Classification of complex maxillofacial apparatuses. Classification of orthopedic devices for the treatment of maxillofacial injuries Disconnecting devices in the maxillofacial

Orthodontics (as defined by the American Association of Orthodontists) is the branch of dentistry concerned with the observation, study, and correction of developing and mature maxillofacial structures, including those conditions that require tooth movement or the correction of discrepancies and abnormalities in said structures by correcting tooth-facial relationships bones using forces and/or stimulation and changes in the direction of functional forces of the intracranial-facial complex.

The main objectives of orthodontic practice are the diagnosis, prevention and treatment of all forms of dental anomalies and associated changes in the surrounding structure; development, application and control of functional and corrective devices; and control of the dentition and its supporting structures in order to achieve and maintain optimal physiological and aesthetic harmony of the facial and cranial structures 5 .

Common orthodontic problems: epidemiology of malocclusions

What Angle defined as normal occlusion would more accurately be called an ideal standard, especially if all criteria are strictly observed. In fact, perfect closure of teeth along a perfectly even occlusal line is quite rare. Over the years, epidemiological studies of malocclusions have been complicated by considerable disagreement among researchers regarding the extent of acceptable deviations from the ideal norm. As a result, from 1930 to 1965, the prevalence of occlusion anomalies in the United States, according to various estimates, ranged from 35 to 95%. This huge discrepancy was mainly the result of differences in the criteria of normality among different researchers. Differences also arose due to the fact that the Angle classification is a description of occlusal relationships, which is not sufficient for epidemiological studies.

Around 1970, a number of studies were carried out by health authorities and university groups in most developed countries, providing the clearest picture of the prevalence of various occlusal discrepancies throughout the world. In the United States, the US Public Health Service (USPHS) conducted two large-scale surveys of children aged 6 to 11 years in 1963-1965. and adolescents from 12 to 17 years old in 1969-1970. 6-7

In 1989-1994. Another large-scale US National Health Survey (NHANESIII) examined the prevalence of malocclusion. The study included 14,000 people, statistically reflecting the condition of about 150 million people of various racial/ethnic and age groups. Oral health data were obtained for children and adolescents as well as adults, with racial/ethnic groups assessed separately 8,9 .

Rice. 1-11. Crowding of incisors is usually expressed using an irregularity index: the total distance in millimeters between the contact points of adjacent teeth.

Characteristics assessed in NHANESIII included irregularity index, incisor position (Figures 1-11), prevalence of diastema greater than 2 mm (Figures 1-12), and prevalence of cross-occlusion (Figures 1-13). In addition, the prevalence of sagittal (Fig. 1-14) and deep/vertical incisal disocclusion (Fig. 1-15) was assessed. Sagittal incisal disocclusion, accompanying class II, subclass 1 and Angle class III, can be assessed more accurately during an epidemiological survey than molar closure, so molar closure was not directly assessed.

Rice. 1-12. The space between adjacent teeth is called a diastema. Diastema between the upper central incisors is quite common, especially during the period of changing teeth. Diastema larger than 2 mm rarely closes on its own.

Rice. 1-13. Cross occlusion occurs when the upper posterior teeth are positioned lingually to the lower posterior teeth, as in this patient. Most often, cross-occlusion reflects a narrowing of the upper dentition, but it can also develop for other reasons.

Rice. 1-14. The sagittal gap characterizes the horizontal overlap of the incisors. Normally, the upper incisors should be in contact with the lower ones, located anterior to them by the size of the thickness of the cutting edge (i.e., normally the sagittal gap is 2-3 mm). If the lower incisors are located anterior to the upper incisors, the anomaly is called a reverse sagittal gap, or anterior reverse occlusion.

Rice. 1-15. Deep occlusion is characterized by deep vertical overlap of the incisors. Normally, the cutting edges of the lower incisors contact the palatal surfaces of the upper incisors at the level of the equator (i.e., normally the incisal overlap is 1-2 mm). With an open bite, there is no vertical contact between the incisors. Measure the size of the vertical gap.

NHANESIII data on the prevalence of malocclusions in children (8-11 years), adolescents (12-17 years) and adults (18-50 years) in the United States are presented in Tables 1-1 and 1-2 and graphically displayed in Figures 1-16-1-19 .

Table1- 1

Maxillofacial apparatuses are distinguished:

By location:

a) intraoral; b) extraoral; c) intra-extraoral; d) single-jawed; e) two-jawed; e) dental; g) supragingival; h) dentogingival; e) bone.

By fixation method:

a) removable; b) non-removable;

By manufacturing method:

a) standard; b) individual (laboratory and non-laboratory production) ;

According to manufacturing materials:

polymer (plastic, composite, polyamide thread);

metal (bent, cast, soldered, combined);

combined (plastic and metal, plastic and polyamide thread, metal and composite, etc.).

