Orthodontics (maxillofacial orthopedics). Presentation on the topic "replacement devices and prostheses" Maxillofacial devices

Jaw fragments are secured using various orthopedic devices. All orthopedic devices are divided into groups depending on their function, area of ​​fixation, therapeutic value, design, manufacturing method and material. By function:

– immobilizing (fixing);

– repositioning (correcting);

– corrective (guides);

– formative;

– resection (replacement);

– combined;

– dentures for defects of the jaws and face.

Chapter 12. Orthopedic treatment of patients with maxillofacial pathology 605

According to the place of fixation: – intraoral (single-maxillary, double-maxillary, intermaxillary); – extraoral; – intra- and extraoral (maxillary, mandibular).

By therapeutic purpose: – basic (having independent medicinal value: fixing, correcting, etc.);

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

By design: – standard; – individual (simple and complex).

By manufacturing method: – laboratory manufacturing; – non-laboratory production.

By materials: – plastic; – metal; – combined.

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

– wire tires (Tigerstedt, Vasiliev, Stepanov); – splints on rings, crowns (with hooks for traction of fragments); – splint guards:

✧ metal - cast, stamped, soldered; ✧ plastic; – removable tires Port, Limberg, Weber, Vankevich, etc.

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

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

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

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

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

– reduction devices for toothless jaws (Guning–Port splints).

Fixing devices are devices that help to retain a break.
kov jaws in a certain position. They are divided:
– to extraoral:

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

Course of orthopedic treatment of patients...

– intraoral: ✧ dental splints:

Aluminum wire (Tigerstedt, Vasiliev, etc.);

Soldered tires on rings, crowns;

Plastic tires;

Fixing dental appliances; ✧ dentogingival splints (Weber, etc.); ✧ supragingival splints (Porta, Limberga);

– combined.

Guides (corrective) are devices that provide
press the bone fragment of the jaw in a certain direction using
an inclined plane, a hinge, a sliding hinge, etc.
– For aluminum wire busbars, the guide planes are curved
beat simultaneously with a bus from the same piece of wire in the form of a row
loops

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

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

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

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

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

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

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

Prostheses used in maxillofacial orthopedics are divided into: – dentoalveolar; – jaw;

Chapter 12. Orthopedic treatment of patients with maxillofacial pathology 607

– facial; – combined;

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

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

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

CLASSIFICATION OF COMPLEX MAXILLOFACIAL APPARATUS

Jaw fragments are secured using various orthopedic devices. All orthopedic devices are divided into groups depending on their function, area of ​​fixation, therapeutic value, design, manufacturing method and material.

By function:

Immobilizing (fixing);

Repairing (correcting);

Corrective (guides);

Formative;

Resection (replacement);

Combined;

Prostheses for defects of the jaws and face.

At the location of fixation:

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

Extraoral;

Intra- and extraoral (maxillary, mandibular).

For therapeutic purposes:

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

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

By design:

Standard;

Individual (simple and complex).

By manufacturing method:

Laboratory production;

Non-laboratory production.

Based on materials:

Plastic;

Metal;

Combined.

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

Wire tires (Tigerstedt, Vasiliev, Stepanov);

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

Tire guards:

V metal - cast, stamped, soldered;

V plastic; - removable tires of Port, Limberg, Weber, Vankevich, etc.

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

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

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

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

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

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

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

For extraoral:

V standard chin sling with head cap;

V standard tire according to Zbarzh et al.

Intraoral:

*V dental splints:

Aluminum wire (Tigerstedt, Vasiliev, etc.);

Soldered tires on rings, crowns;

Plastic tires;

Fixing dental appliances;

* dentogingival splints (Weber, etc.);

* supragingival splints (Porta, Limberg);

Combined.

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

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

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

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

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

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

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

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

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

Prostheses used in maxillofacial orthopedics are divided into:

To the dentoalveolar;

Jaw;

Facial;

Combined;

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

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

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

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

Orthopedic treatment for false joints (Oxman technique):

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

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

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

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

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

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

Orthopedic treatment for improperly fused jaw fragments:

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

When the dental arch of the lower jaw is deformed due to an inclination towards the lingual side of one or more teeth, prosthetics of the dentition defect with a removable plate or arch prosthesis is difficult, since displaced teeth interfere with its application. In this case, the design of the prosthesis is changed so that in the area of ​​​​displaced teeth, part of the base or arch is located on the vestibular, and not on the lingual side. Support-retaining clasps or occlusal pads are applied to displaced teeth, allowing chewing pressure to be transferred through the prosthesis to the supporting teeth and preventing their further displacement to the lingual side.

