 (Fig. 239). 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 to full artificial metal crowns (Fig. 240). 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 quick-hardening plastics, many different designs of dental splints appeared (Fig. 241). 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.

Rice. 241. Tire made of quickly hardening plastic.

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 the fragments, but also to maintain constant pressure between the ends of the fragments (Fig. 242).

Rice. 242. Dental splint made of alloy with “shape memory”,
a - general view of the tire; b - fixing devices; c - loop providing compression of fragments.

Fixing devices used in osteoplastic operations are a dental structure consisting of a system of welded crowns, connecting locking bushings, and rods (Fig. 243).

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 traction (Fig. 244).

Intraoral apparatuses consist of an intraoral part with extraoral levers and a head cap, which are connected to each other by elastic traction or rigid fixing devices (Fig. 245).

Rice. 245. Design inside the extraoral apparatus.

Rehearsal devices

There are one-stage and gradual reposition. One-stage 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 splint (Fig. 246). With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.

Rice. 246. Shina Vankevich.
a - view of the model of the upper jaw; b - reposition and fixation of fragments in case of damage to the toothless lower jaw.

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 (Fig. 247).

Rice. 247. Forming apparatus (according to A.I. Betelman). The fixing part is fixed on the upper teeth, and the forming part is located between the fragments of the lower jaw.

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 (Fig. 248).

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 (Fig. 249).

Rice. 249. Combined action device.

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:

Maximize the use of preserved natural teeth as support, connecting them into blocks using known techniques for splinting teeth;
make maximum use of the retention properties of the 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 with 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 dentistry
Edited by Corresponding Member of the Russian Academy of Medical Sciences, Professor V.N. Kopeikin, Professor M.Z. Mirgazizov

General characteristics of maxillofacial apparatuses and their classification. Transport tires. Ligature binding of teeth, indications, contraindications. Possible errors and complications.

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

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.

Classification of fixing devices

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, two main parts can be distinguished: 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 attachment 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 teeth).

In case of mobility of teeth, severe atrophy of the alveolar bone, it is not possible to ensure reliable stability of fragments with dental splints due to the imperfection of the actual fixing part of the apparatus design. In such cases, the use of dentogingival 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 a coverage 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 the point of view of biomechanics, 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.

Supragingival splint

Monoblock

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.

Tire made of quickly hardening plastic.

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 “memory” effect of shape. 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.

Alloy dental splint with shape memory,

a - general view of the tire; b - fixing devices; c - loop providing compression of fragments.

Fixing devices used in osteoplastic operations are a dental structure consisting of a system of welded crowns, connecting locking bushings, rods. Extraoral devices consist of a chin sling (plaster, plastic, standard or individual) 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.

Design inside the extraoral apparatus.

Rehearsal devices

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

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.

Splint Vankevich.a - view of the model of the upper jaw; b - reposition and fixation of fragments in case of damage to the toothless lower jaw.

Forming apparatus

Forming apparatus (according to A.I. Betelman). The fixing part is fixed on the upper teeth, and the forming part is located between the fragments of the lower jaw.

Replacement devices (prostheses)

Combined devices

Combined action device.

Dental, dentoalveolar and jaw prostheses, in addition to their replacement function, often serve as a formative apparatus. The results of orthopedic treatment of maxillofacial injuries largely depend on the reliability of the fixation of the apparatus. When solving this problem, the following rules should be adhered to: make maximum use of the remaining natural teeth as a support, connecting them into blocks using known techniques for splinting teeth; make maximum use of the retention properties of the 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 with total resections of the upper jaw, serve as a good support for strengthening the prosthesis);

Use 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).

Ligature binding of teeth for jaw fractures. Methods of temporary immobilization.

Reduction and reliable fastening of jaw fragments in an anatomically correct position is the main condition for successful treatment of fractures. At the same time, in cases where the patient cannot be provided with comprehensive medical care at the scene of the incident or in a given medical institution, and the patient with a traumatic lesion of the maxillofacial area must be sent to a specialized medical institution, it is necessary to carry out temporary (transport) immobilization of the debris during transportation jaws. This reduces the risk of early post-traumatic complications - dislocation asphyxia, bleeding, etc., prevents additional displacement of fragments and injury to soft tissues by sharp edges of bone fragments, and reduces the intensity of pain. Ligature binding of teeth is one of the effective and simple methods of temporary immobilization, does not require a significant investment of time, complex equipment and can be used by any doctor at the stage of first aid.

Basic level of knowledge:

Anatomical features of the structure of the upper and lower jaw.

Classification of traumatic lesions of the bones of the facial skull. Classification of mandibular fractures

Biomechanics of the lower jaw during a fracture, mechanisms of displacement of fragments, the nature of displacement of fragments depending on the location of the fracture.

Early post-traumatic complications in facial bone fractures.

Principles of emergency care for traumatic injuries of the maxillofacial area

Methods of transport immobilization for jaw fractures, indications and contraindications for their use, possible complications.

Features of providing medical care to victims with traumatic injuries of the maxillofacial area at different stages of medical evacuation

Ligature binding of teeth refers to temporary (transport) means of immobilization used to transport a patient from the scene of an incident to a medical institution or a district clinic to a specialized hospital. The useful life of intermaxillary ligature bonding of teeth is insignificant - no more than 2-5 days. After which patients begin to experience severe pain in their teeth, their teeth become loose. Therefore, to reduce the load on teeth held together with a ligature, it is advisable to additionally use a chin sling and elastic traction.

Fractures of the lower jaw in the area of the angle and ramus with slight displacement, if the risk of significant dislocation of a small fragment during transportation is minimal.

For fixing loose teeth due to malformation or other reasons.

Maxillary fracture

Fractures outside the dentition with significant displacement

Algorithm for ligature binding of teeth in case of jaw fracture.

1. Place the patient in the dental chair. Take an anamnesis and find out the patient’s complaints. It is imperative to establish the circumstances of the injury (where, when, under what circumstances, how the victim was injured. It is necessary to find out whether there was loss of consciousness, nausea, vomiting, bleeding at the time of injury. Was any assistance provided, by whom, what did it consist of? Collect also a detailed life history and allergy history.

2. Wash your hands, put on rubber gloves, examine and palpate the patient. Pay attention to the general condition of the patient, pallor of the skin, the presence of damage in other parts of the body, signs of damage to the central nervous system, other organs and systems. The presence of alcohol intoxication is determined. When examining the face, the location and nature of the soft tissue damage are determined, all the bones of the face are sequentially palpated, the contours and pathological mobility of the bones of the nose, lower orbital edge, zygomatic arch and bone, and lower jaw are determined. Mouth opening, range of movements in the TMJ, bite, condition of teeth and oral mucosa are assessed. The symptom of indirect load when pressing on the chin is determined, pathological mobility and crepitus in the area of the fracture of the lower jaw are studied bimanually, localized within the dentition, the presence of pathological mobility of the upper jaw is determined. Evaluate data from additional examination methods, in particular radiographs (if available).

3. Fill out medical documentation, establish a preliminary diagnosis, indicating all existing injuries, determine the required amount of assistance at this stage of medical evacuation, and, if necessary, transport the patient to a specialized medical facility, determine the presence of indications and contraindications for ligature binding of teeth.

4. Wash your hands again, treat them with the existing antiseptic solution, prepare sterile instruments for ligature tying of teeth (anatomical tweezers, Pean hemostatic clamp, Farabeuf hook, bronze-aluminum or steel wire 0.4-0.5 mm thick, metal scissors, if necessary, - a hook for removing dental plaque, a syringe and anesthetic for pain relief, sterile gauze balls and napkins). All further manipulations should be performed in strict compliance with the rules of asepsis and antisepsis.

5. Carry out antiseptic treatment of the oral cavity (rinsing with an antiseptic solution), conduct conduction anesthesia to anesthetize the fracture site, remove tartar with a hook for removing dental deposits, which may interfere with the placement of ligatures in the interdental spaces.

6. Place between the maxillary teeth and, if necessary, supplement it with a chin-parietal bandage. If necessary and if technical capabilities are available, additionally carry out the measures provided for at this stage of medical evacuation - carry out anti-tetanus vaccination, administer painkillers, stop bleeding, etc.

7. Draw up an accompanying document - a referral to a specialized medical institution indicating the diagnosis and scope of medical care provided.

Methods for applying ligatures for transport immobilization for fractures of the lower jaw are quite numerous and varied. Among the most famous are the following: according to Ivey, Sh.I. Vilga, M.K. Geiknim, A.A. Limb Erg, Stout, Rodson, Obwegeiser, E.V. Gotsko, Kazanyan, Hauptmeyer, etc.

There are methods of ligature binding of teeth on one jaw and methods of intermaxillary binding of teeth. Ligature binding of teeth on one jaw can be used for fractures within the dentition, while the ligature covers 2 teeth located on either side of the fracture gap. This method is used extremely rarely due to the fact that it usually only leads to loosening of the supporting teeth and does not provide effective fixation. Its use is possible only for the shortest period of time (within a few hours) and only in combination with an external dressing.

Technique of intermaxillary ligature binding of teeth.

One of the simplest methods of intermaxillary bonding of teeth is the so-called “figure eight”. If the fracture is localized within the dentition, the teeth located at the ends of the fragments and their antagonists on the upper jaw are connected. If the fracture is localized outside the dentition, premolars or molars are predominantly connected. Using anatomical tweezers or a Pean clamp, a bronze-aluminum ligature is inserted into the space between two adjacent teeth on the vestibular side and brought out to the lingual side. Then the wire is again brought out into the vestibule of the oral cavity (including the neck of one of the teeth) through the adjacent interdental space. Next, going around 2 teeth to be ligated from the vestibular side, the end of the wire is inserted into the interdental space and brought out next to the other end. It should be remembered that the ligature must be carried out in such a way that one end of the wire is placed above the loop covering the teeth from the vestibular side, and the other below it. Both ends of the wire are grabbed with a Pean hemostat and pulled up and twisted clockwise. A necessary condition for the tight retention of fragments is the application of a ligature to the neck of the tooth, preventing it from slipping. In the same way, a ligature is applied to the teeth of the antagonists of the upper jaw. After digital reposition of the fragments, the ligatures attached to the teeth of the upper and lower jaws are twisted together by turning them clockwise. The twisted ends are cut with scissors and bent in the direction of the dentition.

Opening the mouth during intermaxillary tying of teeth is impossible, so patients should be prescribed only liquid food administered at intervals at the site of missing teeth, or the space behind the molars.

Another method of inter-maxillary ligature binding of teeth is the Ivey technique.

Technique for applying a bandage with Ivy. A piece of bronze-aluminum alloy wire 0.4-0.5 mm thick. bend it in half and twist a small loop at the bend. Both free ends of the wire are inserted into the interdental space from the vestibular side and, upon leaving the lingual side, they are unbent in different directions. Then, bending around the adjacent teeth, the ends of the wire are brought out into the vestibule of the oral cavity through the corresponding interdental spaces. Before twisting, the distal end is passed through a loop to improve the stability of the bandage and prevent it from moving deeper into the interdental space. Then both ends of the ligature wire are pulled up and twisted together clockwise, the excess is cut off, and the ends are bent downward and inward, so that the ends of the ligature wire do not injure the oral mucosa. Two opposite teeth on the upper jaw are connected in a similar way. Then a separate wire ligature is taken, one end of which is passed through the loops on the upper and lower jaws, and then twisted with the other end, providing intermaxillary immobilization.

Ligature binding of teeth is often combined with other methods of transport immobilization, including the use of a chin-parietal bandage or a standard transport bandage. These methods can also be used independently for fractures of the upper and lower jaw in the absence of a threat of dislocation of bone fragments, and early post-traumatic complications - bleeding, asphyxia, vomiting, etc.

Standard transport sling consisting of a main support cap with three rubber loops on each side and a rigid chin sling (Entin chin sling). To securely fasten the supporting cap to the head, it is necessary that its straps, intersecting below the occipital protuberance, be tied on the forehead. If the hat sits loosely on the scalp, then you should place a wad of cotton wool in a special pocket located on the parietal area. A sterile cotton-gauze pad is placed on the sling so that it extends 0.5 -1.0 cm beyond the edges of the sling. The sling is applied to the chin area and fixed to the main support cap using rubber loops. To avoid pressure on the soft tissues of the temporal region, cotton rolls are placed under the rubber loops, which are inserted into a special pocket located in the side sections of the strap of the supporting main cap.

Depending on the number of rubber loops used, the chin sling can act as a pressure or support bandage. A standard transport bandage can be used as a pressure bandage only if there is no risk of asphyxia and the pressure created by the rubber band will not lead to even greater displacement of the fragments. Various combinations of rubber loops allow you to develop pressure in the desired direction.

The chin-parietal bandage is applied as follows. An ordinary gauze bandage is wrapped around the patient's head clockwise, following the rules of desmurgy. The bandage is passed from above through the parietal tubercles, and from below it covers the chin. When applying a bandage, the patient closes his teeth in the bite; the bandages are applied quite tightly. Instead of a gauze bandage, you can use high-compression elastic bandages.

Use of standard spoons with mustaches, planks, etc. for temporary immobilization for fractures of the upper jaw is inappropriate, since it can lead to distortion of bone fragments and their posterior displacement with the subsequent development of asphyxia.

T injury to the interdental papilla and marginal zone of the gums, necrosis of the interdental papilla.

Scaling the ligature when transporting the patient

Dislocation of bone fragments

Development of asphyxia (dislocation - when bone fragments are displaced during manipulation, or aspiration in the event of vomiting or bleeding during transportation of the patient)

Loose teeth

It is advisable to combine ligature binding of teeth with a chin-parietal bandage.

"Ligature binding of teeth on Ivy and Limberg"

1.Material support:

Tray for dental instruments;

Set of dental instruments (probe, tweezers, mirror, spatula)

Hemostatic clamp;

Bronze-aluminum ligature (wire) with a diameter of 0.3-0.6 mm;

Copper ligature (wire) with a diameter of 0.3-0.6 mm;

Scissors for cutting wire;

Entin's chin sling;

Dressing bandage;

Plaster models with intact dentition;

Sterile gauze wipes;

Plaster bandage;

Rubber rings;

Standard main cap for fixing the lower jaw.

2. Basic level of knowledge required to perform skills:

Know the clinical picture of jaw fractures;

Know the classification of jaw fractures;

Know the mechanism of displacement of fragments;

Know the features of first aid in case of trauma to the maxillofacial area;

Know the implementation of medical and evacuation measures among the population and military personnel in emergency situations;

Know the indications for the use of ligature binding techniques for fragments according to Ivey

and Limberg;

Know X-ray examination methods for jaw fractures;

Know the methods of two-jaw binding of fragments according to Ivey, Limberg;

Know the technique of applying a standard Entin sling splint;

Know the technique of fixing the lower jaw using dressing bandages or plaster bandages.

3. Indications and contraindications for the use of immobilization methods:

Indications:

For fractures of the lower jaw without displacement of fragments;

In case of fracture (partial) of the alveolar process of the upper jaw without

displacement of fragments;

If there are fixed teeth on the upper and lower jaws in the fracture zone;

Transport immobilization for 2-3 days for transporting the wounded and sick.

Contraindications:

Fractures of the lower jaw with stable (displaced) fragments;

Fracture of the alveolar process (partial) of the upper jaw due to displacement of fragments;

For epilepsy;

In case of loss of consciousness;

For nausea and vomiting;

For intraoral bleeding;

In case of partial absence of teeth in the fracture zone on the upper or lower jaws;

If there are mobile teeth in the fracture zone;

When transporting sick (wounded) people by air.

4. Advantages of using ligature ligament methods:

There is no need to obtain prints;

There is no need to apply immobilization using the Tigerstedt method;

Effective transport immobilization;

Does not cause discomfort or foreign body sensation in the oral cavity.

Algorithm for performing a practical skill:

Sequence of actions

Criteria for monitoring correct implementation

Cut ligature darts with scissors 10-12 cm long, 0.3-0.6 mm in diameter

Availability of copper or bronze-aluminium ligature wires 10-12 cm long, 0.3 - 0.6 mm in diameter

For the patient, rinse the mouth with a solution of furatsilin concentration (1:5000)

Explain to the patient that it is necessary to rinse the mouth and the presence of furatsilin (1:5000)

According to Ivy - fold the ligature wire in the form of a spike in half (two turns) and roll it up to create a ring with a diameter of 3-4mm.

The doctor visually controls the correct twisting of the wire into a spike (ring)

According to Ivey - the end of the ligature is passed through the interdental space (in the fracture zone) Hemostatic clamp in the vestibular direction until the ring stops in the teeth within 4-6 teeth in the fracture zone

Visually, the doctor controls the correct application of ligature wires, which should fit tightly to 4-6 teeth in the fracture zone. Bone fragments should not move in the fracture zone.

According to Ivy - on the oral side, separate the ends of the wire and pass the end of the ligature through the interdental spaces in the oral-vestibular direction (on the buccal side) going around the adjacent teeth (upper jaw).

According to Ivey, use a hemostatic clamp to pass one of the ends of the wire through the loop (ring) and twist them together on the vestibular side following the clock

Ligature darts should fit snugly against the teeth. Bone fragments should not move in the fracture zone. Ligature wires should not injure the ash edge and should be located between the equator of the tooth and the ash edge.

According to Ivy - use scissors to cut off the end of the wire leaving a curl of 0.5 cm

Visually check the length of the curl (at least 0.5 cm)

According to Ivy, bend the curl forward towards the occlusal surface.

The curl curved in the form of a loop on the vestibular side should not come into contact with the mucous membrane of the gingival margin and should not extend onto the occlusal surface.

9. According to Ivy, make the same loop (ring) on the teeth of the opposite lower jaw

Correct execution is checked in the same way as in the upper jaw

According to Ivy - between loops (rings)

Stretch the ligature wire and twist it.

Make sure that the ligature wires fixed on the teeth of the upper and lower jaw do not move

According to Ivey, bend the resulting curl of the hemostatic wire with a clamp vestibular towards the closure of the teeth.

Check the correct position of the curl so that it does not come into contact with the ash edge and does not extend onto the occlusal surface of the teeth.

According to Limberg, pull the Ligature Hemostatic wire with a clamp from the side of the oral cavity into the interdental spaces, covering one tooth of the upper jaw, thus covering 4-6 teeth in the fracture zone

The ligature darts should be between the equator of the tooth and the ash edge.

Along the Limberg - end of the wire on the vestibular side, roll it up so that the twisted segment is 1.0-1.5 cm long

Make sure that the ligatures do NOT move and fit tightly to the teeth.

According to Limberg - do the same with the teeth on the opposite jaw

Correct execution is controlled in the same way as in the upper jaw

According to Limberg, both curls are folded with a clamp behind the clock hand and bent forward in the direction of the closure of the teeth, thus forming a common curl, between the teeth of the upper and lower jaws

When twisting the curls of antagonizing teeth, make sure that bone fragments and ligature darts on the teeth do not move

After intermaxillary ligature tying of fragments according to Ivey, Limberg, fix the lower jaw using a rigid standard Entin chin sling, line the inside of the sling with a thick layer of cotton wool and cover the top with a sterile gauze napkin.