By application period:

1) temporary devices for first aid (transport immobilization);

2) permanent devices used to provide specialized medical care and in hospital treatment (therapeutic immobilization);

For therapeutic purposes:

1) main devices, i.e. having independent therapeutic value (for example, fixing, reducing, replacing, combined preventive);

2) auxiliary devices used for bone and skin plastic surgery, when the main type of treatment will be surgical intervention (these include: fixing devices - to hold fragments after surgery and forming devices - serving as a support for plastic material or creating a bed for removable dentures);

By functional purpose:

1) fixing devices (retention devices), hold jaw fragments in the correct position, ensure their immobility;

2) reduction devices (correcting or moving), divided into devices of mechanical and functional action (guides), gradually install jaw fragments into the correct position, used in cases where it is impossible to perform a one-step reduction;

3) shaping devices are used in plastic surgery of soft facial tissues to temporarily maintain the shape of the face, create rigid support, prevent cicatricial changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformation of the prosthetic bed, etc.).

4) replacement devices (resection and disconnection) are used to replace jaw defects and restore their shape and function;

5) combined devices (multifunctional);

6) preventive devices (mechanotherapy devices, boxing mouthguard, mouth opening limiters) are used to prevent maxillofacial injuries and their consequences;

Means of transport immobilization for jaw fractures.

The simplest bandage.

It is made using available materials (pencil, spatula, etc.).

Indicationsfor use: transport immobilization for isolated fractures of the upper jaw.

Limberg tablet.

Made from plywood 3-4mm thick,

Fixed with bandages or rubber bands

(rubber band) to the headband or cap.

Indications: for use: transport

immobilization for isolated fractures

upper jaw.

Standard transport splints for the upper jaw:

1) Faltina;

2) Vilga;

3) Romanova;

4) Moscow Institute of Traumatology and Orthopedics;

5) Limberg

6) Ulyanitsky.

Parietomental bandage according to Hippocrates.

I is the most accessible and simplest method of temporary fixation of fragments. Circular tours of the bandage, passing through the chin and parietal bones, do not allow fragments to move during transportation of the victim. For this purpose, you can use an elastic mesh bandage.

P providingfor use: in case of fractures of the lower jaw, it fixes the fragments to the intact upper jaw. In case of fractures of both jaws, the bandage supports and prevents the displacement of fragments of the damaged jaws, thereby significantly limiting their mobility.

Standard elastic sling bandage (according to Z.N. Pomerantseva-Urbanskaya).

Indicationsfor use: means of transport immobilization for fractures of the upper and lower jaw. It is not recommended to use this bandage on toothless jaws in the absence of dentures.

WITH
standard sling-shaped transport bandage by D.A. Entin.

Indicationsfor use: means of transport immobilization for fractures of the upper and lower jaw.

IN
Depending on the number of pairs of rubber rings used in the bandage, the sling can hold the fragments without pressure or apply pressure to them. In case of a fracture of the lower jaw behind the dentition or in case of a fracture of the upper jaw, a standard bandage can be applied using three pairs of rubber rings (as a pressure bandage).

In case of fractures of the lower jaw within the dentition, it should be applied only to support the fragments. Excessive pressure on displaced fragments leads to even greater displacement and the risk of asphyxia.

P If removable dentures are preserved in toothless patients, it is possible to use them together with a chin sling as a means of transport immobilization. The dentures are connected to each other in the area of ​​the lateral teeth with ligatures or self-hardening plastic. In this case, the front teeth should be cut off to provide nutrition.

All transport bandages and slings can be applied with pressure (pressure) and without pressure (supportive).

Pressing the bandage is indicated in the following cases:

to stop bleeding;

for all fractures of the upper jaw, preserving a sufficient number of teeth that will allow the fragments to be placed in correct articulation. This prevents additional injury to the brain and its membranes and helps reduce liquorrhea;

for fractures of the lower jaw outside the dental arch.

Standard, gauze bandages and sling as supporting impose in all other cases damage to the maxillofacial area. Their main purpose is to keep massive sagging flaps of soft tissue and fragments in a calm state, which is important during transportation.

Wire aluminum busbar.

Wire

soldered bus on

rings (crown- Tire nah). Tires from Weber quickly harden-

cabbage soup plastic. Fixing dental appliances for osteoplastic surgeries

Monoblock: Port bus, Lemberg

Chin sling

From the head

Bent wire aluminum intraoral splint with head cap for the treatment of maxillary fractures. Soldered wire busbar with rigid rods and a head cap.

Dental splint

with extraoral rods and with a head cap

(Fig. 237) are represented by a wire bent to the shape of a dental arch, and a ligature wire for attaching the wire arch to the teeth. The actual fixing part of the structure is the teeth, which provide connection between the splinting part and the bone. Obviously, the fixing ability of this design will depend on the stability of the connections between the tooth and the bone, the distance of the teeth in relation to the fracture line, the density of the connection of the wire arch to the teeth, the location of the arch on the teeth (at the cutting edge or chewing surface of the teeth , at the equator, at the neck of the teeth).

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

In such cases, the use of dentogingival splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of ​​contact of the splinting part in the form of coverage of the gums and alveolar process (Fig. 238). In case of complete loss of teeth, the intra-alveolar part (retainer) of the device is absent; the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained (Fig. 239). However, the fixing ability of such devices is extremely low.

From a biomechanical point of view, the most optimal design is a dental wire splint. She

Rice. 237. Components of a dental splint,

a - splinting part (wire arch with ligature); b - the actual fixing part (tooth roots and periodontium).

