Damage to the maxillofacial region. Classification of complex maxillofacial apparatus Classification of orthopedic apparatus for the treatment of fractures of the jaws
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1 Federal Agency for Railway Transport Irkutsk State University of Railway Transport Medical College of Railway Transport WORKING PROGRAM OF THE PROFESSIONAL MODULE PM. 05 Manufacture of maxillofacial apparatus Specialty Orthopedic Dentistry Irkutsk 015
2 Developer: Sidorova E.P., teacher of the first qualification category of FGBOU VPO MK ZhT
3 CONTENTS 1. PASSPORT OF THE WORKING PROGRAM OF THE PROFESSIONAL MODULE. RESULTS OF MASTERING THE PROFESSIONAL MODULE 6 page STRUCTURE AND CONTENT OF THE PROFESSIONAL MODULE 8 4 CONDITIONS FOR THE IMPLEMENTATION OF THE PROFESSIONAL MODULE 1 NOST) 14 3
4 1. PASSPORT OF THE WORKING PROGRAM OF THE PROFESSIONAL MODULE PM.05 Manufacture of maxillofacial apparatuses 1.1. Scope of the work program The work program of the professional module is part of the training program for middle-level specialists in accordance with the Federal State Educational Standard in the specialty Orthopedic Dentistry, in terms of mastering the main type (VPD): PM 05 Production of maxillofacial apparatus and related professional competencies (PC): PC 5.1 To make the main types of maxillofacial apparatus for defects in the maxillofacial region. PC 5. Manufacture treatment-and-prophylactic maxillofacial devices (tires). The work program of the professional module can be used under the program of advanced training and retraining in the specialty Orthopedic Dentistry. 1.. Goals and objectives of the professional module requirements for the results of mastering the professional module In order to master the specified type and the corresponding professional competencies, the student in the course of mastering the professional module must: be able to: make the main types of maxillofacial apparatus; to produce medical and prophylactic maxillofacial devices (tires); zt: goals and objectives of maxillofacial orthopedics; the history of the development of maxillofacial orthopedics; connection of maxillofacial orthopedics with other sciences and disciplines; classification of maxillofacial apparatuses; definition of injury, damage, their classification; gunshot injuries of the maxillofacial region, their features; orthopedic care stages of medical evacuation; non-gunshot fractures of the jaws, their classification and the mechanism of displacement of fragments; features of care and nutrition of maxillofacial patients; methods of dealing with complications of the stages of medical evacuation; principles of treatment of jaw fractures; features of the manufacture of the tire (kappa). 4
5 1.3. The number of hours of mastering the approximate program of the professional module: 16 hours in total, including: the maximum study load of the student is 16 hours, including: the mandatory classroom study load of the student is 108 hours; independent work of the student 84 hours; 5
6. RESULTS OF MASTERING THE PROFESSIONAL MODULE The result of mastering the professional module is the mastery of the following type by students: Manufacture of maxillofacial apparatuses, including professional (PC) and general (OK) competencies: Code PC 1. PC. OK 1 OK OK 3 OK 4 Name of the learning outcome To make the main types of maxillofacial apparatus for defects in the maxillofacial region. To manufacture treatment and prophylactic maxillofacial apparatuses (tires). Understand the essence and social significance of your future profession, show a steady interest in it. Organize their own activities, choose standard methods and methods for performing professional tasks, evaluate their effectiveness and quality. Make decisions in standard and non-standard situations and bear responsibility for them. Search and use the information necessary for the effective implementation of professional tasks, professional and personal development. OK 5 Use information and communication technologies c. OK 6 Work in a team and team, communicate effectively with colleagues, management, consumers. OK 7 Take responsibility for the work of team members (subordinates), for the result of completing tasks. OK 8 Independently determine the tasks of professional and personal development, engage in self-education, consciously plan advanced training. 6
7 OK 9 Navigate in an environment of frequent technology change c. OK 10 Carefully treat the historical trace and cultural traditions of the clan, respect social, cultural and religious differences. OK 11 To be ready to take on moral obligations in relation to nature, society and man. OK 1 Provide first (pre-medical) medical care in case of emergency. OK 13 OK 14 OK 15 Organize the workplace in compliance with the requirements of labor protection, industrial sanitation, infectious and fire safety. Lead a healthy lifestyle, engage in physical culture and sports to improve health, achieve life and professional goals. Perform military duty, including with the use of acquired professional knowledge (for young men). 7
8 1. STRUCTURE AND CONTENT OF PROFESSIONAL MODULE PM.05. MANUFACTURING OF MAXILLOFACIAL DEVICES 3.1. Thematic plan of the professional module Codes of professional competencies Names of sections of the professional module 1 Total hours (max. study load and practice) Amount of time allotted for the development of an interdisciplinary course (courses) Obligatory audience studying student load Total, hours incl. laboratory work and practical classes, hours including course work (project), hours Independent work of the student Total, hours including coursework (project), hours Studying, hours Practice Production (according to the specialty profile ), hours (if dispersed practice is envisaged) PC 5.1., PC 5.. Section 1. Manufacturing of the main types of maxillofacial apparatus week (36 hours) Industrial practice (according to the specialty), hours (if final (concentrating) practice is provided) Total: week (36 hours) 8
9 3.. The content of training on the professional module PM.05 Manufacturing of maxillofacial apparatus Name of the sections of the professional module (PM), interdisciplinary courses (MDC) and topics ) (if provided) Amount of hours Mastery level Section PM Production of the main types of maxillofacial apparatuses MDK Technology of manufacturing maxillofacial apparatuses 108 Topic 1.1. The content of the educational material 4 Gunshot fractures of the maxillofacial region 1 The concept of maxillofacial orthopedics. Types of damage to the maxillofacial region. Gunshot fractures. Classification of gunshot fractures Topic 1 .. Non-gunshot fractures of the maxillofacial region Organization of medical care for the maxillofacial wounded stages of evacuation Methods for dealing with complications stages of medical evacuation Content of educational material 1 Non-gunshot fractures of the maxillofacial area. Classification of non-gunshot jaw fractures Topic 1.3. Orthopedic methods of treatment of fractures of the jaws with fixation devices Content of educational material 1. Classification of maxillofacial apparatuses. Apparatus for fixation of jaw fragments Practical exercises 18 9
10 Topic 1.4. Orthopedic methods of treatment of jaw fractures with repositioning devices Topic 1.5. Orthopedic methods of treatment for non-united and improperly fused fractures of the jaws Topic 1.6. Orthopedic methods of treatment for contractures and microstomia 1. Weber splint manufacturing technology. Metal frame fabrication. 3. Modeling the wax composition of the tire. Replacing wax with plastic Content of educational material 1. Apparatus for repositioning jaw fragments Design features of the manufacture of splints for the treatment of fractures in childhood Content of educational material 1. Prosthetics of patients with nonunion of jaw fractures. Prosthetics of patients with incorrectly fused fractures Content of educational material 1. Etiology, clinic and treatment of jaw contractures Etiology, clinic and treatment of microstomy 3 1 Topic 1.7. Orthopedic methods of treatment of patients with congenital defects of the hard and (or) soft palate Topic 1.8. Replacing, resection devices Content of educational material 1. Provision of orthopedic care to children with congenital defects of the hard and (or) soft palate. Types of obturators. The content of the educational material 1. Orthopedic methods of treatment of patients with defects of the hard and soft palate Practical exercises 1. Technology of manufacturing a replacement prosthesis for a median defect of the hard and soft palate. Making models, determining the central ratio of the jaws. 3. Setting of artificial teeth. Modeling the wax composition of the prosthesis