Spread cotton wool and napkin in an even layer on the chin sling

Fix the rigid sling with rubber rings to the standard main cap

Entin's sling, lying exactly symmetrically on the chin, should be fixed with rubber rings of a standard main cap.

Instead of Entin's hard sling, you can use a soft sling-like bandage made from ordinary dressing bandages, plaster bandages or a scarf.

Monitor the correct application of fixing chin bandages so that they do not cause traumatic bedsores.

Already in Hippocrates and Celsus there are instructions for fixing fragments of the jaw when it is damaged. Hippocrates used a rather primitive apparatus consisting of two belts: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus used a cord of hair to strengthen the fragments of the lower jaw by the teeth standing on both sides of the fracture line. At the end of the 18th century, Ryutenik and in 1806 E. O. Mukhin proposed a “submandibular splint” for fixing fragments of the lower jaw. A rigid chin sling with a plaster cast for the treatment of fractures of the lower jaw was first used by the founder of military field surgery, the great Russian surgeon N. I. Pirogov. He also suggested a sippy cup for feeding the wounded with maxillofacial injuries.

During the Franco-Russian War (1870-1871), plate splints in the form of a base attached to the teeth of the upper and lower jaws, with bite rollers made of rubber and metal (tin), in which there was a hole in the anterior region for eating, became widespread ( Gunning-Port devices). The latter was used to secure fragments of the toothless lower jaw. In addition to these devices, patients were given a rigid chin sling to support jaw fragments, securing it to the head. These devices, quite complex in design, could be made individually based on impressions of the upper and lower jaw of a wounded person in special dental prosthetic laboratories and therefore were used mainly in rear medical institutions. Thus, by the end of the 19th century, military field splinting was no longer available and assistance for maxillofacial wounds was provided very late.

In the first half of the 19th century, a method was proposed for securing fragments of the lower jaw using a bone suture (Rogers). Bone sutures for fractures of the lower jaw were also used during the Russo-Japanese War. However, at that time, the bone suture was not justified due to the complexity of its use, and most importantly, subsequent complications associated with the lack of antibiotics (development of osteomyelitis of the jaw, repeated displacement of fragments and bite deformation). Currently, the bone suture has been improved and is widely used.

The prominent surgeon Yu. K. Shimanovsky (1857), rejecting the bone suture, combined a plaster cast in the chin area with an intraoral “stick splint” to immobilize jaw fragments. Further improvement of the chin sling was carried out by Russian surgeons: A. A. Balzamanov proposed a metal sling, and I. G. Karpinsky - a rubber one.

The next stage in the development of methods for fixing jaw fragments is dental splints. They contributed to the development of methods for early immobilization of jaw fragments in front-line military medical institutions. Since the 90s of the last century, Russian surgeons and dentists (M. I. Rostovtsev, B. I. Kuzmin, etc.) used dental splints to fix jaw fragments.

Wire splints found widespread use during the First World War and took a strong place, later replacing plate splints in the treatment of gunshot wounds of the jaws. In Russia, aluminum wire tires were introduced into practice during the First World War by S. S. Tigerstedt (1916). Thanks to the softness of aluminum, the wire arch can easily be bent into a dental arch in the form of a single- and double-jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires turned out to be rational in a military field situation. They do not require special dental equipment or support personnel, therefore they have gained universal recognition and are currently used with minor modifications.

During the First World War, the sanitary service in the Russian army was poorly organized, and service to those wounded in the maxillofacial area suffered especially. Thus, the wounded arrived late at the maxillofacial hospital in Moscow organized by G.I. Vilga in 1915, sometimes 2-6 months after injury, without proper fastening of jaw fragments. As a result, the treatment period was extended and persistent deformities occurred with impaired function of the masticatory apparatus.

After the Great October Socialist Revolution, all shortcomings in the organization of the sanitary service were gradually eliminated. Currently, good maxillofacial hospitals and clinics have been created in the Soviet Union. A coherent doctrine has been developed for organizing the sanitary service in the Soviet Army at the stages of medical evacuation of the wounded, including in the maxillofacial area.

During the Great Patriotic War, Soviet dentists significantly improved the quality of treatment for those wounded in the maxillofacial area. Medical assistance was provided to them at all stages of evacuation, starting from the military area. Specialized hospitals or maxillofacial departments were established in army and front-line areas. The same specialized hospitals were deployed in rear areas for the wounded who needed longer treatment. Simultaneously with the improvement of the organization of sanitary services, methods of orthopedic treatment of jaw fractures were significantly improved. All this played a big role in the outcome of treatment of maxillofacial wounds. Thus, according to D. A. Entin and V. D. Kabakov, the number of completely healed wounded with damage to the face and jaw was 85.1%, and with isolated damage to the soft tissues of the face - 95.5%, whereas in the First World War (1914-1918) 41% of those wounded in the maxillofacial area were discharged from the army due to disability.

Classification of jaw fractures

I. G. Lukomsky divides fractures of the upper jaw into three groups depending on the location and severity of clinical treatment:

1) fracture of the alveolar process;

2) suborbital fracture at the level of the nose and maxillary sinuses;

3) an orbital, or subbasal, fracture at the level of the nasal bones, orbit and main bone of the skull.

By localization, this classification corresponds to those zones where fractures of the upper jaw most often occur. The most severe cases are fractures of the upper jaw, accompanied by a fracture, separation of the nasal bones and the base of the skull. These fractures are sometimes sealed with death. It should be pointed out that fractures of the upper jaw occur not only in typical places. Very often one type of fracture is combined with another.

D. A. Entin divides neohyestrel fractures of the lower jaw according to their location into median, mental (lateral), angular (angular) and cervical (cervical). An isolated fracture of the coronoid process is relatively rare.

1) by the nature of the damage (through, blind, tangential, single, multiple, penetrating and not penetrating into the oral and nasal cavity, isolated with and without damage to the palatine process and combined);

2) by the nature of the fracture (linear, splintered, perforated, with displacement, without displacement of fragments, with and without bone defect, unilateral, bilateral and combined;

3) by localization (within and outside the dentition);

4) by type of wounding weapon (bullet, fragmentation).

Localization of typical fractures in the lower jaw.

Currently, this classification includes all facial injuries and has the following form.

I. Gunshot wounds

By type of damaged tissue

1.Soft tissue injuries.

2.Wounds with bone damage:

A. Lower jaw

B. Upper jaw.

B. Both jaws.

G. Zygomatic bone.

D. Damage to several bones of the facial skeleton

II.Non-gunshot wounds and damage

IV. Frostbite

According to the nature of the damage

1. Through.

3. Tangents.

A.Insulated:

a) without damage to facial organs (tongue, salivary glands, etc.);

b) with damage to facial organs

B. Combined (simultaneous injuries to other areas of the body).

B. Singles.

G. Multiple.

D. Penetrating into the oral and nasal cavity

E. Non-penetrating

By type of wounding weapon

1. Bullet.

2. Fragmentation.

3. Radiation.

Classification of orthopedic devices used to treat jaw fractures

Fixing jaw fragments is done using various devices. It is advisable to divide all orthopedic devices into groups in accordance with function, area of fixation, therapeutic value, and design.

Division of devices according to function. Devices are divided into corrective (reducing), fixing, guiding, shaping, replacing and combined.

Regulating (reducing) devices are devices that facilitate the reposition of bone fragments: tightening or stretching them until they are installed in the correct position. These include aluminum wire splints with elastic traction, elastic wire brackets, devices with extraoral control levers, devices for jaw retraction for contractures, etc.

The guides are mainly devices with an inclined plane, a sliding hinge, which provide a certain direction to the bone fragment of the jaw.

Devices (spikes) that hold parts of an organ (for example, the jaw) in a certain position are called fixators. These include a smooth wire bracket, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw during bone grafting, etc.

Formative devices are devices that support plastic material (skin, mucous membrane) or create a bed for a prosthesis in the postoperative period.

Replacement devices include devices that replace defects in the dentition formed after tooth extraction, filling defects in the jaws and parts of the face that arise after injury or surgery. They are also called dentures.

Combined devices include devices that have several purposes, for example, fixing jaw fragments and forming a prosthetic bed, or replacing a jaw bone defect and simultaneously forming a skin flap.

Division of devices according to the place of fixation. Some authors divide devices for the treatment of jaw injuries into intraoral, extraoral and intra-extraoral. Intraoral include devices attached to the teeth or adjacent to the surface of the oral mucosa, extraoral - adjacent to the surface of the integumentary tissues outside the oral cavity (chin sling with a headband or extraoral bone and intraosseous spikes for securing jaw fragments), intraoral - devices, one part of which is fixed inside and the other outside the oral cavity.

In turn, intraoral splints are divided into single-jaw and double-jaw splints. The former, regardless of their function, are located only within one jaw and do not interfere with the movements of the lower jaw. Double-jaw appliances are applied simultaneously to the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.

Division of devices according to therapeutic purpose. Based on their therapeutic purpose, orthopedic devices are divided into primary and auxiliary.

The main ones are fixing and correcting splints, used for injuries and deformations of the jaws and having an independent therapeutic value. These include replacement devices that compensate for defects in the dentition, jaw and parts of the face, since most of them help restore organ function (chewing, speech, etc.).

Auxiliary devices are devices that serve to successfully perform skin-plastic or osteoplastic operations. In these cases, the main type of medical care will be surgical intervention, and the auxiliary one will be orthopedic (fixing devices for bone grafting, shaping devices for facial plastic surgery, protective palatal plastic surgery for palate plastic surgery, etc.).

Division of devices by design.

By design, orthopedic devices and splints are divided into standard and individual.

The first include the chin sling, which is used as a temporary measure to facilitate transportation of the patient. Individual tires can be of simple or complex design. The first (wire) ones are bent directly in front of the patient and secured to the teeth.

The second, more complex ones (plate, cap, etc.) can be manufactured in a denture laboratory.

In some cases, from the very beginning of treatment, permanent devices are used - removable and non-removable splints (prostheses), which initially serve to secure jaw fragments and remain in the mouth as a prosthesis after fusion of the fragments.

Orthopedic devices consist of two parts - supporting and acting.

The supporting parts are crowns, mouthguards, rings, wire arches, removable plates, head caps, etc.

The active part of the apparatus is rubber rings, ligatures, elastic brackets, etc. The active part of the apparatus can be continuously operating (rubber rod) and intermittent, operating after activation (screw, inclined plane). Traction and fixation of bone fragments can also be carried out by applying traction directly to the jaw bone (the so-called skeletal traction), and the supporting part is a head plaster cast with a metal rod. The traction of the bone fragment is carried out using an elastic traction, attached at one end to the jaw fragment by means of a wire ligature, and at the other end to the metal rod of the head plaster cast.

FIRST SPECIALIZED AID FOR JAW FRACTURES (IMMOBILIZATION OF FRAGMENTS)

In wartime, when treating patients wounded in the maxillofacial area, transport splints and sometimes ligature bandages are widely used. Of the transport tires, the most comfortable is the rigid chin sling. It consists of a headband with side bolsters, a plastic chin sling and rubber rods (2-3 on each side).

A rigid chin sling is used for fractures of the lower and upper jaws. In case of fractures of the body of the upper jaw and intact lower jaw and in the presence of teeth in both jaws, the use of a chin sling is indicated. The sling is attached to the headband with rubber bands with significant traction, which is transmitted to the upper dentition and facilitates the reduction of the fragment.

In case of comminuted fractures of the lower jaw, rubber bands connecting the chin sling with the head band should not be tightly applied in order to avoid significant displacement of the fragments.

3. N. Pomerantseva-Urbanskaya, instead of the standard rigid chin sling, proposed a sling that looked like a wide strip of dense material, into which pieces of rubber were sewn on both sides. Using a soft sling is easier than a hard sling, and in some cases it is more convenient for the patient.

Ya. M. Zbarzh recommended a standard splint for securing fragments of the upper jaw. Its splint consists of an intraoral part in the vnds of a double wire arch made of stainless steel, covering the dentition of the upper jaw on both sides, and extraoral levers extending outward, directed posteriorly to the auricles. The extraoral arms of the splint are connected to the headband using connecting metal rods. The diameter of the wire of the internal arc is 1-2 mm, of the extraoral rods - 3.2 mm. Dimensions

the wire arch is regulated by extension and shortening of its palatal part. The splint is used only in cases where manual reduction of fragments of the upper jaw is possible. M. 3. Mirgazizov proposed a similar device for a standard splint for securing fragments of the upper jaw, but only using a palatal plane made of plastic. The latter is corrected using quick-hardening plastic.

Ligature binding of teeth

Intermaxillary bonding of teeth.

1 - according to Ivy; 2 - according to Geikin; .3-but Vilga.

One of the simplest ways to immobilize jaw fragments, which does not require much time, is ligature binding of teeth. Bronze-aluminum wire 0.5 mm thick is used as a ligature. There are several ways to apply wire ligatures (according to Ivey, Vilga, Geikin, Limberg, etc.). Ligature binding is only a temporary immobilization of jaw fragments (for 2-5 days) and is combined with the application of a chin sling.

Wire splint application

Immobilization of jaw fragments using splints is more rational. There are simple special treatments and complex ones. The first is to use wire tires. They are applied, as a rule, in the military area, since production does not require a denture laboratory. Complex orthopedic treatment is possible in those institutions where there is an equipped dental laboratory.

Before splinting, conduction anesthesia is performed, and then the oral cavity is treated with disinfectant solutions (hydrogen peroxide, potassium permanganate, furatsilin, chloramine, etc.). The wire splint should be curved along the vestibular side of the dentition so that it adheres to each tooth at least at one point, without imposing on the gum mucosa.

Wire bars come in a variety of shapes. There are a smooth wire splint-bracket and a wire splint with a spacer corresponding to the size of the dentition defect. For intermaxillary traction, wire arches with hooking loops are used on both jaws for A.I. Stepanov and P.I. For the manufacture of a wire splint with hooking loops, it is recommended to use a smooth wire splint and pre-prepared movable hooking hooks made of brass for intermaxillary traction, which are installed on required section of the tire.

Method of applying ligatures

To secure the tire, they use wire ligatures - pieces of bronze-aluminum wire 7 cm long and 0.4-0.6 mm thick. The most common method is to pass ligatures through interdental spaces. The ligature is bent into a hairpin shape with ends of different lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and brought out from the vestibule (one under the splint, the other above the splint). Here the ends of the ligatures are twisted, the excess spiral is cut off and folded between the teeth so that they do not damage the mucous membrane of the gums. To save time, you can first place a ligature between the teeth, bending one end down and the other up, then place a splint between them and secure it with ligatures.

Indications for the use of bent wire tires

A smooth arch made of aluminum wire is indicated for fractures of the alveolar process of the upper and lower jaws, median fractures of the lower jaw, as well as fractures of other locations, but within the dentition without vertical displacement of fragments. If part of the teeth are missing, a smooth splint with a retention loop is used - an arch with a spacer.

Vertical displacement of fragments is eliminated with wire splints with hooked loops and intermaxillary traction using rubber rings. If simultaneous reduction of jaw fragments is performed, then the wire mud is immediately attached to the teeth of both fragments. In case of stiff and displaced fragments and the impossibility of their immediate reduction, the wire splint is first attached with ligatures to only one fragment (long), and the second end of the splint is attached with ligatures to the teeth of the other fragment only after restoration of normal closure of the dentition. A rubber gasket is placed between the teeth of the short fragment and their antagonists to speed up bite correction.

For a fracture of the lower jaw behind the dentition, the method of choice is the use of wire spikes with intermaxillary traction. If the fragment of the lower jaw is displaced in two planes (vertical and horizontal), intermaxillary traction is indicated. In case of a fracture of the lower jaw in the area of the angle with horizontal displacement of the long fragment towards the fracture, it is advisable to use a splint with a sliding hinge. It is distinguished by the fact that it secures jaw fragments, eliminates their horizontal displacement and allows free movement in the temporomandibular joints.

With a bilateral fracture of the lower jaw, the middle fragment, as a rule, moves downward, and sometimes also posteriorly under the influence of muscle traction. In this case, the lateral fragments often shift towards each other. In such cases, it is convenient to immobilize jaw fragments in two stages. At the first stage, the lateral fragments are separated and secured using a wire arch with the correct closure of the dentition; at the second stage, the middle fragment is pulled upward using intermaxillary traction. Having placed the middle fragment in the correct bite position, it is attached to a common splint.

In case of a fracture of the lower jaw with one toothless fragment, the latter is secured using a bent spike made of aluminum wire with a loop and a lining. The free end of the aluminum splint is secured to the teeth of the other jaw fragment with wire ligatures.

Wire tire according to Tigerstedt.

a - smooth splint-arc; b - smooth tire with spacer; v-tire s. hooks; g - a tenon with hooks and an inclined plane; d - splint with hooks and intermaxillary traction; e - rubber rings.

For fractures of the edentulous lower jaw, if the patient has dentures, they can be used as splints for temporary immobilization of jaw fragments while simultaneously applying a chin sling. To ensure food intake, all 4 incisors are cut out in the lower denture and the patient is fed from a sippy cup through the hole formed.

Treatment of alveolar bone fractures

In case of fractures of the alveolar process of the upper or lower jaw, the fragment is usually secured with a wire splint, most often smooth and single-jawed. When treating a non-gunshot fracture of the alveolar process, the fragment is usually reduced simultaneously under novocaine anesthesia. The fragment is secured using a smooth aluminum wire arch with a thickness of 1.5-2 mm.

In case of a fracture of the anterior part of the alveolar process with the fragment displaced backward, the wire arch is attached with ligatures to the lateral teeth on both sides, after which the fragment is pulled anteriorly with rubber rings.

In case of a fracture of the lateral part of the alveolar process with its displacement to the lingual side, a spring steel wire with a thickness of 1.2-1.5 mm is used. The arch is first attached with ligatures to the teeth of the healthy side, then the fragment is pulled with ligatures to the free end of the arch. When the fragment is vertically displaced, an aluminum wire arch with hooking loops and rubber rings is used.

In case of gunshot damage to the alveolar process with fragmentation of teeth, the latter are removed and the dentition defect is replaced with a prosthesis.

In case of fractures of the palatine process with damage to the mucous membrane, the fragment and flap of the mucous membrane are secured with an aluminum staple with supporting loops directed back to the site of damage. The mucosal flap can also be fixed using a celluloid or plastic palatal plate.

Orthopedic treatment of fractures of the upper jaw

Fixing splints, attached to the headband with elastic traction, often cause displacement of fragments of the upper jaw and bite deformation, which is especially important to remember in case of comminuted fractures of the upper jaw with bone defects. For these reasons, wire fixing splints without rubber traction have been proposed.

Ya. M. Zbarzh recommends two options for bending splints made of aluminum wire for fixing fragments of the upper jaw. In the first option, take a piece of aluminum wire 60 cm long, bend its ends, each 15 cm long, towards each other, then twist these ends into spirals. In order for the spirals to be uniform, the following conditions must be met:

1) during twisting, the angle formed by the long axes of the wire must be constant and no more than 45°;

2) one process should have the direction of turns clockwise, the other, on the contrary, counterclockwise. The formation of twisted processes is considered complete when the middle part of the wire between the last turns is equal to the distance between the premolars. This part then becomes the front part of the dental splint.