Rice. 238. Dental gingival splint, a - general view; b - metal frame of the tire.

attached to rings or full artificial metal crowns (Fig. 240). The good fixing ability of this splint 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 you use it

Rice. 239. Supragingival splint (monoblock).

Rice. 240. Soldered bus.

Rice. 241. Tire made of quickly hardening plastic.

With the splint, the tension of the ligature weakens, the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.

With the introduction of quick-hardening plastics, many different designs of dental splints appeared (Fig. 241). However, in terms of their fixing abilities, they are inferior to soldered splints in a very important parameter - the quality of the connection between the splinting part of the device and the supporting teeth. A gap remains between the surface of the tooth and the plastic, which is a receptacle for food debris and microbes. Long-term use of such tires is contraindicated.

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

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

Extraoral apparatuses consist of a chin sling (plaster, plastic, standard or individual) and a head cap (gauze, plaster, standard strip

Rice. 242. Dental splint made of alloy with “shape memory”,

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

Rice. 243. Fixation device used for bone grafting

ical operations. Rice. 244. Chin sling.

belt or ribbon juice). The chin sling is connected to the head cap using a bandage or elastic traction (Fig. 244).

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

Rice. 245. Design of the inside - extraoral apparatus.

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 and 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, aligners, rings, base plates, and a head cap.

The active part of the apparatus are devices that develop certain forces: rubber rings, an elastic bracket, screws. In a functionally functioning reduction apparatus, the force of muscle contraction is used to reposition fragments, which is transmitted through guide planes to the fragments, displacing them in the desired direction. A classic example of such a device is the Vankevich splint (Fig. 246). With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.

Forming apparatus

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

The design of the devices can be very diverse depending on the area of ​​damage and its anatomical and physiological characteristics. In the design of the forming apparatus, one can distinguish the forming part and the fixing devices (Fig. 247).

Rice. 246. Sheena Vankevich.

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

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 distant 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 designs of resection dentures and dentures restoring dentoalveolar defects (Fig. 248).

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

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

Rice. 248. Prosthesis based on a solid cast frame with multi-link clasps.

a - palate defect; b - solid-cast frame; c - general view of the prosthesis.

Combined devices

For reposition, fixation, formation and replacement, a single design is advisable, capable of reliably solving all problems. An example of such a design is a device consisting of soldered crowns with levers, fixing locking devices and a forming plate (Fig. 249).

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 device.

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

Use preserved natural teeth as support as much as possible, connecting them into blocks using known techniques for splinting teeth;

Make maximum use of the retention properties of the alveolar processes, bone fragments, soft tissues, skin, cartilage that limit the defect (for example, the cutaneous-cartilaginous part of the lower nasal passage and part of the soft palate, preserved even after total resections of the upper jaw, serve as a good support for strengthening the prosthesis );

Use surgical methods to strengthen prostheses and devices in the absence of conditions for their fixation in a conservative way;

Use the head and upper body as a support for orthopedic devices if the possibilities of intraoral fixation have been exhausted;

Use external supports (for example, a traction system for 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 use of these devices adequately for 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

Dislocations tooth 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-related injury, dental interventions. The clinical picture of a dislocation is characterized by swelling of soft tissues, sometimes rupture around the tooth, displacement, mobility of the tooth, disruption of occlusal relationships.

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

Treatment for complete dislocation is combined (tooth replantation followed by fixation), and for incomplete dislocation

Rice. 249. Combined action device.

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

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

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

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

For fractures at the neck of the tooth, which often occur as a result of 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 core pin and an artificial crown is 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-ray images 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 through 1 1/2-2 months There are 4 types of fracture healing (Fig. 250).

Type A: fragments are closely juxtaposed with each other, healing ends with 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.

> Fig. 250. Types of healing of a tooth root fracture (according to Pindborg). Explanation in the text.

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

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

Fractures of the alveolar ridge

The most common fractures of the alveolar process of the upper jaw are predominantly localized in the area of ​​the anterior teeth. Their causes include road traffic accidents, impacts, and falls.

Diagnosing fractures is not very difficult. Recognition of dental alveolar 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. To determine damage to the neurovascular bundle of teeth, electroodontodiagnosis is used. The final conclusion about the nature of the fracture can be made on the basis of x-ray 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.

Rice. 251. Displacement of a fragment of the alveolar process to the palatal side (a) and a palatal plate with a screw and wire arch (b) for repositioning and fixing the fragment.

Treatment of alveolar process 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 (Fig. 251). The mechanism of action of the device is the gradual movement of the fragment due to the pressing force of the screw. The same problem can be solved by using an orthodontic apparatus by stretching the fragment to 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 (Fig. 252).

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 principles of treatment are given in accordance with the Le Fort classification, based on the localization of fractures along lines corresponding to weak points. The main clinical symptoms of fractures are shown in Fig. 253.

. Rice. 252. Displacement of the fragment to the vestibular side and its reposition using an orthodontic apparatus (diagram).

| a - fracture and displacement of the alveolar process; b - sagittal gap between the incisors as a result of displacement of the fragment; c - general view of the apparatus, strengthened

t tooth decay; d - design of the apparatus (rings, arc, rubber rings); d - the fragment is installed in the correct position.