11 Topic 1.9. Shaping devices Topic Ectoprosthetics of the face Topic Orthopedic protection for athletes 4. Replacement of wax plastic. Processing, grinding, polishing of the prosthesis. The content of educational material 1. Immediate and subsequent prosthetics after resection of the jaws. Forming devices. Indications for use. Requirements and principles of manufacturing Content of educational material 1. Orthopedic treatment with ectoprostheses. Modern materials for the manufacture of ectoprostheses Practical exercises 4 1. Making an ectoprosthesis of the ear from hard plastics.. Making an ectoprosthesis of the ear from elastic materials. 3. Making an ectoprosthesis of the nose. 4. Making an ectoprosthesis of the nose from elastic materials. The content of the educational material 1. The technology of manufacturing a boxing splint from various materials. Practical exercises Boxing splint manufacturing technology. Making casts, models. Making a boxing splint from elastic materials. 3. Production of a boxing splint from silicone masses. Independent work in the study of section PM 5 1. Work with textbooks, atlases, notes on teaching aids compiled by the teacher. Independent study of algorithms for practical manipulations in section 3. Independent development of practical manipulations (manufacturing of the main types of maxillofacial apparatus)
12 Trying out the topics of extracurricular independent work 1. Work with educational and additional literature. Filling in the tables for the topics “Gunshot and non-gunshot fractures of the maxillofacial region” 3. Abstract message to the topics of the section: “Manufacturing of the main types of maxillofacial apparatus” 4. Filling in the table “Clinical and laboratory stages of manufacturing a Weber splint” 5. Give a comparative description of the articulated prostheses according to Gavrilov, Oksman, Weinstein 6. Compilation of test tasks 7. Compilation of terminological dictation 8. Compilation of graphic diagrams using multimedia technologies 9. Work with Internet resources Industrial practice in the specialty profile Types of work: Production of the main types of maxillofacial apparatus in case of defects maxillofacial area. Production of treatment-and-prophylactic maxillofacial apparatuses (tires). 1 week (36 hours) Total 16 1
13 4.1. Requirements for minimum logistics. The implementation of the professional module requires the presence of laboratories. Manufacturing technology of maxillofacial apparatuses. Equipment of the laboratory and workplaces of the laboratory "Technology for the manufacture of maxillofacial apparatuses": 1. A set of furniture. A set of equipment, instruments and consumables: dental tables, portable drills, grinders, pneumopolymerizer, electric spatulas, occluders, electric stoves, cuvette press, fume hood, dental compressor, models, phantom models of jaws, tools for the manufacture of maxillofacial apparatus, consumables for manufacture of maxillofacial apparatuses; Teaching aids: computers, modem (satellite system), projector, interactive whiteboard, TV, DVD player, general and professional software. The implementation of the module program does not imply mandatory work experience. 4 .. Information support for education Basic literature: 1. Dental technique./ solution Rasulova M.M. etc. M.: GEOTAR-Media, Smirnov B.A. Dental business in dentistry.- M .: GEOTAR-Media, 014 Additional literature: 1. Smirnov B. Dental business in dentistry- M .: ANMI, General requirements for the organization of the educational process 13
14 The main forms of student learning are classroom activities, including lectures, seminars, lessons, and practical exercises. The topics of lectures and practical exercises should correspond to the content of the program of this professional module. Theoretical classes are held in classrooms equipped with technical teaching aids, visual aids, and ready-made maxillofacial apparatuses. Practical classes should be held in a dental laboratory. Knowledge is consolidated and skills are acquired to work with specific structures, materials and equipment of an educational dental laboratory used in maxillofacial orthopedics. The level of independence in the work of students should be determined by the teacher individually and gradually increase as the development of theoretical knowledge and manual skills. Outside the classroom, independent work should be accompanied by methodological support and consulting assistance to students in all sections of the professional module, the possibility of practicing practical skills in phantoms and treasures, as well as the possibility of working out missed ones. The development of this module should be preceded by the study of the following disciplines: "Atomy and human physiology with a course in biomechanics of the dentoalveolar system", "Dental materials science with a course in labor protection and safety", "First medical aid", "Dental diseases", "Life safety", and also the study of professional modules: PM.01 Manufacture of removable laminar dentures, PM.0 Manufacture of fixed dentures, PM.03 Manufacture of clasp dentures Personnel support of the educational process The implementation of the main educational program in the specialty of secondary vocational education should be provided by teaching staff with higher education corresponding to the profile of the discipline (module) being taught. Experience in organizations of the relevant field is mandatory for teachers responsible for mastering the professional cycle by students; these teachers must undergo internships in specialized organizations at least once every 3 years 14
15 5. Monitoring and evaluation of the results of mastering the professional module (type) Results (mastered professional competencies) PC5.1 Production of the main types of maxillofacial apparatus for defects in the maxillofacial area PC5. Manufacture of therapeutic and prophylactic maxillofacial apparatuses (tires) Key indicators for evaluating the result Knowledge of the goals and objectives of maxillofacial orthopedics. Knowledge of the etiology, clinic and orthopedic treatment of defects in the maxillofacial region. Demonstration of skills in the manufacture of a replacement prosthesis. Ability to identify maxillofacial trauma Knowledge of clinics and orthopedic treatment of gunshot and non-gunshot fractures of the maxillofacial region Demonstration of the skills of making a Weber splint. Demonstration of the skills of making a boxing splint. Forms and methods of control and evaluation Current control in the form of: - conversations; - oral questioning; - test control; - problematic situational tasks. Expert assessment of the manufacture of a replacement prosthesis in a practical lesson Intermediate certification Current control in the form of: - conversations; - oral questioning; - test control; - problematic situational tasks Expert evaluation of the manufacture of a Weber splint in a practical lesson Expert evaluation of the manufacture of a boxing splint in a practical lesson Intermediate certification Forms and methods for monitoring and evaluating learning outcomes should allow students to check not only the formation of professional competencies, but also the development of general competencies and skills that provide them. 15