In the second option, they take a piece of aluminum wire of the same length as in the previous case and bend it so that the intraoral part of the splint and the remains of the extraoral part are identified immediately, after which they begin to twist the extraoral rods, which, as in the first option, bend over the cheek towards the ears and is attached to the headband by means of connecting, vertically extending rods. The lower ends of the connecting rods are bent upward in the form of a hook and connected with a ligature wire to the extension of the splint, and the upper ends of the connecting rods are strengthened with plaster on the head bandage, which gives the lm greater stability.

Posterior displacement of a fragment of the upper jaw can cause asphyxia due to the closure of the lumen of the pharynx. In order to prevent this complication, it is necessary to pull the fragment anteriorly. Traction and fixation of the fragment is carried out using an extraoral method. To do this, a headband is made and in its anterior section a plate of tin with a soldered lever made of steel wire 3-4 mm thick is plastered or 3-4 twisted aluminum wires are plastered along the midline, sealed with a hook loop against the oral slit. A bracket made of aluminum wire with hooking loops is applied to the teeth of the upper jaw, or a supragingival plate spike with hooking loops is used in the area of the incisors. Using an elastic rod (rubber ring), the fragment of the upper jaw is pulled to the lever of the headband.

In case of lateral displacement of a fragment of the upper jaw, a metal rod is plastered on the opposite side of the displacement of the fragment to the lateral surface of the head plaster cast. Traction is carried out by elastic traction, as with posterior displacement of the upper jaw. The fragment is pulled out under bite control. With vertical displacement, the apparatus is supplemented with traction in the vertical plane through horizontal extraoral levers, a supragingival plate splint and rubber bands. The plate splint is made individually according to the impression of the upper jaw. It is better to use alginate impression materials. Based on the resulting plaster model, they begin to model the lamellar splint. It should cover the teeth and mucous membrane of the gums both from the palatal side and from the vestibule of the oral cavity. The chewing and cutting surfaces of the teeth remain exposed. Tetrahedral sleeves are welded to the side surface of the apparatus on both sides, which serve as bushings for extraoral levers. Levers can be made in advance. They have tetrahedral ends corresponding to the bushings into which they slide in the anteroposterior direction. In the area of the fangs, the levers form a bend around the corners of the mouth and, coming out, go towards the auricle. A loop-shaped wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. Levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband using rubber rings.

A similar splint can also be used to treat combined fractures of the upper and lower jaw. In such cases, hooking loops bent upward at a right angle are welded to the plate tenon of the upper jaw. Fixation of jaw fragments is carried out in two stages. At the first stage, fragments of the upper jaw are secured to the head using a splint with extraoral levers connected to the plaster cast with rubber rods (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled to the upper jaw splint using an aluminum wire splint with hooking loops, fixed to the lower jaw.

Orthopedic treatment of mandibular fractures

Orthopedic treatment of fractures of the lower jaw, midline or close to the midline, in the presence of teeth on both fragments, is carried out using a smooth aluminum arch wire. As a rule, wire ligatures that go around the teeth should be secured to the splint with the jaws closed under control of the bite. Long-term treatment of mandibular fractures with wire splints with intermaxillary traction can lead to the formation of scar cords and the occurrence of extra-articular contractures of the jaws due to prolonged inactivity of the temporomandibular joints. In this regard, a need arose for functional treatment of injuries to the maxillofacial area, providing physiological rather than mechanical rest. This problem can be solved by returning to the undeservedly forgotten single-jaw splint, to fixing jaw fragments with devices that preserve movement in the temporomandibular joints. Single-jaw fixation of fragments ensures the early use of maxillofacial gymnastics techniques as a therapeutic factor. This complex formed the basis for the treatment of gunshot injuries to the lower jaw and was called the functional method. Of course, the treatment of some patients without more or less significant damage to the mucous membrane of the oral cavity and perioral area, patients with linear fractures, with closed fractures of the lower jaw branch can be completed by intermaxillary fixation of fragments without any harmful consequences.

In case of fractures of the lower jaw in the area of the angle, at the site of attachment of the masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. In case of comminuted fractures, damage to the mucous membrane, oral cavity and facial coverings, fractures accompanied by a bone defect, etc., the wounded need single-maxillary fixation of fragments, which allows maintaining movement in the temporomandibular joints.

A. Ya. Katz proposed a regulatory apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin region. The device consists of rings reinforced with cement on the teeth of the jaw fragment, oval-shaped sleeves soldered to the buccal surface of the rings, and levers originating in the sleeves and protruding from the oral cavity. Using the protruding parts of the lever, you can quite successfully adjust jaw fragments in any plane and install them in the correct position.

Among other single-jaw devices for the treatment of fractures of the lower jaw, the spring bracket made of stainless steel by Pomerantseva-Urbaiskaya should be noted. This author recommends the Shelhorn method of applying ligatures to regulate the movement of jaw fragments in the vertical direction. If there is a significant defect in the body of the lower jaw and a small number of teeth on the jaw fragments, A. L. Grozovsky suggests using a kappa-rod reduction apparatus. The preserved teeth are covered with crowns, to which rods in the form of half-arches are soldered. At the free ends of the rods there are holes into which screws and nuts are inserted, with which the position of the jaw fragments is adjusted and secured.

We proposed a spring apparatus, which is a modification of the Katz apparatus for the reposition of fragments of the lower jaw with a defect in the chin area. This is a device of combined and sequential action: first reducing, then fixing, forming and replacing. It consists of metal mouth guards, with double tubes soldered to the buccal surface, and springy stainless steel levers 1.5-2 mm thick. One end of the lever ends with two rods and is inserted into the tubes, the other protrudes from the oral cavity and serves to regulate the movement of jaw fragments. Having placed the jaw fragments in the correct position, the extraoral levers fixed in the mouthguard tubes are replaced with a vestibular clamp or a shaping device.

The mouth guard undoubtedly has some advantages over wire splints. Its advantages are that, being single-jawed, it does not limit movements in the temporomandibular joints. With the help of this device, it is possible to achieve stable immobilization of jaw fragments and at the same time stabilization of the teeth of the damaged jaw (the latter is especially important when there are a small number of teeth and their mobility). A mouthguard apparatus without wire ligatures is used; the gums are not damaged. Its disadvantages include the need for constant monitoring, since the cement in the aligners may be reabsorbed and jaw fragments may be displaced. To monitor the condition of the cement, holes (“windows”) are made on the chewing surface of the mouth guards. For this reason, these patients should not be transported, since decementing of the mouth guards along the way will lead to disruption of the immobilization of jaw fragments. Mouth guards have found wider use in pediatric practice for jaw fractures.

Reduction apparatus (according to Oksman).

a - reducing; 6 - fixing; c - formative and replacing.

M. M. Vankevich proposed a lamellar splint covering the palatal and vestibular surface of the mucous membrane of the upper jaw. From the palatal surface of the splint, two inclined planes extend downwards to the lingual surface of the lower molars. When the jaws close, these planes push apart the fragments of the lower jaw, displaced in the lingual direction, and secure them in the correct position. The Vankevich tire was modified by A.I. Stepanov. Instead of the palatal plate, he introduced an arch, thus freeing part of the hard palate.

For a fracture of the lower jaw in the area of the angle, as well as for other fractures with displacement of fragments to the lingual side, splints with an inclined plane are often used, and among them, a plate supragingival splint with an inclined plane. However, it should be noted that a supragingival splint with an inclined plane can be useful only with a slight horizontal displacement of the jaw fragment, when the plane deviates from the buccal surface of the maxillary teeth by 10-15°. If there is a large deviation of the plane of the splint from the teeth of the upper jaw, the inclined plane, and with it the fragment of the lower jaw (will be pushed downwards. Thus, the horizontal displacement will be complicated by the vertical one. In order to eliminate the possibility of this position, 3. Ya. Shur recommends equipping an orthopedic apparatus springy inclined plane.

Dental splint for the lower jaw.

a - general view; b - tire with an inclined plane; c - orthopedic devices with sliding hinges (according to Schroeder); g - steel wire tire with a sliding hinge (according to Pomerantseva-Urbanskaya).

All described fixing and regulating devices maintain mobility of the lower jaw in the temporomandibular joints.

Treatment of fractures of the body of the lower jaw with toothless fragments

Fixation of fragments of the edentulous lower jaw is possible using surgical methods: bone suture, intraosseous pins, extraoral bone splints.

In case of a fracture of the lower jaw behind the dentition in the area of an angle or ramus with vertical displacement of a long fragment or a shift forward and towards the fracture, intermaxillary fixation with oblique traction should be used in the first period. In the future, to eliminate horizontal displacement (shift towards the fracture), satisfactory results are achieved by using the Pomerantseva-Urbanskaya articulated splint.

Some authors (Schroeder, Brun, Gofrath, etc.) recommend standard splints with a sliding hinge, secured to the teeth using mouth guards. 3. N. Pomerantseva-Urbanskaya proposed a simplified design of a sliding hinge made of stainless wire with a thickness of 1.5-2 mm.

The use of splints with a sliding hinge for fractures of the lower jaw in the area of the angle and ramus prevents the displacement of fragments, the occurrence of facial asymmetry deformities and is also the prevention of jaw contractures, because this splinting method preserves the vertical movements of the jaw and is easily combined with therapeutic exercises. A short fragment of a branch in a fracture of the lower jaw in the area of the angle is strengthened by skeletal traction using elastic traction to the head plaster cast with a rod behind the ear, as well as a wire ligature around the angle of the jaw.

In case of a fracture of the lower jaw with one toothless fragment, the long fragment is pulled out and the short fragment is secured using a wire bracket with hooking loops, secured to the teeth of the long fragment with a flight to the alveolar process of the toothless fragment. Intermaxillary fixation eliminates displacement of the long fragment, and the pelot keeps the toothless fragment from moving upward and to the side. There is no downward displacement of the short fragment, since it is held by the muscles that elevate the mandible. The tire can be made of elastic wire, and the pilot can be made of plastic.

For fractures of the body of the edentulous lower jaw, the simplest method of temporary fixation is the use of the patient's dentures and fixation of the lower jaw using a rigid chin sling. In their absence, temporary immobilization can be carried out using a block of bite ridges made of thermoplastic mass with bases made of the same material. Subsequent treatment is carried out surgically.

Plastic tires

For jaw fractures combined with radiation injuries, the use of metal splints is contraindicated, since metals, as some believe, can become a source of secondary radiation, causing necrosis of the gum mucosa. It is more expedient to make tires from plastic. M.R. Marey recommends using nylon threads instead of ligature wire to secure the splint, and a splint for fractures of the lower jaw - made of quick-hardening plastic along a pre-made aluminum channel of an arcuate shape, which is filled with freshly prepared plastic, placing it on the vestibular surface of the dental arch. After the plastic hardens, the aluminum gutter is easily removed, and the plastic is firmly connected to the nylon threads and fixes the jaw fragments.

Method of applying plastic by G. A. Vasiliev and co-workers. A nylon thread with a plastic bead on the vestibular surface of the tooth is applied to each tooth. This creates a more reliable fixation of the ligatures in the splint. Then a splint is applied according to the method described by M. R. Marey. If intermaxillary fixation of jaw fragments is necessary, holes are drilled in the appropriate areas with a spherical bur and pre-prepared plastic spikes are inserted into them, which are fixed with freshly prepared quick-hardening plastic. The spikes serve as a place for applying rubber rings for intermaxillary traction and fixation of jaw fragments.

F. L. Gardashnikov proposed a universal elastic plastic dental splint with mushroom-shaped rods for intermaxillary traction. The tire is reinforced with a bronze-aluminum ligature.

Orthopedic treatment of jaw fractures in children

Dental trauma. Bruises of the facial area may be accompanied by injury to one tooth or a group of teeth. Dental trauma is detected in 1.8-2.5% of examined schoolchildren. Trauma to the maxillary incisors is more common.

When the enamel of a baby or permanent tooth is broken, the sharp edges are ground with a carborundum head to avoid injury to the mucous membrane of the lip, cheek, and tongue. If the integrity of the dentin is damaged, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed to artificial dentin without preparing it. During this time, replacement dentin is expected to form. Subsequently, the crown is replaced with a tooth-colored filling or inlay. If the crown of a tooth is fractured and the pulp is damaged, the pulp is removed. After filling the root canal, treatment is completed by applying an inlay with a pin or a plastic crown. When the crown of a tooth is broken off at its neck, the crown is removed, and an attempt is made to preserve the root in order to use it to strengthen the pin tooth.

When a tooth is fractured in the middle part of the root, when there is no significant displacement of the tooth along the vertical axis, they try to save it. To do this, apply a wire splint to a group of teeth with a ligature bandage on the damaged tooth. In young children (under 5 years old), it is best to fix broken teeth using a plastic mouthguard. The experience of domestic dentists has shown that a fracture of the tooth root sometimes heals within l"/g-2 months after splinting. The tooth becomes stable, and its functional value is completely restored. If the color of the tooth changes, electrical excitability sharply decreases, pain occurs during percussion or palpation in near the apical region, then the crown of the tooth is trepanned and the pulp is removed, the corpus canal is filled with cement and thus the tooth is preserved.

In case of bruises with root wedging into a fractured alveolus, it is better to adhere to a wait-and-see approach, remembering that in some cases the tooth root is somewhat pushed out due to the development of traumatic inflammation. In the absence of inflammation, after healing of the socket injury, orthopedic treatment is resorted to.

If a child’s permanent tooth has to be removed due to an injury, the resulting defect in the dentition will be replaced with a fixed denture with unilateral fixation or a sliding removable denture with bilateral fixation to avoid bite deformation. Crowns and pin teeth can serve as supports. A dental defect can also be replaced with a removable denture.

If 2 or 3 front teeth are lost, the defect is replaced using a hinged and removable prosthesis according to Ilina-Markosyan. If individual front teeth fall out due to a bruise, but their sockets are intact, they can be replanted, provided that assistance is provided soon after the injury. After replantation, the tooth is fixed for 4-6 weeks with a plastic tray. It is not recommended to replant baby teeth, as they may interfere with the normal eruption of permanent teeth or cause the development of a follicular cyst.

Treatment of dislocated teeth and fractured sockets.

In children under the age of 27 years, with bruises, dislocation of teeth or fracture of the sockets and incisor areas and displacement of teeth to the labial or lingual side are observed. At this age, securing teeth using a wire arch and wire ligatures is contraindicated due to the instability of baby teeth and the small size of their crowns. In these cases, the method of choice should be to manually adjust the teeth (if possible) and secure them with a celluloid or plastic mouthguard. The psychology of a child at this age has its own characteristics: he is afraid of the doctor’s manipulations. The unusual furnishings of the office have a negative effect on the child. The child's preparation and some caution in the doctor's behavior are necessary. First, the doctor teaches the child to look at the instruments (spatula and mirror and orthopedic apparatus) as if they were toys, and then carefully begins orthopedic treatment. The methods of applying a wire arch and wire ligatures are rough and painful, so preference should be given to mouth guards, the application of which is much easier for the child to tolerate.

Method for making a mouthguard by Pomerantseva-Urbanskaya.

After a preparatory conversation between the doctor and the child, the teeth are smeared with a thin layer of Vaseline and an impression is carefully taken from the damaged jaw. On the resulting plaster model, the displaced teeth are broken at the base, set in the correct position and glued with cement. On the model prepared in this way, a mouthguard is formed from wax, which should cover the displaced and adjacent stable teeth on both sides. The wax is then replaced with plastic. When the mouth guard is ready, the teeth are manually adjusted under appropriate anesthesia and the mouth guard is secured to them. In extreme cases, you can carefully not completely apply the mouthguard and invite the child to gradually close his jaws, which will help install the teeth in their sockets. A mouthguard for fixing dislocated teeth is strengthened with artificial dentin and left in the mouth for 2-4 weeks, depending on the nature of the damage.

Jaw fractures in children. Jaw fractures in children occur as a result of trauma due to the fact that children are mobile and careless. Fractures of the alveolar process or dislocation of teeth are more common, and jaw fractures are less common. When choosing a treatment method, it is necessary to take into account some age-related anatomical and physiological features of the dental system associated with the growth and development of the child’s body. In addition, it is necessary to take into account the child’s psychology in order to develop the correct methods of approaching him.

Orthopedic treatment of mandibular fractures in children.

When treating fractures of the alveolar process or the body of the lower jaw, the nature of the displacement of bone fragments and the direction of the fracture line in relation to the dental follicles are of great importance. Healing of a fracture proceeds faster if its line passes at some distance from the dental follicle. If the latter is located on the fracture line, it may become infected and complicate the jaw fracture with osteomyelitis. In the future, the formation of a follicular cyst is also possible. Similar complications can develop when a fragment is displaced and its sharp edges are embedded in the tissues of the follicle. In order to determine the relationship of the fracture line to the dental follicle, it is necessary to take x-rays in two directions - in profile and frontal. To avoid overlap of primary teeth with permanent images, photographs should be taken with the mouth half-open. For a fracture of the lower jaw under the age of 3 years, you can use a palatal plate made of plastic with imprints of the chewing surfaces of the dentition of the upper and lower jaws (splint-guard) in combination with a chin sling.

Technique for making a plate-shaped splint.

After some psychological preparation of the little patient, an impression is taken from the jaws (first from the upper, then from the lower). The resulting model of the lower jaw is sawed into two parts at the fracture site, then they are combined with a plaster model of the upper jaw in the correct ratio, glued with wax and plastered in an occluder. After this, take a well-heated semicircular wax roller and place it between the teeth of the plaster models to get an impression of the dentition. The latter should be at a distance of 6-8 mm from each other. The wax roller with the plate is checked in the mouth and, if necessary, it is corrected. Then the plate is made of plastic according to the usual rules. This device is used in conjunction with a chin sling. The child uses it for 4-6 weeks until the jaw fragments heal. When feeding the baby, the device can be temporarily removed, then immediately reapplied. Food should be given only in liquid form.

In children with chronic osteomyelitis, pathological fractures of the lower jaw are observed. To prevent them, as well as displacement of jaw fragments, especially after sequestrotomy, splinting is indicated. Of the wide variety of tires, preference should be given to the Vankevich tire as modified by Stepanov as more hygienic and easily portable.

Impressions from both jaws are taken before sequestrotomy. Plaster models are plastered into the occluder in the position of central occlusion. The palatal plate of the splint is modeled with an inclined plane downwards (one or two depending on the topography of the possible fracture), towards the lingual surface of the chewing teeth of the lower jaw. It is recommended to fix the device using arrow-shaped clasps.

In case of jaw fractures between the ages of 21/2 and 6 years, the roots of the baby teeth are already formed to one degree or another and the teeth are more stable. At this time, the child is more easily persuaded. Orthopedic treatment can often be carried out using stainless steel wire splints with a thickness of 1-1.3 mm. The splints are strengthened with ligatures to each tooth along the entire length of the dentition. In case of low crowns or tooth decay due to caries, plastic mouthguards are used, as already described above.