Orthopedic treatment of fractures of the upper jaw includes

It involves repositioning the upper jaw and immobilizing it with intra-oral devices.

At In the first type (Le Fort I), when it is possible to manually install 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. Zbarzhu), 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 apparatus can be made in the form of a wire dental splint, and in the case of multiple missing teeth or mobility of existing teeth - in the form of a dentogingival splint. In the toothless areas of the dentition there are teeth

The gum splint will consist entirely of plastic

Base with impressions of antagonist teeth (Fig. 254). In case of multiple or complete absence of teeth, surgical treatment methods are indicated.

Orthopedic treatment of a Le Fort type II fracture is carried out in a similar 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

Rice. 253. Types of fractures of the upper jaw and their clinical symptoms.

In some cases, the design of the apparatus consists of an intraoral part, a plaster head 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 apparatus 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, a hooking loop is created in the anterior section of the splint, in the area of ​​the incisors, to connect the intraoral splint with with a rod coming from the headband.

The extraoral supporting part of the apparatus can be located not only on the head, but also on the torso (Fig. 255).

Orthopedic treatment of Le Fort II, especially Le Fort III, fractures of the upper jaw 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.

Rice. 254. Treatment of Le Fort fracture.

a - diagram of the fracture; b - dentogingival splint with extraoral levers; c - splint fixed to the skull.

Rice. 255. Extraoral apparatus for traction of the upper jaw.

18-3384 431

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 rank 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 (Table 18).

Table a 18. Diagnostic value of clinical signs of mandibular fractures for choosing the method of immobilization

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 immo-

bilization. In other cases, there are indications for the use of surgical and combined methods of fixation of fragments.

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.

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 under conditions

Via the function of the lower jaw, 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 method of fixation of fragments of the lower jaw. There are certain contraindications to them: for example, for 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-maxillary 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 features, or is determined by the sequence of therapeutic interventions. For example, with a median fracture of the body of the lower

Rice. 256. Median fracture of the lower jaw (a) and fixation of fragments using a single-jaw wire dental splint (b).

jaws with a sufficient number of stable teeth on the fragments undergo manual reposition and fix the fragments 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 (Fig. 256). With a unilateral lateral fracture of the body of the lower jaw,

When a typical displacement of fragments occurs: up the small one under the influence of the masticatory, medial pterygoid, temporal muscles and downward the large one as a result of the 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 (Fig. 257).

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 (Fig. 258).

Of the possible options for immobilization of fragments in this type of mandibular fractures, the optimal one is intermaxillary fixation using dental splints: soldered wire splints with hooking loops, bent aluminum splints with hooking loops, standard tape splints Vasilye-

Rice. 258. Double fracture of the lower jaw.

a - posterior displacement of the middle fragment; b - retraction of the tongue; c - stretching the tongue and fixing it in the anterior position with a pin.

Rice. 259. A device with a hinged intermaxillary joint for the treatment of fractures in the area of ​​the angle of the lower jaw. Explanation in the text. "

va, tires with toe lugs made of quick-hardening plastic. Their choice depends on specific conditions, availability of material, technological capabilities and other factors.

Fractures in the area of ​​the angle, rami 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, others are used to treat fractures of the indicated localization.

devices - with a hinged intermaxillary connection (Fig. 259). 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. For this purpose, splints with hooking loops are made 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 bus and the entire block is fixed to the top bus

of the dentition according to the type of intermaxillary fixation.

Orthopedic treatment of fractures of the lower jaw 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

Rice. 260. Fracture of the lower jaw with a bone defect (a) and a mouthguard-rod apparatus (b) for its treatment.

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 (Fig. 260). It allows for sequential reposition of fragments, their fixation, and formation of soft tissues. The design of the apparatus is known (I.M. Oksman), with the help of which it is possible to carry out both reposition and fixation of fragments, and replacement of a bone tissue defect (Fig. 261). At the same time, 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 (Fig. 262).

Treatment of fractures of the lower jaw with a bone tissue defect in the absence of the possibility of constructing tooth-supported devices 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. In non-gunshot fractures, the fragments heal after 4-5 weeks, although the fracture gap can be determined radiologically even after 2 months. To obtain such a favorable outcome, three main conditions must be met:

1) accurate anatomical comparison of fragments; 2) mechanical stability of the connection of fragments; 3) preservation of blood supply to fixed fragments and function of the lower jaw.

Fig.261. The device is combined - Fig. 262. Reducing and fictitious sequential action syring apparatus,

(according to I.M. Oksman). Explanation in the text.

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

Long-term 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 healing in the wrong position.

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

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

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

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

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

Relatively minor occlusal disorders can be corrected by prosthetics. Vertical discrepancies can be leveled with both fixed and removable prostheses: metal crowns, aligners, removable dentures with a cast occlusal overlay. In case of transversal violations of occlusion and a small number of remaining teeth,

Rice. 263. Removable denture with duplicated dentition.

change a removable denture with a duplicated dentition (Fig. 263). 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 and surgical methods for correcting bite deformities can give a high positive effect in the treatment of improperly healed jaw 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-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, interposition of soft tissues, bone tissue defect, and complications of a fracture due to chronic inflammation of the bone.