16 Results (mastered general competencies) OK1. Understand the essence and social significance of your future profession, show a steady interest in it. OK. Organize your own activities, choose standard methods and methods for performing professional tasks, evaluate their effectiveness and quality. OK3. Make decisions in standard and non-standard situations and bear responsibility for them. OK4. Search and use the information necessary for the effective implementation of professional tasks, professional and personal development. OK5. Use information and communication technologies c. OK6. The main indicators for evaluating the result The presence of interest in the future profession The validity of the choice and application of methods and methods for solving professional problems in the manufacture of maxillofacial apparatuses The effectiveness and quality of the performance of professional tasks. Ability to make decisions in standard and non-standard situations and bear responsibility for them. Search and use of information for the effective implementation of professional tasks, professional and personal development. Skills for using information and communication technologies in Effective interaction with students, Forms and methods of monitoring and evaluation Observing the activities of the student in the process of mastering the educational program Solving problem-situational tasks Solving problem-situational tasks
17 Work in a team and team, communicate effectively with colleagues, management, consumers. OK7. Take responsibility for the work of team members (subordinates), for the result of completing tasks. OK8. Independently determine the tasks of professional and personal development, engage in self-education, consciously plan advanced training. OK9. Navigate in conditions of frequent change of technologies in OK10. Carefully treat the historical trace and cultural traditions of the clan, respect social, cultural and religious differences. teachers in the course of training Responsibility for the work of team members, for the result of completing tasks Increasing the personal and qualification level Showing interest in innovations in the field Careful attitude to the historical trace and cultural traditions of the family, respect for social, cultural and religious differences Providing a portfolio of results of improving the personal and qualification level . Evaluation of independent work OK11. Be ready to take on moral obligations in relation to nature, society and man. OK1. Provide first (pre-medical) medical care in case of emergency. OK13. Organize the workplace in compliance with the requirements Willingness to assume moral obligations in relation to nature, society and man Ability to provide first (first aid) medical care in emergency conditions Organization of the workplace in compliance with the requirements 17
18 labor protection, industrial sanitation, infectious and fire safety. labor protection, industrial sanitation, infectious and fire safety OK14. Lead a healthy lifestyle, engage in physical culture and sports to improve health, achieve life and professional goals. OK15. Perform military duty, including with the use of acquired professional knowledge (for young men). Maintaining a healthy lifestyle, engaging in physical culture and sports to improve health, achieve life and professional goals Willingness to perform military duty, including using acquired professional knowledge (for young men) 18
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CLASSIFICATION OF COMPLEX MAXILLOFACIAL APPARATUS
Fastening of fragments of the jaws is carried out using various orthopedic devices. All orthopedic devices are divided into groups depending on the function, area of fixation, therapeutic value, design, manufacturing method and material.
By function:
Immobilizing (fixing);
Repositioning (correcting);
Corrective (guides);
Formative;
Resection (replacement);
Combined;
Prostheses for defects of the jaws and face.
Place of fixation:
Intraoral (single jaw, double jaw, intermaxillary);
extraoral;
Intra- and extraoral (maxillary, mandibular).
For medical purposes:
Basic (having an independent therapeutic value: fixing, correcting, etc.);
Auxiliary (serving for the successful implementation of skin-plastic or bone-plastic operations).
By design:
Standard;
Individual (simple and complex).
According to the manufacturing method:
Laboratory production;
Non-laboratory production.
According to materials:
plastic;
metal;
Combined.
Immobilizing devices are used in the treatment of severe fractures of the jaws, insufficient number or absence of teeth on fragments. These include:
Wire tires (Tigerstedt, Vasiliev, Stepanov);
Tires on rings, crowns (with hooks for fragments traction);
Mouthguard tires:
V metal - cast, stamped, soldered;
V plastic; - removable tires of Port, Limberg, Weber, Vankevich, etc.
Repositioning devices that promote the reposition of bone fragments are also used for chronic fractures with stiff jaw fragments. These include:
Repositioning devices made of wire with elastic intermaxillary traction, etc.;
Devices with intraoral and extraoral levers (Kurlyandsky, Oksman);
Repositioning devices with a screw and a repulsive platform of Kurlyandsky, Grozovsky);
Repositioning apparatus with a pelotom on an edentulous fragment (Kurlyandskogo and others);
Repositioning apparatus for edentulous jaws (Guning-Port splints).
Fixing devices are called devices that help hold fragments of the jaw in a certain position. They are subdivided:
For extraoral:
V standard chin sling with head cap;
V standard tire according to Zbarzh and others.
Intraoral:
*V tooth bars:
Wire aluminum (Tigerstedt, Vasiliev, etc.);
Soldered tires on rings, crowns;
plastic tires;
Fixing dental devices;
* tooth-gingival tires (Weber and others);
* gum tires (Port, Limberg);
Combined.
Guides (corrective) are called devices that provide a bone fragment of the jaw with a certain direction with the help of an inclined plane, a pilot, a sliding hinge, etc.
For wire aluminum tires, the guide planes are bent simultaneously with the tire from the same piece of wire in the form of a series of loops.
For stamped crowns and mouth guards, inclined planes are made of a dense metal plate and soldered.
For cast tires, the planes are modeled from wax and cast along with the tire.
On plastic tires, the guide plane can be modeled simultaneously with the tire as a whole.
In case of insufficient number or absence of teeth in the lower jaw, tires according to Vankevich are used.
Forming devices are called devices that are the support of plastic material (skin, mucous membrane), create a bed for the prosthesis in the postoperative period and prevent the formation of cicatricial changes in soft tissues and their consequences (displacement of fragments due to constricting forces, deformations of the prosthetic bed, etc.). According to the design, the devices can be very diverse, depending on the area of damage and its anatomical and physiological features. In the design of the forming apparatus, a forming part and fixing devices are distinguished.
Resection (replacement) devices are called devices that replace defects in the dentition formed after the extraction of teeth, filling defects in the jaws, parts of the face that arose after injury, operations. The purpose of these devices is to restore the function of the organ, and sometimes to keep fragments of the jaw from moving or soft tissues of the face from retraction.
Combined devices are called devices that have several purposes and perform various functions, for example: fixing fragments of the jaw and forming a prosthetic bed or replacing a defect in the jawbone and at the same time forming a skin flap. A typical representative of this group is the kappa-rod device of combined sequential action according to Oxman for fractures of the lower jaw with a bone defect and the presence of a sufficient number of stable teeth on fragments.
Prostheses used in maxillofacial orthopedics are divided into:
On the dentoalveolar;
jaw;
Facial;
Combined;
During resection of the jaws, prostheses are used, which are called post-resection prostheses.
