Traumatic injuries of the maxillofacial area. Chest injuries Malposition of the fetus
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Classification.
I. Production.
- Industrial.
- Agricultural.
II. Non-productive.
- Household:
- transport;
- street;
- sports;
- others.
Types of injuries to the maxillofacial area.
I. Mechanical damage.
By localization.
- Soft tissue injury:
- language;
- large salivary glands;
- large nerve trunks;
- large vessels.
- Bone injury:
- lower jaw;
- upper jaw;
- zygomatic bones;
- nose bones;
- damage to two or more bones.
According to the nature of the injury:
- end-to-end;
- blind;
- tangents;
- penetrating into the oral cavity;
- non-penetrating into the oral cavity;
- penetrating into the maxillary sinuses and nasal cavity.
According to the mechanism of damage:
- bullets;
- splintered;
- ball;
- arrow-shaped elements.
II. Combined damage
- radial;
- poisoning by chemicals.
III. Burns.
IV. Frostbite.
Damage is divided into:
- isolated;
- single;
- isolated multiple;
- combined isolated;
- combined multiple.
Combined injury- damage to two or more anatomical areas by one or more damaging agents.
Combined injury- damage resulting from exposure to various traumatic factors.
Fracture- partial or complete disruption of bone continuity.
Traumatic dental injuries
There are acute and chronic tooth trauma. Acute tooth trauma occurs when a large force is simultaneously applied to the tooth, resulting in a bruise, dislocation, or fracture of the tooth; it is more common in children; the anterior teeth of the upper jaw are predominantly injured.
Chronic tooth trauma occurs when a weak force is applied over a long period of time.
Etiology: falling on the street, being hit by objects, sports injury; Among the factors predisposing to injury, malocclusion is noted.
Features of the examination of a patient with acute dental trauma: anamnesis is ascertained from the victim, as well as from the person accompanying him, the date and exact time of the injury, the location and circumstances of the injury are recorded, how much time passed before seeing a doctor; when, where and by whom first medical aid was provided, its nature and volume. They find out whether there was a loss of consciousness, nausea, vomiting, headache (maybe a traumatic brain injury), and find out whether they have been vaccinated against tetanus.
Features of the external examination: note a change in the configuration of the face due to post-traumatic edema; the presence of hematomas, abrasions, tears in the skin and mucous membrane, changes in the color of the facial skin. Also pay attention to the presence of abrasions and tears in the mucous membrane of the vestibule and oral cavity. A thorough examination of the injured tooth, radiography and electrical odontometry of the injured and adjacent teeth are carried out.
Trauma to the anterior teeth leads to consequences such as impaired aesthetics due to the absence of a tooth, occlusion, the development of the Popov-Godon symptom (protrusion of a tooth that has lost its antagonist), as well as speech disorders.
Classification of acute dental trauma.
1. Tooth bruise.
2. Tooth dislocation:
- incomplete: without displacement, with displacement of the crown towards the adjacent tooth, with rotation of the tooth around the longitudinal axis, with displacement of the crown in the vestibular direction, with displacement of the crown towards the oral cavity, with displacement of the crown towards the occlusal plane;
- hammered in;
- full.
3. Tooth crack.
4. Tooth fracture (transverse, oblique, longitudinal):
- crowns in the enamel zone;
- crowns in the area of enamel and dentin without opening the tooth cavity;
- crowns in the area of enamel and dentin with opening of the tooth cavity;
- tooth in the area of enamel, dentin and cement.
- root (in the cervical, middle and apical thirds).
5. Combined (combined) injury.
6. Trauma to the tooth germ.
Bruised tooth- closed mechanical damage to the tooth without violating its anatomical integrity.
Pathohistology: periodontal fibers are damaged, ischemia, tear or rupture of part of the periodontal fibers is observed, especially in the area of the tooth apex; reversible changes develop in the pulp. The neurovascular bundle may be completely preserved, but partial or complete rupture may occur. When the neurovascular bundle is completely ruptured, hemorrhage into the pulp and its death are observed.
Clinical picture of a tooth bruise: there is constant aching pain in the tooth, pain when biting and vertical percussion of the tooth, a feeling of an “overgrown tooth”, pink staining and darkening of the crown of the tooth, mobility of the tooth, swelling, hyperemia of the mucous membrane of the gums in the area of the injured tooth; There are no radiological changes.
Treatment: pain relief, resting the tooth until pain stops when biting on the tooth (excluding solid food for 3-5 days, reducing contact with antagonist teeth by grinding them off; anti-inflammatory treatment: physiotherapy.
D.V. Sharov
"Dentistry"
CONVENTIONAL ABBREVIATIONS
CT – computed tomography
PSO – primary surgical treatment
FTL – physiotherapeutic treatment
MFA – maxillofacial region
TOPIC No. 1
TRAUMA OF THE MAXILLOFACIAL AREA IN CHILDREN
Frequency of injuries to the maxillofacial region in children. Facial wounds: classification, clinic, features, treatment. Damage to the bones of the facial skeleton, especially in childhood, damage to teeth, trauma to the oral cavity. Fracture of the lower jaw, dislocation of the lower jaw. Fracture of the upper jaw, zygomatic bone and zygomatic arch.
Purpose of the lesson.
To become familiar with the types of injuries to the maxillofacial area in childhood, the principles of treatment and follow-up, and the outcomes of injuries. Learn how to provide first aid and care for children who have suffered trauma to the maxillofacial area. Determine the role of the pediatrician in further monitoring of patients.
Damage to the maxillofacial area (MFA) in children, according to N. G. Damier (1960), occurs in 8% of cases in relation to all injuries in childhood. The most common injuries in children are the soft tissues of the face and oral cavity. This is usually the result of domestic injuries (on the street, in a traffic accident, while playing sports), and there are also cases of gunshot injuries. Insufficient supervision of the child and children's failure to comply with traffic rules often lead to injury. The age factor determines the nature of the damage, which is associated with anatomical features at a certain age. The smaller the child, the larger the layer of subcutaneous fat and the more elastic the bones of the facial skeleton, therefore bone injuries are less common than soft tissue trauma (bruises, hematomas, abrasions, wounds). With the appearance of the lower central incisors, various wounds of the tongue become possible; the child can bite the tongue, for example, during a fall. With age, when a child begins to put various objects in his mouth, there is a possibility of injury to the mucous membrane and palate. In children aged 3 to 5 years, as a result of a fall, dislocations and fractures of teeth occur, usually in the frontal part of the jaw. Facial bone fractures are more common in older children, but can also occur in newborns during obstetric care.
Medical care provided to children can be divided into emergency and specialized. Emergency care is provided in the institution where the patient is admitted; it is aimed at eliminating factors that threaten the child’s life - shock, asphyxia, bleeding. Transport mobilization is underway. Specialized care consists of primary surgical treatment of wounds and therapeutic immobilization of fragments if soft tissue damage is combined with damage to the bones of the facial skeleton.
Wounds classified as isolated when there is only soft tissue damage, and combined when soft tissue damage is combined with damage to the bones of the facial skeleton and teeth. There are wounds single And multiple, penetrating(in the mouth, nose, eye socket, skull) and non-penetrating,With defect And no defect fabrics. According to the nature of the wounding object, they are cut,stabbed,torn, bruised,bitten, which is more common in childhood. Firearms wounds in children are less common.
Negative features of wounds in the maxillofacial area include:
1. Facial disfigurement.
2. Impaired speech and chewing function.
3. Danger of damage to vital organs - the brain, eyes, hearing organs, upper respiratory tract, large vessels and nerves.
4. The likelihood of damage to teeth, which, being carious, are an additional infectious and sometimes wounding factor.
5. Difficulty in making a diagnosis due to the discrepancy between the type of victim and the severity of the injury.
6. Features of care: most of these patients require special care and nutrition. Nutrition is provided from a sippy cup with liquid food, in extremely severe conditions - through a tube.
The positive features include:
1. Increased regenerative ability of facial tissues.
2. Tissue resistance to microbial contamination.
These features are due to the richness of blood supply and innervation. When the perioral area is damaged, despite the leakage of saliva and food ingress, the wounds regenerate well due to the presence in the perioral area of a significant amount of connective tissue with poorly differentiated cellular elements, which are the potential for tissue regeneration.
Cosmetic considerations when treating facial wounds dictate the use of gentle surgical techniques. Primary surgical treatment of facial wounds is most effective in the first 24 hours from the moment of injury. However, when using antibiotics, and also taking into account the characteristics of the maxillofacial area, primary surgical treatment can be performed within 36 hours from the moment of injury. Before treating wounds, a thorough x-ray examination should be performed to diagnose possible bone injuries. Primary surgical treatment of the wound (PST) includes: wound care, stopping bleeding, removal of foreign bodies, revision of the wound (with inspection of the walls and bottom of the wound), excision of non-viable edges and layer-by-layer suturing.
Toilet of the wound is carried out after anesthesia with antiseptic drugs (furacilin, aqueous solution of chlorhexidine, catapol, octenisept, etc.). Only mechanical treatment of the wound with these solutions is important, which significantly reduces the risk of purulent inflammation. Inspection of the wound is carried out in all cases, which, with knowledge of the anatomy, makes it possible to detect damage to important anatomical formations and carry out their speedy full surgical restoration. This allows you to avoid serious consequences, and in some cases, disability. For example, undetected damage to the branches of the facial nerve leads to persistent paralysis of the facial muscles and it is sometimes impossible to restore the function of the nerve. Unnoticed damage to the facial muscles leads to disruption of facial expressions or chewing function, and damage to the salivary glands (especially the parotid glands) can cause the formation of salivary fistulas.
When examining the oral cavity, the size of the rupture in the mucous membrane and the presence of damage to the tongue are determined. The puncture wound must be cut to the bottom so that it is possible to conduct a full inspection of the wound to identify damage to important anatomical structures and subsequently restore them. The specific treatment for facial wounds depends on the time that has passed since the injury, as well as the nature and location of the injury. Wounds of the oral cavity, tongue, perioral area, area of the corners of the mouth, corner of the eye, wings of the nose are sutured without excision of the edges. Economical excision is done only when the edges of the wound are severely crushed. A primary blind suture is applied, which gives a good cosmetic result and prevents displacement and eversion in the area of the corners of the mouth, eyes, and wings of the nose. In all areas of the face and neck, when suturing wounds, all damaged structures (mucous membrane, muscles, skin with subcutaneous tissue) are restored layer by layer until drainage occurs. If the branches of the facial nerve, vessels and nerves of the neck are damaged, their mandatory restoration is necessary.