When applying wire ligatures, it is necessary to take into account some anatomical features of the primary teeth. Baby teeth are known to be short and have convex crowns, especially in the posterior teeth. Their larger circumference is located closer to the neck of the tooth. As a result, wire ligatures applied in the usual way slip off. In such cases, special techniques for applying ligatures are recommended: the ligature is wrapped around the tooth around the neck and twisted, forming 1-2 turns. The ends of the ligature are then pulled over and under the wire and twisted in the usual way.

For jaw fractures between the ages of 6 and 12 years, it is necessary to take into account the characteristics of the dentition of this period (resorption of the roots of baby teeth, eruption of the crowns of permanent teeth with unformed roots). Medical tactics depend on the degree of resorption of baby teeth. When their roots are completely absorbed, the dislocated teeth are removed; if they are incomplete, they are splinted, preserving them until the permanent teeth erupt. When the roots of baby teeth are broken, the latter are removed, and the defect in the dentition is replaced with a temporary removable denture to avoid bite deformation. To immobilize fragments of the lower jaw, it is advisable to use a soldered splint, and as supporting teeth it is better to use the 6th teeth as more stable and primary fangs, on which crowns or rings are applied and connected with a wire arch. In some cases, it is indicated to make a mouthguard for a group of chewing teeth with hooking loops for intermaxillary fixation of jaw fragments. At the age of 13 years and older, splinting is usually not difficult, since the roots of the permanent teeth are already sufficiently formed.

Complications during ligature binding of teeth

T injury to the interdental papilla and marginal zone of the gums, necrosis of the interdental papilla.

Scaling the ligature when transporting the patient

Dislocation of bone fragments

Development of asphyxia (dislocation - when bone fragments are displaced during manipulation, or aspiration in the event of vomiting or bleeding during transportation of the patient)

Loose teeth

Prevention of complications - carry out manipulations carefully, having previously removed the tartar, use a wire of appropriate thickness, tightly cover the neck of the tooth and twist the end of the ligature under tension, clearly determine the indications and contraindications for inter-maxillary ligature tying of teeth, the choice of teeth to be tied taking into account location and nature of the fracture, when twisting the ligatures, ensure sufficient digital reposition of the fragments.

Conclusions. Ligature binding of teeth is a method of temporary (transport) immobilization, which can be successfully used in patients with fractures of the lower jaw to transport the patient from the scene of an accident or a separate medical institution to a specialized inpatient department, if the provision of comprehensive medical care in these conditions is impossible. Ligature binding of teeth is used for a period of no more than 3-5 days.

The use of ligature bonding of teeth is possible only with clear indications in the absence of contraindications and the impossibility of using another, more effective method of fixation (for example, double-jaw splinting).

The most appropriate ligature binding of teeth with inter-jaw fixation, for example, according to the Ivey method

Ligature binding should be carried out quickly, carefully, avoiding injury to the soft tissues of the gums, tightly encircling the neck of the tooth, twisting the wire ligatures under tension, clockwise. Bend the twisted ends to avoid injury to the mucous membrane.

It is advisable to combine ligature binding of teeth with a chin-parietal bandage.

In some cases, it is advisable to use other means of transport immobilization - a standard transport bandage with a chin sling, a chin-parietal bandage and others.

Indications for ligature bonding of teeth.

Fractures of the lower jaw within the dentition, if each fragment contains at least 2 stable teeth that have antagonists in the upper jaw.

Fractures of the lower jaw in the area of the angle and ramus with slight displacement, if the risk of significant dislocation of a small fragment during transportation is minimal.

For fixing loose teeth due to tooth decay or other reasons.

Contraindications to ligature bonding of teeth

Maxillary fracture

Fractures of the alveolar processes of the jaws

Lack of a sufficient number of stable teeth in the lower and upper jaw, loose teeth

Fractured, unstable fractures of the lower jaw, or fractures with a bone defect.

Fractures outside the dentition with significant displacement

The risk of early post-traumatic complications during transportation of the patient - asphyxia, bleeding, vomiting, etc.

Postoperative DEFECTS OF THE maxillofacial AREA

Postoperative defects of the maxillofacial area are usually the result of surgical operations for neoplasms. Particularly difficult clinical situations arise after jaw resection. Replacement of defects formed after significant operations is carried out mainly by prosthetics. Problems that an orthopedic dentist has to solve related to restoring the patient’s appearance, tongue, swallowing and chewing functions. Particular care should be taken when preserving the remaining teeth in the oral cavity. Solving these complex problems requires close collaboration between the oral surgeon and the orthopedic dentist.

Orthopedic treatment of patients after jaw resection should be staged. The staged approach consists in carrying out direct and remote prosthetics.

Direct prosthetics solves the following problems: it allows you to correctly form the future prosthetic bed, fix jaw fragments, prevent speech disorders and chewing function, prevent the formation of large and deformable scars, severe facial deformations and distortion of appearance, and allow you to create a sparing treatment regimen. Direct prosthetics are not performed in the case of economical resection of the lower jaw while maintaining bone integrity and in case of resection of the lower jaw with simultaneous bone grafting.

Remote prosthetics are carried out after the final formation of the prosthetic bed, after 3-4 months.

PROSTHETICS after resection of the UPPER JAW

In the upper jaw, a distinction is made between resection of the alveolar process, unilateral and bilateral resection of the body of the upper jaw.

Orthopedic care for patients with resection of the alveolar process is provided according to the method proposed by I.M. Oksman, thus. The immediate prosthesis is made before surgery using models of the jaws. In particular, a fixing plate of the clasps is made and checked in the oral cavity. An impression is taken from the upper jaw along with the fixing plate and the model is cast. Models of the jaws are cast into the occluder in the position of central occlusion. On the model, the teeth and alveolar process are cut off according to the plan outlined by the surgeon. The phantom osteotomy line should extend 1-2 mm inward from the osteotomy line. This is necessary so that there is room for epithelization of the wound.

A part is modeled from wax, replaced, and the teeth are set. Replacing wax with plastic follows the usual method. The prosthesis is fixed in the oral cavity on the operating table. Correction of occlusion and edges of the prosthesis is carried out no earlier than 2-3 days after fixation.

Remote prosthetics are carried out using small saddle-shaped arch and plate prostheses with retaining and support-retaining clasps. The use of a telescopic fixation system is indicated in the presence of teeth with healthy periodontal tissues.

Prosthetics for patients after unilateral resection of the upper jaw are carried out by direct prosthetics according to the method of I.A. Oksman. This type of prosthetics is carried out in three stages. First, the fixing part of the prosthesis with clasps for the supporting teeth is made on a model obtained from an impression from the upper jaw. The fixing plate is checked in the oral cavity and an impression is taken along with it. At the same time, an impression is taken from the lower jaw, models are cast and cast in an occluder, after which the resection part of the prosthesis is manufactured (second stage).

On the model of the upper jaw, the resection boundary is indicated according to the operation plan. On the side where there is a tumor, one tooth is cut off at the level of its neck so that in the future the prosthesis does not create obstacles to the epithelization of the bone wound. The remaining teeth are cut together from the alveolar process to the apical base. The surface of the fixing plate is made rough, and the resulting defect is filled with wax and artificial teeth are placed in occlusion with the teeth of the lower jaw. Artificial final molars and premolars are modeled with a roller that goes in the anteroposterior direction. In the postoperative period, the cushion forms a bed in the buccal mucosa, which in the future will serve as a point of anatomical retention. The wax reproduction of the prosthesis is replaced with a plastic one. After the operation, the prosthesis is fixed to the postoperative wound.

After epithelization of the wound surface, an occluding part of the prosthesis is made (third stage). The palatal part of the prosthesis is cut down with a milling cutter to a thickness of 0.5-1 mm, covered with a layer of quick-hardening plastic so that a roll of plastic dough is formed along the edges of the prosthesis to obtain an impression of the edges of the postoperative cavity. After 1-2 minutes, the prosthesis is removed from the oral cavity and after final polymerization, the plastic is processed and polished. The patient uses such a prosthesis for 3-6 months under constant medical supervision.

Remote prosthetics are performed after complete epithelization of the wound. Resection of half of the upper jaw leads to changes in the conditions of fixation of the prosthesis. In this case, the prosthesis has one-sided bone support, increases the range of vertical movements and leads to overload of the supporting teeth.

When drawing up a treatment plan, the condition of the periodontal tissues should be taken into account. If there are changes, then splinting is necessary; fixation will be ensured if the number of clamp fixation points is increased. To prevent displacement of the prosthesis from the prosthetic bed, it is advisable to use flexible connections of me-mers with the base of the prosthesis. To improve fixation, E.Ya. Vares suggests using a dentomirco clasp. To prevent displacement of the resection prosthesis in the vertical direction, it is necessary to reduce its weight. It is recommended to use the design of a resection prosthesis for the upper jaw according to the method of E.Ya. Vares.

ORTHOPEDIC CARE after resection of the LOWER JAW

When planning the amount of necessary orthopedic care for patients after surgical operations performed on the lower jaw, it is necessary to take into account the severity of their condition. Most often, such operations are resection of the chin of the lower jaw, resection of half of the lower jaw, removal of the entire lower jaw, resection of the lower jaw with bone grafting.

Depending on the type of resection, the size of the bone defect, and the number of remaining teeth in the jaws, the treatment problem is solved using direct or remote prosthetics.

Thus, after resection of the chin of the lower jaw, a bone tissue defect is formed with a violation of its integrity. The main tasks of prosthetics in this case are: fixing bone fragments in the correct position and preventing their displacement, restoring the patient’s appearance, tongue, chewing and swallowing functions, replacing a postoperative bone defect, forming a prosthetic bed, preserving the remaining teeth.

In order to prevent the fragments from moving inward, if bone grafting is postponed for some time, direct prosthetics are performed or splints are used. The Vankevich splint or the Rudko and Chulki extraoral devices are used. These devices are used in cases of significant bone tissue defects, in the presence of a small number of remaining teeth, and periodontal tissue diseases.

The use of direct prosthetics leads to functional overload of the supporting teeth and their subsequent removal. Direct prosthetics are indicated in cases of minor bone defects and stable remaining teeth. According to Oksman's method, direct prosthetics are carried out in two stages.

Before the surgical procedure, an impression is taken from the lower jaw, two removable plates are made (for placement on the left and right sides) with support-retaining clasps and adjusted in the oral cavity. After that, an impression is taken from the lower jaw again, but with fixing plates in the oral cavity. At the same time, an impression is taken from the upper jaw and models are cast, and they are plastered in an occluder. According to the surgical plan outlined by the surgeon, teeth with a significant part of the alveolar process and the chin are cut from the plaster model. The defect is filled with wax and artificial teeth are placed. The incisor block, sometimes the fangs, is made removable so that the tongue can be fixed in the postoperative period to prevent asphyxia. The anterior part of the prosthesis is modeled with a slight mental protrusion to form the soft tissues of the lower lip and chin. The chin protrusion is made dismountable, polymerization is carried out separately and only after removal of the sutures it is connected to the prosthesis using quick-hardening plastic.

The orthopedic dentist has to solve complex problems after resection of half of the lower jaw. Resection of half of the lower jaw can be combined with disarticulation or carried out within the body of the jaw while preserving its branches.

Removing half of the lower jaw along with the branch significantly worsens the conditions for providing orthopedic care. With such a clinical picture, the method of direct prosthetics according to I.M. Oksman is used.

The jaw prosthesis consists of two parts - fixing and resection. The fixing part is made from multi-clamp fixation according to the model of the lower jaw. The fixing plate has an inclined platform, which can be removable or non-removable; it keeps fragments of the jaw from moving and is placed on the synchronous side of the teeth on the healthy part of the jaw.

After adjusting the fixing plate along with it in the mouth, an impression of the lower jaw is taken, as well as an auxiliary anatomical impression of the upper jaw. Models are cast and plastered in an occluder. The model indicates the boundaries of the upcoming surgical intervention. Stepping back from the operation line, it is necessary to cut off two plaster teeth bordering the tumor at the level of their necks so that the immediate prosthesis does not interfere with the epithelization of the mucous membrane on the bone fragment. The teeth that are in the projection of the tumor are cut 2-3 mm below the base of the collar part. Modeling of the resection part of the prosthesis and installation of artificial teeth are carried out. The base behind the dentition should be somewhat extended and thickened. The lower edge of the prosthesis should have a rounded shape and a concavity on the lingual side with a sublingual ridge. Further production of the prosthesis is carried out using generally accepted technology.

Remote prosthetics are performed after epithelization of the wound. Difficulties with remote prosthetics are mainly associated with fixing the prosthesis on the prosthetic bed and preserving the teeth on the bone fragment of the jaw.

It is necessary to use more flexible connections between the clasps and the prosthesis base and splinting the teeth remaining with crowns. In order to prevent traumatic damage along the osteotomy line, it is necessary to isolate the edges of the base.

Providing orthopedic care to patients after removal of the entire lower jaw is a very big problem, which lies primarily in the impossibility of fixing the post-resection prosthesis, because, having a bone base, the prosthesis cannot be fixed, and it becomes unsuitable for food. In this case, the task of orthopedic treatment comes down to restoring the contours of the face and speech function.

The technique for making a prosthesis is as follows. Before the operation, using the obtained models, all teeth on the lower jaw are cut off at the level of the base of the collar part. The base of the prosthesis is modeled and artificial teeth are installed. The wax composition is removed from the model and extended behind the dentition at the angles of the lower jaw. The inner surface of the prosthesis should have a rounded shape, but the lingual side in the area of the lateral teeth, the base of the prosthesis should be concave, with a hyoid protrusion. All this is done with the aim of at least a slight fixation in the oral cavity.

Initially, after the operation, the prosthesis is fixed with the help of fastening loops to the teeth of the upper jaw, and then a Fauchard spiral spring is used.

To prevent chronic injury to the mucous membrane of the cheek, a niche is made in the prosthesis, and the spring itself is placed in a protective cover.

Prosthetics for patients after resection of the lower jaw with bone grafting are usually carried out after 7-8 months, when the bone graft has engrafted.

Prosthetics for such patients has its own characteristics that must be taken into account. First of all, this is an unusual prosthetic bed, the presence of large scars on the oral mucosa, the presence of a transition of the healthy collar part into the operation line, and the unusual placement of healthy teeth in relation to the artificial collar part. It is also necessary to take into account that the graft is not adapted to absorb chewing pressure. All these features must be remembered when taking impressions using silicone imprinting masses, and the finished prosthesis itself must have an elastic gasket in the projection of the graft. Fixation is carried out using support-retaining class-mers using healthy teeth on the opposite side of the jaw.

PROSTHETICS FOR FACIAL DEFECTS

Facial defects are formed as a result of gunshot wounds, mechanical damage and after removal of tumors. Specific inflammatory processes (syphilis, tuberculous lupus) lead to the appearance of defects in the nose and lips. Such facial distortions are usually very difficult for patients to bear; they become withdrawn, which is often the cause of neuroses. Loss of performance is caused by the loss of a large area of facial skin. Defects in the soft tissues surrounding the oral cavity cause food to fall out during chewing and constant drooling. Facial defects are eliminated through plastic surgery and prosthetics. Prosthetics are performed when the patient refuses surgery, as well as when it is necessary to replace significant and complex defects (ear, nose).

Prosthetics is aimed at restoring the patient’s appearance and language, protecting tissues from environmental influences, and eliminating psychological disorders. So, orthopedic treatment for facial defects completes the complex of measures for the rehabilitation of patients with damage to the facial area.

Facial prosthetics are usually made of soft or hard plastic, in some cases a combination of the two. It is important to ensure that the color of the prosthesis matches your facial skin color as closely as possible.

Soft plastics (orthoplast) are painted with special dyes, which are selected according to color. A denture made of hard plastic can be painted over in two ways. The best results are obtained when using oil paints. The second method is to add dyes to the polymer (ultramarine, crown lead, cadmium red). The required color is obtained by adding dyes to the polymer powder as well as to the monomer.

Ectoprostheses are fixed using spectacle frames, special clamps inserted into natural and artificial holes, by gluing to the skin of the face or connecting them with jaw prostheses.

Orthopedic treatment in case of significant facial defects requires the manufacture of a mask. The patient is placed in a horizontal position, the defect is covered with gauze, rubber tubes are inserted into the nasal passages, and if there is no nasal breathing, the patient holds the tube with his lips. The hairy parts of the face are smeared with Vaseline, and the hair is hidden under a scarf. The face is covered with a layer of plaster approximately 1 cm thick. Liquid plaster is first applied to the forehead, eyes, nose, then to the cheeks and chin, then covered with a thick layer of plaster. The patient is asked to lie still; it is necessary to explain that the procedure is completely harmless and does not pose any threat. After crystallization of the plaster, the imprint on the face is removed with an anterior and slightly downward movement to prevent the occurrence of a hematoma on the back of the nose. The plaster print must be immersed in a soap solution for 15-20 minutes.

The face mask can be simple and dismountable. A simple mask is cast monolithically over a plaster print. A dismountable plaster model of the face is necessary to connect the ectoprosthesis with the jaw prosthesis.

The facial prosthesis should be light and thin-walled. It is very important that the edge of the prosthesis fits tightly to the skin.

The auricle prosthesis is made as follows. Remove the mask from the face, where the area should be recorded in detail and will be restored. After that, a wax modeling of the auricle is carried out, the shape and size corresponds to the auricle of the opposite side. At the same time, a piece of softened wax is stuck into the external auditory canal to display its relief. A wax reproduction of the auricle is glued to a reproduction of the external auditory canal and, after detailed processing, a collapsible model is cast from marble or other high-quality super plaster. The wax reproduction is then released from the plaster mold and stored for control purposes. Melted wax is again poured into the plaster mold, the new wax reproduction obtained under this condition is plastered into the ditch and the wax is replaced with elastic plastic.

According to B.D. Kabakov, in wartime (the experience of the Great Patriotic War), injuries to the maxillofacial area accounted for 93-95% of the total number of injuries, burns - 2-3%, concussions - 2-3%. In the conditions of modern war and the use of nuclear weapons, it is assumed that damage to the maxillofacial area will be only 20% (burns 8%, trauma 6%, radiation injuries 6%), and combined - 80% (burn + trauma - 60%, burn + radiation damage - 5%, trauma + radiation + burn - 10%). It becomes clear that severe injuries will predominate.

In the era of industrialization and automation, the number of man-made disasters is growing, and with them the number of injuries to the maxillofacial and craniofacial areas. The increasing intensity of injuries suggests that its danger for people under 60 years of age is higher than cardiovascular diseases and cancer.

According to numerous statistics, in road accidents in 70% of cases the head is injured, in other types of accidents the frequency of head injuries is 30%. Trauma to the midface and jaws in Europe is steadily increasing. The ratio of fractures in the middle part of the face and jaws is currently approaching 1+1 or 1+2, as road accidents, household, sports and industrial injuries are becoming more frequent. The incidence of trauma in men is 7 times higher than in women. Currently, among the fractures of the bones of the facial skeleton: 71% are fractures of the lower jaw, 25% are fractures of the middle part of the face, 4% are combined injuries of the middle and lower parts of the face.