Distinguish between immediate, immediate and distant prosthetics. In this regard, the prostheses are divided into operational and postoperative. Replacement devices also include orthopedic devices used for palate defects: protective plates, obturators, etc.
Prostheses for defects of the face and jaws are made in case of contraindications to surgical interventions or in case of persistent unwillingness of patients to undergo plastic surgery.
If the defect captures a number of organs at the same time: nose, cheeks, lips, eyes, etc., a facial prosthesis is made in such a way as to restore all the lost tissues. Facial prostheses can be fixed with spectacle frames, dentures, steel springs, implants, and other devices.
Orthopedic treatment for false joints (Oxman method):
Prosthetics for a false joint has its own characteristics. The denture, regardless of fixation (ie, removable or non-removable), in place of the false joint must have a movable connection (preferably hinged).
Impressions are taken from each fragment, a basis with clasps and an inclined plane or an extragingival splint with an inclined plane are made on plaster models.
The bases are fitted to the jaw fragments so that the inclined plane holds them when the mouth is opened, then the area of the jaw defect is filled on both sides (vestibular and oral) with an impression material that is inserted without a spoon.
Based on this impression, a single prosthesis is prepared, which is, as it were, a spacer between the fragments of the lower jaw, preventing them from approaching when the mouth is opened (in this case, the inclined planes are removed).
The central occlusion is determined on a rigid plastic base, after which the prosthesis is made in the usual way.
It should be noted that hinged prostheses do not restore chewing function to the same extent as conventional prostheses. The functional value of prostheses will be much higher if they are made after osteoplasty. Radical treatment of a false joint is only surgical, by osteoplasty.
Orthopedic treatment for improperly fused jaw fragments:
With improperly fused fractures of the jaws and a small number of remaining teeth that are out of occlusion, removable dentures with a duplicated dentition are made. The remaining teeth are used to fix the prosthesis with support-retaining clasps.
When the dental arch of the lower jaw is deformed due to the inclination of one or more teeth to the lingual side, it is difficult to prosthetic the defect of the dentition with a removable plate or arc prosthesis, since the displaced teeth interfere with its application. In this case, the design of the prosthesis is changed in such a way that in the area of displaced teeth, a part of the base or arch is located on the vestibular, and not on the lingual side. On the displaced teeth, support-retaining clasps or occlusive linings are applied, which allow transferring chewing pressure through the prosthesis to the supporting teeth and prevent their further displacement to the lingual side.
In case of incorrectly fused fractures with a shortening of the length of the dental arch and jaw (microgenia), a removable prosthesis is made with a duplicating row of artificial teeth, which creates the correct occlusion with antagonists. Displaced natural teeth, as a rule, are used only for fixing the prosthesis.
Orthopedic treatment for microstomy:
With prosthetics, the best result is obtained only after the expansion of the oral fissure by surgery. In those cases when the operation is not indicated (age of the patient, state of health, systemic scleroderma), prosthetics are performed with a narrowed oral fissure and encounter great difficulties in orthopedic manipulations.
When prosthetics of defects in the dentition with bridges or other fixed structures, conduction anesthesia is difficult. In these cases, other types of anesthesia are used. The preparation of abutment teeth during microstomy is inconvenient for both the doctor and the patient. Sick teeth should be separated not with metal discs, but with shaped heads on turbine or contra-angle tips, without damaging intact neighboring teeth. Removal of the impression is complicated due to the difficulty of introducing a spoon with an impression mass into the oral cavity and removing it from there in the usual way. In patients with a defect in the alveolar process, it is difficult to remove the impression, since it has a large volume. When prosthetics are fixed with fixed dentures, impressions are taken with partial spoons, with removable structures - with special collapsible spoons. If there are no such spoons, then you can use the usual standard spoon, sawn into two parts. The technique consists in sequentially obtaining an impression from each half of the jaw. It is advisable to make an individual tray from a collapsible impression and use it to obtain the final impression. In addition, the impression can be taken by first placing the impression material on the prosthetic bed and then covering it with an empty standard tray. It is also possible to form an individual wax tray in the oral cavity, make a plastic one on it and get the final impression with a hard tray.
With a significant decrease in the oral fissure, the determination of central occlusion in the usual way using wax bases with bite ridges is difficult. When removing the wax base from the oral cavity, its deformation is possible. For this purpose, it is better to use bite rollers and bases made of thermoplastic mass. If necessary, they are shortened.
The degree of reduction of the oral fissure affects the choice of prosthesis design. To facilitate insertion and removal in patients with microstomia and defects in the alveolar process and the alveolar part of the jaws, the design of the prosthesis should be simple. With a significant microstomy, collapsible and hinged removable dentures are used. However, these constructs should be avoided. It is better to reduce the boundaries of the prosthesis, narrow the dental arch and use flat artificial teeth. Improving the fixation of a removable prosthesis when its base is shortened is facilitated by a telescopic fastening system. In the process of getting used to removable dentures, the doctor must teach the patient how to insert the denture into the oral cavity.
With a significant microstomy, collapsible or folding dentures using hinged devices are sometimes used. A folding prosthesis consists of two lateral parts connected by a hinge and an anterior locking part. In the oral cavity, it moves apart, is installed on the jaw and strengthened by the anterior locking part. The latter is a block of the anterior group of teeth, the base and pins of which fall into the tubes located in the thickness of the halves of the prosthesis.
Collapsible prostheses consist of separate parts. In the oral cavity, they are made up and fastened into a single whole with the help of pins and tubes. You can make a conventional prosthesis, but to facilitate the introduction and removal of it from the mouth through a narrowed oral fissure, the dental arch of the prosthesis should be narrowed, while using the telescopic fastening system as the most reliable.
Orthopedic treatment of defects of the hard and soft palate:
Treatment of acquired defects consists in their elimination by performing bone and soft tissue plasty. Orthopedic treatment of such defects is carried out if there are contraindications to surgical treatment or the patient refuses to undergo surgery.
In the case of congenital defects of the palate, the treatment of patients in all civilized countries is carried out by interdisciplinary working groups according to a pre-planned comprehensive program. Such groups usually include: geneticist, neonatologist, pediatrician, surgeon (maxillofacial surgeon), pediatric surgeon, plastic surgeon, anesthesiologist, orthodontist, speech therapist, orthopedic dentist, psychiatrist.
Rehabilitation of this group of patients consists in eliminating the defect, restoring the functions of chewing, swallowing, recreating the appearance and phonetics.
The orthodontist treats the patient from birth to the post-pubertal period, conducting periodic treatment according to the indications.