If the wound does not have a tissue defect, it is closed by simply bringing the edges together (towards oneself). If the direction of the wound is not along the natural folds of the face, it is advisable to carry out primary plastic surgery using the figures of opposing triangular flaps, especially in the area of the inner corner of the eye, nasolabial groove, in places where the relief changes from convex to concave, etc. If there is a defect, primary plastic using nearby tissues, by moving a pedicle flap or opposing triangular flaps. In cases involving traumatic amputation of a tissue area (tip of the nose, auricle), it is necessary to deliver the amputated tissue segment to the hospital under cold ischemia conditions, which allows for replantation with a good cosmetic result or using parts of these tissues for plastic restoration of the defect.
Bite wounds occupy a special place in pediatric practice. These are most often gross injuries to soft tissues with trauma to important anatomical structures. These wounds are always accompanied by massive microbial contamination and crushing of the edges. It is generally accepted that bite wounds almost always fester and suturing them is useless. But with carefully carried out PST of the wound in a short time after injury (up to 12 - 24 hours) and the use of antibacterial therapy, the occurrence of complications practically does not occur. This allows you to get a good result in the treatment of such severe injuries.
To obtain a good cosmetic result, the use of suitable suture material is necessary. Thus, muscles and fiber are more often restored with absorbable suture material (catgut, vicryl); artificial prolene monofilament thread from 5/0 to 7/0 is used for skin sutures. Such suture material does not cause an inflammatory reaction, unlike nylon and silk, and allows you to avoid rough scars. For extensive, deep and bite wounds, wound drainage with thin strips of rubber gloves is often used. Seamless approximation of the edges of the wound using strips of adhesive plaster should not be used, especially on actively moving surfaces of the face, since, being saturated with the contents of the wound and saliva, the plaster does not hold the edges of the wound, they diverge and subsequently a rough scar is formed. If the wound process is smooth and there is no tension, the sutures on the face can be removed on the 4th – 7th day after surgery. Next, according to indications, scar massage with Contractubex and FTL is prescribed. Sutures in the tongue are placed with long-lasting absorbable suture material and removed no earlier than the 10th day.
Damage to teeth: Bruises are the most common, resulting in slight mobility of the teeth. If the pulp is damaged, the tooth becomes dark in color. When dislocated, its position changes. Sometimes an embedded or impacted dislocation occurs; the type depends on the direction of the acting force. With an impacted dislocation, the tooth moves towards the body of the jaw. A tooth fracture can occur in any part (root, crown); in this case, they try to preserve the permanent tooth. An impacted dislocation does not require treatment; the tooth will heal in 6 months. is restored in the dental arch. If there is significant tooth mobility, splinting is necessary. In case of complete dislocation of a permanent tooth, reimplantation is possible.
Damage to the bones of the facial skeleton can be observed from the moment of birth - these are injuries during obstetric care during childbirth. Most often, a fracture of the body of the mandible occurs in the midline, the condylar process of the head of the mandible, or the zygomatic arch. Often, trauma to the facial bones remains unrecognized and only its consequences are diagnosed: deformation of the facial bones, dysfunction of the temporomandibular joint. According to G. A. Kotov (1973), jaw fractures in childhood account for 31.3% of maxillofacial injuries.
Fracture of the lower jaw. Subperiosteal fractures are often observed in children; most often they occur in the lateral parts of the lower jaw. As a rule, these are non-displaced fractures. “Greenstick” or “willow twig” fractures are complete fractures localized in the area of the condylar processes.
Traumatic osteolysis occurs when the head of the mandibular joint is torn off. It can be compared to epiphysiolysis of long tubular bones. Fractures of the mandible in older children are more common in typical places: in the midline, at the level of premolars, in the area of the angle of the mandible and the neck of the articular process. Fractures localized within the dentition are always open, since the mucous membrane is torn at the time of injury. Closed are subperiosteal fractures and fractures localized in the area of the ramus and neck of the articular process of the mandible. The fracture line may pass at the location of the dental germ of a permanent tooth, which, despite the injury, in most cases does not die and therefore is not removed. If the tooth germ becomes necrotic, it separates spontaneously, like a sequestrum. Baby teeth found in the fracture line are removed.
With fractures of the lower jaw, children complain of pain at the site of injury, difficulty speaking, and inability to chew and close teeth. An external examination reveals facial asymmetry, a half-open mouth, and a hematoma at the site of injury. An examination from the oral cavity makes it possible to detect a rupture of the mucous membrane, malocclusion, or tooth damage. Bimanual examination determines the pathological mobility of fragments. To clarify the diagnosis, an x-ray examination is performed.
When providing first aid in a clinic, the child is given temporary, or transport, immobilization, for which a rigid chin sling is used or a soft bandage is applied. In the emergency room, fragments can be tied with wire passed through the interdental spaces. In the hospital, the fragments are reduced, if necessary, and therapeutic immobilization is applied using dental wire splints or cap splints made of quick-hardening plastic. To apply dental splints, there must be a sufficient number of teeth on all fragments. In addition, the choice of fixation method depends on age. The height of the crowns of baby teeth is much less than that of permanent teeth, and the length of the roots is also short. Therefore, it is almost impossible to apply wire splints before the age of 3 years. In children of this age group, it is better to use soft chin-head bandages with intermaxillary spacers or cap splints made of quick-hardening plastic. At the age of 9–10 years, metal splints are used; for displaced fractures, bimaxillary splints are used with intermaxillary traction. The surgical fixation method is indicated if it is not possible to use orthopedic methods (splints). The most rational option at present is the application of a bone suture or fixation with titanium miniplates. After a fracture of the lower jaw, especially in the area of the articular process, stiffness in the joint, or ankylosis, may develop, as well as retardation in the growth of the lower jaw, which is clinically expressed as malocclusion. In this regard, it is necessary to monitor the child for 5–6 years.
Dislocation of the lower jaw. It is more common in older children and is predominantly anterior - unilateral or bilateral. Anterior dislocation occurs when you try to open your mouth wide - screaming, yawning, or wanting to bite off too large a piece of food.
Clinical picture. The wide open mouth does not close, there is drooling, and immobility of the lower jaw. By palpation, the heads of the articular processes are determined under the zygomatic arches. With a unilateral dislocation, the mouth is half-open and the lower jaw is shifted to the healthy side, the bite on the side of the dislocation is disturbed. In this case, an X-ray examination is also necessary, since the dislocation can be combined with a fracture of the neck of the articular process.
Treatment. With a fresh dislocation, reduction can be performed without pain relief. If the dislocation is old, i.e. several days have passed since the injury, then to relieve muscle tension, infiltration anesthesia of the masticatory muscles is performed or under general anesthesia.
Technique for reducing dislocation. The patient is seated on a chair. The assistant stands behind the child and holds his head. The doctor is located to the right or in front of the patient. The doctor wraps the thumbs of both hands with gauze and places them on the chewing surfaces of the lower molars on the right and left. The remaining fingers cover the jaw from the outside. Then three successive movements are made: pressing down with the thumbs, the head is brought down to the level of the articular tubercles. Without stopping the pressure, the jaw is shifted posteriorly, moving the heads into the articular sockets. The last movement forward and upward completes the reduction, which is accompanied by a characteristic click. After this, the mouth closes and opens freely. In case of unilateral dislocation, these movements are performed with the free hand. Immobilization after reduction is carried out with a soft circular bandage or scarf for 5–6 days. A gentle diet is prescribed.
Maxillary fracture in childhood it occurs after 4 years. In children, the alveolar process is most often damaged with dislocation of teeth in the anterior region.
Clinical picture. With fractures of the alveolar process, swelling, pain, and impaired closure of the teeth are observed. Crepitus is determined by palpation. X-ray examination allows us to clarify the nature of the fracture. In older children, fractures along the lines of “weakness” are possible - Lefor 1, Lefor 2, Lefor 3. With a Lefor 1 fracture, the fracture line runs from the pyriform opening parallel to the alveolar process (on both sides) to the tubercle of the upper jaw. With this fracture, swelling, pain, and bleeding from the nose are noted. There is no malocclusion. With a Lefort 2 fracture, the clinical picture is more severe. The fracture line passes through the root of the nose, the inner wall of the orbit and along the zygomaticomaxillary suture on both sides. There is bleeding from the nose due to damage to the ethmoid bone, malocclusion and elongation of the face due to displacement of the anterior section, and diplopia. The most severe fracture is considered to be the Lefort type 3, when the fracture line passes through the root of the nose, the zygomatic bone (on both sides) and the pterygopalatine fossa.
A fracture of the upper jaw can be combined with a fracture of the base of the skull.
Clinical picture: pain, swelling, liquorrhea, bleeding from the nose and ears, malocclusion. Transport immobilization is carried out by applying a Limberg splint or a Limberg plank attached to the supporting head cap. For therapeutic immobilization, dental wire splints or splints made of quick-hardening plastic are used; when fragments are displaced, extraoral rods are attached to the supporting head cap. Surgical treatment is carried out by applying titanium miniplates. Children who have suffered a jaw fracture are under medical observation. If there is a tendency towards deformation (narrowing of the maxillary arch, malocclusion), orthodontic treatment becomes necessary.
Fracture of the zygomatic bone and zygomatic arch occurs more often in older children. In 4% of cases, the maxillary sinus is damaged.
Clinical picture depends on the location of the fracture and the degree of displacement of the fragments. Immediately after the fracture, a depression of the zygomatic region is visible, which after 2–4 hours is masked by swelling of the soft tissues. An unevenness is palpated at the lower orbital margin - a “step” symptom. If the fracture line passes through the inferior orbital foramen and the inferior orbital nerve is compressed, then numbness appears in the area of the lateral wall of the nose and upper lip on the corresponding side. If the walls of the maxillary sinus are damaged, bleeding from the nose is observed, and subcutaneous air emphysema on the face is possible. When the zygomatic arch is fractured, opening the mouth is difficult due to the infringement of the coronoid process of the lower jaw and the tendon of the temporal muscle attached to it. X-ray examination confirms the clinical diagnosis. Reduction of the fracture is performed under general anesthesia using the extraoral or intraoral method. The intraoral method is used when there is a combination of a fracture of the zygomatic bone and the zygomatic arch, the presence of fragments in the maxillary sinus and damage to its walls. In children, the extraoral method is more often used, using a Limberg hook. At the edge of the displaced fragment, a puncture of the skin is made with a scalpel. Using a hemostatic clamp, the tissue is bluntly separated to the bone. Then a Limberg hook is inserted into the wound, which is used to grab the edge of the displaced fragment and lift it. Immobilization is not required. Late complications include facial deformation and paresthesia, which requires surgical treatment.