The morphological picture of fracture healing that ends in the formation of a pseudarthrosis differs sharply from that observed with complete healing of fractures. With pseudarthrosis, signs are clearly revealed 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. (Diagram 5).

The clinical picture of a pseudarthrosis is characterized by deformation of the mandibular bone and impaired closure of the teeth, cicatricial changes in the soft tissues in the area of ​​the pseudarthrosis.

Maxillofacial orthopedics

For the first time, fixation of fragments began to be carried out using intra- and extraoral bandages - at the end of the 18th and beginning of the 19th centuries.

Hippocrates treated fractures using reposition of fragments followed by splinting using a sling bandage.

The first specialist to apply a plaster cast for fractures of the lower part - Pirogov

Injuries of the maxillofacial area.

Damage to the face occurs both in peacetime and in wartime, of which 70% are due to injuries to the soft tissues of the face and 30% to a combination of injuries with damage to the bones of the facial area.

Damage includes 5 groups:

1. Firearms

2. Non-gunshot

3. Combined

5. Frostbite

According to etiology they are divided:

1. Traumatic (gunshot, non-gunshot)

2. Pathological – arise in connection with a pathological process in the jaw bone

Fractures happen:

2. Incomplete

3. Under the periosteal

Fractures can be open or closed.

Depending on the fracture line, there are:

1. Transverse

2. Longitudinal

4. Zigzag

By number of fragments:

1. Single

2. Double on one side

3. Double sided

4. Multiple (fragmentation)

Non-gunshot wounds

There are household, transport, industrial, etc.

They occur when a blow is applied directly to the wide surface of the jaw, a fall, or compression. Non-gunshot fractures are characterized by linear damage to the bone; however, they occur in areas of reduced strength, accompanied by minor functional impairments, bleeding, malocclusion, and swelling.

Patients are treated on an outpatient basis.

In case of a fracture in the middle, the condition is more severe because The VCH connects to many bones of the skull, so injuries are often combined with damage to the vessels and nerves of the brain and organs of vision.

Gunshot wounds

They are divided according to the type of wounding weapon - bullet, fragmentation, beam.

By nature – through, tangential, blind.

Gunshot fractures are always accompanied by damage to the jaw and nearby tissues because They are always open, the entrance holes are torn. They are characterized by significant damage to blood vessels and nerves; if large vessels are damaged, severe bleeding occurs. The salivary glands and tongue are often damaged, resulting in dysfunction of chewing, swallowing, speech, and eating. The condition of the patients is serious due to the proximity of vital organs of the skull.

Gunshot fractures in the middle are more dangerous.

In case of gunshot fractures, the central block of the face with the participation of the zygomatic and ethmoid bones is damaged.

General features of wounds

1. Teeth and jaws are damaged, the bite is disturbed.

2. A facial injury disfigures a person’s appearance (psychological trauma)

3. A facial wound leaves permanent scars.

4. Oral and facial wounds heal faster due to good blood supply

5. There are fewer inflammatory processes

6. Hip fractures are sometimes combined with fractures of the base of the skull; these are very severe fractures.

Clinic and diagnosis of fractures

Recognizing gunshot wounds is not difficult; non-gunshot fractures are more difficult to diagnose. To clarify the diagnosis there are:

I. Main symptoms

1. Mobility of fragments using a certain biomanual technique

2. Creptation (crunching)

3. Malocclusion

If there is at least one of the symptoms, then we can talk about a jaw fracture

II. Additional symptoms

2. Chewing disorders

3. Bleeding

4. Swelling

With a fracture of the upper jaw, the following are observed: deformation, asymmetry of the face, elongation of the face, hemorrhage in the conjunctiva (symptom of glasses), nausea, vomiting, loss of consciousness.

The diagnostic method is x-ray.

Complication of injuries due to fractures.

1) Asphyxia, shock, blood loss

2) Osteomyelitis of the jaw due to infection, inflammation

3) Violation of facial appearance, scars, asymmetry

4) Deformation of the bite, with improperly healed fractures

5) Violation of bone integrity

6) Formation of a false joint, growth of 1-2 cm of connective tissue between fragments

7) Contracture – limitation of joint mobility

8) Ankylosis – joint immobility

9) Microstomia - narrowing of the mouth (small mouth opening)

Features of combined lesions of the maxillofacial area.

(trauma + radiation)

Symptoms of aggravation are observed:

1. Increased bleeding

2. General condition worsens

3. Wound healing is slow

Stage 1 – primary reaction to radiation (headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, etc.)

Stage 2 – the latent period lasts 2-3 weeks, with light exposure, with strong exposure for several days. During this period, all necessary interventions (surgical, orthopedic) are carried out; steel prostheses are replaced with plastic ones, since metal was a source of radiation.

Stage 3 – the period of the height of radiation sickness, all symptoms intensify, stomatitis, gingivitis, hair loss, anemia, disorders of the cardiovascular system, nervous system, suppuration, infection develop. Evacuation from the affected area, removal of radioactive isotopes from the skin and mucous membrane of wounds.