Currently, usually in the first week after the birth of a child, according to indications, cheiloplasty or correction of the deformity of the upper jaw using the McNeil method is performed. This method is aimed at eliminating the incorrect location of the unfused processes of the upper jaw in the anteroposterior direction (with a unilateral cleft) or in the transversal direction (with a bilateral cleft). To do this, the newborn is put on a protective plate with extraoral fixation to the head cap. The plate is periodically (once a week) cut along the line of the cleft, and its halves are moved in the desired direction by 1 mm. The components of the plate are connected with quick-hardening plastic. This creates pressure on the palatine process in the right direction and ensures its constant movement. Thus, the correct dental arch is formed. The method is indicated until teething (5-6 months).
Classification of the maxillofacial apparatus
n By function:
1). Fixing
2). Replicating
4). Formative
5). Substitute
n According to the place of attachment:
1). Inside oral
2). Outside mouth
3). Combined
n According to the medicinal value:
1). Main
2). Auxiliary
n By location:
1). single jaw
2). Double jaw
n By design
1). Removable
2). Fixed
3). Standard
4). Individual
Bent wire tires.
At present, the following types of bent wire tires are best known: 1) single-jaw smooth connecting tire-bracket; 2) single-jaw connecting bar with spacer bend; 3) splint with hook loops for intermaxillary fixation;
4) single-jaw tire with an inclined plane; 5) single jaw splint with a support plane. Single-jaw smooth connecting tire-bracket. A single-jaw smooth connecting splint-bracket is used in cases where it is possible to hold the fragments firmly in the correct position with the help of a single-jaw fixation.
To use this splint-bracket, it is necessary to have a sufficient number of stable teeth on each fragment. For the manufacture of a smooth connecting bus-bracket, aluminum wire 2 mm thick and 15-20 cm long is used.
The tire is bent in such a way that it covers the molars standing at the end of the dental arch from the distal and lingual sides with hooks. The hook should be bent so that it follows the shape of the equator of the tooth. If the extreme tooth cannot be covered with a hook (it is affected by caries or has a low crown), then a spike is bent that enters the gaps between the two extreme teeth and is sharpened with a file in the form of a trihedral pyramid. The spike should capture no more than half of the distal side of the penultimate tooth, and the edge should be curved towards the chewing surface. Then the tire is bent along the dental arch in such a way that it is adjacent to each tooth at one point of its vestibular surface. The tire should be located on the gingival part of the tooth crown, i.e. between the equator and the gingival margin, being 1-1.5 mm from the gingival margin. The technique for fitting the splint to the teeth is as follows: bending a hook or spike on one, say the left side, insert the wire into the oral cavity, inserting the spike or hook into its designated place, and mark a point on the wire that is adjacent to the teeth.
The wire is grasped with kampon forceps at the marked point, removed from the oral cavity, and the splint is bent with a finger towards the teeth that are not yet adjacent to it. Then they try on the splint in the oral cavity, again grab it with forceps and bend the splint with your fingers towards the teeth that are not yet adjacent to it.
This is done until the tire is adjacent to the teeth of the left side. It is more difficult to fit the tire to the other, i.e., the right side, since the other end of the wire enters the mouth with difficulty. In these cases proceed as follows. First, the splint is bent so that it enters the mouth and approximates the teeth on the right side. 0
At the same time, the right end of the wire is cut so that the splint is only 2-3 cm longer than the dentition. Then the splint is attached to each tooth of the right side in the described way, and a hook is bent from the excess wire of 2-3 cm. One important rule to remember is that you need to bend the wire with your fingers, and hold it with tongs.
When the tire is fully bent, tie it with a wire ligature. The splint should be tied to as many stable teeth as possible, preferably all teeth. Before tying the splint, clean the mouth of food residues,
blood clots, wipe the teeth and mucous membranes with a cotton swab with a 3% solution of hydrogen peroxide, and then irrigate with a solution of potassium permanganate. They also remove tartar, which prevents the passage of ligatures through the interdental spaces, and proceed to tying the splint to the teeth.
To strengthen the tire, take a piece of wire ligature 140-160 cm long and wipe it with a swab with alcohol, this simultaneously eliminates curls and gives the ligature an even direction. Then it is cut into segments 6-7 cm long for the front teeth and 14-15 cm for the lateral ones.
Each segment is bent in the form of a hairpin, having one end longer than the second, and the hairpin is given a semicircular shape. The tire is tied to the teeth with a ligature of a single nodal oblique ligature. For this purpose, both ends of the hairpin are passed from the side of the oral cavity through the gaps between the intended tooth and two adjacent ones, so that the wire covers the tooth on both sides. One end must pass in the vestibule of the mouth over the wire splint, the other under the splint. Grabbing both ends from the vestibular side with forceps, twist them clockwise, cut off the excess ligature so that the ends are no more than 3-4 mm long, and bend them on the lower jaw up above the splint, and on the upper jaw down - under the splint . For easy passage of the ligature through the interdental space, it is necessary that the position of the hairpin initially has a vertical direction.
When the ends have already entered the interdental spaces, you need to give the hairpin a horizontal position. You should not push the ligature by force, in these cases it bends and does not go in the right direction. Then both ends are pulled from the vestibular side and twisted in a clockwise direction.
Already in Hippocrates and Celsus there are indications of the fixation of fragments of the jaw when it is damaged. Hippocrates used a rather primitive apparatus, consisting of two straps: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus, using a cord of hair, strengthened the fragments of the lower jaw by the teeth standing on both sides of the fracture line. At the end of the 18th century, Ryutenik and in 1806 E. O. Mukhin proposed a “submandibular splint” for fixing fragments of the lower jaw. A hard chin sling with a plaster bandage for the treatment of fractures of the lower jaw was first used by the founder of military field surgery, the great Russian surgeon N. I. Pirogov. He also offered a drinker for feeding the wounded with maxillofacial injuries.
During the Franco-Prussian war (1870-1871), lamellar splints in the form of a base attached to the teeth of the upper and lower jaws, with bite rollers made of rubber and metal (tin), became widespread, in which there was a hole in the anterior region for eating ( Guning-Port apparatus). The latter was used to fix fragments of the edentulous lower jaw. In addition to these devices, a hard chin sling was applied to the patients to support the fragments of the jaw, fixing it on the head. These devices, quite complex in design, could be made individually from the impressions of the upper and lower jaws of the wounded in special dental laboratories and, therefore, were used mainly in the rear medical institutions. Thus, by the end of the 19th century, there was still no military field splinting, and assistance for maxillofacial wounds was provided with a great delay.
In the first half of the 19th century, a method was proposed for fixing fragments of the lower jaw with a bone suture (Rogers). A bone suture for fractures of the lower jaw was also used during the Russo-Japanese War. However, at that time, the bone suture did not justify itself due to the complexity of its use, and most importantly, subsequent complications associated with the lack of antibiotics (development of osteomyelitis of the jaw, repeated displacement of fragments and malocclusion). Currently, the bone suture has been improved and is widely used.