Situational tasks
Task No. 1. A child has a penetrating wound into the oral cavity with a tissue defect. What wound treatment method should be used in this case?
Task No. 2. The patient has a puncture wound in the submandibular region, swelling, and hematoma. How will you treat a wound in this location?
Task No. 3. The patient's mouth is half-open, teeth cannot be closed, there is swelling in the lower jaw and submandibular region. How to make a diagnosis, what research method will you use? What first aid will you provide and how will you transport the patient?
Task No. 4. The child's mouth is open, the lower jaw is motionless, drooling, and speech is impossible. What is your presumptive diagnosis? What will you do to confirm the diagnosis? Once the diagnosis is confirmed, what should be done as an emergency?
Task No. 5. The patient has bleeding from the nose, a hematoma in the upper half of the face on the right or left. When examined from the oral cavity, there is no malocclusion. What is your presumptive diagnosis? What examination should be prescribed for the patient? What must be used during transportation?
Task No. 6. The patient's condition is serious. Bleeding and liquorrhea from the nose, malocclusion. When interviewed, he complained of double vision. What is your presumptive diagnosis? What examination method should be used? What kind of emergency assistance will you provide? What type of care will he receive in the hospital?
Literature
Alexandrov N. M. Clinical operative maxillofacial surgery. – L.: Medicine, 1985.
Kovaleva N. N. Trauma of the maxillofacial region in children // G. A. Bairov. Traumatology of childhood. – L.: Medicine, 1976.
Kolesov A. A. Pediatric dentistry. – M.: Medicine, 1985.
Kotov G. A. Jaw fractures in children: abstract. dis. ...cand. honey. Sci. – L., 1973.
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Epidemiology
At the age of 3-5 years, soft tissue injury prevails, at the age of over 5 years - bone injury and combined injuries.Classification
Injuries to the maxillofacial area (MFA) are:- isolated - damage to one organ (tooth dislocation, tongue injury, fracture of the lower jaw);
- multiple - types of trauma of unidirectional action (tooth dislocation and alveolar bone fracture);
- combined - simultaneous injuries of functionally multidirectional action (fracture of the lower jaw and traumatic brain injury).
- closed - without violating the integrity of the skin (bruises);
- open - with violation of the skin (abrasions, scratches, wounds).
Depending on the source of injury and the mechanism of injury, wounds are divided into:
- non-firearm:
- torn and their combinations;
- cut;
- bitten;
- chopped;
- chopped;
- firearms:
- bullets;
- compression;
- electrical injury;
- burns.
- tangents;
- end-to-end;
- blind (dislocated teeth may be foreign bodies).
Etiology and pathogenesis
A variety of environmental factors determine the cause of childhood injuries. Birth injury- occurs in a newborn during a pathological birth act, the peculiarities of obstetric care or resuscitation measures. In case of birth trauma, damage to the TMJ and lower jaw often occurs. Domestic injury- the most common type of childhood injury, accounting for more than 70% of other types of injuries. Domestic trauma prevails in early childhood and preschool age and is associated with a child falling or being hit by various objects.Hot and toxic liquids, open flames, electrical appliances, matches and other factors can also cause household injuries. Street trauma(transport, non-transport) as a type of domestic trauma prevails among children of school and senior school age. Transport injury is the heaviest; As a rule, it is combined; this type includes craniomaxillofacial injuries. Such injuries lead to disability and can cause the death of a child.
Sports injury:
- organized - happens at school and in the sports section, is associated with improper organization of classes and training;
- unorganized - violation of the rules of street sports games, in particular extreme ones (roller skates, motorcycles, etc.).
Burns
Among those burned, children aged 1–4 years predominate. At this age, children knock over vessels with hot water, put unprotected electrical wires in their mouths, play with matches, etc. The typical location of burns is noted: head, face, neck and upper extremities. At the age of 10-15 years, more often in boys, burns to the face and hands occur when playing with explosives. Frostbite on the face usually develops with a single, more or less prolonged exposure to temperatures below 0 C.Clinical signs and symptoms
The anatomical and topographical features of the structure of the maxillofacial area in children (elastic skin, large volume of fiber, well-developed blood supply to the face, not fully mineralized bones, the presence of growth zones of the facial skull bones and the presence of teeth and tooth buds) determine the general features of the manifestation of injuries in children.Injuries to the soft tissues of the face in children are accompanied by:
- extensive and rapidly growing collateral edema;
- hemorrhages in the tissue (infiltrate type);
- formation of interstitial hematomas;
- “greenstick” type bone injuries.
Bruises
With bruises, there is an increasing traumatic swelling at the site of injury, a bruise appears, which has a bluish coloration, which then acquires a dark red or yellow-green hue. The appearance of a child with a bruise often does not correspond to the severity of the injury due to increasing swelling and forming hematomas. Bruises in the chin area can lead to damage to the ligamentous apparatus of the temporomandibular joints (reflected). Abrasions and scratches are primarily infected.Signs of abrasions and scratches:
- pain;
- violation of the integrity of the skin and oral mucosa;
- edema;
- hematoma.
Wounds
Depending on the location of the wounds of the head, face and neck, the clinical picture will be different, but common signs for them are pain, bleeding, and infection. With wounds of the perioral area, tongue, floor of the mouth, and soft palate, there is often a danger of asphyxia due to blood clots and necrotic masses. Concomitant changes in the general condition are traumatic brain injury, bleeding, shock, respiratory failure (conditions for the development of asphyxia).Burns to the face and neck
With a small burn, the child actively reacts to pain by crying and screaming, while with extensive burns, the child’s general condition is serious, the child is pale and apathetic. Consciousness is completely preserved. Cyanosis, small and rapid pulse, cold extremities and thirst are symptoms of a severe burn, indicating the presence of shock. Shock in children develops with a significantly smaller area of damage than in adults.During a burn disease there are 4 phases:
- burn shock;
- acute toxemia;
- septicopyemia;
- convalescence.
Frostbite
Frostbite occurs mainly on the cheeks, nose, ears, and backs of the fingers. A red or bluish-purple swelling appears. When warm, the affected areas experience itching, sometimes a burning sensation and soreness. Subsequently, if cooling continues, scratches and erosions form on the skin, which can become secondarily infected. Disorders or complete cessation of blood circulation, impaired sensitivity and local changes are observed, expressed depending on the degree of damage and associated infection. The degree of frostbite is determined only after some time (bubbles may appear on the 2-5th day).There are 4 degrees of local frostbite:
- I degree is characterized by a disorder of the blood circulation of the skin without irreversible damage, i.e. without necrosis;
- II degree is accompanied by necrosis of the superficial layers of the skin up to the germ layer;
- III degree - total necrosis of the skin, including the germ layer, and the underlying layers;
- at stage IV, all tissues, including bone, die.
Maxillofacial orthopedics is one of the sections of orthopedic dentistry and includes the clinic, diagnosis and treatment of damage to the maxillofacial area resulting from trauma, wounds, surgical interventions for inflammatory processes, and neoplasms. Orthopedic treatment can be independent or used in combination with surgical methods.
Maxillofacial orthopedics consists of two parts: maxillofacial traumatology and maxillofacial prosthetics. In recent years, maxillofacial traumatology has become predominantly a surgical discipline. Surgical methods for fixing jaw fragments: osteosynthesis for jaw fractures, extraoral methods of fixing fragments of the lower jaw, suspended craniofacial fixation for fractures of the upper jaw, fixation using alloy devices with “shape memory” - have replaced many orthopedic devices.
Advances in facial reconstructive surgery have also influenced the field of maxillofacial prosthetics. The emergence of new methods and improvement of existing methods of skin grafting, bone grafting of the lower jaw, and plastic surgery for congenital cleft lip and palate have significantly changed the indications for orthopedic treatment methods.
Modern ideas about the indications for the use of orthopedic methods for treating injuries of the maxillofacial area are due to the following circumstances.
The history of maxillofacial orthopedics goes back thousands of years. Artificial ears, noses and eyes have been discovered in Egyptian mummies. The ancient Chinese restored lost parts of the nose and ears using wax and various alloys. However, before the 16th century there is no scientific information about maxillofacial orthopedics.
For the first time, facial prostheses and an obturator for closing a palate defect were described by Ambroise Pare (1575).
Pierre Fauchard in 1728 recommended drilling the palate to strengthen dentures. Kingsley (1880) described prosthetic structures for replacing congenital and acquired defects of the palate, nose, and orbit. Claude Martin (1889), in his book on dentures, describes structures for replacing lost parts of the upper and lower jaws. He is the founder of direct prosthetics after resection of the upper jaw.
Modern maxillofacial orthopedics, based on the rehabilitation principles of general traumatology and orthopedics, based on the achievements of clinical dentistry, plays a huge role in the system of providing dental care to the population.
- Tooth dislocations
Tooth luxation is the displacement of a tooth as a result of acute trauma. Tooth dislocation is accompanied by rupture of the periodontium, circular ligament, and gum. There are complete, incomplete and impacted dislocations. The history always contains indications of the specific cause that caused the tooth dislocation: transport, household, sports, work injury, dental interventions.
What causes damage to the maxillofacial area
- Tooth fractures
- False joints
The causes leading to the formation of false joints are divided into general and local. Common ones include: malnutrition, vitamin deficiencies, severe, long-term diseases (tuberculosis, systemic blood diseases, endocrine disorders, etc.). In these conditions, the body’s compensatory and adaptive reactions are reduced and reparative regeneration of bone tissue is inhibited.
Among the local causes, the most likely are violations of the treatment technique, soft tissue interposition, bone defect, and complications of the fracture due to chronic bone inflammation.
