15.07.2020

Functional disorders in maxillofacial injuries. Traumatic injuries of the maxillofacial area. Combined injury – damage to at least two anatomical areas by one or more damaging

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

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. THORACOABDOMINAL WOUNDS

CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

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

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

18.1. TERMINOLOGY AND CLASSIFICATION OF DAMAGES TO THE MAXILLOFACIAL AREA

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Examples of diagnoses of injuries to the maxillofacial area.

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

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

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

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

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

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

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

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

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

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

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

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

Rice. 18.5. Malocclusion in mandibular fractures

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

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

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

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

Brow ridges;

Lateral edges of the orbits;

Inferior orbital margins;

Elevations of the zygomatic bones;

Zygomatic arches;

Upper jaw;

Nose bones;

Lower jaw.

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

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

Instrumental research methods:

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

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

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

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

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

Photograph of the nasal bones;

Frontomental-parietal projection;

Orthopantomography.

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

18.3. PROVIDING ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rice. 18.8. Tamponade of the mouth and pharynx

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

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

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

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

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

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

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

structures penetrating the oral cavity, nose and paranasal sinuses;

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

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

Gunshot fractures of the facial skeleton without a bone defect;

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

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

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

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

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

its integrity; - isolated wounds of the alveolar process within

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

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

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

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

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

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

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

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

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

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

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

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

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

Tooth dislocations

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

What causes damage to the maxillofacial area

Tooth fractures

False joints

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

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

Contracture of the lower jaw

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

Pathogenesis (what happens?) during Injuries to the maxillofacial region

Tooth fractures

Contracture of the lower jaw

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

Symptoms of Injuries to the Maxillofacial Area

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

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

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

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

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

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

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

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

Tooth dislocations

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

Tooth fractures

Fractures of the lower jaw

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

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

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

Contracture of the lower jaw

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

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

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

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

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

Diagnosis of Injuries to the maxillofacial area

Tooth dislocations

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

Tooth fractures

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

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

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

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

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

Fractures of the lower jaw

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

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

Treatment of Injuries to the Maxillofacial Area

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

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

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

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

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

Orthopedic devices, their classification, mechanism of action

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

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

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

According to the design and manufacturing method, orthopedic devices can be divided into standard and individual (non-laboratory and laboratory manufacturing).

Fixing devices

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

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

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

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

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

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

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

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

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

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

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

AST. Rehearsal devices

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

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

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

Forming apparatus

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

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

Replacement devices (prostheses)

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

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

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

Combined devices

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

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

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

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

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

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

Orthopedic treatment methods for injuries of the maxillofacial area

Dislocations and fractures of teeth

Tooth dislocations

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

Tooth fractures

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

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

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

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

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

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

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

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

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

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

Fractures of the alveolar ridge

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

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

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

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

Fractures of the body of the upper jaw

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

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

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Damage to the maxillofacial area

What are Injuries to the maxillofacial area -

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

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

Tooth dislocations

What provokes / Causes of Injuries to the maxillofacial area:

Tooth fractures

False joints

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

Contracture of the lower jaw

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

Tooth fractures

Contracture of the lower jaw

Symptoms of Injuries to the Maxillofacial Area:

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

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

Tooth dislocations

Tooth fractures

Fractures of the lower jaw

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

Contracture of the lower jaw

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

Diagnosis of Injuries to the maxillofacial area:

Tooth dislocations

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

Tooth fractures

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

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

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

Fractures of the lower jaw

Treatment of Injuries to the Maxillofacial Area:

Orthopedic devices, their classification, mechanism of action

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

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

According to the design and manufacturing method, orthopedic devices can be divided into standard and individual (non-laboratory and laboratory manufacturing).

Fixing devices

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

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

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

AST. Rehearsal devices

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

Forming apparatus

Replacement devices (prostheses)

Combined devices

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

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

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

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

Orthopedic treatment methods for injuries of the maxillofacial area

Dislocations and fractures of teeth

Tooth dislocations

Tooth fractures

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

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

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

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

Fractures of the alveolar ridge

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

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

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

Fractures of the body of the upper jaw

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

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

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

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

Fractures of the lower jaw

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Improperly healed jaw fractures

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

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

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

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

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

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

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

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

False joints

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

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

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

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

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

Contracture of the lower jaw

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

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

Orthopedist
Maxillofacial surgeon

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

How to contact the clinic:
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(+38 044) 206-20-00

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

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

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

Other diseases from the group Dental and oral cavity diseases:

Abrasive precancerous cheilitis Manganotti

Abscess in the facial area

Adenophlegmon

Edentia partial or complete

Actinic and meteorological cheilitis

Actinomycosis of the maxillofacial region

Allergic diseases of the oral cavity

Allergic stomatitis

Alveolitis

Anaphylactic shock

Angioedema

Anomalies of development, teething, changes in their color

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

Arthrosis of the temporomandibular joint

Atopic cheilitis

Behçet's disease of the mouth

Bowen's disease

Warty precancer

HIV infection in the oral cavity

The effect of acute respiratory viral infections on the oral cavity

Inflammation of the tooth pulp

Inflammatory infiltrate

Dislocations of the lower jaw

Galvanosis

Hematogenous osteomyelitis

Dühring's dermatitis herpetiformis

F KSMU 4/3-04/03

Karaganda State Medical University

Department of Surgical Dentistry

LECTURE

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

Discipline PHS 4302 “Propaedeutics of surgical dentistry”