Prominent surgeon Yu. K. Shimanovsky (1857), rejecting a bone suture, combined a plaster cast in the chin area with an intraoral "stick splint" for immobilizing jaw fragments. Further improvement of the chin sling was carried out by Russian surgeons: A. A. Balzamanov proposed a metal sling, and I. G. Karpinsky - a rubber one.
The next stage in the development of methods for fixing jaw fragments are dental splints. They contributed to the development of methods for early immobilization of jaw fragments in front-line military sanitary institutions. Since the 90s of the last century, Russian surgeons and dentists (M. I. Rostovtsev, B. I. Kuzmin, etc.) have used dental splints to fix jaw fragments.
Wire splints were widely used during the First World War and took a firm place, later replacing plate splints in the treatment of gunshot wounds of the jaws. In Russia, aluminum wire tires were put into practice during the First World War by S. S. Tigerstedt (1916). Due to the softness of aluminum, the wire arc can be easily bent into the dental arch in the form of a single and double jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires proved to be rational in a military field situation. They do not require special prosthetic equipment and support staff, therefore they have won universal recognition and are currently used with minor changes.
During the First World War, the medical service in the Russian army was poorly organized, and the care of the wounded in the maxillofacial region suffered especially. So, in the maxillofacial hospital organized by G. I. Vilga in 1915 in Moscow, the wounded arrived late, sometimes 2-6 months after the injury, without proper fixation of jaw fragments. As a result, the duration of treatment was prolonged and persistent deformities occurred with a violation of the function of the masticatory apparatus.
After the Great October Socialist Revolution, all the shortcomings in the organization of the sanitary service were gradually eliminated. Good maxillofacial hospitals and clinics have now been set up in the Soviet Union. A coherent doctrine of the organization of the sanitary service in the Soviet Army at the stages of medical evacuation of the wounded, including to the maxillofacial area, has been developed.
During the Great Patriotic War, Soviet dentists significantly improved the quality of treatment of the wounded in the maxillofacial region. Medical assistance was provided to them at all stages of the evacuation, starting from the military district. Specialized hospitals or maxillofacial departments were deployed in the army and front-line areas. The same specialized hospitals were deployed in the rear areas for the wounded in need of longer treatment. Simultaneously with the improvement of the organization of the sanitary service, the methods of orthopedic treatment of fractures of the jaws were significantly improved. All this played a big role in the outcomes of treatment of maxillofacial wounds. So, according to D. A. Entin and V. D. Kabakov, the number of completely healed wounded with damage to the face and jaw was 85.1%, and with isolated damage to the soft tissues of the face - 95.5%, while in the First World War (1914-1918) 41% of those wounded in the maxillofacial region were dismissed from the army due to disability.
Classification of fractures of the jaws
Some authors base the classification of jaw fractures on the localization of the fracture along the lines corresponding to the places of the weakest bone resistance, and the ratio of the fracture lines to the facial skeleton and skull.
I. G. Lukomsky divides fractures of the upper jaw into three groups depending on the location and severity of clinical treatment:
1) fracture of the alveolar process;
2) suborbital fracture at the level of the nose and maxillary sinuses;
3) orbital fracture, or subbasal, at the level of the nasal bones, the orbit and the main bone of the skull.
By localization, this classification corresponds to those areas where fractures of the upper jaw most often occur. The most severe are fractures of the upper jaw, accompanied by a fracture, separation of the nasal bones and the base of the skull. These fractures are sometimes pumped up by death. It should be pointed out that fractures of the upper jaw occur not only in typical places. Very often one type of fracture is combined with another.
D. A. Entin divides non-gunshot fractures of the lower jaw according to their localization into median, mental (lateral), angular (angular) and cervical (cervical). An isolated fracture of the coronoid process is relatively rare. (fig. 226).
D. A. Entin and B. D. Kabakov recommend a more detailed classification of jaw fractures, consisting of two main groups: gunshot and non-gunshot injuries. In turn, gunshot injuries are divided into four groups:
1) by the nature of the damage (through, blind, tangential, single, multiple, penetrating and not penetrating the mouth and nose, isolated with and without damage to the palatine process and combined);
2) by the nature of the fracture (linear, comminuted, perforated, with displacement, without displacement of fragments, with and without defect of the bone, unilateral, bilateral and combined;
3) by localization (within and outside the dentition);
4) according to the type of injuring weapon (bullet, fragmentation).
Rice. 226 Localization of typical fractures in the lower jaw.
Currently, this classification includes all facial injuries and has the following form.
I . gunshot wounds
Type of damaged tissue
1. Wounds of soft tissues.
2. Wounds with bone damage:
A. Mandible
B. Upper jaw.
B. Both jaws.
G. Zygomatic bone.
D. Damage to several bones of the facial skeleton
II. Non-fire wounds and damage
III. Burns
IV. Frostbite
According to the nature of the damage
1. Through.
2. Blind.
3. Tangents.
A.Insulated:
a) without damage to the organs of the face (tongue, salivary glands and others);
b) with damage to the organs of the face
B. Combined (simultaneous injuries to other areas of the body).
B. Single.
D. Multiple.
D. Penetrating into the mouth and nose
E. Non-penetrating
By the type of weapon that hurts
1. Bullets.
2. Fragmentation.
3.Ray.
Classification of orthopedic devices used for the treatment of jaw fractures
Fixation of fragments of the jaws is carried out using various devices. It is advisable to divide all orthopedic devices into groups in accordance with the function, area of fixation, therapeutic value, design.
Division of devices according to function. Apparatuses are divided into corrective (reponing), fixing, guiding, shaping, replacing and combined.
Regulatory (reponing) devices are called, contributing to the reposition of bone fragments: tightening or stretching them until they are placed in the correct position. These include wire aluminum splints with elastic traction, wire elastic braces, devices with extraoral control levers, devices for spreading the jaw with contractures, etc.
Guides are mainly devices with an inclined plane, a sliding hinge, which provide a certain direction to the bone fragment of the jaw.
Devices (spikes) that hold parts of an organ (for example, the jaw) in a certain position are called fixing devices. These include a smooth wire clamp, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw during bone grafting, etc.
Forming devices are called, which are the support of the plastic material (skin, mucous membrane) or create a bed for the prosthesis in the postoperative period.
Substitutes include devices, replacing the defects of the dentition, formed after the extraction of teeth, filling the defects of the jaws, parts of the face that arose after an injury, operations. They are also called prostheses.