Classification of mandibular fractures according to Entin.

Entin divides non-gunshot fractures of the lower jaw according to their location into fractures of the alveolar process.

Group 1 – median fracture, with and without displacement of fragments into the incisor area

Group 2 – lateral (mental) fracture in the area of ​​the canine and premolar

Group 3 – corner (angular)

Group 4 – fracture of the coronoid process in the area of ​​the lower limb branch.

Group 5 – fracture of the articular process in the area of ​​the neck of the articular process.

Entin divides fractures according to their nature: single, double, multiple, displacement of fragments is caused by muscle traction because in the region of the lower part all the masticatory muscles and a number of facial muscles are attached.

Functional disorders - slight swelling, bleeding, malocclusion, treated on an outpatient basis.

Principles of treatment of jaw fractures.

Treatment of a fracture has the ultimate goal of restoring anatomical integrity and full function.

Achieved:

1. Reposition - comparison of fragments in the correct position.

2. Immobilization – immobility of fragments and retention until healing.

Problems are solved surgically or orthopedically.

Reposition can be carried out: manually (under anesthesia), using devices, surgically (bloody).

The complex of treatment systems includes:

1. Primary wound treatment

2. Reposition and fixation of fragments

3. Infection control measures

4. Bone grafting

5. Plastic surgery of soft tissues

6. Measures to combat contractures

7. Solving the problems of false joints, microstomia

Dislocations and fractures of teeth

They often occur in the frontal area of ​​the forehead, as a result of a blow or fall, when biting food, adjacent teeth can be dislocated when the teeth are removed by the roots. Partial or complete rupture of tissue, periodontal fibers and damage to the neurovascular bundle occurs. Swelling, hemorrhage, and abrasions in the mouth area are visible. The mouth is sometimes half-open, the gum mucosa may be torn, one of the walls of the alveoli is broken, a defect in the dentition occurs, the teeth are rotated, tilted.

Treatment: under local anesthesia, the dislocated tooth is repositioned, its immobilization is reliably ensured by a plastic splint - mouth guard.

Teeth fracture

Reasons: similar to those of a dislocation, the fracture can be longitudinal or transverse. Crown fracture:

1. Within the enamel or dentin without violating the integrity of its cavity.

2. With exposed coronal pulp.

3. Complete fracture of the crown at the level of the neck.

Root fracture

Occurs in the middle of the upper and lower third of the root. When the root is fractured, a defect of varying shape is visible; the crown sometimes takes on a color from pink to purple. The x-ray shows the fracture lines of the tooth root.

Treatment: if the crown is fractured without opening the cavity, the sharp edges should be ground off and the defect should be eliminated using an inlay or filling. If the pulp is exposed, it is removed, the canal is filled and the broken part is restored. In case of complete fracture of the tooth crown, the root is not removed; it is used for tooth pins or stump inlays.

Repanning devices.

These include wire or plastic splints for intermaxillary tension, devices with screws, extraoral levers, spring loops, and inclined planes. They operate on the principle of tension, pressure on displaced fragments. They consist of supporting and operating parts.

1. Tigerstedt tire No. 3 with toe loops

2. Sheena Vankevich

3. Weber tire No. 3, 5

4. Katz apparatus

5. Courland apparatus

6. Grozovsky apparatus

The following devices are used to tension and reduce stiff fragments in chronic fractures:

1. Katz apparatus with extraoral levers on the lower jaw. Used in the presence of a bone defect. It consists of rings to the buccal surfaces of which tubes for extraoral levers are soldered. The levers are removed from the oral cavity, going around the corner of the mouth, forming a pneumatic loop and the second is directed in the opposite direction. The Katz apparatus is activated by lateral extension outside the oral rods. The rods are too wide and are tied together with a ligature.

2. The Kurland apparatus is used for fractures within the dentition. It consists of mouthguards on the buccal surfaces of which double tubes or corresponding rods are soldered. Mouth guards are made, placed in the oral cavity, and impressions are taken of the high and low frequencies. The LF model is sawed into 2 parts in the area of ​​the fracture and assembled in the bite in the occluder. Soldering the double tubes horizontally, the rods are selected, then the tubes are sawed and the tray is cemented. A spring arch is installed for reposition in the form of a loop. After its removal, the rods are inserted into the tubes.

3. Grozovsky apparatus at low end. Used when there is a small number of teeth on both fragments. The device consists of a met guard with soldered flat tubes and humeral extensions with holes for screws. The repanning device consists of extra-oral rods into which bushings are inserted; on one rod there is a nut for securing the pushing screw, and on the other there is a support platform. Reposition takes 2-3 days, tightening the screw. Then the fixing appendages are put on.

Resection devices.

Devices that replace dental defects, filling jaw defects after surgery.

The goal is to restore the function of sometimes keeping fragments from moving and the soft tissues of the face from sinking.

1. Direct or immediate prostheses. They are prepared before surgery and inserted into the oral cavity after resection.

2. Subsequent, post-resection - made in the near future or in the long term after 2-3 months. The domestic specialist who was the first to propose a replacement prosthesis for resection of half of the high part was Oksman. He proposed a 3-stage manufacturing method for HF.