Among fractures of the lower jaw: 36% - condylar process, processus condylaris; 21% - jaw angle; 3% are ramus, and the remaining part are fractures in the area of canines, premolars, molars.

A fracture is a partial or complete disruption of the integrity of a bone under the influence of increased mechanical load or a pathological process.

By etiological sign jaw fractures are distinguished:

Traumatic:

Firearms;

Non-gunshot, according to the number of fragments they can be: V single;

V double;

V triple;

V multiple;

V bilateral;

Pathological (spontaneous) fractures occur as a result of a disease process in the bone or body, for example, osteomyelitis, bone tumors, syphilis, tuberculosis.

By nature of the fracture jaws are distinguished:

Complete (the continuity of the jaw is disrupted);

Incomplete. Fractures also share:

To open;

Closed.

Depending on the fracture line, there are:

Linear;

Fragmentation;

Transverse;

Longitudinal;

Oblique;

Zigzag;

Within the dentition;

Outside the dentition.

Given the wide variety of fractures, detailed classifications of jaw fractures are used to correctly diagnose and select a treatment method for patients. The most informative classifications are V.Yu. Kurlyandsky, Z.Ya. Shur, I.G. Lukomsky, I.M. Oksman.

12.1. PRINCIPLES OF COMPREHENSIVE TREATMENT OF GUN AND NON-GUN FRACTURES

When treating jaw fractures, there are 4 types of help:

First aid at the scene of an accident - it is provided by the victim himself or by strangers;

First aid or medical aid - provided by a nurse, paramedic, dentist or ambulance doctor;

Simple outpatient treatment (outpatient specialized treatment) - carried out by a dentist on an outpatient basis;

Complex specialized treatment (inpatient treatment) is carried out by a dentist in a specialized medical institution.

The basic principles of treatment at all stages are timeliness, individuality, complexity, continuity, simplicity and reliability of methods for treating injuries to the facial bones while preserving the function of the lower jaw and temporomandibular joint, as well as early functional treatment.

First aid consists of preventing complications after injury, combating pain shock, bleeding, and asphyxia. The patient is placed on his side or stomach. If there is no dressing material when providing first aid, you can make a bandage from any piece of material folded into a triangular scarf. For fractures of the lower jaw, a curved piece of cardboard, plywood or other dense material can be used as an improvised sling splint. This splint is lined with cotton wool, wrapped in gauze and secured with a circular headband or sling-shaped bandage.

The most important thing is to ensure free breathing, eliminate asphyxia, which can occur due to the displacement of the tongue back, closing the lumen of the trachea with a blood clot or a removable prosthesis.

First medical aid (transport immobilization) consists of providing transport immobilization and covering the wound surface with a gauze bandage, pain relief and ensuring delivery of the victim to the hospital. To prevent asphyxia, it is necessary to carefully examine the oral cavity, remove blood clots, foreign bodies, mucus, food debris, vomit, and move the angle of the lower jaw forward. If these measures do not allow the airway to be cleared, a tracheotomy must be performed. The simplest and fastest method is conicotomy (dissection of the cricoid cartilage) or thyrotomy (dissection of the thyroid cartilage), a cannula is inserted into the gap formed.

Temporary splinting of fragments serves as one of the means of preventing shock; it is integral to stopping bleeding or preventing it, to stop pain. In peacetime, transport immobilization is carried out by doctors or paramedics at ambulance stations or doctors at local hospitals.

To temporarily secure fragments of the upper and lower jaw, you can use standard transport sling-like bandages, splints, and D.A. slings. Entina, set by Ya.M. Zbarzha (Fig. 12-1). The chin sling is used for a period of 2-3 days, when there are a sufficient number of teeth fixing the bite.

To immobilize fragments of the lower jaw and for fractures of the alveolar process of the upper jaw, ligature binding of the jaws with bronze-aluminum wire with a diameter of 0.5 mm can be used. Additional

Rice. 12-1.Standard chin sling according to D.A. Entinu is attached using a headband from the standard set of Ya.M. Zbarzha

Finally, after this, fixation is carried out with a chin-parietal sling bandage. For fractures of edentulous jaws, patient dentures can be used as a transport splint in combination with a chin sling.

To strengthen transport tires, there are special headbands - caps, which are a circle of fabric, a head hoop with head rolls and hooks or loops for fixing rubber tubes.

Depending on the severity and nature of the traumatic injury, simple outpatient treatment (outpatient specialized treatment) can be carried out, which is carried out by a dentist on an outpatient basis, or the patient can be transported to an inpatient dental department, where he will undergo complex specialized treatment. Outpatient treatment is usually carried out in cases of uncomplicated fractures of the lower jaw, as well as fractures of the alveolar process of the upper jaw when inpatient treatment is impossible or refused.

Treatment of jaw fractures has 2 goals: restoration of anatomical integrity, restoration of the functions of the affected elements of the dental system.

To do this, it is necessary to compare the fragments into the correct position (reposition) and hold them (immobilization) until the fracture heals. For these tasks, orthopedic and surgical treatment methods are used.

Specialized treatment usually begins with an examination, which is carried out with an x-ray determination of the nature of the fracture. If necessary, in addition to the dentist, the examination involves surgeons, traumatologists, neurosurgeons, otolaryngologists, ophthalmologists, resuscitators, etc.

Depending on the clinical picture, the doctor chooses the method of pain relief.

In case of multiple and combined fractures of the facial skeleton, after removing the victim from a state of shock under general anesthesia, measures are taken to immobilize the fragments using methods that do not interfere with the revision of the bronchial tree, the function of the lower jaw, feeding and oral care.

Therapeutic tactics for traumatic brain injury depend on its type and severity. In case of respiratory failure, bleeding, or increasing symptoms of pneumothorax, surgical treatment is first performed, and then immobilization of the damaged facial bones is performed.

The choice of treatment method for injuries to the facial skeleton depends on the nature and severity of the dominant injury, the general condition and age of the patient, as well as the location and nature of the displacement of fragments.

The most common method of orthopedic treatment is dental wire splinting, proposed by S.S. Tigerstedt during the First World War (1916). In 1967 V.S. Vasilyev developed a standard stainless steel tape splint with ready-made hooks (Fig. 12-2).

Rice. 12-2. Splints for dental splinting for jaw fractures: a - bent wire splint S.S. Tigerstedt; b - standard tape splint for intermaxillary fixation according to V.S. Vasiliev

Distinguish bent tires from wire:

Smooth splint;

Smooth tire with spacer;

Tire with hook loops;

A tire with hook loops and an inclined plane;

Splint with hook loops and intermaxillary traction. For splinting The following tools are needed:

Crampon tongs;

Pliers;

Anatomical and dental tweezers;

Needle holder;

Clamp;

Dental mirror;

Metal file;

Crown scissors.

From materials required:

Aluminum wire 1.5-2 mm thick in pieces of 25 cm;

Bronze-aluminum or copper wire 5-6 cm long, 0.40.6 cm thick;

Rubber drainage tube with a 4-6 mm hole for rubber rings;

Dressing.

Before applying a splint, it is necessary to free the patient’s mouth from food debris, plaque, broken teeth, bone fragments, blood clots with gauze balls soaked in a 3% solution of hydrogen peroxide, followed by irrigation with potassium permanganate 1÷1000. If necessary, anesthesia is performed.

When fitting and applying aluminum tires(Fig. 12-3) certain requirements must be adhered to.

The splint must be curved along the vestibular surface of the dentition in such a way that it adheres to each tooth at least at one point. It is not necessary to bend it along the contours of the crowns of the teeth.

The splint should not be adjacent to the gum mucosa to avoid the formation of bedsores.

The ends of the splint are bent in the form of a hook around the distal tooth in the shape of an equator or in the form of a spike and inserted into the interdental space of the distal teeth from the vestibular side.

Rice. 12-3.Types of wire busbars: a - smooth busbar-bracket; b - Schelhorn tire; c - wire tire with a sliding hinge according to Pomerantseva-Urbanskaya; d - smooth wire splint for an impacted fracture

The arch is bent with the fingers along the dentition with frequent correction in the oral cavity, avoiding repeated bending.

It is unacceptable to forcibly press the splint against the teeth to avoid pain and displacement of fragments.

If there is a defect in the dentition, a loop is bent on the splint in the shape of the letter P, the upper crossbar of which corresponds to the width of the defect and faces the oral cavity.

The loops are bent using crampon tongs. The distance between the loops is no more than 15 mm, 2-3 loops on each side. The hook loop should be no more than 3 mm long and bent at an angle of 45° to the gum. The loops should not injure the oral mucosa.

The splint is fixed with ligatures to as many teeth as possible. The ligatures are twisted clockwise, the excess is cut off and folded towards the center so that they do not injure the mucous membrane.

Smooth splint shown:

For fractures of the alveolar process, if immediate reduction of the fragments is possible;

With median fractures of the lower jaw without vertical displacement of fragments;

For fractures within the dentition, if it is not accompanied by vertical displacement of fragments;

In case of bilateral and multiple fractures of the lower jaw within the dentition, when a sufficient number of teeth are preserved on each fragment.

For the same indications, standard V.S. tires can be used. Vasilyeva.

A smooth splint with a spacer is used for fractures with a defect in the dentition.

In case of vertical displacement of fragments in the event of a fracture within the dentition, splints with hooking loops are used.

Splints with intermaxillary traction are used to treat fractures behind the dentition. When treating fractures with vertical displacement of fragments, a direct intermaxillary rubber traction is used. For the treatment of fractures with displacement of fragments in two planes, oblique intermaxillary traction is indicated.

For fractures of the lower jaw with a small number of teeth on the fragments or in their complete absence, V.F. bone-based extraoral devices are used. Rud-ko, Ya.M. Zbarzha.

In order to simplify the technique of manufacturing dental splints and improve the fixation of fragments of the lower jaw, it is proposed to use quick-hardening plastic, the main indication for use of which is the fastening of bone fragments after they are established in the correct position.

For fractures in the lateral sections, for osteomyelitis of the lateral section, to prevent displacement of fragments in the case of a pathological fracture during surgery, a stable inclined plane is used, which consists of 2-3 crowns made on the lateral teeth of the undamaged side, or a soldered splint, on the vestibular side of which solder a stainless steel plate. The plate rests on the vestibular surface of the antagonist teeth of the upper jaw. Its edge should not be higher than the necks of the teeth of the upper jaw with the teeth closed, so as not to injure the mucous membrane. The plate is soldered to the crowns of the lower teeth just below the equator so that it does not interfere with the closure of the teeth.

In case of bilateral fractures of the lower jaw with a downward displacement of the median fragment, the lateral fragments are separated and fixed in the correct position with a steel wire arch, and the short fragment is pulled upward using intermaxillary traction. The treatment is completed with a smooth splint-brace after all fragments have been established in the correct closure of the teeth.

In case of a fracture of the lower jaw with one toothless fragment, it is secured with a bent splint with a loop and a thermoplastic lining. The fragment with teeth is strengthened with wire ligatures to the teeth of the upper jaw.

For the treatment of single fractures of the lower jaw with complete mobility of fragments, in the case of a small number of teeth on the fragments or mobility of all teeth, a removable Weber subgingival splint is used (Fig. 12-4). This splint covers the entire remaining dentition and gums on both fragments, leaving the chewing and cutting surfaces of the teeth open. It can be used for post-treatment of fractures of the lower jaw.

Rice. 12-4.Weber tire: a - stage of manufacturing the wire frame of the tire; b - finished tire

For fractures of the toothless lower jaw and absence of teeth in the upper jaw, Gunning-Port and Limberg apparatuses are used in combination with a chin sling (Fig. 12-5).

Among fractures of the upper jaw, fractures of the alveolar process are most often noted. They can be without offset or with offset. The direction of displacement of the fragment is determined by the direction of the acting force. Basically, the fragments are displaced back or towards the midline.

First aid for treatment alveolar bone fractures comes down to placing the fragment in the correct position and applying a sling or external bandage so that the antagonist teeth are tightly closed. An elastic sling bandage can be successfully used. Simple specialized treatment of alveolar bone fractures is carried out with a smooth aluminum or steel splint. First, the fragment is reduced

Rice. 12-5.Devices used for the treatment of jaw fractures with complete absence of teeth: a - Gunning-Port apparatus; b - Limberg apparatus

with your hands and with your teeth closed, bend the splint-bracket onto the upper row of teeth. Then wire ligatures in the form of pins are threaded between all the teeth and their ends are brought out into the vestibule of the mouth. The splint is fixed to the teeth of the undamaged side, the patient is asked to close the teeth in the correct position, a sling is applied, and then the fragment is tied to the splint-bracket. The sling is removed after complete fixation of the staple. If there are contraindications to a splint-bracket, a full splint is made with the support crowns placed on the teeth of the undamaged area and the fragment.

At fractures of the body of the upper jaw(suborbital and subbasal) with free mobility of fragments, first aid comes down to placing the fragments in the correct position and fixing them to the head cap. For this purpose, standard devices are used: Entin, Limberg spoon splints, and a rigid chin sling. Sling bandages are effective if the lower jaw is not damaged and there are at least 6-8 pairs of antagonist teeth on both jaws. Standard spoon splints are applied for 1-2 days. Their main disadvantages include: bulkiness, weak fixation of fragments, unhygienic conditions, inability to monitor the correct installation of the damaged upper jaw, since the spoon splint covers the entire dental

row.

Simple specialized treatment comes down to immediate reduction and fixation of fragments in the correct position. For this purpose, individual wire tires are used: solid and composite. Intraoral and extraoral processes-levers, connected to splints, are attached to a plaster cap. For the treatment of fractures of the anterior jaw Ya.M. Zbarzh proposed a solid-bent tire made of aluminum wire (Fig. 12-6).

For the treatment of Le Fort type I and II fractures of the upper jaw Ya.M. Zbarzh developed a standard set consisting of an arch splint, a supporting bandage and connecting rods, which can simultaneously fix and reduce fragments. Complex specialized treatment of a fracture of the upper

Rice. 12-6.Apparatus for the treatment of fractures of the upper jaw according to Ya.M. Zbarzhu: a - plaster head cap; b - bent wire splint with extraoral processes fixed to the head cap

jaws with a downward displacement with free mobility of the fragment (suborbital fracture) and the integrity of the lower jaw are carried out using the method of intra-oral fixation with a Weber splint with extra-oral levers attached by means of elastic traction to the head bandage. It covers the teeth and mucous membrane of the gums around the dentition on the palatal and vestibular sides. Tubes are welded into the side sections on both sides, into which rods are inserted to connect to the headband. TO subgingival deficiencies splints include bulkiness, overlap of the mucous membrane of the alveolar process and hard palate, the need to obtain a full impression of the upper jaw, and weak fixation of the fragment. In order to eliminate the shortcomings of Z.Ya. Schur proposed replacing the Weber splint with a single soldered splint with tetrahedral tubes in the lateral sections to strengthen the extraoral rods in them. The outer ends of the rods are connected rigidly to the plaster cap by counter rods extending vertically down from the plaster cap.

When treating a simultaneous fracture of the upper and lower jaw, a dentogingival splint with extraoral whisker rods and hooks for intermaxillary fixation of fragments of the lower jaw, fixed to a soft head cap, proposed by A.A., is indicated. Limberg.

With timely immobilization of jaw fragments in non-gunshot fractures, they heal within 4-5 weeks. Usually, 12-15 days after the injury, a primary callus in the form of a dense formation can be detected along the fracture line. The mobility of bone fragments is noticeably reduced. By the end of the 4-5th week, and sometimes earlier, the mobility of the fragments disappears with a decrease in compaction in the fracture area - a secondary callus is formed. With radiographic examination, the gap between bone fragments can be determined up to 2 months after clinical healing of the fracture.

Therapeutic splints can be removed after the clinical mobility of the fragments disappears. Healing times for gunshot fractures are significantly increased.

Complex restorative treatment of fractures is carried out under the control of radiography, myography and laboratory research methods.

12.2. CLASSIFICATION OF COMPLEX MAXILLOFACIAL APPARATUS

Fixation of jaw fragments is carried out using various orthopedic devices. All orthopedic devices are divided into groups depending on their function, area of fixation, therapeutic value, design, manufacturing method and material.

By function:

Immobilizing (fixing);

Repairing (correcting);

Corrective (guides);

Formative;

Resection (replacement);

Combined;

Prostheses for defects of the jaws and face.

At the location of fixation:

Intraoral (single-maxillary, double-maxillary, intermaxillary);

Extraoral;

Intra- and extraoral (maxillary, mandibular).

For therapeutic purposes:

Basic (having independent medicinal value: fixing, correcting, etc.);

Auxiliary (serving for the successful performance of skin-plastic or osteoplastic operations).

By design:

Standard;

Individual (simple and complex).

By manufacturing method:

Laboratory production;

Non-laboratory production.

Based on materials:

Plastic;

Metal;

Combined.

Immobilizing devices are used in the treatment of severe jaw fractures, insufficient or absent teeth on the fragments. These include:

Wire tires (Tigerstedt, Vasiliev, Stepanov);

Splints on rings, crowns (with hooks for traction of fragments);

Tire guards:

V metal - cast, stamped, soldered; V plastic;

Removable tires by Port, Limberg, Weber, Vankevich, etc.

Reduction devices that facilitate the reposition of bone fragments are also used for old fractures with stiff jaw fragments. These include:

Reduction devices made of wire with elastic intermaxillary rods, etc.;

Apparatuses with intra- and extraoral levers (Kurlyandsky, Oksman);

Reduction devices with a screw and a repelling platform (Kurlyandsky, Grozovsky);

Reduction devices with a pelot for a toothless fragment (Kurlyandsky, etc.);

Reduction devices for toothless jaws (Guning-Port splints).

Fixing devices are devices that help hold jaw fragments in a certain position. They are divided:

For extraoral:

V standard chin sling with head cap; V standard tire according to Zbarzh et al.

Intraoral:

■V dental splints:

Aluminum wire (Tigerstedt, Vasiliev, etc.);

Soldered tires on rings, crowns;

Plastic tires;

Fixing dental appliances;

■ dental splints (Weber, etc.);

■ supragingival splints (Porta, Limberga);

Combined.

Guides (corrective) are devices that provide a bone fragment of the jaw with a certain direction using an inclined plane, a pilot, a sliding hinge, etc.

For aluminum wire buses, the guide planes are bent simultaneously with the bus from the same piece of wire in the form of a series of loops.

Inclined planes for stamped crowns and aligners are made of a dense metal plate and soldered.

For cast tires, the planes are modeled in wax and cast along with the tire.

On plastic tires, the guide plane can be modeled simultaneously with the tire as a single unit.

If there is an insufficient number or absence of teeth in the lower jaw, Vankevich splints are used.

Formative devices are devices that support plastic material (skin, mucous membrane), create a bed for the prosthesis in the postoperative period and prevent the formation of scar changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformations of the prosthetic bed, etc.). The design of the devices can be very diverse depending on the area of damage and its anatomical and physiological characteristics. The design of the forming apparatus includes a forming part and fixing devices.