Combined devices include that have several purposes, for example, fixation of fragments of the jaw and the formation of a prosthetic bed or replacement of a defect in the jawbone and at the same time the formation of a skin flap.
Division of devices according to the place of fixation. Some authors divide devices for the treatment of jaw injuries into intraoral, extraoral and intra-extraoral. Intraoral devices include devices attached to the teeth or adjacent to the surface of the oral mucosa, extraoral devices - adjacent to the surface of integumentary tissues outside the oral cavity (chin sling with a headband or extraoral bone and intraosseous spikes for fixing fragments of the jaw), to intra-extraoral - devices, one part of which is fixed inside, and the other outside the oral cavity.
In turn, intraoral splints are divided into single-jawed and double-jawed. The former, regardless of their function, are located only within one jaw and do not interfere with the movements of the lower jaw. Two-jaw devices are applied simultaneously to the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.
Division of devices for medical purposes. According to the therapeutic purpose, orthopedic devices are divided into basic and auxiliary.
The main ones are fixing and correcting splints, used for injuries and deformities of the jaws and having independent therapeutic value. These include replacement devices that compensate for defects in the dentition, jaw and parts of the face, since most of them help restore the function of the organ (chewing, speech, etc.).
Auxiliary devices are those that serve to successfully perform skin-plastic or osteoplastic operations. In these cases, the main type of medical care will be surgery, and the auxiliary one will be orthopedic (fixing devices for bone grafting, shaping devices for facial plastic surgery, protective palatal plastic surgery for palate plastic surgery, etc.).
Division of devices by design.
By design, orthopedic devices and splints are divided into standard and individual.
The first include the chin sling, which is used as a temporary measure to facilitate the transportation of the patient. Individual tires can be of simple or complex design. The first (wire) ones are bent directly at the patient and fixed on the teeth.
The second, more complex ones (plate, cap, etc.) can be made in a dental laboratory.
In some cases, from the very beginning of treatment, permanent devices are used - removable and non-removable splints (prostheses), which at first serve to fix the jaw fragments and remain in the mouth as a prosthesis after the fragments have fused.
Orthopedic devices consist of two parts - supporting and acting.
The supporting part is crowns, mouthguards, rings, wire arches, removable plates, head caps, etc.
The active part of the device is rubber rings, ligatures, an elastic bracket, etc. The active part of the device can be continuously operating (rubber rod) and intermittent, acting after activation (screw, inclined plane). Traction and fixation of bone fragments can also be carried out by applying traction directly to the jawbone (the so-called skeletal traction), with a head plaster bandage with a metal rod serving as the supporting part. The traction of the bone fragment is performed using an elastic traction attached at one end to the jaw fragment by means of a wire ligature, and at the other end to the metal rod of the head plaster bandage.
FIRST SPECIALIZED AID FOR JAW FRACTURES (IMMOBILIZATION OF FRAGMENTS)
In wartime, in the treatment of wounded in the maxillofacial region, transport tires, and sometimes ligature bandages, are widely used. Of the transport tires, the most convenient is a hard chin sling. It consists of a headband with side rollers, a plastic chin sling and rubber bands (2-3 on each side).
Rigid chin sling is used for fractures of the lower and upper jaws. In case of fractures of the body of the upper jaw and intact lower jaw, and in the presence of teeth on both jaws, the use of a chin sling is indicated. The sling is attached to the headband with rubber bands with significant traction, which is transmitted to the upper dentition and contributes to the reduction of the fragment.
In case of multi-comminuted fractures of the lower jaw, rubber bands connecting the chin sling with the head bandage should not be tightly applied, in order to avoid significant displacement of the fragments.
3. N. Pomerantseva-Urbanskaya, instead of the standard hard chin sling, proposed a sling that looked like a wide strip of dense material, into which pieces of rubber were sewn on both sides. The use of a soft sling is easier than a hard one, and in some cases more comfortable for the patient.
Ya. M. Zbarzh recommended a standard splint for fixing fragments of the upper jaw. Its splint consists of an intraoral part in the VNDS of a double stainless steel wire arc, covering the dentition of the upper jaw on both sides, and outwardly extending extraoral levers directed posteriorly to the auricles. The extraoral levers of the tire are connected to the head bandage using connecting metal rods (Fig. 227). The diameter of the wire of the inner arc is 1-2 mm, the diameter of the extraoral rods is 3.2 mm. Dimensions
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Rice. 227. Standard tires Zbarzha for immobilization of fragments of the upper jaw.
a - bus-arc; b - headband; c - connecting rods; e - connecting clamps.
wire arch are regulated by extension and shortening of its palatal part. The tire is used only in cases where manual reduction of fragments of the upper jaw is possible. M. 3. Mirgazizov proposed a similar device for a standard splint for fixing fragments of the upper jaw, but only using a plastic palatal plane. The latter is corrected with a quick-hardening plastic.
Ligature bonding of teeth
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Rice. 228. Intermaxillary bonding of teeth.
1 - according to Ivy; 2 - according to Geikin; .3—but Wilga.
One of the simplest ways of immobilization of jaw fragments, which does not require much time, is ligature binding of teeth. A bronze-aluminum wire 0.5 mm thick is used as a ligature. There are several ways to apply wire ligatures (according to Ivy, Wilga, Geikin, Limberg, etc.) (Fig. 228). Ligature binding is only a temporary immobilization of fragments of the jaw (for 2-5 days) and is combined with the imposition of a chin sling.
Wire busbar overlay
More rational immobilization of fragments of the jaw with splints. Distinguish between simple special treatment and complex. The first is the use of wire tires. They are imposed, as a rule, in the army area, since the manufacture does not require a dental laboratory. Complex orthopedic treatment is possible in those institutions where there is an equipped prosthetic laboratory.
Before splinting, conduction anesthesia is performed, and then the oral cavity is treated with disinfectant solutions (hydrogen peroxide, potassium permanganate, furatsilin, chloramine, etc.). The wire splint should be curved along the vestibular side of the dentition so that it is adjacent to each tooth at least at one point, without imposing on the gingival mucosa.
Wire tires have a variety of shapes (Fig. 229). Distinguish between a smooth wire splint-bracket and a wire splint with a spacer corresponding to the size of the defect in the dentition. For intermaxillary traction, wire arches with hook loops on both jaws are used for A.I. Stepanov and P.I. desired section of the tire.
The method of applying ligatures
To fix the tire, wire ligatures are used - pieces of bronze-aluminum wire 7 cm long and 0.4-0.6 mm thick. The most common is the following method of conducting ligatures through the interdental spaces. The ligature is bent in the form of a hairpin with ends of various lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and removed from the vestibule (one under the splint, the other over the splint). Here the ends of the ligatures are twisted, the excess spiral is cut off and bent between the teeth so that they do not damage the gum mucosa. In order to save time, you can first hold the ligature between the teeth, bending one end down and the other up, then lay the tire between them and secure it with ligatures.