Specialty 051302 “Dentistry”

Course: 4

Time (duration) 1 hour

Karaganda 2014

Approved at a meeting of the Department of Surgical Dentistry

“” 20_ protocol No. ____

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

3. Branches of the lower part:

a) the branches themselves;

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

c) coronoid process;

B. Fractures of the i/h.

a) alveolar process;

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

c) the jaw with nasal and zygomatic bones;

D. Fractures of the zygomatic bone and zygomatic arch:

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

sinuses or without damage;

b) zygomatic bone and zygomatic arch;

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

a) nasal septum in the cartilaginous section;

b) nasal septum in the osteochondral section;

c) nasal bones;

The nature:

A.a) single;

b) double;

d) multiple;

B.a) one-sided;

b) double-sided;

B.a) without displacement of fragments;

b) with displacement of fragments;

D.a) isolated;

b) combined;

1. with traumatic brain injury;

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

other areas of the body;

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

D.a) closed;

b) open;

E. a) penetrating into the oral cavity;

d) do not penetrate the maxillary sinus;

According to the mechanism of damage:

A. Firearms;

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

WOUND AND DAMAGE OF HUMAN BEINGS -

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

kovy zones of the face.

1. Soft tissue injuries.

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

By localization:

a) dental injuries;

b) fractures of the lower part;

c) fractures of the h/h;

d) fractures of the zygomatic bone and zygomatic arch;

e) fractures of the nasal bones;

The nature:

A.a) ordinary;

b) double;

c) multiple;

B. a) unilateral;

b) double-sided;

B. a) without displacement of fragments;

b) with displacement of fragments;

D. a) isolated;

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

With damage to the soft tissues of the face

E. a) closed;

b) open;

D. a) penetrating into the oral cavity;

b) do not penetrate into the oral cavity;

c) penetrating the maxillary sinus;

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

A. firearms;

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

CLASSIFICATION OF FIRE SHOOTINGS

DAMAGE TO THE MODEL

O B L A S T I.

1. By type of wounding weapon:

a) bullet;

b) splintered;

c) fraction;

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

a) single;

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

a) blind;

b) through;

c) tangents;

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

a) abrasions;

b) point;

d) gifted;

e) scalped;

f) torn and crushed, etc.

6. According to the location of bone damage:

a) lower jaw;

b) upper jaw;

c) both jaws;

d) zygomatic bone;

e) nasal bones;

e) hyoid bone;

g) combined injuries to several facial bones;

7. According to the nature of bone damage:

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

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

a) segmental;

b) contour;

c) diametrical;

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

a) isolated;

b) combined;

c) multi-regional;

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

a) non-penetrating;

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

a) without damage;

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

salivary glands, blood vessels, nerves;

12. By the nature of tooth damage;

a) incomplete fractures;

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

a) without damage;

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

a) without damage;

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

a) lungs;

b) average;

c) heavy;

d) terminal;

METHODS OF INVESTIGATION OF PATIENTS

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

The examination of any patient must be carried out according to a specific, well-established system, strictly sequentially. Particular attention should be paid to the nature of complaints, to the anamnesis data, to establish the causes and circumstances of the occurrence

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

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

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

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

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

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

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

time.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Damage to the upper part

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

COMBINED WOUNDS OF THE FACE AND Neck.

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

III. Laboratory, functional, radioisotonic.

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

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

and investigation.

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

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

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

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

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

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

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

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

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

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

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

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

Immunological studies.

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

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

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

quantitative characteristics, i.e. objectify observations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Illustrative material

Foley No. 15

Literature

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

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Methods of surgical treatment:

A. Osteosynthesis with bone suture.

B. Osteosynthesis with Kirschner wires.

B. Osteosynthesis with miniplates.

D. Osteosynthesis with a structure with shape memory effect.

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CHAPTER 18 COMBAT TRAUMA OF THE MAXILLOFACIAL AREA

What causes damage to the maxillofacial area

Pathogenesis (what happens?) during Injuries to the maxillofacial region

Symptoms of Injuries to the Maxillofacial Area

Diagnosis of Injuries to the maxillofacial area

Treatment of Injuries to the Maxillofacial Area

Online Tests

Damage to the maxillofacial area

What are Injuries to the maxillofacial area -

What provokes / Causes of Injuries to the maxillofacial area:

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

Symptoms of Injuries to the Maxillofacial Area:

Diagnosis of Injuries to the maxillofacial area:

Treatment of Injuries to the Maxillofacial Area:

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

Other diseases from the group Dental and oral cavity diseases:

Karaganda State Medical University

Department of Surgical Dentistry

Time (duration) 1 hour

“____”______ 20___ protocol No. ____

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

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