- Contracture of the lower jaw
Contracture of the lower jaw can occur not only as a result of mechanical traumatic damage to the jaw bones, soft tissues of the mouth and face, but also other reasons (ulcerative-necrotic processes in the oral cavity, chronic specific diseases, thermal and chemical burns, frostbite, myositis ossificans, tumors and etc.). Here we consider contracture in connection with trauma to the maxillofacial area, when contractures of the lower jaw arise as a result of improper primary treatment of wounds, prolonged intermaxillary fixation of jaw fragments, and untimely use of physical therapy.
Pathogenesis (what happens?) during Injuries to the maxillofacial region
- Tooth fractures
- Contracture of the lower jaw
The pathogenesis of mandibular contractures can be presented in the form of diagrams. In scheme I, the main pathogenetic link is the reflex-muscular mechanism, and in scheme II, the formation of scar tissue and its negative effects on the function of the lower jaw.
Symptoms of Injuries to the Maxillofacial Area
The presence or absence of teeth on jaw fragments, the condition of the hard tissues of the teeth, the shape, size, position of the teeth, the condition of the periodontium, the oral mucosa and soft tissues that interact with prosthetic devices are important.
Depending on these characteristics, the design of the orthopedic apparatus and prosthesis changes significantly. The reliability of fixation of fragments and the stability of maxillofacial prostheses, which are the main factors for the favorable outcome of orthopedic treatment, depend on them.
It is advisable to divide the signs of damage to the maxillofacial area into two groups: signs indicating favorable and unfavorable conditions for orthopedic treatment.
The first group includes the following signs: the presence on jaw fragments of teeth with full-fledged periodontium during fractures; the presence of teeth with full periodontium on both sides of the jaw defect; absence of cicatricial changes in the soft tissues of the mouth and perioral area; integrity of the TMJ.
The second group of signs consists of: the absence of teeth on jaw fragments or the presence of teeth with diseased periodontal disease; pronounced cicatricial changes in the soft tissues of the mouth and perioral area (microstomy), lack of a bone base for the prosthetic bed in case of extensive defects of the jaw; pronounced disturbances in the structure and function of the TMJ.
The predominance of signs of the second group narrows the indications for orthopedic treatment and indicates the need for complex interventions: surgical and orthopedic.
When assessing the clinical picture of damage, it is important to pay attention to signs that help establish the type of bite before the damage. This need arises due to the fact that displacement of fragments during jaw fractures can create relationships in the dentition similar to a prognathic, open, cross bite. For example, with a bilateral fracture of the lower jaw, the fragments shift along the length and cause shortening of the branches; the lower jaw moves back and upward with a simultaneous lowering of the chin. In this case, the closure of the dentition will be similar to prognathia and open bite.
Knowing that each type of bite is characterized by its own signs of physiological tooth wear, it is possible to determine the type of bite the victim had before the injury. For example, with an orthognathic bite, wear facets will be on the incisal and vestibular surfaces of the lower incisors, as well as on the palatal surface of the upper incisors. With progeny, on the contrary, there is abrasion of the lingual surface of the lower incisors and the vestibular surface of the upper incisors. A direct bite is characterized by flat wear facets only on the cutting surface of the upper and lower incisors, and with an open bite there will be no wear facets. In addition, anamnestic data can also help to correctly determine the type of bite before damage to the jaws.
- Tooth dislocations
The clinical picture of a dislocation is characterized by swelling of the soft tissues, sometimes rupture around the tooth, displacement, mobility of the tooth, and disruption of occlusal relationships.
- Tooth fractures
- Fractures of the lower jaw
Of all the bones of the facial skull, the lower jaw is most often damaged (up to 75-78%). Among the causes, traffic accidents come first, followed by domestic, industrial and sports injuries.
The clinical picture of fractures of the lower jaw, in addition to general symptoms (impaired function, pain, facial deformation, occlusion disorder, mobility of the jaw in an unusual place, etc.), has a number of features depending on the type of fracture, the mechanism of displacement of fragments and the condition of the teeth. When diagnosing fractures of the lower jaw, it is important to identify signs indicating the possibility of choosing one or another method of immobilization: conservative, surgical, combined.
The presence of stable teeth on jaw fragments; their slight displacement; localization of the fracture in the area of the angle, ramus, condylar process without displacement of fragments indicates the possibility of using a conservative method of immobilization. In other cases, there are indications for the use of surgical and combined methods of fixation of fragments.
- Contracture of the lower jaw
Clinically, unstable and persistent contractures of the jaws are distinguished. According to the degree of mouth opening, contractures are divided into mild (2-3 cm), medium (1-2 cm) and severe (up to 1 cm).
Unstable contractures most often they are reflex-muscular. They occur when jaws are fractured at the attachment points of the muscles that lift the mandible. As a result of irritation of the muscle receptor apparatus by the edges of fragments or decay products of damaged tissue, a sharp increase in muscle tone occurs, which leads to contracture of the lower jaw
Scar contractures, depending on which tissues are affected: skin, mucous membrane or muscle, are called dermatogenic, myogenic or mixed. In addition, contractures are distinguished between temporo-coronal, zygomatic-coronal, zygomatic-maxillary and intermaxillary.
Although the division of contractures into reflex-muscular and cicatricial is justified, in some cases these processes do not exclude each other. Sometimes, with damage to soft tissues and muscles, muscle hypertension turns into persistent scar contracture. Preventing the development of contractures is a very real and concrete measure. It includes:
- preventing the development of rough scars by correct and timely treatment of the wound (maximum approximation of the edges with sutures; for large tissue defects, suturing the edge of the mucous membrane with the edges of the skin is indicated);
- timely immobilization of fragments, if possible, using a single-jaw splint;
- timely intermaxillary fixation of fragments in case of fractures at the sites of muscle attachment in order to prevent muscle hypertension;
- the use of early therapeutic exercises.
Diagnosis of Injuries to the maxillofacial area
- Tooth dislocations
Diagnosis of tooth dislocation is carried out on the basis of examination, tooth displacement, palpation and x-ray examination.
- Tooth fractures
The most common fractures of the alveolar process of the upper jaw are predominantly localized in the area of the anterior teeth. They are caused by road accidents, impacts, falls.
Diagnosing fractures is not very difficult. Recognition of dentoalveolar damage is carried out on the basis of anamnesis, examination, palpation, and x-ray examination.
During a clinical examination of the patient, it should be remembered that fractures of the alveolar process can be combined with damage to the lips, cheeks, dislocation and fracture of teeth located in the broken area.
Palpation and percussion of each tooth, determining its position and stability make it possible to recognize damage. Electroodontodiagnosis is used to determine damage to the neurovascular bundle of teeth. The final conclusion about the nature of the fracture can be made on the basis of radiological data. It is important to establish the direction of displacement of the fragment. Fragments can be displaced vertically, in the palatine-lingual, vestibular direction, which depends on the direction of the blow.
Treatment of alveolar process fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.
- Fractures of the lower jaw
Clinical diagnosis of mandibular fractures is supplemented by radiography. Based on radiographs obtained in anterior and lateral projections, the degree of displacement of fragments, the presence of fragments, and the location of the tooth in the fracture gap are determined.
For fractures of the condylar process, TMJ tomography provides valuable information. The most informative is computed tomography, which allows you to reproduce the detailed structure of the bones of the articular area and accurately identify the relative position of fragments.
Treatment of Injuries to the Maxillofacial Area
Development surgical treatment methods, especially neoplasms of the maxillofacial area, required widespread use of orthopedic interventions in the surgical and postoperative period. Radical treatment of malignant neoplasms of the maxillofacial region improves survival rates. After surgical interventions, serious consequences remain in the form of extensive defects of the jaws and face. Severe anatomical and functional disorders that disfigure the face cause painful psychological suffering to patients.
Very often, reconstructive surgery alone is ineffective. The tasks of restoring the patient's face, chewing, swallowing functions and returning him to work, as well as to perform other important social functions, as a rule, require the use of orthopedic treatment methods. Therefore, the joint work of dentists - a surgeon and an orthopedist - comes to the fore in the complex of rehabilitation measures.
There are certain contraindications to the use of surgical methods for treating jaw fractures and performing operations on the face. Usually this is the presence in patients of severe blood diseases, the cardiovascular system, an open form of pulmonary tuberculosis, severe psycho-emotional disorders and other factors. In addition, there are injuries for which surgical treatment is impossible or ineffective. For example, in case of defects of the alveolar process or part of the palate, prosthetics are more effective than surgical restoration. In these cases, the use of orthopedic measures as the main and permanent method of treatment was shown.
The timing of restoration operations varies. Despite the tendency of surgeons to perform the operation as early as possible, a certain amount of time must be allowed when the patient is left with an unrepaired defect or deformity while awaiting surgical treatment or plastic surgery. The duration of this period can be from several months to 1 year or more. For example, reconstructive operations for facial defects after tuberculous lupus are recommended to be carried out after permanent elimination of the process, which is approximately 1 year. In such a situation, orthopedic methods are indicated as the main treatment for this period. During the surgical treatment of patients with injuries to the maxillofacial area, auxiliary tasks often arise: creating support for soft tissues, closing the postoperative wound surface, feeding patients, etc. In these cases, the use of the orthopedic method is indicated as one of the auxiliary measures in complex treatment.
Modern biomechanical studies of methods for fixing fragments of the lower jaw have made it possible to establish that dental splints, in comparison with known on-bone and intraosseous devices, are the fixators that most fully meet the conditions of functional stability of bone fragments. Dental splints should be considered as a complex retainer, consisting of an artificial (splint) and natural (tooth) retainer. Their high fixing abilities are explained by the maximum area of contact of the fixator with the bone due to the surface of the roots of the teeth to which the splint is attached. These data are consistent with the successful results of the widespread use of dental splints by dentists in the treatment of jaw fractures. All this is another justification for the indications for the use of orthopedic devices for the treatment of injuries to the maxillofacial area.
Orthopedic devices, their classification, mechanism of action
Treatment of injuries to the maxillofacial area is carried out using conservative, surgical and combined methods.
The main method of conservative treatment is orthopedic devices. With their help, they solve problems of fixation, reposition of fragments, formation of soft tissues and replacement of defects in the maxillofacial area. In accordance with these tasks (functions), devices are divided into fixing, reducing, forming, replacing and combined. In cases where one device performs several functions, they are called combined.
Based on the place of attachment, the devices are divided into intraoral (unimaxillary, bimaxillary and intermaxillary), extraoral, intra-extraoral (maxillary, mandibular).