Stage 1 – production of the fixing part

Stage 2 - production of the resection part, after casting the HF model with a fixing plate, the resection boundaries are marked on the model. The outermost tooth is cut down to the level of the neck to cover the mucous bone in this place. The remaining teeth are cut to the level of the base of the alveolar process on the vestibular side and the palatal teeth to the middle of the palate. They clean the plate at the junction, set the teeth, model it, polymerize it, etc.

Stage 3 – production of the opturizing part or transformation of the temporary prosthesis into a permanent one. As the wound heals, the tampons are removed and the palatal part of the prosthesis is covered with a roller made of self-hardening plastic to obtain impressions of the edges of the cavity and separation of the oral and nasal cavities. After 1-2 minutes, remove and process.

Production of a prosthesis for resection of half of the lower part, stage 2. The difficulty lies in more complex fixation since the replacement part is located on one side, the more massive one does not have bone support. The healthy part is displaced in the midline, the occlusion is broken. This position can be fixed with scars. To prevent this complication, an inclined plane is installed on the fixing plate.

Stage 1 – production of crowns, fixing plates with clasps and an inclined plane.

Stage 2 – production of the resection part. The base is thickened outward and lengthened behind the dentition to support the soft tissue at the angle of the jaw.

Forming devices.

Used for damage to the soft tissues of the oral cavity and the oral area. They serve as a support for soft tissues, replace bone defects in the dentition, form a plastic material, form a bed for a prosthesis, and prevent the formation of scars. Without them, the soft tissues wrinkle and the face loses its natural shape, so they need to be made before surgery. Forming devices consist of fixing, replacing and forming elements in the form of thickened bases against the areas to be formed. They can be removable and combined, with combinations in the form of crowns and removable forming elements attached to them.

1. When plasticizing the transitional fold in the vestibule of the oral cavity, thermal mass is layered on the edge of the prosthesis or splint facing the wound. You can use a wire splint, bending it along the dental arch with loops for layering thermal mass.

2. In case of partial loss of teeth in prosthetics, removable dentures are soldered to the vestibular edge opposite the surgical field with a zigzag wire on which a thermomass is layered.

3. Forming apparatus according to Schur. The domestic specialist was the first to develop a replacement prosthesis for complete removal of the upper jaw Shur. Post-resection devices include the combined Schur prosthesis. Schur recommends making a formative prosthesis of the upper jaw with finger-like processes in its posterior part; pockets (niches) are created along them in the posterior parts of the cheeks by skin grafting, this ensures fixation of the prosthesis in its posterior part, the front part of the prosthesis is fixed with a special extraoral rod attached to the plaster head bandage. Subsequently, the front part of the prosthesis is fixed with scars formed around the prosthesis during the post-resection period. A prosthesis of this design can be used after unilateral and bilateral resection of the edentulous upper jaw. Its production and skin grafting are carried out 3-4 months after resection of the upper jaw using the method of remote prosthetics. In case of extensive defects of the jaw and a large volume of the forming prosthesis or in case of microstomy, they are made folding or collapsible.

Facial prostheses (ecto)

Traumatic facial defects are eliminated by plastic surgery, but if patients are weakened or exhausted, facial prostheses are made; prostheses of the lips, cheeks, eyes, chin, nose, and ears are distinguished. They are used as temporary before surgery and permanent. Requirements:

1. Restore the shape and contour of the face.

2. Dyeing and color must match the fabrics

3. Adhere tightly to the edges of the defect at rest and during function

4. Fixation must be reliable

To make Ecto prostheses, it is necessary to take an impression of the entire face. The patient is placed in a horizontal position and tubes are inserted into the nose. I smear Vaseline on my eyebrows, mustache, beard, cover my head and neck with a napkin . I cover my face with 1-1.5 cm of plaster. then the impression is taken forward and slightly downward to avoid hematoma on the back of the nose. Place it in water for 15-20 minutes and cast the model. The prosthesis is modeled from wax, plasticine, focusing on the second half, photo, etc. The modeled composition is smeared with Vaseline and an impression is taken from it, isolated, wax 1-1.5 mm thick is poured in, removed, and a 5-10 mm layer of wax is applied to the plaster mask at the edges of the defect and the wax composition of the prosthesis is glued to it. They try it on the face, adjust it and replace it with the appropriate plastic. Fastening is provided to the spectacle frame using plates covering the earpieces. And the lower part of the nose enters the bottom of the nasal openings through a spring.

Orbital prosthesis.

A wax model of the prosthesis is created on the mask; the prosthetic eye is mounted on the inner surface of the eyelids; then it is carefully separated and eyebrows and eyelashes are glued to the wax. Plastered and replaced with plastic, processed. The eye is attached to the back wall of the orbit and fixed to the face using brackets and a spectacle frame. The auricle prosthesis is made of elastic plastic, modeled from wax, and the color is selected. In the complete absence of an ear, the auditory opening is used to make a prosthesis with an appendage included in it. This helps to secure the lower part of the prosthesis. The upper part of the prosthesis is strengthened with a spring thrown over the opposite side of the head. In cases of severe damage to the face, there is a need for simultaneous prosthetics of the jaws and facial tissues; facial prostheses are connected on one side using hinges or magnets with jaw prostheses on the other on a spectacle frame. To strengthen the ear prosthesis, it is better to use springs. Facial ectoprostheses are fixed with a spectacle frame. Egmos 12 plastic is used.