Resection (replacement) devices are devices that replace defects in the dentition formed after tooth extraction, filling defects in the jaws and parts of the face that arise after injury or surgery. The purpose of these devices is to restore the function of the organ, and sometimes to keep jaw fragments from moving or the soft tissues of the face from retraction.

Combined devices are devices that have several purposes and perform different functions, for example: securing jaw fragments and forming a prosthetic bed or replacing a jaw bone defect and simultaneously forming a skin flap. A typical representative of this group is the Kappa-rod apparatus of combined sequential action according to Oxman for fractures of the lower jaw with a bone defect and the presence of a sufficient number of stable teeth on the fragments.

Prostheses used in maxillofacial orthopedics are divided into:

To the dentoalveolar;

Jaw;

Facial;

Combined;

When resection of the jaws, prostheses are used, which are called post-resection.

There are immediate, immediate and remote prosthetics. In this regard, prostheses are divided into operational and postoperative. Replacement devices also include orthopedic devices used for palate defects: protective plates, obturators, etc.

Prosthetics for facial and jaw defects are made in case of contraindications to surgical interventions or in case of persistent reluctance of patients to undergo plastic surgery.

If the defect affects a number of organs at the same time: nose, cheeks, lips, eyes, etc., a facial prosthesis is made in such a way as to restore all lost tissue. Facial prostheses can be supported by eyeglass frames, dentures, steel springs, implants, and other devices.

12.3. TREATMENT TECHNIQUE FOR RIGID FRAGMENTS

Simple specialized treatment of fractures of the lower jaw with limited mobility and stiffness of fragments is carried out with various devices that are well fixed on the jaw and have sufficient resistance to muscle traction. Limited mobility of fragments is observed when first aid is not provided in a timely manner or is carried out incorrectly. If the patient seeks help 2-3 weeks after the fracture, the position of the fragments is almost always incorrect.

For single fractures with horizontal displacement of fragments to the midline, S.S. splints are most widely used, as well as for the treatment of fractures with freely movable fragments. Tigerstedt with hook loops.

For fractures within the dentition with rigid fragments, splints with hooking loops are made for the upper jaw and a large fragment of the lower jaw, a rubber rod is installed, and a spacer is placed on the small fragment between the antagonist teeth to press it out. After stable comparison of the fragments, the splint is removed and treatment is completed with a single smooth splint. In some cases, it is advisable to leave the free end of the wire in the area of the small fragment, and after correcting the position of the fragments, bend it to the teeth of the small fragment and fix it with a ligature.

For bilateral and multiple fractures, along with Tiger-stedt splints, splints with vertical U- and L-shaped bends are shown, to which the fragments are pulled with ligatures. In case of fractures of the lower jaw with a shortened dentition or in the presence of a toothless fragment, Tigerstedt splints with hooking loops are applied to the large fragment and the upper jaw, and a pelot is made on the toothless fragment. In case of fractures, Tigerstedt splints with intermaxillary traction are applied behind the dentition, which are retained even after the position of the fragments is corrected. In this case, it is necessary to prescribe myogymnastics.

For the treatment of single fractures and fractures with a bone defect in the anterior section, the A.Ya. apparatus is used. Katz with intraoral spring levers. It consists of supporting elements - mouthguards or crowns, to which a flat or quadrangular tube is soldered on the vestibular side, and two rods. The advantage of the Katz apparatus is that it is possible to move fragments in any direction: parallel moving apart or bringing together fragments, moving fragments in the sagittal and vertical directions, moving apart or moving only in the area of the ascending branches and angles of the jaw, rotation of fragments around the sagittal (longitudinal) axes.

In case of complete avulsion of the upper jaw with stiff fragments (subbasal fracture) with posterior displacement and rotation around the transverse axis, traction is applied to a rod fixed to a plaster cast for simple specialized treatment. The rod is made of steel wire, its free end ends in a loop. A wire splint with hooking loops is placed on the teeth of the upper jaw. Using a rubber rod, the displaced jaw is pulled to a lever mounted on the headband.

In case of a unilateral complete avulsion of the upper jaw, when a sufficient number of teeth have been preserved on both jaws, reposition of the rigid fragment is achieved by intermaxillary traction. A splint with hooking loops is applied to the lower jaw, and the upper splint is attached only to the healthy side, where the hooking loops are made. On the affected side, the end of the splint is smooth and remains free. A rubber rod is placed between the hooking loops, and an elastic gasket is placed between the teeth on the fracture side. After repositioning the fragment, a splint is fixed to the teeth of the affected side.

12.4. ORTHOPEDIC TREATMENT METHODS FOR FALSE JOINTS

Consequences of maxillofacial trauma also include non-union of jaw fractures or false joint (pseudoarthrosis). The most characteristic sign of a non-united fracture is the mobility of jaw fragments. During the Great Patriotic War, about 10% of fractures of the lower jaw ended in the formation of a false joint. These were fractures predominantly with a bone defect.

Causes of pseudarthrosis formation can be general and local.

Common diseases include: tuberculosis, syphilis, metabolic diseases, dystrophy, vitamin deficiency, diseases of the endocrine glands, cardiovascular system, etc.

Local factors include: untimely or insufficient immobilization of jaw fragments, jaw fractures with a bone tissue defect, soft tissue (mucous membrane or muscle) getting between fragments, jaw osteomyelitis.

The mechanism of formation of a pseudarthrosis was once described by B.N. Byni-nym. Based on morphological studies, Bynin established that the process of fusion of bone fragments of the jaw, in contrast to the fusion of tubular bones, goes through only two stages: fibroblastic and osteoblastic, bypassing chondroblastic, i.e. cartilaginous. Thus, if any of the stages of callus development on the jaw are delayed, the process stops at

fibroblastic fusion of fragments without moving to the cartilaginous stage, which leads to mobility of fragments.

The radical and only treatment for pseudarthrosis is surgical - through osteoplasty (bone continuity is restored with a bone plate, followed by dental prosthetics). Many patients, for a number of reasons, cannot or do not want to undergo surgical interventions, but need dental prosthetics.

Prosthetics for pseudarthrosis has its own characteristics. A dental prosthesis, regardless of fixation (i.e., removable or fixed), at the site of the false joint must have a movable connection (preferably a hinge).

At the beginning of the Great Patriotic War, prosthetics for pseudarthrosis were quite widely carried out using bridges, i.e. by rigidly connecting jaw fragments. The immediate results were very good: the jaw fragments were fixed, and the chewing function was sufficiently restored. However, in the first 3 months, and sometimes even in the first days, the intermediate part of the prosthesis broke. If it was strengthened with an arch or made thicker, the crowns became uncemented or the supporting teeth became loose.

A.Ya. Katz explained this by saying that when the mouth opens, the fragments still move, and when the mouth closes, they move back and take their original position. In this case, the supporting teeth are dislocated, structural changes occur in the metal, its “fatigue” occurs, and the body of the bridge prosthesis breaks.

To eliminate these complications, I.M. Oksman proposed using hinged bridges rather than monolithic ones. The hinge is placed at the site of the false joint. At the same time, you should know that bridges are indicated if the false joint is located within the dentition and there are 3-4 teeth on each fragment. The bone defect should not exceed 1-2 cm. The supporting teeth must be stable. Usually 2 teeth are selected on each side of the defect. The production of a bridge prosthesis is usual, with the only difference being that its intermediate part is divided along the line of the false joint into 2 parts connected by a hinge. The hinge (in the form of a “dumbbell”) is introduced into the wax composition before it is cast from metal. This design provides microexcursion of the prosthesis in the vertical direction.

If the fragments contain only 1-2 teeth, or there are toothless fragments, or the bone defect exceeds 2 cm, then removable dentures with a movable joint should be used (Fig. 12-7).

It should be remembered that hinged prostheses are indicated only when fragments are mobile in the vertical plane, which is very rare. Much more often a shift is observed

Rice. 12-7. Removable prosthesis for pseudarthrosis

fragments in the lingual direction horizontally. In these cases, it is not hinged joints that are indicated, but conventional removable dentures, during the manufacture of which it is necessary to carry out the functional formation of the entire internal surface of the base, especially in the area of the jaw defect, with the elimination of areas of greatest pressure. This allows the fragments to move with the presence of a prosthesis in the oral cavity in the same way as without it, which eliminates injury to the fragments of the lower jaw by the base of the prosthesis and ensures the successful use of it. It must be remembered that only those fragments that are approximately close in length should be combined with a prosthesis. Such conditions are created in the presence of a fracture of the lower jaw in the area of the front teeth. If the fracture line passes in the area of the molars, especially behind the second or third molar, constructing a removable denture within both fragments is irrational, because the small fragment is displaced due to muscle traction inward and upward. In such cases, it is recommended to place the prosthesis only on a large fragment with the obligatory use of a system of support-retaining clasps with splinting elements in the design of the prosthesis. However, the method of manufacturing such prostheses is somewhat different. The general technique for taking an impression with the mouth wide open cannot be used, since when the mouth is opened, the jaw fragments move horizontally (towards each other). THEM. Oksman offers the following prosthetics technique.

Impressions are taken from each fragment, and a base with clasps and an inclined plane or a subgingival splint with an inclined plane is made on plaster models.

The bases are fitted to the jaw fragments so that the inclined plane holds them when the mouth is opened, then the area of the jaw defect on both sides (vestibular and oral) is filled with impression material, which is inserted without a spoon.

Based on this impression, a single prosthesis is prepared, which acts as a spacer between the fragments of the lower jaw, preventing them from coming together when opening the mouth (the inclined planes are removed).

The central occlusion is determined on a rigid plastic base, after which the prosthesis is made in the usual way.

It should be noted that hinged dentures do not restore chewing function to the same extent as conventional dentures. The functional value of prostheses will be significantly higher if they are made after osteoplasty. Radical treatment of pseudarthrosis is only surgical, through osteoplasty.

12.5. ORTHOPEDIC TREATMENT METHODS FOR IMPROPERLY UNIONED JAW FRACTURES

Improperly healed fractures are a consequence of traumatic damage to the jaws. Their reasons may be:

Late provision of specialized assistance;

Long-term use of temporary ligature splints;

Incorrect reposition of fragments;

Insufficient fixation or early removal of the fixation device.

The nature of the injury itself and the general condition of the patient also matter. Depending on the degree of displacement of fragments and bite deformation, chewing functions, lower jaw movements, and speech may be impaired. With sudden displacement of fragments, there may be limited mouth opening, facial asymmetry, and impaired breathing function.

Incorrectly fused fragments can be displaced vertically or transversely. Treatment of such patients is primarily aimed at restoring the anatomical integrity of the jaws, establishing fragments in the correct relationship, eliminating restrictions in mouth opening, and restoring the function of chewing and speech.

Surgical, orthopedic and complex methods are used to treat improperly healed fractures. The most radical is surgical, which consists of refracture (i.e. artificially breaking the integrity of the bone along the line of the former fracture) and establishing the fragments in the correct relationship.

If surgical interventions are contraindicated for one reason or another (heart disease, old age, etc.), or there is a relatively minor malocclusion, or the patient refuses surgery, orthopedic treatment is performed to restore chewing function.

With small displacements of fragments vertically and transversely, a slight violation of multiple contacts between teeth is noted. In these cases, correction of the malocclusion is achieved by grinding the teeth or using fixed prostheses: crowns, bridges, metal and plastic aligners.

With significant displacements of fragments of the lower jaw in the horizontal direction (inward), the jaw arch sharply narrows and the teeth do not fit correctly with the teeth of the upper jaw. This relationship between the cusps of the lateral teeth makes it difficult to crush and chew food. In these cases, the interocclusal relationship between the teeth of the upper and lower jaws is restored by making a dental gingival plate with a double row of teeth in the lateral areas.

In case of incorrectly fused fragments with a slight defect in the dentition of the anterior section, telescopic overdentures can be made (Fig. 12-8). In these cases, due to the increased load on the abutment teeth, it is necessary to include additional abutment teeth in the bridge design.

In case of improperly healed jaw fractures and a small number of remaining teeth that are outside the occlusion, removable dentures with duplicated dentition are made. The remaining teeth are used to fix the prosthesis with support-retaining clasps.

When the dental arch of the lower jaw is deformed due to an inclination towards the lingual side of one or more teeth, prosthetics of the dentition defect with a removable plate or arch prosthesis is difficult, since displaced teeth interfere with its application. In this case, the design of the prosthesis is changed so that in the area of displaced teeth part of the base or

Rice. 12-8.A clinical case of the use of a prosthesis with a duplicated dentition (observation by S.R. Ryavkin, S.E. Zholudev): a - a solid splint was made for the remaining teeth; b - type of dentures; c - the denture is fixed in the oral cavity

the arch was located on the vestibular, and not on the lingual side. Support-retaining clasps or occlusal pads are applied to displaced teeth, allowing chewing pressure to be transferred through the prosthesis to the supporting teeth and preventing their further displacement to the lingual side.

In case of improperly healed fractures with shortening of the length of the dental arch and jaw (microgenia), a removable denture is made with a duplicate row of artificial teeth, creating the correct occlusion with antagonists. Displaced natural teeth are usually used only to secure the prosthesis.

12.6. ORTHOPEDIC TREATMENT METHODS FOR BONE DEFECTS

LOWER JAW

Acquired defects of the lower jaw are mainly observed in adults, when the formation of the maxillofacial skeleton has already completed. They arise as a result of trauma (mechanical, thermal, chemical), previous infections (noma, lupus, osteomyelitis), necrosis due to severe cardiovascular diseases and blood diseases; operations for neoplasms; damage resulting from radiation therapy. Bone defects of the lower jaw cause severe disturbances in the functions of chewing and speech, and lead to serious changes in the bite and appearance of patients. If the integrity of the jaw is violated, facial deformation is observed due to the retraction of soft tissues, cicatricial deformation, and limited mouth opening is determined. Often the sharp edges of jaw fragments injure soft tissues, causing bedsores.

For defects in the lower jaw bone, the best functional effect is achieved by osteoplastic surgery followed by prosthetics. The success of prosthetics directly depends on the extent, localization of the jaw defect, and on the condition of the tissues of the prosthetic bed. The best results are observed after alveolotomy. Less favorable conditions arise after extensive osteoplastic operations and in the complete absence of teeth. Carrying out direct bone grafting using various grafts (auto-, allo-, combined), implantation of materials (perforated titanium plates and meshes, porous carbon composite, etc.) promotes rapid tissue regeneration in the area of jaw defects and allows you to create the most complete prosthetic bed. Early orthopedic treatment after osteoplasty stimulates the processes of regeneration and tissue restructuring in the area of the defect, promotes patient adaptation to dentures. However, quite often a thick layer of scar-altered mobile mucous membrane forms in the regenerate area, which leads to balancing and shedding of removable structures. After osteoplastic surgery, patients develop a flattened lower vault of the oral vestibule, and sometimes even its absence. Planning of orthopedic structures for such patients in each specific case is carried out strictly individually.

After reconstructive operations on the lower jaw, depending on the conditions, it is possible to use various fixed and removable denture designs (clasp, plate dentures with cast metal and plastic bases) with various types of fixing elements. According to indications, various splinting structures are made.

In cases where the amount of bone tissue allows, a good solution to the problem of restoring the functions of the dental system is the use of implants of various systems (including mini-implants) for the manufacture of fixed, combined, conditionally removable and removable structures.

After osteoplasty, patients who do not use dentures for a long time may develop serious deformations of the jaws and dentition. Dentoalveolar elongation in the area of the dentition defect, inflammatory processes in periodontal tissues caused by poor oral hygiene, and the presence of dental plaque on a non-functioning group of teeth are possible. Typically, the tooth bordering the defect does not have an alveolar wall on the side where the bone tissue was resected. Such teeth are usually mobile. One should also take into account the fact that in patients after osteoplastic surgery on the lower jaw, the pain sensitivity threshold increases. In the presence of these factors, it is extremely difficult to achieve satisfactory stabilization of removable structures, even using modern fixation methods.

12.7. ORTHOPEDIC TREATMENT METHODS FOR MICROSTOMIA

Narrowing of the oral fissure (microstomia) occurs as a result of injury to the oral area, after surgery for tumors, after a burn of the face. Less commonly, narrowing of the oral cavity is caused by systemic scleroderma. In patients who have suffered injuries to the maxillofacial area, the oral fissure is narrowed by keloid scars. They prevent the mouth from opening and reduce the elasticity of the soft tissues of the oral area. Prosthetics are complicated by secondary deformations of the dentition resulting from the pressure of keloid scars.

Narrowing of the oral cavity entails severe functional disorders: disturbances in eating, speech and mental health due to facial disfigurement.

When using prosthetics, the best results are obtained only after surgically widening the mouth. In cases where surgery is not indicated (patient's age, health status, systemic scleroderma), prosthetics are performed with a narrowed oral cavity and encounter great difficulties during orthopedic manipulations.

When prosthetizing defects in the dentition with bridges or other fixed structures, conduction anesthesia is difficult. In these cases, other types of anesthesia are used.

pouring. Preparation of supporting teeth during microstomy is inconvenient for both the doctor and the patient. Diseased teeth should be separated not with metal discs, but with shaped heads on turbine or angular tips, without damaging intact adjacent teeth. Taking an impression is complicated due to the difficulty of inserting a tray with impression material into the oral cavity and removing it from there in the usual way. In patients with a defect of the alveolar process, it is difficult to make an impression, since it has a large volume. When using fixed prosthetics, impressions are taken with partial trays; for removable structures, impressions are taken with special collapsible trays. If there are no such spoons, then you can use an ordinary standard spoon, sawn into two parts. The technique consists of sequentially taking an impression from each half of the jaw. It is advisable to make an individual tray based on a collapsible impression and use it to obtain the final impression. In addition, the impression can be taken by first placing impression material on the denture bed and then covering it with an empty standard tray. You can also form a wax individual tray in the oral cavity, use it to make a plastic one, and take the final impression with a hard tray.

With a significant reduction in the oral gap, determining central occlusion in the usual way using wax bases with bite ridges is difficult. When removing the wax base from the oral cavity, it may become deformed. For this purpose, it is better to use bite ridges and bases made of thermoplastic mass. If necessary, they are shortened.

The degree of reduction in the oral gap affects the choice of prosthesis design. To facilitate insertion and removal in patients with microstomia and defects of the alveolar process and alveolar part of the jaws, the design of the prosthesis should be simple. For significant microstomia, collapsible and hinged removable dentures are used. However, these constructions should be avoided. It is better to reduce the boundaries of the prosthesis, narrow the dental arch and use flat artificial teeth. The telescopic fastening system helps improve the fixation of a removable denture when its base is shortened. In the process of getting used to removable dentures, the doctor must teach the patient how to insert the denture into the oral cavity.

With significant microstomia, collapsible or foldable dentures using hinged devices are sometimes used. A folding prosthesis consists of two side parts connected by a hinge and a front locking part. In the oral cavity, it moves apart, is installed on the jaw and is strengthened by the anterior locking part. The latter is a block of the anterior group of teeth, the base and pins of which fall into tubes located in the thickness of the halves of the prosthesis.