According to the design and manufacturing method, orthopedic devices can be divided into standard and individual (non-laboratory and laboratory manufacturing).
Fixing devices
There are many designs of fixing devices. They are the main means of conservative treatment of injuries to the maxillofacial area. Most of them are used in the treatment of jaw fractures and only a few - in bone grafting.
For primary healing of bone fractures, it is necessary to ensure the functional stability of the fragments. The strength of fixation depends on the design of the device and its fixing ability. Considering the orthopedic device as a biotechnical system, it can be divided into two main parts: splinting and actually fixing. The latter ensures the connection of the entire structure of the device with the bone. For example, the splinting part of a dental wire splint consists of a wire bent to the shape of a dental arch and a ligature wire for attaching the wire arch to the teeth. The actual fixing part of the structure is the teeth, which provide connection between the splinting part and the bone. Obviously, the fixing ability of this design will depend on the stability of the connections between the tooth and the bone, the distance of the teeth in relation to the fracture line, the density of the connection of the wire arch to the teeth, the location of the arch on the teeth (at the cutting edge or chewing surface of the teeth, at the equator, at the neck of the teeth) .
With tooth mobility and severe atrophy of the alveolar bone, it is not possible to ensure reliable stability of fragments using dental splints due to the imperfection of the actual fixing part of the device design.
In such cases, the use of periodontal splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of contact of the splinting part in the form of coverage of the gums and alveolar process. In case of complete loss of teeth, the intra-alveolar part (retainer) of the device is absent; the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained. However, the fixing ability of such devices is extremely low.
From a biomechanical point of view, the most optimal design is a soldered wire splint. It is attached to rings or full artificial metal crowns. The good fixing ability of this tire is explained by the reliable, almost motionless connection of all structural elements. The sinus arc is soldered to a ring or to a metal crown, which is fixed to the supporting teeth using phosphate cement. When ligating teeth with an aluminum wire arch, such a reliable connection cannot be achieved. As the splint is used, the tension of the ligature weakens, and the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.
With the introduction of fast-hardening plastics, many different designs of dental splints have appeared. However, in terms of their fixing abilities, they are inferior to soldered splints in a very important parameter - the quality of the connection between the splinting part of the device and the supporting teeth. A gap remains between the surface of the tooth and the plastic, which is a receptacle for food debris and microbes. Long-term use of such tires is contraindicated.
The designs of dental splints are constantly being improved. By introducing actuator loops into a splinting aluminum wire arch, they try to create compression of fragments in the treatment of mandibular fractures.
The real possibility of immobilization with the creation of compression of fragments with a dental splint appeared with the introduction of alloys with a shape “memory” effect. A dental splint on rings or crowns made of wire with thermomechanical “memory” allows not only to strengthen fragments, but also to maintain constant pressure between the ends of the fragments.
Fixing devices used in osteoplastic operations are a dental structure consisting of a system of welded crowns, connecting locking bushings, and rods.
Extraoral apparatuses consist of a chin sling (plaster, plastic, standard or customized) and a head cap (gauze, plaster, standard strips of belt or ribbon). The chin sling is connected to the head cap using a bandage or elastic cord.
Intraoral apparatuses consist of an intraoral part with extraoral levers and a head cap, which are interconnected by elastic traction or rigid fixing devices.
AST. Rehearsal devices
There are one-stage and gradual reposition. One-time reposition is carried out manually, and gradual reposition is carried out using hardware.
In cases where it is not possible to compare the fragments manually, reduction devices are used. The mechanism of their action is based on the principles of traction, pressure on displaced fragments. Reduction devices can be mechanical or functional. Mechanically operating reduction devices consist of 2 parts - supporting and acting. The supporting parts are crowns, mouthguards, rings, base plates, and a head cap.
The active part of the apparatus are devices that develop certain forces: rubber rings, an elastic bracket, screws. In a functionally functioning reduction apparatus, the force of muscle contraction is used to reposition fragments, which is transmitted through guide planes to the fragments, displacing them in the desired direction. A classic example of such a device is the Vankevich tire. With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.
Forming apparatus
These devices are designed to temporarily maintain the shape of the face, create a rigid support, prevent cicatricial changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformation of the prosthetic bed, etc.). Forming devices are used before and during reconstructive surgical interventions.
The design of the devices can be very diverse depending on the area of damage and its anatomical and physiological characteristics. In the design of the forming apparatus, one can distinguish the forming part and the fixing devices.
Replacement devices (prostheses)
Prostheses used in maxillofacial orthopedics can be divided into dentoalveolar, maxillary, facial, and combined. When resection of the jaws, prostheses are used, which are called post-resection. There are immediate, immediate and remote prosthetics. It is legitimate to divide prostheses into surgical and postoperative.
Dental prosthetics is inextricably linked with maxillofacial prosthetics. Advances in clinical practice, materials science, and technology for manufacturing dentures have a positive impact on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid-cast clasp dentures have found application in the design of resection dentures and dentures restoring dentoalveolar defects.
Replacement devices also include orthopedic devices used for palate defects. This is primarily a protective plate - used for palate plastic surgery; obturators - used for congenital and acquired palate defects.
Combined devices
For reposition, fixation, shaping and replacement, a single design that can reliably solve all problems is advisable. An example of such a design is an apparatus consisting of soldered crowns with levers, fixing locking devices and a forming plate.
Dental, dentoalveolar and jaw prostheses, in addition to their replacement function, often serve as a forming apparatus.
The results of orthopedic treatment of maxillofacial injuries largely depend on the reliability of fixation of the devices.
When solving this problem, you should adhere to the following rules:
- use the preserved natural teeth as support as much as possible, connecting them into blocks, using well-known techniques for splinting teeth;
- make maximum use of the retention properties of 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);
- apply surgical methods to strengthen prostheses and devices in the absence of conditions for their fixation in a conservative way;
- use the head and upper body as a support for orthopedic devices if the possibilities of intraoral fixation have been exhausted;
- use external supports (for example, a system of traction of the upper jaw through blocks with the patient in a horizontal position on the bed).
Clasps, rings, crowns, telescopic crowns, mouthguards, ligature binding, springs, magnets, spectacle frames, sling-shaped bandages, and corsets can be used as fixing devices for maxillofacial devices. The correct selection and application of these devices adequately to clinical situations allows us to achieve success in the orthopedic treatment of injuries to the maxillofacial area.
Orthopedic treatment methods for injuries of the maxillofacial area
Dislocations and fractures of teeth
- Tooth dislocations
Treatment of complete dislocation is combined (tooth replantation followed by fixation), and treatment of incomplete dislocation is conservative. In fresh cases of incomplete dislocation, the tooth is set with the fingers and strengthened in the alveolus, fixing it with a dental splint. As a result of untimely reduction of a dislocation or subluxation, the tooth remains in an incorrect position (rotation around an axis, palatoglossal, vestibular position). In such cases, orthodontic intervention is required.
- Tooth fractures
The previously mentioned factors can also cause tooth fractures. In addition, enamel hypoplasia and dental caries often create conditions for tooth fracture. Root fractures can occur from corrosion of metal pins.
Clinical diagnosis includes: anamnesis, examination of the soft tissues of the lips and cheeks, teeth, manual examination of the teeth, alveolar processes. To clarify the diagnosis and draw up a treatment plan, it is necessary to conduct x-ray studies of the alveolar process and electroodontic diagnostics.
Fractures of teeth occur in the area of the crown, root, crown and root; microfractures of cement are distinguished, when sections of cement with attached perforating (Sharpey) fibers peel off from the dentin of the root. The most common fractures of the tooth crown are within the enamel, enamel and dentin with exposure of the pulp. The fracture line can be transverse, oblique and longitudinal. If the fracture line is transverse or oblique, passing closer to the cutting or chewing surface, the fragment is usually lost. In these cases, tooth restoration is indicated by prosthetics with inlays and artificial crowns. When opening the pulp, orthopedic measures are carried out after appropriate therapeutic preparation of the tooth.
For fractures at the neck of the tooth, often resulting from cervical caries, often associated with an artificial crown that does not tightly cover the neck of the tooth, removal of the broken part and restoration using a stump pin insert and an artificial crown are indicated.
A root fracture is clinically manifested by tooth mobility and pain when biting. The fracture line is clearly visible on dental x-rays. Sometimes, in order to trace the fracture line along its entire length, it is necessary to have x-rays obtained in different projections.
The main method of treating root fractures is to strengthen the tooth using a dental splint. Healing of tooth fractures occurs after 1 1/2-2 months. There are 4 types of fracture healing.
Type A: the fragments are closely juxtaposed with each other, healing ends with the mineralization of the tooth root tissue.
Type B: healing occurs with the formation of pseudarthrosis. The gap along the fracture line is filled with connective tissue. The radiograph shows an uncalcified band between the fragments.
Type C: connective tissue and bone tissue grow between the fragments. The x-ray shows the bone between the fragments.
Type D: the gap between the fragments is filled with granulation tissue: either from the inflamed pulp or from gum tissue. The type of healing depends on the position of the fragments, immobilization of the teeth, and pulp viability.
- Fractures of the alveolar ridge
Treatment of alveolar bone fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.
Reposition of the fragment in case of fresh fractures can be carried out manually, in case of old fractures - by the method of bloody reposition or with the help of orthopedic devices. When the fractured alveolar process with teeth is displaced to the palatal side, reposition can be performed using a palatal release plate with a screw. The mechanism of action of the device is to gradually move the fragment due to the pressing force of the screw. The same problem can be solved by using an orthodontic apparatus by pulling the fragment towards the wire arch. In a similar way, it is possible to reposition a vertically displaced fragment.
If the fragment is displaced to the vestibular side, reposition can be carried out using an orthodontic apparatus, in particular a vestibular sliding arch fixed on the molars.
Fixation of the fragment can be carried out with any dental splint: bent, wire, soldered wire on crowns or rings, made of quick-hardening plastic.
- Fractures of the body of the upper jaw
Non-gunshot fractures of the upper jaw are described in textbooks on surgical dentistry. Clinical features and treatment principles are given in accordance with Le Fort's classification, based on the location of fractures along lines corresponding to weak points. Orthopedic treatment of fractures of the upper jaw consists of repositioning the upper jaw and immobilizing it with intra-extraoral devices.