Maxillofacial orthopedics

It is a section of orthopedic dentistry that deals with clinical issues, diagnosis and treatment of injuries and defects of the maxillofacial area resulting from trauma of a gunshot or non-gunshot origin, or previous diseases, defects of the soft palate, palate and lip.

ChL orthopedics consists of two parts:

1. Maxillofacial traumatology – surgical diagnosis (surgical methods for fixing fragments)

2. Maxillofacial prosthetics

1. Restore the anatomical integrity of the maxillofacial area, facial contours, bone integrity

2. Restore functions: chewing, eating, speaking.

Main tasks of maxillofacial orthopedics

1. Prosthetics for patients with congenital and acquired defects of the face and jaws

2. Creation of orthopedic structures for the correct composition of fragments, to correct incorrectly fused fragments, to eliminate the consequences of injuries (scars, contractures)

3. Manufacturing of orthopedic structures in preparing patients for surgery and to ensure the most favorable conditions in post. operating period.

4. Manufacturing of special prostheses during osteofacial operations and soft tissue plastic surgery

5. Treatment of diseases of the masticatory muscles and TMJ

20334 0

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 (Scheme 4). They are the main means of conservative treatment of injuries to the maxillofacial area. Most of them are used in the treatment of jaw fractures and only a few - in bone grafting.

Scheme 4
Classification of fixing devices

For primary healing of bone fractures, it is necessary to ensure the functional stability of the fragments. The strength of fixation depends on the design of the device and its fixing ability. Considering the orthopedic device as a biotechnical system, 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 (Fig. 237) is represented by a wire bent to the shape of a dental arch, and a ligature wire for attaching the wire arch to the teeth. The actual fixing part of the structure is the teeth, which provide connection between the splinting part and the bone. Obviously, the fixing ability of this design will depend on the stability of the connections between the tooth and the bone, the distance of the teeth in relation to the fracture line, the density of the connection of the wire arch to the teeth, the location of the arch on the teeth (at the cutting edge or chewing surface of the teeth, at the equator, at the neck teeth).

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

In such cases, the use of periodontal splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of ​​contact of the splinting part in the form of coverage of the gums and alveolar process (Fig. 238). In case of complete loss of teeth, the intra-alveolar part (retainer) of the device is absent; the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained (Fig. 239). However, the fixing ability of such devices is extremely low.

From a biomechanical point of view, the most optimal design is a soldered wire splint. It is attached to rings or full artificial metal crowns (Fig. 240). The good fixing ability of this tire is explained by the reliable, almost motionless connection of all structural elements. The splinting arch is soldered to a ring or to a metal crown, which is fixed to the supporting teeth using phosphate cement. When ligating teeth with an aluminum wire arch, such a reliable connection cannot be achieved. As the splint is used, the tension of the ligature weakens, and the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.

With the introduction of quick-hardening plastics, many different designs of dental splints appeared (Fig. 241). However, in terms of their fixing abilities, they are inferior to soldered splints in a very important parameter - the quality of the connection between the splinting part of the device and the supporting teeth. A gap remains between the surface of the tooth and the plastic, which is a receptacle for food debris and microbes. Long-term use of such tires is contraindicated.

Rice. 241. Tire made of quickly hardening plastic.

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

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

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

Extraoral apparatuses consist of a chin sling (plaster, plastic, standard or customized) and a head cap (gauze, plaster, standard strips of belt or ribbon). The chin sling is connected to the head cap using a bandage or elastic traction (Fig. 244).

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

Rice. 245. Design inside the extraoral apparatus.

Rehearsal devices

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

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

The active part of the apparatus are devices that develop certain forces: rubber rings, an elastic bracket, screws. In a functionally functioning reduction apparatus, the force of muscle contraction is used to reposition fragments, which is transmitted through guide planes to the fragments, displacing them in the desired direction. A classic example of such a device is the Vankevich splint (Fig. 246). With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.

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

Forming apparatus

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

The design of the devices can be very diverse depending on the area of ​​damage and its anatomical and physiological characteristics. In the design of the forming apparatus, one can distinguish the forming part and the fixing devices (Fig. 247).

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

Replacement devices (prostheses)

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

Dental prosthetics is inextricably linked with maxillofacial prosthetics. 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 designs of resection dentures and dentures restoring dentoalveolar defects (Fig. 248).

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

Combined devices

For reposition, fixation, shaping and replacement, a single design that can reliably solve all problems is advisable. An example of such a design is an apparatus consisting of soldered crowns with levers, fixing locking devices and a forming plate (Fig. 249).

Rice. 249. Combined action device.

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

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

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

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

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

Orthopedic dentistry
Edited by Corresponding Member of the Russian Academy of Medical Sciences, Professor V.N. Kopeikin, Professor M.Z. Mirgazizov