Collapsible dentures consist of separate parts. In the oral cavity, they are assembled and secured into a single unit using pins and tubes. You can make a regular prosthesis, but to facilitate its insertion and removal from the mouth through a narrowed oral fissure, you should narrow the dental arch of the prosthesis, using a telescopic fastening system as the most reliable (Fig. 12-9).

Rice. 12-9.Collapsible prostheses used for microstomia: a - fragments of a collapsible prosthesis; b - assembled dismountable prosthesis; c - folding prosthesis with a lock on the vestibular surface of the prosthesis

12.8. ORTHOPEDIC TREATMENT METHODS FOR DEFECTS OF THE HARD AND SOFT PALATE

Defects of the hard and soft palate can be congenital or acquired. Congenital cleft palates currently occur in European countries in a ratio of 1:500-1:600 newborns. Such a high frequency (compared to 1:1000 in the twentieth century) is associated with deterioration of environmental indicators, ionization of the Earth’s atmosphere, and environmental pollution. The frequency of clefts varies among people of different races: more often than among Europeans, they are found in Japan (1 + 372), among American Indians (1 + 300); among Negroids it is much less common (1+1875). Isolated cleft palate accounts for 30-50% of all cleft cases, 2 times more often in girls than in boys.

Acquired defects arise, as a rule, as a result of gunshot or mechanical injuries, after removal of tumors, as a result of inflammatory processes, such as osteomyelitis (especially after gunshot wounds). Very rarely, palate defects can occur with syphilis and tuberculous lupus.

V.Yu. Kurlyandsky, depending on the location of the defect and the preservation of the teeth on the jaw, describes four groups acquired palate defects:

Group I - defects of the hard palate in the presence of teeth on both sides of the jaw:

Median palate defect;

Lateral (communication with the maxillary sinus);

Front.

Group II - defects of the hard palate in the presence of supporting teeth on one side of the jaw:

Median palate defect;

Complete absence of one half of the jaw;

The absence of most of the jaw while maintaining no more than 1-2 teeth on one side.

Group III - palate defects with complete absence of teeth on the jaw:

Median defect;

Complete absence of the upper jaw with disruption of the orbital edge.

Group IV - defects of the soft palate or soft and hard palate:

Cicatricial shortening and displacement of the soft palate;

Defect of the hard and soft palate in the presence of teeth on one half of the jaws;

Defect of the hard and soft palate in the absence of teeth in the upper jaw;

Isolated defect of the soft palate.

Congenital palate defects are located in the middle of the roof of the mouth and have the shape of a cleft. Acquired defects can have different locations and shapes. They can be located in the area of the hard or soft palate, or both. Unlike congenital ones, they are accompanied by cicatricial changes in the mucous membrane. There are anterior, lateral and median defects of the hard palate. Anterior and lateral defects may cause

may occur with damage to the alveolar process, cicatricial deformities of the transitional fold, and retraction of soft tissues.

With this pathology, the oral cavity communicates with the nasal cavity, which leads to such functional disorders as changes in breathing and swallowing, as well as distortion of speech. In children, the sucking function is difficult due to the impossibility of creating a vacuum. Food passes from the mouth to the nasal cavity. Constant regurgitation of food and saliva leads to chronic inflammation in the nasal cavity and pharynx. There is an increase in the palatine and pharyngeal tonsils. Inflammatory processes of the upper respiratory tract, bronchitis, and pneumonia are more often observed. Speech function is impaired due to improper formation of sounds. Rhinophony is noted, rhinophonia, and open rhinolalia, rhinolalia aperta. Already in childhood, the child suffers from limited communication with others, and mental disorders are observed.

Cicatricial shortening of the soft palate as a result of injury causes swallowing disorders and can, if the muscle that strains the velum palatine is damaged, m. tensor velipalatini, lead to gaping of the auditory tube, which causes chronic inflammation of the inner ear and hearing loss.

Treatment of acquired defects consists of eliminating them by performing bone and soft tissue plastic surgery. Orthopedic treatment of such defects is carried out if there are contraindications to surgical treatment or the patient refuses surgery.

In the case of congenital defects of the palate, treatment of patients in all civilized countries is carried out by interdisciplinary working groups according to a pre-planned comprehensive program. Such groups usually include: geneticist, neonatologist, pediatrician, surgeon (oral and maxillofacial surgeon), pediatric surgeon, plastic surgeon, anesthesiologist, orthodontist, speech therapist, orthopedic dentist, psychiatrist.

Rehabilitation of this group of patients consists of eliminating the defect, restoring the functions of chewing, swallowing, recreating appearance and phonetics.

The orthodontist treats the patient from birth to the post-pubertal period, conducting periodic treatment according to indications.

Currently, usually in the first week after the birth of a child, according to indications, he undergoes cheiloplasty or correction of the deformation of the upper jaw using the McNeil method. This method is aimed at eliminating the incorrect location of unfused processes of the upper jaw in the anteroposterior direction (with a unilateral cleft) or in the transversal direction (with a bilateral cleft). To do this, the newborn is put on a protective plate with extraoral fixation to the head cap. The plate is periodically (once a week) cut along the line of the cleft, and its halves are moved in the desired direction by 1 mm. The components of the plate are connected with quick-hardening plastic. This creates pressure on the palatine process in the desired direction and ensures its constant movement. In this way, a correct dental arch is formed. The method is indicated until teeth erupt (5-6 months).

After correcting the deformity, cheiloplasty is performed, if it has not been performed on a newborn, and then a floating Kez obturator is made according to the method of Z.I. Chasovskaya (Fig. 12-10).

Rice. 12-10. Floating obturator

A thermomass impression is taken from the edges of the cleft using an S-shaped curved spatula. To do this, the thermoplastic mass, heated to a temperature of 70 ° C, is glued to the convex surface of the spatula in the form of a roller. The impression mass is introduced into the patient’s oral cavity, moving it to the back wall of the pharynx over the Passavan roller until a gag reflex appears. A spatula with an impression mass is pressed to the palate, an imprint of the mucous membrane covering the palatine processes and the edges of the cleft on the side of the oral cavity is obtained. The spatula is then slowly moved forward to obtain an impression of the anterolateral edges of the nasal surface of the palatine processes. The impression is taken out by moving it in the opposite direction back, down, and then forward.

Impressions of the cleft edges can be taken with alginate or silicone impression materials. To do this, an S-shaped spatula is perforated to better retain the impression material. The resulting impression should clearly display the imprints of the nasal and lingual surfaces of the edges of the cleft of the hard and soft palate, as well as the imprint of the posterior wall of the pharynx. After excess material is cut off from the resulting impression, it is plastered into a cuvette. After the plaster has hardened, the impression material is carefully removed, and the resulting depression is covered with a plate of wax (clasp). Next, the second part of the mold is cast. The obturator is made using both the traditional plastic molding method and the casting method. After polymerization of the plastic, the obturator is processed and tested in the patient’s oral cavity. The edges of the obturator are refined using wax and quick-hardening plastic. It is important that the nasopharyngeal part of the obturator is slightly higher than the nasal surface of the edges of the cleft of the soft palate (to allow movement of the palatine muscles). The pharyngeal edge is located directly above the Passavan roller. When modeling an obturator, the middle part and palatine wings are made thin, and the edges that come into contact with the movable edges during function are thickened.

Usually, in the first days of getting used to the obturator, it is fixed with a thread. After a few days, patients adapt to the obturator, and it stays well in the cleft without additional fixation.

Uranostaphyloplasty is performed between 6 and 7 years of age; subsequently, the child receives speech therapy training and orthodontic treatment if necessary to correct malocclusions.

Currently, surgical interventions for congenital cleft palates are usually carried out within a period of up to 18 months in order to form the bone base of the hard palate, i.e. before the start of articulatory speech.

However, for various reasons, some children who did not undergo timely treatment and rehabilitation measures, as adults, are forced to go to dental institutions. Especially among adults, the first place in solving the problem of their rehabilitation is given to aesthetic tasks, the purpose of which is the full restoration of the anatomical and functional state of the maxillofacial area.

The purpose of prosthetics is to separate the oral cavity and nasal cavity and restore lost functions. For each patient, orthopedic treatment has its own characteristics, determined by the nature and location of the defect, the condition of the soft tissues of its edges, the presence and condition of the teeth in the upper jaw.

For small defects of the hard palate located in its middle part, if there are a sufficient number of teeth for clasp fixation, prosthetics with arched or plate dentures are possible. The obturating part is modeled in the form of a roller (on an arch or the base of a plate prosthesis), retreating from the edge of the defect by 0.5-1.0 mm, which, plunging into the mucous membrane, creates a closing valve. Elastic plastic can also be used for these purposes. When making a prosthesis with an obturating part, the impression is taken with elastic impression materials with preliminary tamponade of the defect with gauze napkins.

If teeth are completely missing, springs or magnets can be used to hold the denture. V.Yu. Kurlyandsky proposed to create external and internal closing valves in such situations. The internal one is provided by a roller on the palatal surface of the prosthesis along the edge of the defect, and the external or peripheral one is provided in the usual way along the transitional fold in the area of its neutral zone. THEM. Oxman proposed using the immediate prosthesis as a permanent prosthesis after correction of the replacement part. However, such a prosthesis is quite heavy, and it is impossible to create a full-fledged closing valve in it.

The prosthesis proposed by Kelly is more advanced. Based on the anatomical impression, an individual tray is made, with which a functional impression is obtained, and the central relationship of the jaws is determined. First, an obturator similar to a cork is made from elastic plastic. Its inner part enters the defect and is located in the area of the nose, somewhat extending beyond the defect. The outer part of the obturator is made of hard plastic in the shape of a shell and covers the defect on the side of the oral cavity. Then a removable lamellar prosthesis is made using traditional methods. The prosthesis easily slides over the obturator, touching it only at its highest point, without transmitting chewing pressure, thereby preventing an increase in the size of the defect from the pressure of the obturator.

Prosthetics for defects of the hard palate in the lateral and anterior sections in the presence of teeth on the jaw are carried out using removable plate dentures using elastic materials in the obturating part, since difficulties often arise in isolating the nasal and oral cavity. In case of extensive defects of the anterior or lateral parts of the hard palate, to prevent the prosthesis from tipping over and improve its fixation, it is necessary to increase the number of clasps in the prosthesis or use a telescopic

ical fixation system. Small defects that arise after the removal of lateral teeth with perforation of the maxillary sinus can be filled by using small saddle dentures with clasp, telescopic or locking fixation. When manufacturing removable structures, it is advisable to use parallelometry. For better fixation of structures on artificial crowns, you can make soldering or protrusions according to Gafner.

In case of scar shortening of the soft palate, surgical treatment is performed to eliminate it, and in the presence of defects in the soft palate, prosthetics with obturators are usually performed. Obturators consist of fixing and obturating parts. The fixing part is usually a palatal plate, the fixation of which, if there are teeth on the jaw, is carried out using clasps (retaining or support-retaining), telescopic crowns or locking fasteners. The obturating part is made of rigid plastic or a combination of rigid and elastic plastics and is connected motionlessly or semi-labilely to the fixing part. Obturators can be “floating”, i.e. exactly correspond to the area of the defect and close it, including only the obstructing part.

When prosthetizing patients with defects of the soft palate, obturator designs according to Pomerantseva-Urbanskaya, Ilina-Markosyan, Schildsky, Kurlyandsky, Suersen, Kez-Chasovskaya, McNeil, Kelly, etc. can be used (Fig. 12-11).

The Pomerantseva-Urbanskaya obturator is used for defects of the soft palate complicated by cicatricial muscle changes. It consists of a fixing palatal plate with clasps and an obturating part, connected by a springy steel tape 5-8 mm wide and 0.4-0.5 mm thick. In the obturating part there are two openings located in the anteroposterior direction. They are covered with two thin celluloid plates (one on the side of the oral cavity, the other on the side of the nasal cavity), attached at only one end. This creates two valves, one of which opens on inhalation and the other on exhalation.

In Ilina-Markosyan’s design, the obturating part is connected with a button and is made of elastic plastic. In the Schildsky apparatus, the obturating part is connected to the fixing part by a hinge. In case of defects or complete absence of the soft palate, prosthetic obturators with a movable obturating part (Kingsley obturator) and a fixed one (Suersen obturator) can be used. The fixing part can be in the form of a plate or arc prosthesis.

12.9. ORTHOPEDIC TREATMENT AFTER UNILATERAL RESECTION OF THE UPPER JAW

After unilateral resection of the upper jaw, a complex clinical picture arises, in which the conditions for fixation of the prosthesis worsen. Therefore, the choice of its design and fixation methods depends on the number of teeth on the healthy side of the jaw and their condition.

If there are stable and intact teeth on the healthy half of the jaw with the absence of one of the premolars or the first molar, the prosthesis is fixed with

Rice. 12-11.Obturators used for defects of the soft palate: a - Pomerantseva-Urbanskaya; b - Ilyina-Markosyan; c - Schildsky; d - palatal plate with an obturating part in the complete absence of teeth

using 3-4 holding clasps. Retaining clasps have the advantage that they do not interfere with the tight fit of the structure to the prosthetic bed. The tight fit of the prosthesis to the mucous membrane is not disturbed even with subsequent atrophy of bone tissue.

In the case of intact dentition on the healthy side, the fixation of the prosthesis can be improved by using a telescopic crown or a locking attachment on the first molar. If there are a small number of teeth on the healthy side of the jaw or their stability is insufficient, the fixing part of the prosthesis is made as a subgingival splint. To fix the immediate prosthesis after unilateral resection of the upper jaw, the central and lateral incisors of the healthy side are covered with interconnected crowns. If the shape of the natural crown of a distal molar on the healthy side cannot provide good fixation of the prosthesis, then it is also covered with a crown with a pronounced equator.

THEM. Oksman proposed using a three-stage method for manufacturing a resection prosthesis of the upper jaw (Fig. 12-12). At the first stage, the fixing part of the prosthesis with clasps on the supporting teeth is prepared. For this

Rice. 12-12. Manufacturing of a prosthesis after resection of the upper jaw according to I.M. Oksman: a - the fixing plate is on the plaster model; b - a temporary prosthesis is made; c - prosthesis supplemented with an obturating part along the edges of the operating cavity

An impression is taken from a healthy area of the jaw. A fixation plate made in the laboratory is carefully fitted in the oral cavity and impressions are taken from the upper jaw. Models are cast. In this case, the fixing part of the prosthesis is placed on the model. The central relationship of the jaws is determined. Next, proceed to the second stage - the manufacture of the resection part of the prosthesis. The models are installed in the articulator in the position of central occlusion. The resection boundary is marked on the upper jaw model in accordance with the surgical plan. Then the central incisor on the side of the tumor is cut off at the level of the neck. This is necessary so that the prosthesis does not interfere with covering the bone with a flap of mucous membrane. The remaining teeth are cut off at the level of the base of the alveolar process from the vestibular and palatal sides to the middle of the palate, i.e. to the fixing plate. The surface of the edge of the fixing plate is made rough, as when repairing a plastic prosthesis, and the resulting defect is filled with wax and artificial teeth are installed in occlusion with the teeth of the lower jaw. The artificial gum of the resection prosthesis in the area of the chewing teeth is modeled in the form of a roller running in the anteroposterior direction. In the postoperative period

scars are formed along the roller, forming a bed. Subsequently, the structure is fixed with a roller by the soft tissues of the cheek. In this form, the prosthesis can be used after resection of the upper jaw as a temporary one. Subsequently, as the surgical wound heals, the tampons are removed and after epithelization of the wound surface, the occlusive part of the prosthesis is made (third stage).

12.10. ORTHOPEDIC TREATMENT AFTER BILATERAL RESECTION OF THE UPPER JAW

To make a direct maxillary denture, after bilateral resection, impressions are taken from the upper and lower jaws. After casting the models, the centric occlusion is determined and the models are cast into the articulator. Then, on the model of the upper jaw, the alveolar process is cut down to the base. The cut part is restored from wax and the teeth are set. In the area of the lateral teeth, horizontal tubes are strengthened on the vestibular side to fix an arch in them, connected to an intraextraoral vertical rod that rises upward according to the midline of the face. The rod ends in a metal plate, with which it is connected to the head cap. This method of attaching the prosthesis ensures good fixation in the postoperative period and proper formation of soft tissues. Subsequently, fixation of the prosthesis to the head cap using a rod will be necessary for the patient to chew food normally.

The technique for correcting the obstructing part of the resection prosthesis after healing of the surgical wound is as follows. After epithelization of the surgical wound, the dressing material is completely removed, resulting in a space being formed between the base of the prosthesis and the mucous membrane. To correct the obstructing part, a method is used to “clarify” the immediate prosthesis, which consists in filling the free space between the prosthesis and the mucous membrane with silicone mass for functional impressions and inserting the prosthesis into the oral cavity. The patient is asked to close the dentition, due to which excess mass is displaced and an accurate representation of the prosthetic bed is obtained. After the mass hardens, the prosthesis is removed from the oral cavity, a plaster model is cast and the impression mass is removed. The free space is filled with quick-hardening plastic. The prosthesis is placed on the model until the plastic has completely hardened, then it is processed to the desired thickness, polished and fixed in the oral cavity. The advantage of this technique is that the refinement of the occlusive part of the prosthesis is carried out outside the oral cavity and the epithelial surface of the wound does not come into contact with the monomer. The patient does not experience any discomfort or pain. Thanks to the impression obtained under the influence of the bite, the pressure from the prosthesis is transmitted evenly to the prosthetic bed. Subsequently, the patient is recommended to undergo prosthetics with a permanent jaw prosthesis. The corrected resection prosthesis can be used as a spare in case of breakage of the jaw prosthesis and during the production of a new one.

12.11. METHOD FOR MANUFACTURING PROSTHESES AFTER SURGERY INTERVENTIONS. DESIGNS OF FORMING APPARATUS

Prosthetics after partial resection of the lower jaw

After resection of the chin of the lower jaw, a sharp displacement of the lateral fragments occurs inside the oral cavity (toward the midline) as a result of the action of the external pterygoid muscle on them. In addition, the lateral fragments are rotated by the chewing surface of the teeth inward, and by the edge of the jaw outward. This displacement is explained by the fact that the contracted mylohyoid muscle acts on the fragments from the inner surface, and the masticatory muscle itself acts from the outer surface.

In order to prevent displacement of fragments of the lower jaw in the postoperative period, it is necessary to use splints or immediate dentures. The latter should be considered the method of choice, since immediate prostheses not only fix fragments, but also eliminate facial deformation, restore the function of chewing and speech, and form a bed for the future prosthesis. Splints are used if primary bone grafting is performed after resection.

To fix toothless fragments that may form after resection of the anterior part of the lower jaw, standard V.F. fixing devices can be used. Rudko, Ya.M. Zbarzha, etc. All of them are temporary. Subsequently, the patient undergoes bone grafting and prosthetics. If bone grafting is not indicated for any reason, then a splinting removable prosthesis is prepared after the operation.