In the first type (Le Fort I), when it is possible to manually set the upper jaw into the correct position, intra-extraoral devices supported on the head can be used to immobilize fragments: a solid-bent wire splint (according to Ya. M. Zbarzh), a dentogingival splint with extraoral levers, soldered splint with extraoral levers. The choice of design for the intraoral part of the apparatus depends on the presence of teeth and the condition of the periodontium. If there are a large number of stable teeth, the intraoral part of the device can be made in the form of a wire dental splint, and in the case of multiple absences of teeth or mobility of existing teeth - in the form of a dentogingival splint. In toothless areas of the dentition, the dentogingival splint will consist entirely of a plastic base with imprints of antagonist teeth. In case of multiple or complete absence of teeth, surgical treatment methods are indicated.
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CHAPTER 1
GENERAL INFORMATION ABOUT INJURY OF THE MAXILLOFACIAL AREA, STATISTICS, CLASSIFICATION
Patients with injuries to the maxillofacial region make up about 30% of all patients treated in maxillofacial surgery hospitals. The frequency of facial injuries is 0.3 cases per 1000 people, and the proportion of all maxillofacial trauma among injuries with bone damage in the urban population ranges from 3.2 to 8%. According to Yu.I. Bernadsky (2000), the most common are fractures of the facial bones (88.2%), soft tissue injuries - in 9.9%, facial burns - in 1.9%.
There is a predominance of injuries to the maxillofacial area in men compared to women. The number of traumatic injuries increases in the summer and on holidays.
Classification of injuries of the maxillofacial region.
1. Depending on the circumstances of the injury, the following types of traumatic injuries are distinguished: industrial and non-industrial (domestic, transport, street, sports) injuries.
2. According to the mechanism of damage (the nature of the damaging factors), the following are distinguished:
· mechanical (firearm and non-firearm),
· thermal (burns, frostbite);
· chemical;
· radial;
· combined.
3. Mechanical damage in accordance with the “Classification of damage to the maxillofacial area” is divided depending on:
a) localization (injuries to the soft tissues of the face with damage to the tongue, salivary glands, large nerves, large vessels; injuries to the bones of the lower jaw, upper jaw, cheekbones, nasal bones, two bones or more);
b) the nature of the wound (through, blind, tangential, penetrating and non-penetrating into the oral cavity, maxillary sinuses or nasal cavity);
c) mechanism of damage (gunshot and non-gunshot, open and closed).
There are also: combined lesions, burns and frostbite.
It is necessary to distinguish between the concepts of combined and combined injury.
Combined injury represents damage to at least two anatomical areas by one or more damaging factors.
Combined injuries a is damage caused by exposure to various traumatic agents. In this case, the participation of the radiation factor is possible.
In traumatology there are open and closed damage. Open ones include those in which there is damage to the integumentary tissues of the body (skin and mucous membrane), which usually leads to infection of the damaged tissues. With a closed injury, the skin and mucous membrane remain intact.
The nature of facial injury, clinical course and outcome depend on the type of wounding object, the strength of its impact, the location of the injury, as well as the anatomical and physiological characteristics of the area of injury.
Features of primary surgical treatment of facial wounds.
· early surgical treatment of the wound up to 24 hours from the onset of injury;
· final surgical treatment of the wound in a specialized institution;
· the edges of the wound are not excised, only clearly non-viable tissues are cut off;
· narrow wound channels are not completely dissected;
· foreign bodies are removed from the wound, but no search is undertaken for foreign bodies located in hard-to-reach places;
· wounds penetrating into the oral cavity must be isolated from the oral cavity by applying blind sutures. It is necessary to protect the bone wound from the contents of the oral cavity;
· on wounds of the eyelids, wings of the nose and lips, a primary suture is always applied, regardless of the timing of surgical treatment of the wound.
When suturing wounds on the side of the face, drainage is inserted in the submandibular area.
At wound penetrating the oral cavity First of all, the mucous membrane is sutured, then the muscles and skin.
At lip wounds The muscle is sutured, the first suture is placed on the border of the skin and the red border of the lip.
At damage to the soft tissues of the face, combined with bone trauma, First, the bone wound is treated. In this case, fragments not connected to the periosteum are removed, the fragments are repositioned and immobilized, and the bone wound is isolated from the contents of the oral cavity. Then they begin surgical treatment of soft tissues.
At wounds penetrating the maxillary sinus, perform a revision of the sinus, form an anastomosis with the inferior nasal passage, through which the iodoform tampon is removed from the sinus. After this, surgical treatment of the facial wound is performed with layer-by-layer sutures.
If damaged salivary gland First, sutures are placed on the parenchyma of the gland, then on the capsule, fascia and skin.
If damaged duct conditions should be created for the flow of saliva into the oral cavity. To do this, a rubber drainage is placed at the central end of the duct and discharged into the oral cavity. The drainage is removed on day 14. The central excretory duct can be sewn onto a polyamide catheter. In this case, its central and peripheral sections are compared.
Crushed submandibular salivary gland may be removed during primary surgical treatment of the wound, but the parotid one, due to the complex anatomical relationship with the facial nerve due to injury, cannot be removed.
At large through defects soft tissues of the face, the convergence of the edges of the wound almost always leads to pronounced deformations of the face. Surgical treatment of wounds should be completed by “suturing” them, connecting the skin with the mucous membrane with sutures. Subsequently, plastic closure of the defect is performed.
In case of extensive trauma to the lower third of the face, floor of the mouth, or neck, a tracheostomy is necessary, followed by intubation and primary surgical treatment of the wound.
Wound in the infraorbital region with a large defect, it is not sutured “on its own” parallel to the lower orbital edge, but is eliminated by cutting out additional flaps (triangular, tongue-shaped), which are moved to the site of the defect and fixed with appropriate suture material.
After the initial surgical treatment of the wound, it is necessary to carry out tetanus prophylaxis.
DENTAL INJURIES
Tooth injury– this is a violation of the anatomical integrity of the tooth or the tissues surrounding it, with a change in the position of the tooth in the dentition.
Cause of acute dental injury: fall on hard objects and blow to the face.
Most often, the incisors are susceptible to acute dental trauma, mainly in the upper jaw, especially with prognathism.
Classification of traumatic dental injuries.
I. WHO classification of injuries.
Class I: Tooth contusion with minor structural damage.
Class II. Uncomplicated fracture of the tooth crown.
Class III. Complicated fracture of the tooth crown.
Class IV. Complete fracture of the tooth crown.
Class V. Coronal-root longitudinal fracture.
Class VI. Tooth root fracture.
Class VII. The tooth dislocation is incomplete.
Class VIII. Complete tooth dislocation.
II. Classification of the clinic of pediatric maxillofacial surgery of the Belarusian State Medical University.
1. Tooth bruise.
1.1. with rupture of the neurovascular bundle (NVB).
1.2. without breaking the SNP.
2. Tooth dislocation.
2.1. incomplete dislocation.
2.2. with a rupture of the SNP.
2.3. without breaking the SNP.
2.4. complete dislocation.
2.5. impacted dislocation
3. Tooth fracture.
3.1. tooth crown fracture.
3.1.1. within the enamel.
3.1.2. within dentin (with opening of the tooth cavity, without opening of the tooth cavity).
3.1.3. fracture of the tooth crown.
3.2. tooth root fracture (longitudinal, transverse, oblique, displaced, without displacement).
4. Injury to the tooth germ.
5. Combined tooth trauma (luxation + fracture, etc.)
TOOTH CONTRIBUTION
Bruised tooth - traumatic damage to a tooth, characterized by concussion and/or hemorrhage into the pulp chamber. When a tooth is bruised, the periodontium is first damaged in the form of rupture of part of its fibers, damage to small blood vessels and nerves, mainly in the apical part of the tooth root. In some cases, complete rupture of the neurovascular bundle at its entrance to the apical foramen is possible, which usually leads to the death of the dental pulp due to the cessation of blood circulation in it.
Clinic.
The symptoms of acute traumatic periodontitis are determined: pain in the tooth, aggravated by biting, pain during percussion. Due to swelling of the periodontal tissues, there is a feeling of the tooth “pushing out” of the socket, and its moderate mobility is determined. At the same time, the tooth retains its shape and position in the dentition. Sometimes the crown of a damaged tooth turns pink due to hemorrhage in the tooth pulp.
An X-ray examination is required to rule out a root fracture. If a tooth is bruised, an x-ray can reveal a moderate widening of the periodontal fissure.
· creating conditions for the damaged tooth to rest, removing it from occlusion by grinding the cutting edges of the teeth;
mechanically gentle diet;
· in case of pulp death – extirpation and canal filling.
Pulp viability is controlled using
electroodontic diagnostics over a period of 3-4 weeks, as well as on the basis of clinical signs (darkening of the tooth crown, pain on percussion, the appearance of a fistula on the gum).
TEETH BREAKING
Tooth luxation– traumatic damage to a tooth, as a result of which its connection with the socket is disrupted.
Tooth dislocation occurs most often as a result of a blow to the crown.
tooth More often than others, the frontal teeth on the upper jaw are dislocated and less often on the lower jaw. Dislocations of premolars and molars most often occur when neighboring teeth are carelessly removed using an elevator.
There are:
incomplete dislocation (extrusion),
complete dislocation (avulsion),
Impacted dislocation (intrusion).
In case of incomplete dislocation, the tooth partially loses its connection with the tooth socket,
becomes mobile and shifts due to rupture of periodontal fibers and disruption of the integrity of the cortical plate of the tooth alveolus.
With complete luxation, the tooth loses connection with the tooth socket due to rupture
of all periodontal tissues, falls out of the socket or is held only by the soft tissues of the gums.
With an impacted dislocation, the tooth is embedded in the spongy
substance of the bone tissue of the alveolar process of the jaw (immersion of the tooth into the socket).