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

Orthopedic treatment for microstomia:

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

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

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

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

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

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

Orthopedic treatment of defects of the hard and soft palate:

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

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

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

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

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

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

Slide 2

Replacement prostheses are used for jaw resection or congenital and post-traumatic jaw defects.

Slide 3

Replacement dentures for jaw resection can be made: 1) before surgery and inserted into the oral cavity immediately after resection; 2) after the operation after a certain period of time. In the first case, such prostheses are called immediate, in the second - post-resection.

Slide 4

Manufacturing of direct replacement prostheses.

The production of these types of prostheses is preceded by an imitation of the operation on plaster models in accordance with the plan outlined by the surgeon. Based on the casts obtained from the jaws, models are cast, the central relationship of the jaws is determined and the models are fixed in the occluder. A partial base is made for the fragment of the jaw that should remain after the operation.

Slide 5

In this case, it is advisable to use support-retaining clasps on all remaining teeth (the use of conventional retaining clasps is allowed). The boundaries of the partial base correspond to the boundaries of a conventional removable denture. If partial resection of the lower jaw in the area of ​​the chin or upper jaw in the group of anterior teeth is expected, a complete denture base is made.

Slide 6

In these cases, the border of the base completely corresponds to the borders of the removable denture. In the area of ​​the teeth that will be removed along with part of the jaw, the border runs along the base line of the prosthesis, as in the case of a partial dentition defect. The prepared partial base is placed in the oral cavity and an impression is taken along with it. This stage is necessary in order to avoid fitting the prosthesis when applying it to the jaw fragment immediately after surgery. The dental technician, having received the impression, places a partial base in it, casts a model with it and fixes it in the occluder.

Slide 7

The next stage is preparing the model for the manufacture of resection and forming parts of the prosthesis. The technician, together with the surgeon or orthopedist, pencils the resection boundaries onto the plaster model and determines the boundaries of the replacement part of the prosthesis. The reference point for the zone of plaster removal of the lower jaw model is the boundaries of the transitional fold on the vestibular and lingual sides, on the upper jaw - the boundary of the transitional fold on the vestibular side and the boundary of the transition of the alveolar process into the hard and soft palate. Thus, first the teeth are cut off, and then the entire alveolar process or the alveolar part of the lower jaw is cut layer by layer (Fig. 1, 2)

Slide 8

Rice. 1. The sequence of manufacturing a direct resection prosthesis replacing a defect in the lower jaw.

Slide 9

Slide 10

Slide 11

Slide 12

Rice. 2. The sequence of manufacturing a direct resection prosthesis replacing the defect of the upper jaw.

Slide 13

Slide 14

Slide 15

Considering that when resection of a part of the jaw during the operation, an additional 1-2 teeth are removed from the side of the resulting defect, in this area the technician cuts off only the teeth (indicated by the doctor) from the alveolar process and shapes this area, rounding it, simulating a toothless alveolar process. The area where the plaster is cut is smoothed using sandpaper or discs.

Slide 16

The fixing part of the prosthesis is removed from the model and the edge facing the replacement part is processed in the same way as when repairing a denture. The fixing part is again placed on the model, the wax plate is pressed along the marked boundaries, the wax roller replacing the alveolar process is strengthened on it, the teeth are positioned and the forming and replacing parts of the prosthesis are modeled.

Slide 17

The volume of this part of the prosthesis is slightly larger than the alveolar process, but the vestibular border should pass along the level of the transitional fold. The further process does not differ from the technology for manufacturing a removable denture. When making a prosthesis during resection of half of the lower jaw, an inclined plane must be modeled on the fixing part according to the rules specified in the description of the manufacture of a periodontal splint for jaw fractures.

View all slides

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 area:

• Tooth fractures

• Contracture of the lower jaw

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

Symptoms of Injuries to the Maxillofacial Area:

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

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

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

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

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

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

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

Knowing that each type of bite is characterized by its own signs of physiological wear of the teeth, they can be used 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. Their causes include road traffic accidents, impacts, and 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 splinting arch is soldered to a ring or to a metal crown, which is fixed to the supporting teeth using phosphate cement. When ligating teeth with an aluminum wire arch, such a reliable connection cannot be achieved. As the splint is used, the tension of the ligature weakens, and the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.

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

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

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

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

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

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

AST. Rehearsal devices

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

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

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

Forming apparatus

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

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

Replacement devices (prostheses)

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

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

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

Combined devices

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

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

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

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

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

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

Orthopedic treatment methods for injuries of the maxillofacial area

Dislocations and fractures of teeth

• Tooth dislocations

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

• Tooth fractures

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

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

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 mandibular fractures is to restore