In case of complete absence of teeth and resection of the lower jaw in the chin region, instead of a subgingival splint, a plastic base should be made on the upper jaw, which in the lateral sections is connected to pelotas covering the toothless lateral parts of the lower jaw. The peculiarity of the technique is that to make a plastic base for the upper jaw, an individual tray is prepared, which is used to take an impression.

During resection of half the jaw A jaw prosthesis is made, consisting of two parts: fixing and replacing. The fixing part consists of the prosthesis base and clasps. Covering the rest of the jaw and teeth, it holds the denture in place. It should be borne in mind that the entire load during any function, especially when chewing, falls on the fixing part of the prosthesis, so you should carefully fit it in the mouth even before resection. The quality of fixation of the prosthesis will determine the maximum restoration of the functions of the masticatory apparatus and the prevention of overloading of the supporting teeth. When using prosthetics on one side, fixation with 3-4 clasps is indicated. For fixation, stable teeth are selected, including as many of them as possible. To cushion the harmful effects of the prosthesis on the teeth, the connection of the clasps to the prosthesis should be made semi-labile. When using single-rooted teeth as supporting teeth, they are covered with soldered crowns or clasps are made with 2-3 arms covering adjacent teeth.

The replacement part of the prosthesis is of great cosmetic and phonetic importance. It is made taking into account the accuracy of the prosthesis fit along the edge

postoperative defect and articulation of artificial teeth with antagonist teeth.

An essential point is to keep the remaining bone fragment from moving towards the defect. This is achieved using an inclined plane, which is a necessary part of the prosthesis.

Prosthetics after complete resection of the lower jaw

Prosthetics after complete resection of the lower jaw or the body of the lower jaw present great difficulties in fixing the prosthesis, and most importantly, in achieving its functional effectiveness, since the prosthesis, without a bone base, is not suitable for chewing solid food. In such cases, the tasks of prosthetics are reduced to restoring the contours of the face and speech function, and in the case of facial skin defects and plastic surgery, to the formation of a skin flap. However, it should be noted that jaw prostheses, after removal of the lower jaw, to a certain extent restore the function of chewing, as they help retain the bolus of food in the mouth and facilitate the acceptance of liquid food and its swallowing. Jaw prostheses are of great importance for the patient’s psyche, reducing moral distress associated with facial disfigurement.

Prosthetic technique

First stage. Before surgery, impressions are taken from the upper and lower jaws, and plaster models are cast. The resulting models are plastered into the articulator in the position of the central relationship of the jaws. After this, all the teeth are cut off from the lower model at the level of the top of the alveolar ridge, after which artificial teeth are placed in occlusion with the teeth of the upper jaw and the base is modeled. The lower surface of the prosthesis should have a rounded shape; on the lingual side, the prosthesis in the area of the chewing teeth must have a concavity with hyoid protrusions so that the tongue is placed above them and this contributes to its fixation. In the area of the canines and premolars, hooking loops are strengthened on both sides for intermaxillary fixation in the postoperative period.

Second stage- application of a prosthesis in the oral cavity. After resection or complete disarticulation of the lower jaw, a wire aluminum splint with hooking loops is placed on the teeth of the upper jaw: the resection prosthesis is held for the first time by intermaxillary fastening with rubber rings. 2-3 weeks after the operation and wearing the prosthesis, a prosthetic bed is formed around it in the soft tissues: the rubber rings and hooking loops are removed, and the prosthesis is fixed by the scars formed around it, and on the lingual side it is held by the tongue. If the prosthesis is not held sufficiently, then mechanical fixation with springs is resorted to (Fig. 12-13).

Orthopedic care after resection of the upper jaw

Rice. 12-13. Resection prosthesis for the lower jaw

A direct prosthesis, inserted immediately on the operating table, eliminates functional disorders that arise after surgery and helps create a bed for the subsequent prosthesis, since soft tissues are formed along it. In the absence of a direct prosthesis, the healing of soft tissues occurs arbitrarily, and the resulting scars do not make it possible to make a full-fledged jaw prosthesis. In addition, the immediate prosthesis supports the dressing material filling the postoperative cavity and protects it from infection. By holding soft tissues that have lost their bone base, the direct prosthesis to some extent eliminates facial deformation, which, of course, helps maintain the patient’s psychological balance after surgery (Fig. 12-14).

Rice. 12-14. Prosthetics after resection of the upper jaw with a plate prosthesis: a - individual plastic impression tray; b - plaster model with a postoperative defect of the upper jaw; c - ready-made upper jaw prosthesis with a hollow obturating part

The design of the immediate maxillary denture depends on the size and location of the resected part.

There are immediate dentures used after resection of the alveolar process, after unilateral and bilateral resection of the upper jaw.

Replacement of small defects of the alveolar process of the upper jaw in the presence of teeth for fixing the prosthesis, in the absence of cicatricial adhesions on the mucous membrane of the alveolar process and through defects penetrating into the nose or maxillary sinus, is essentially no different from the replacement of a defect in the dentition. In the presence of these complications, preliminary surgical intervention is necessary.

Overhanging scars that interfere with prosthetics are removed by excision followed by free skin grafting, or split skin flaps are moved using triangular flaps.

Finally, in such cases it is very advisable to use the direct prosthetic technique. The prosthesis is made before surgery and fits in the mouth. After excision of the scars, softened thermoplastic material is layered onto the prosthesis in the area of the artificial gum and an impression of the operating cavity is taken. The thermoplastic material is cooled and a flap of free epithelial “seedling” is melted on it with the bloody surface facing out. Thus, the prosthesis initially plays the role of a forming apparatus and serves to form the arch of the vestibule of the oral cavity. A few days after the graft has engrafted, the thermoplastic mass on the prosthesis is replaced with plastic, and the prosthesis functions as a replacement device.

It is very difficult to replace significant defects of the alveolar process in the area of the anterior or lateral teeth, especially in the case of a toothless jaw.

In such cases, the chewing pressure of the base in the area of the bone defect is transferred to soft, pliable tissue, since the base in this place is devoid of a solid base, as a result of which the denture balances when chewing. In addition, the strengthening of the prosthesis is often hampered by overhanging scars or folds of the mucous membrane. In such cases, it is recommended to take functional impressions even if a certain number of teeth are present. When taking an impression, special attention must be paid to the physiological mobility of the mucous membrane on the vestibular side under the influence of folds and scars so that the mobility of the mucous membrane is sufficiently reflected on the impression. It is better to remove the impression on the side of the defect under pressure. In some cases, scars of the mucous membrane of the cheek, if they are located in the area of the chewing teeth in the anteroposterior direction, not only do not interfere, but even contribute to the fixation of the prosthesis. Therefore, when examining the oral cavity, it is necessary to take this important circumstance into account and take it into account. In the case of complete absence of teeth, it is sometimes necessary to resort to springs to fix the prosthesis.

TEST TASKS

1. To obtain an impression, the impression mass for palate defects is injected:

1) on an S-shaped curved spatula with a slight upward movement;

2) on a special spoon from bottom to top and forward;

3) with a special impression tray from bottom to top and back to the back wall of the pharynx.

2. For a false joint of the lower jaw, a removable denture is made:

1) with one basis;

2) with two fragments and a movable fixation between them;

3) with a metal base.

3. The reasons for the formation of a false joint are:

2) incorrect composition of bone fragments;

3) osteomyelitis at the fracture site;

4) interposition;

5) early prosthetics;

6) 1+3+4;

7) 1+2+3+4+5;

8) 1+2+4.

4. Time frame for manufacturing a resection prosthesis:

1) 2 months after surgery;

2) 6 months after surgery;

3) 2 weeks after surgery;

4) before surgery;

5) immediately after surgery.

5. The main functions of the resection prosthesis are:

1) restoration of aesthetics of the maxillofacial area;

2) restoration of respiratory function;

3) protection of the wound surface;

4) partial restoration of lost functions;

5) formation of a prosthetic bed;

6) 1+2+3+4+5;

7) 2+3+4.

Choose several correct answers.

6. With a bilateral fracture of the lower jaw, the fragments are displaced:

1) down;

2) forward;

3) up;

4) back.

7. The reasons for the formation of a false joint of the lower jaw can be:

1) late, ineffective immobilization of fragments;

2) incorrect composition of bone fragments;

3) osteomyelitis;

4) extensive ruptures of soft tissues, their introduction between fragments;

5) bone defect more than 2 cm;

6) detachment of the periosteum over a large area;

7) poor oral hygiene;

8) early tire removal.

8. The causes of contracture of the lower jaw can be:

1) mechanical injury to the jaw bones;

2) chemical, thermal burns;

3) frostbite;

4) diseases of the mucous membrane;

5) chronic specific diseases;

6) diseases of the temporomandibular joint.

9. To take impressions of palate defects, you can use:

1) thermoplastic materials;

2) gypsum;

3) alginate materials;

4) artificial rubbers.

Add.

10. With underdevelopment of the upper jaw associated with the presence of a cleft palate, an overbite is most often observed.

11. Acquired palate defects can be a consequence of:

1) inflammatory processes;

2) specific diseases;

3)_;

4)_.

12. For orthopedic treatment of patients with acquired defects of the hard palate in the presence of supporting teeth on both halves of the upper jaw, use

13. The goal of maxillofacial orthopedic dentistry is

14. With improperly healed fractures, the following functional disorders are possible:

1)_;

2)_;

3)_;

4)_;

5)_.

Match.

15. Maxillofacial apparatuses are divided into groups:

1) for its intended purpose;

2) method of fixation;

3) technology.

Types of devices in groups:

a) intraoral;

b) corrective;

c) dividing;

d) standard;

e) fixing;

f) guides;

g) individual;

h) substitutes;

i) formative;

j) combined;

l) extraoral;

m) intra- and extraoral.

16. Type of jaw fracture:

1) fracture of the alveolar process;

2) fracture of the upper jaw;

3) fracture of the lower jaw with the presence of teeth on the fragments;

4) fracture of the toothless lower jaw.

Design of the medical device:

a) bent wire tire Zbarzh;

b) smooth wire staple;

c) standard Zbarzh tire;

d) springy Angle arc;

e) Weber periodontal splint;

f) Schur apparatus;

g) standard tape tire according to Vasiliev;

h) wire tire with hooking loops;

i) complete removable dentures;

j) Port, Gunning-Port bus; l) Limberg tire.

17. Causes of formation of a false joint of the lower jaw:

1) general;

2) local.

Nature of reasons:

a) tuberculosis;

b) angina pectoris;

c) diabetes mellitus;

d) chronic pyelonephritis;

e) anemia;

f) insufficient immobilization of fragments;

g) extensive ruptures of soft tissues and their penetration between fragments;

h) early tire removal;

i) bone defect in the fracture area of more than 2 cm;

j) long-term detachment of the periosteum in the area of the fracture;

k) traumatic fracture;

m) a tooth located in the fracture line.

Choose one correct answer.

18. To immobilize fragments of the lower jaw, ligature binding is used:

1) bronze-aluminum wire 1 mm thick;

2) bronze-aluminum wire 0.5 mm thick;

3) aluminum wire 0.5 mm thick.

19. To treat fractures of the upper jaw, splints are used:

1) Zbarzh, Weber;

2) Vankevich, Pomerantseva-Urbanskaya;

3) Zbarzh, Weber, Shura.

20. In case of a bilateral fracture of the upper jaw and limited mobility of the fragments, reduction and fixation is carried out using:

1) Zbarzh tires;

2) Schur device;

3) Weber type I tires.

21. Treatment of unilateral fractures of the upper jaw with stiff fragments is carried out using:

1) Vankevich tires;

2) Tigerstedt tires;

3) Schur device.

22. For fractures of the lower jaw outside the dentition and the presence of teeth on the jaw, the following is used:

1) single-jaw wire splint;

2) Tigerstedt tire;

3) Vankevich tire.

Answers

1. 1.

2. 2.

3. 6.

4. 3.

5. 6.

6. 1, 4.

7. 1, 3, 4, 5, 6, 8.

8. 1, 2, 3, 5.

9. 1, 3.

10. Open.

11. 3 - injuries and gunshot wounds; 4 - operations for cancer.

12. Plate prosthesis, arc prosthesis.

13. Rehabilitation of patients with defects of the dental system.

14. 1 - speech impairment; 2 - violation of aesthetics; 3 - chewing disorder; 4 - dysfunction of the masticatory muscles; 5 - dysfunction of the temporomandibular joint.

15. 1 - b, c, d, f, h, i, j; 2 - a, l, m; 3 - g, g.

16. 1 - b, d; 2 - a, c, e; 3 - g, h, d; 4 - k, l, i.

17. 1 - a, c; 2 - f, g, h, i, j, l, m, n.

Topic: Classification of maxillofacial and facial prostheses.
Methods of retention of maxillofacial and facial prostheses.

Two categories of terms are used to
characteristics of medical face masks
purposes: plastic facial prostheses and
epitheses. Prosthesis (from the Greek pro “instead of” and
Tithemi "I place") - device,
used instead of lost
a natural organ or part of the body,
reproducing the form and, if it
perhaps partially or completely
restorative functions. Term
“plastic” (from the Greek Plastein
"to form, model") defines
the ability of a prosthesis to restore the shape of the face.
Surgery, on the other hand, is divided into 2
categories that cannot exist in
maxillofacial prosthetics:
aesthetic and plastic.

The first concerns healthy people, it
“decorates” the body and focuses on
socio-cultural norms based on
generally accepted canons of beauty. Object
the second, like prosthetics, become
patients with body injuries.
Plastic prosthesis is also necessary
sick people, both physically and mentally
psychological aspect. Today more often
the term "epithesis" is used (short for
"epiprosthesis", "marginal prosthesis", "Epi" on,
on top, at the end.) This is a medical product
appointments to replace missing
parts of the body, repeating the relief and
covering an existing defect.

Typology of facial prostheses.

Typological classification of prostheses
based on the location of the tissue defect.
First of all, there are:
External prostheses (ectoprostheses) –
external devices, movable, in
contact with skin, mucous membrane or
teeth;
Internal prostheses (endoprostheses) –
fixed, surgical
implanted into the body.

Maxillofacial specialists
prosthetics are more often used
external prostheses, which are divided into:
intraoral - when they are in
oral cavity;
extraoral – located outside the cavity
mouth
The role of the latter is to replace
skin defects (external nose, ear
shell, orbital area).

Another type of prosthesis, such as maxillofacial prosthesis, combining
statistical and dynamic
designs, capable of replacing
complex defects. Most often
The following types are manufactured
epitheses: prosthetic nose, auricle,
eyelids and eyes, facial masks and complex
"multi-story" prostheses that can
combine facial and dentofacial prosthesis.

Organigram.

Structural elements for fixation of facial prostheses (ectoprostheses)

Facial defects can be formed by
due to a number of factors, such as
removal of tumors, especially
malignant, various wounds
areas of the face, burns (thermal,
electrical, chemical), innate
defects and deformations of the facial area,
consequences of diseases (tuberculosis
lupus, syphilis), etc.

Facial defects can be isolated and
combined. Their elimination is possible
through plastic surgery and
prosthetics. Prosthetics
indicated for extensive and complex
form of defects of a part of the face (ear
shell, nose). If the patient refuses
surgeries also prosthetize defects
small faces.

Plastic surgery gives positive results
results, but they may not always
be fulfilled due to
morbidity and duration
treatment requiring a range of
repeated surgical interventions,
before it is received
satisfactory aesthetic effect,
which is often the reason for refusal
patients from this treatment method.

Contraindications to plastic surgery:

1. Weakened general condition of the body;
2. Unfavorable conditions for engraftment
tissue created after removal
malignant tumor and performed
courses of radiation and chemotherapy;
3. Danger of tumor recurrence;
4. The extent of the defect in part of the face and its
complex shape (ear, nose);
5. Old age of the patient;
6. Small facial defects in case of
patient's refusal to undergo surgery.

In these cases, you should give
preference for the orthopedic method
treatment. Prosthetics are aimed at
restoration of speech appearance
patient, tissue protection from exposure
external environment, elimination of drooling
and food loss, prevention
mental disorders.
Ectoprosthetics completes the complex
activities for the rehabilitation of patients with
facial damage.

Facial prostheses are made from soft
(orthroplast) or rigid plastic based
polymethyl methacrylate - PMMA (-7, -9, -10,
EGMASS-12), sometimes a combination is used
plastics Modern ectoprostheses
are made from materials based on
silicone and PMMA. To get the best
aesthetic effect, soft plastics
painted with special dyes,
which are selected by color. Facial
hard plastic prosthesis painted
in two ways. Gives the best result
painting the prosthesis with oil paints.
The second way is to add to
dye polymer (ultramarine, crown
lead, cadmium red, etc.)

Mechanical fixation.

Ectoprostheses are strengthened using glasses frames,
which either connects to a facial prosthesis
monolithically, or done using locking
devices such as magnets. For fastening
ectoprostheses are also used special
fixatives that are introduced into natural or
specially created surgically
retention points, clamps (as in auditory
apparatus), a rubber band passing under
hair from one temple of the glasses frame to the other.
In some cases, the ectoprosthesis is fixed when
using a screw-shaped implant with a rough
surface that provides the best
connection with bone.

Chemical fixation.

As an additional method
fixation of ectoprostheses are also used
special adhesives or theatrical
glue used for facial prostheses
small sizes (for example, with
replacing a wing or tip defect
nose), where other methods of fastening
impossible to apply are
the main method of fixation.

Physical fixation.

Combination of implant with magnetic
elements simplifies the design
ectoprosthesis without reducing quality
fixation and completely avoids
danger of implant infection
by maintaining the integrity of the skin
covers.

All facial prosthetics are prepared on a facial model
(plaster mask). When modeling
the exoprosthesis is checked against photographs
patient, take into account the shape of the face,
anthropometric data,
symmetry of the paired organ, take into account
personal complaints and wishes.

Facial exoprosthetics:

1.
2.
3.
Orbital and nasal prosthesis with
fixation on the frame.
Prosthetic nose.
Nasal prosthesis with fixation on
frame

Ear prosthesis.

Replacement prosthesis for soft tissue defects in the perioral area (according to B.K. Kostur and V.A. Minyaeva)

The prosthesis is fixed using
one-piece dental frame with occlusal
overlays - splints, with intact dentition, and
prosthetic splint – in case of partial absence of teeth.
The intraoral part of the ectoprosthesis can be
used as a forming apparatus for
delayed osteoplasty, and after it how
replacement prosthesis. In the manufacture of ectoprostheses in
case of unilateral combined defect of the upper and
lower lip and corner of the mouth, they are made separately and
each is attached to dentures
on one's own. Considering that when you open your mouth
the defect in the area of the corner of the mouth increases by
distal edge of the ectoprosthesis of the upper and lower lips
a special protrusion is modeled, going up to
ectoprosthesis of the lower lip.

Combined maxillofacial
dentures are a connection
ectoprosthesis with jaw prostheses.
You can fix them together
carried out using hinges or
magnets, rigid connection.

Combined maxillofacial prosthesis (according to I.M. Oksman).

The facial prosthesis is fixed
using a frame and rods
included in the bushings
upper replacement prosthesis
jaws.