Incomplete tooth dislocations
Clinic. Complaints of pain, tooth mobility, changes in sex
its presence in the dentition, dysfunction of chewing. When examining the oral cavity, incomplete tooth dislocation is characterized by a change in position (displacement) of the crown of the injured tooth in different directions (orally, vestibularly, distally, towards the occlusal plane, etc.). The tooth may be mobile and sharply painful upon percussion, but not displaced beyond the dentition. The gums are swollen and hyperemic, and ruptures are possible. Due to rupture of the circular ligament of the tooth, periodontal tissues and damage to the alveolar wall, pathological dental-gingival pockets and bleeding from them can be determined. When a tooth is dislocated and its crown is displaced orally, the root of the tooth is usually displaced vestibularly, and vice versa. When a tooth moves towards the occlusal plane, it protrudes above the level of neighboring teeth, is mobile and interferes with occlusion. Very often the patient has a concomitant injury to the soft tissues of the lips (bruise, hemorrhage, wound).
In case of incomplete dislocation of a tooth, a widening of the periodontal fissure and some “shortening” of the tooth root are determined radiologically if it is displaced orally or vestibularly.
Treatment of incomplete dislocation.
tooth repositioning;
· fixation with a mouthguard or a smooth splint;
· gentle diet;
· examination after 1 month;
· when it is established that the pulp is dead, extirpate it and fill the canal.
Immobilization or fixation of teeth is carried out in the following ways:
1. Ligature binding of teeth (simple ligature binding, continuous in the form of a figure eight, binding of teeth according to Baronov, Obwegeser, Frigof, etc.). Ligature binding of teeth is indicated, as a rule, in permanent dentition in the presence of stable, adjacent teeth (2-3 on both sides of the dislocated one). For ligature binding of teeth, thin (0.4 mm) soft bronze-aluminum or stainless steel wire is usually used. The disadvantage of these splinting methods is the impossibility of their use in temporary dentition for the reasons stated above. In addition, applying wire ligatures is a rather labor-intensive process. At the same time, this method does not allow sufficiently rigid fixation of dislocated teeth.
2. Bus bracket (wire or tape). A tire is made (bent) from stainless wire from 0.6 to 1.0 mm. thickness or standard steel tape and is fixed to the teeth (2-3 on both sides of the dislocated one) using a thin (0.4 mm) ligature wire. A splint-bracket is indicated in permanent dentition, as a rule, in the presence of a sufficient number of stable adjacent teeth.
Disadvantages: traumatic, labor-intensive and limited use in temporary dentition.
3. Splint-kappa. It is usually made from plastic in one visit, directly in the patient’s mouth after teeth repositioning. Disadvantages: bite separation and difficulty in performing EDI.
4. Teeth-gingival splints. Indicated in any bite in the absence of a sufficient number of supporting teeth, including adjacent teeth. They are made of plastic with reinforced wire, in the laboratory after taking an impression and casting a jaw model.
5. The use of composite materials, with the help of which wire arches or other splinting structures are fixed to the teeth.
Immobilization of dislocated teeth is usually carried out within 1 month (4 weeks). In this case, it is necessary to strictly observe oral hygiene to prevent inflammatory processes and damage to the enamel of splinted teeth.
Complications and outcomes of incomplete dislocation: shortening of the tooth root,
obliteration or expansion of the tooth root canal with the formation of intrapulpar granuloma, stopping the formation and growth of the root, curvature of the tooth root, changes in the periapical tissues in the form of chronic periodontitis, root cyst.
Complete dislocation of teeth.
Complete tooth dislocation (traumatic extraction) occurs after complete rupture of periodontal tissue and the circular ligament of the tooth as a result of a strong blow to the tooth crown. Most often, the frontal teeth on the upper jaw (mainly the central incisors) are affected and less often on the lower jaw.
Clinical picture: upon examination of the oral cavity, there is no tooth in the dentition and there is a hole in the dislocated tooth that is bleeding or filled with a fresh blood clot. There are often concomitant injuries to the soft tissues of the lips (bruises, wounds to the mucous membrane, etc.). When visiting a dentist, dislocated teeth are often brought “in your pocket.” To draw up a treatment plan, you should evaluate the condition of the dislocated tooth (the integrity of the crown and root, the presence of carious cavities, a temporary tooth or a permanent one, etc.).
Treatment of complete dislocation consists of the following stages.
· pulp extirpation and canal filling;
· replantation;
· fixation for 4 weeks with a mouthguard or a smooth splint;
· mechanically gentle diet.
It is necessary to examine the tooth socket and assess its integrity. X-ray, with complete dislocation of the tooth, a free (empty) tooth socket with clear contours is determined. If the socket of a dislocated tooth is destroyed, then the boundaries of the alveoli are not determined radiographically.
Indications for tooth replantation depend on the patient’s age, his
the general condition, the condition of the tooth itself and its socket, whether the tooth is temporary or permanent, whether the root of the tooth is formed or not.
Tooth replantation- this is the return of the tooth to its own socket. Distinguish immediate and delayed tooth replantation. With one-stage replantation, in one visit, the tooth is prepared for replantation, its root canal is filled, and the replantation itself is carried out, followed by splinting it. In case of delayed replantation, the avulsed tooth is washed, immersed in a saline solution with an antibiotic and placed temporarily (until replantation) in the refrigerator. After a few hours or days, the tooth is trepanned, filled, and replanted.
The tooth replantation operation can be divided into the following stages:
1. Preparing the tooth for replantation.
2. Preparing the tooth socket for replantation.
3. The actual replantation of the tooth and its fixation in the socket.
4. Postoperative treatment and monitoring over time.
1-1.5 months after tooth replantation surgery, the following types of tooth engraftment are possible:
1. Healing of the tooth according to the type of primary intention through the periodontium (syndesmosis). This is the most favorable periodontal type of fusion, depending mainly on the preservation of the viability of periodontal tissues. With this type of fusion, the control radiograph shows a uniform width of the periodontal gap.
2. Engraftment of the tooth according to the type of synostosis or bone fusion of the tooth root and the wall of the socket. This occurs with the complete death of periodontal tissue and is the least favorable type of fusion (ankylosis of the tooth). In case of ankylosis of the tooth, the periodontal fissure is not visible on the control radiograph.
3. Engraftment of the tooth using a mixed (periodontal-fibrous-osseous) type of fusion of the tooth root and alveolar wall. On a control radiograph with such a fusion, the line of the periodontal fissure alternates with areas of its narrowing or absence.
In the long-term period (several years) after tooth replantation, resorption (resorption) of the root of the replanted tooth may occur.
Surgical methods of treatment.
1. Suspension of the upper jaw to the orbital edge of the frontal bone according to Faltin-Adams.
For a fracture:
· according to the lower type, the upper jaw is fixed to the lower edge of the orbit or to the edge of the pyriform opening;
· according to the middle type - to the zygomatic arch;
· by the upper type – to the zygomatic process of the frontal bone;
Operation stages:
· A wire splint with two hooking loops facing downwards is placed on the upper jaw.
· An intact area of the upper outer edge of the orbit is exposed, in which a hole is made. A thin wire or polyamide thread is passed through it.
· Using a long needle, both ends of the ligature are passed through the thickness of the soft tissues so that they exit into the vestibule of the oral cavity at the level of the first molar.
· After repositioning the fragment into the correct position, the ligature is fixed by the hook of the dental splint.
· This operation is carried out on both sides.
· If it is necessary to correct the bite, apply a splint with hooking loops to the lower jaw and an intermaxillary rubber rod or a parietal-mental sling.
2. Frontomaxillary osteosynthesis according to Chernyatina-Svistunov indicated for fractures of the upper jaw of the middle and upper type.
The fragments are fixed not to the splint, but to the zygomaticalveolar ridge.
3. Fixing fragments of the upper jaw with Kirschner wires according to Makienko.
4. Osteosynthesis of fractures of the upper jaw with titanium mini-plates.
· In case of a fracture of the lower type, osteosynthesis is performed in the area of the zygomatic-alveolar ridge and along the edge of the pyriform opening through intraoral incisions.
· For a mid-type fracture, mini-plates are applied along the zygomatic-alveolar ridge, as well as along the lower edge of the orbit and in the area of the bridge of the nose.
· In case of a fracture of the upper type, osteosynthesis is indicated in the area of the bridge of the nose, the upper outer corner of the orbit and the zygomatic arch.
· To prevent traumatic maxillary sinusitis, an inspection of the maxillary sinus is performed, an anastomosis is applied to the lower nasal meatus, and the defect is closed with local tissues to isolate the oral cavity from the sinus.
FRACTURES OF THE ZYGOMIC BONE AND ZYGOMICAL ARCH
Classification of non-gunshot fractures of the zygomatic bone and arch:
1. Fractures of the zygomatic bone (with and without displacement of fragments).
2. Fractures of the zygomatic arch (with and without displacement of fragments).
Displaced fractures of the zygomatic bone are usually open.
Fractures of the zygomatic arch are most often closed.
Clinic for fractures of the zygomatic bone (zygomatic maxillary complex).
The following symptoms are identified:
· Severe swelling of the eyelids and hemorrhage into the tissue around one eye, which leads to narrowing or closure of the palpebral fissure.
· Bleeding from the nose (from one nostril).
· Limited mouth opening due to blocking of the coronoid process of the lower jaw, displaced by the zygomatic.
· Anesthesia or paresthesia of soft tissues in the area of innervation of the infraorbital nerve on the side of the injury (upper lip, wing of the nose, infraorbital region, etc.).
· Impaired binocular vision (diplopia or double vision) due to displacement of the eyeball.
· Retraction, determined by palpation in the zygomatic region.
· Pain and the “step” symptom upon palpation along the lower orbital edge, the superior outer edge of the orbit, along the zygomatic arch and along the zygomatic-alveolar ridge.
Clinic for zygomatic arch fractures:
· Damage to the soft tissues of the zygomatic area (swelling, wounds, hemorrhages), which are masked by retraction in the zygomatic area.
· Limited mouth opening due to blocking of the coronoid process of the mandible by the displaced zygomatic arch.
· Absence of unilateral lateral movements of the lower jaw.
· Recession, pain and “step” symptom upon palpation in the area of the zygomatic arch.
X-ray examination.
Radiographs of the paranasal sinuses and zygomatic bones are studied in the nasomental (semi-axial) and axial projections.
Defined by:
· violation of the integrity of bone tissue at the junction of the zygomatic bone with other bones of the facial and cerebral skull;
· darkening of the maxillary sinus on one side as a result of hemosinus in fractures of the zygomatic bone.
Treatment.
Patients are treated in a hospital.
For fractures of the zygomatic bone and arch without significant displacement of fragments and dysfunction, conservative treatment is carried out, limiting the intake of solid food.
Indications for repositioning fragments of the zygomatic arch and bone:
· deformation of the face due to retraction of tissues in the zygomatic region,
· impaired sensitivity in the area of innervation of the infraorbital and zygomatic nerve, diplopia,
· violation of movements of the lower jaw.
Fractures of the nasal bones
Occurs when a fall or strong blow to the bridge of the nose. The displacement of bone fragments depends on the strength and direction of the traumatic factor.
Classification.
There are fractures of the nasal bones with displacement and without displacement of bone fragments, as well as impacted fractures of the nasal bones.
All displaced fractures of the nasal bones are open fractures, as they are accompanied by ruptures of the nasal mucosa and profuse nosebleeds.
40% of patients with nasal bone fractures have a traumatic brain injury.
Clinical symptoms of a nasal bone fracture:
· Deformation of the external nose in the form of lateral curvature or saddle-shaped retraction.
· Nose bleed.
· Difficulty in nasal breathing.
· Damage to the skin of the back of the nose.
· Swelling of the eyelids and hemorrhage into the tissue around the eyes (a symptom of glasses).
· Pain, crepitus and mobility of bone fragments, determined by palpation in the dorsum of the nose.
· Displacement of the bone and cartilaginous part of the nasal septum, which is detected during anterior rhinoscopy.
· For the final diagnosis of a fracture, radiography of the nasal bones in direct and lateral projection is indicated.
Treatment.
First aid- stopping bleeding (anterior or posterior tamponade).
Reposition of fragments under local anesthesia using a hemostatic clamp inserted into the upper nasal passage or a special elevator, which is used to lift the displaced bones, forming the contours of the nasal bridge with the index and thumbs of the left hand. The nasal passages are packed.
Application of an external fixation bandage (splint) for fixation of bone fragments for 8-10 days (gauze collodion dressing or plaster).
COMPLICATIONS OF FACIAL INJURIES
The following types of complications of injuries to the maxillofacial area are distinguished:
1. Direct (asphyxia, bleeding, traumatic shock).
2. Immediate complications (wound suppuration, abscess and phlegmon of soft tissues, traumatic osteomyelitis, traumatic maxillary sinusitis, secondary bleeding due to melting of a blood clot, sepsis).
3. Long-term complications (scar deformation of soft tissues, soft tissue defects, adentia and death of the rudiments of permanent teeth, jaw deformation, improperly healed fracture of the jaw, malocclusion, bone tissue defects, pseudarthrosis, delayed jaw growth, ankylosis and other diseases of the temporomandibular joint).
TRAUMATIC SHOCK
Traumatic shock- a general reaction of the body to severe damage, in the pathogenesis of which a central place is occupied by impaired tissue circulation, a decrease in cardiac output, hypovolemia and a drop in peripheral vascular tone. Ischemia occurs in vital organs and systems (heart, brain, kidneys).
Traumatic shock occurs as a result of severe polytrauma, severe bone damage, crushing of soft tissues, extensive burns, combined trauma of the face and internal organs. With such injuries, severe pain occurs, which is the root cause of traumatic shock and disruption of the interrelated functions of the circulatory, respiratory and excretory organs.
During shock, erectile and torpid phases are distinguished. The erectile phase is usually short-lived and is manifested by general anxiety.
The torpid phase is divided into 3 degrees according to the severity of clinical manifestations:
1st degree – mild shock;
2nd degree – severe shock;
3rd degree – terminal condition.
The 1st degree of the torpid phase is characterized by: indifference to the environment, pallor of the skin, pulse 90-110 beats per minute, systolic pressure 100-80 mm. rt. Art., diastolic – 65-55 mm. rt. Art. The volume of circulating blood is reduced by 15-20%.
With 2 degrees of shock, the victim’s condition is severe, the skin is pale with a grayish tint, although consciousness is preserved, indifference to the environment increases, the pupils react poorly to light, reflexes are decreased, the pulse is rapid, and the heart sounds are muffled. Systolic pressure – 70 mm. rt. Art., diastolic – 30-40 mm. rt. Art., is not always caught. The volume of circulating blood is reduced by 35% or more. Breathing is frequent and shallow.
The terminal state is characterized by: loss of consciousness, pale gray skin, covered with sticky sweat, cold. The pupils are dilated and weakly or completely unresponsive to light. Pulse and blood pressure are not determined. Breathing is barely noticeable. The volume of circulating blood is reduced by 35% or more.
Treatment.
Main objectives of treatment:
local and general anesthesia;
stopping bleeding;
· compensation of blood loss and normalization of hemodynamics;
· maintaining external respiration and combating asphyxia and hypoxia;
· temporary or transport immobilization of a jaw fracture, as well as timely surgical intervention;
· correction of metabolic processes;
· satisfying hunger and thirst.
When providing first aid at the scene of an accident, bleeding can be reduced by applying finger pressure to the damaged blood vessel. Effective general anesthesia is achieved by using non-narcotic analgesics (analgin, fentanyl, etc.) or neuroleptanalgesia (droperidol, etc.). Local anesthesia - conduction or infiltration. If there is a risk of asphyxia, subcutaneous administration of morphine (omnopon) is contraindicated. In cases of respiratory depression, victims inhale carbon dioxide and inject ephedrine subcutaneously.
BRONCHOPULMONARY COMPLICATIONS
Bronchopulmonary complications develop as a result of prolonged aspiration of infected oral fluid, bone, blood, and vomit. With gunshot wounds of soft tissues and bones of the face, bronchopulmonary complications occur more often than with injuries to other areas.
Predisposing factors for the development of bronchopulmonary complications:
· constant drooling from the mouth, which, especially in winter, can lead to significant hypothermia of the anterior surface of the chest;
· blood loss;
· dehydration;
· eating disorders;
· weakening of the body's defenses.
The most common complication is aspiration pneumonia. Develops 4-6 days after injury.
Prevention:
· timely provision of specialized assistance;
· antibiotic therapy;
· prevention of aspiration of food during feeding;
· mechanical protection of the chest organs from wetting with saliva;
· breathing exercises.
ASPHYXIA
Asphyxia Clinic. The breathing of victims is accelerated and deep, auxiliary muscles are involved in the act of breathing, and when inhaling, the intercostal spaces and the epigastric region sink. The inhalation is noisy, with a whistle. The victim's face is bluish or pale, the skin becomes gray in color, the lips and nails are cyanotic. The pulse slows down or quickens, and cardiac activity decreases. The blood takes on a dark color. Victims often experience agitation and motor restlessness is replaced by loss of consciousness.
Types of asphyxia in those wounded in the face and jaws and treatment according to G.M. Ivashchenko
Indications for tracheostomy:
· damage to the maxillofacial area in combination with severe traumatic brain injury, causing loss of consciousness and respiratory depression;
· the need for long-term artificial ventilation and systematic drainage of the tracheobronchial tree;
· wounds with separation of the upper and lower jaws, when there is significant aspiration of blood into the respiratory tract and their drainage cannot be ensured through the endotracheal tube;
· after extensive and severe operations (resection of the lower jaw with a one-stage Crail operation, excision of a cancerous tumor of the root of the tongue and floor of the mouth).
In the postoperative period, due to impaired swallowing and a decreased cough reflex, as well as due to a violation of the integrity of the muscles of the floor of the mouth, such patients often experience a retraction of the tongue, blood mixed with saliva constantly flows into the trachea, and a large amount of fluid accumulates in the trachea and bronchi itself. amount of mucus and phlegm.
The following types of tracheostomy are distinguished:
· upper (stoma placement above the isthmus of the thyroid gland);
· medium (stomy through the isthmus of the thyroid gland);
· lower (stoma placement below the isthmus of the thyroid gland);
The lower one is shown only in children, the middle one is practically not performed.
Tracheostomy technique(after V. O. Bjork, 1960).
· The patient lies on his back with a cushion under his shoulder blades and his head thrown back as much as possible.
· An incision of the skin and subcutaneous tissue 2.5-3 cm long is made along the midline of the neck 1.5 cm below the cricoid cartilage.
· The muscles are bluntly separated and the isthmus of the thyroid gland is moved upward or downward, depending on the anatomical features. In the first case, to prevent pressure on the tracheostomy tube, the isthmus capsule is fixed to the upper skin flap.
· In the anterior wall of the trachea, a flap is cut out from the second or from the second and third rings of the trachea, with the base facing downwards. To avoid trauma to the cricoid cartilage with the tracheostomy tube, the first tracheal ring is preserved.
· The top of the flap is fixed to the dermis of the lower skin flap with one catgut suture.
· A tracheostomy cannula of the appropriate diameter with a replaceable inner tube is inserted into the stoma. The diameter of the outer cannula should correspond to the opening in the trachea.
Removal of the tracheostomy tube (decannulation) is usually performed on the 3-7th day, after making sure that the patient can breathe normally through the glottis, the stoma is then tightened with a strip of adhesive tape. As a rule, it closes on its own after 7-10 days.
Crico-conicotomy indicated for asphyxia, when there is no time left for tracheostomy and intubation is impossible.
Operation technique:
· Rapid dissection (simultaneously with the skin) of the cricoid cartilage and thyroid cricoid ligament.
· The edges of the wound are separated with any instrument suitable for this purpose.
· A narrow cannula is temporarily inserted into the wound and the trachea is drained through it.
BLEEDING
Bleeding is called the leakage of blood from a blood vessel when the integrity of its walls is violated.
Depending on the place where blood flows after an injury, there are:
· interstitial bleeding - blood leaving the vessels, permeating the tissue surrounding the damaged vessel, causes the formation of petechiae, ecchymoses and hematomas;
External bleeding - bleeding onto the surface of the body;
· internal bleeding - the flow of blood into any organ cavity.
According to the source of blood flow from the vessel, they are distinguished arterial, venous, capillary and mixed bleeding.
According to the time factor of blood flow, the following are distinguished:
· primary;
· secondary early (in the first 3 days after injury).
Causes: cutting through a vessel with a ligature, slipping of the ligature from the vessel, technical errors in hemostasis, improvement of central and peripheral hemodynamics as a result of the patient recovering from a state of circulatory failure;
· secondary late (on the 10-15th day after injury).
Causes: purulent melting of the blood clot and the vessel wall, disseminated intravascular coagulation syndrome with subsequent hypocoagulation of the blood.
Criteria for assessing the severity of blood loss.