Indications for the use of bent wire bars
A smooth arc made of aluminum wire is indicated for fractures of the alveolar process of the upper and lower jaws, median fractures of the lower jaw, as well as fractures of other localization, but within the dentition without vertical displacement of fragments. In the absence of a part of the teeth, a smooth splint with a retention loop is used - an arc with a spacer.
The vertical displacement of fragments is eliminated with wire splints with hook loops and intermaxillary traction using rubber rings. If the jaw fragments are simultaneously reduced, then the wire slime is immediately attached to the teeth of both fragments. With stiff and displaced fragments and the impossibility of their simultaneous reduction, the wire splint is first attached with ligatures to only one fragment (long), and the second end of the splint is attached with ligatures to the teeth of another fragment only after the normal closure of the dentition is restored. Between the teeth of a short fragment and their antagonists, a rubber gasket is placed to speed up the bite correction.
In case of a fracture of the lower jaw behind the dentition, the method of choice is the use of a wire spike with intermaxillary traction. If the fragment of the lower jaw is displaced in two planes (vertical and horizontal), an intermaxillary traction is shown. In case of a fracture of the lower jaw in the area of the angle with a horizontal displacement of a long fragment towards the fracture, it is advisable to use a splint with a sliding hinge (Fig. 229, e). It differs in that it fixes the fragments of the jaw, eliminates their horizontal displacement and allows free movement in the temporomandibular joints.
With a bilateral fracture of the lower jaw, the middle fragment, as a rule, is displaced downwards, and sometimes also backwards under the influence of muscle traction. In this case, often the lateral fragments are displaced towards each other. In such cases, it is convenient to immobilize the jaw fragments in two stages. At the first stage, the lateral fragments are bred and fixed with a wire arc with the correct closure of the dentition, at the second, the middle fragment is pulled up with the help of intermaxillary traction. Having set the middle fragment in the position of the correct bite, it is attached to a common tire.
In case of a fracture of the lower jaw with one toothless fragment, the latter is fixed with a bent spike made of aluminum wire with a loop and lining. The free end of the aluminum tire is fixed on the teeth of another fragment of the jaw with wire ligatures.
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Rice. 229. Wire bus according to Tigerstedt.
a - smooth tire-arc; b - a smooth tire with a spacer; in - bus with. hooks; g - a spike with hooks and an inclined plane; e - splint with hooks and intermaxillary traction; e - rubber rings.
In case of fractures of the edentulous lower jaw, if the patient has dentures, they can be used as splints for temporary immobilization of jaw fragments with simultaneous application of a chin sling. To ensure the intake of food in the lower prosthesis, all 4 incisors are cut out and the patient is fed from a drinker through the hole formed.
Treatment of fractures of the alveolar process
Rice. 231. Treatment of fractures of the alveolar process.
a - with an inward displacement; b - with posterior displacement; c - with vertical displacement.
In case of fractures of the alveolar process of the upper or lower jaw, the fragment, as a rule, is fixed with a wire splint, most often smooth and single-jawed. In the treatment of a non-gunshot fracture of the alveolar process, the fragment is usually set at the same time under novocaine anesthesia. The fragment is fixed with a smooth aluminum wire arc 1.5–2 mm thick.
In case of a fracture of the anterior alveolar process with a displacement of the fragment back, the wire arc is attached with ligatures to the lateral teeth on both sides, after which the fragment is pulled anteriorly with rubber rings (Fig. 231, b).
In case of a fracture of the lateral part of the alveolar process with its displacement to the lingual side, a springy steel wire 1.2-1.5 mm thick is used (Fig. 231, a). The arc is first attached with ligatures to the teeth of the healthy side, then the fragment is pulled with ligatures to the free end of the arc. When the fragment is vertically displaced, an aluminum wire arc with hook loops and rubber rings is used (Fig. 231, c).
In case of gunshot injuries of the alveolar process with crushing of the teeth, the latter are removed and the defect in the dentition is replaced with a prosthesis.
In case of fractures of the palatine process with damage to the mucous membrane, a fragment and a flap of the mucous membrane are fixed with an aluminum clip with support loops directed back to the site of damage. The mucosal flap can also be fixed with a celluloid or plastic palatal plate.
Orthopedic treatment of fractures of the upper jaw
Fixation splints, attached to the headband with elastic traction, often cause displacement of fragments of the upper jaw in and deformities of the bite, which is especially important to remember in case of comminuted fractures of the upper jaw with bone defects. For these reasons, wire fixing splints without rubber traction have been proposed.
Ya. M. Zbarzh recommends two options for bending splints made of aluminum wire for fixing fragments of the upper jaw. In the first option, a piece of aluminum wire 60 cm long is taken, its ends15 cm long, each is bent towards each other, then these ends are twisted in the form of spirals (Fig. 232). In order for the spirals to be uniform, the following conditions must be met:
1) during twisting, the angle formed by the long axes of the wire must be constant and not more than 45°;
2) one process must have the direction of the turns clockwise, the other, on the contrary, counterclockwise. The formation of twisted processes is considered complete when the middle part of the wire between the last turns is equal to the distance between the premolars. This part is further the front part of the tooth splint.
In the second option, they take a piece of aluminum wire of the same length as in the previous case, and bend it so that the intraoral part of the splint and the remains of the extraoral part are immediately determined (Fig. 232, b), after which they begin to twist the extraoral rods, which, as in the first variant, they are bent over the cheeks towards the auricles and are attached to the headband by means of connecting, vertically extending rods. The lower ends of the connecting rods are bent upwards in the form of a hook and connected with a ligature wire to the process of the tire, and the upper ends of the connecting rods are reinforced with plaster on the head bandage, which gives the lm greater stability.
Displacement of a fragment of the upper jaw posteriorly can cause asphyxia due to the closure of the lumen of the pharynx. In order to prevent this complication, it is necessary to pull the fragment anteriorly. Traction and fixation of the fragment is performed by an extraoral method. To do this, a head bandage is made and in its anterior part a plate of tin with a soldered lever made of steel wire 3-4 mm thick is plastered or 3-4 twisted
Fig, 232. The sequence of manufacturing wire tires from aluminum wire (according to Zbarzh).
a - the first option; b - the second option; e - fastening of solid-bent aluminum wiretires using connecting rods.
aluminum wires, which are hooked with a toe loop against the oral fissure. A brace made of aluminum wire with hook loops is applied to the teeth of the upper jaw or a supragingival lamellar spike with hook loops in the area of the incisors is used. By means of an elastic traction (rubber ring), a fragment of the upper jaw is pulled up to the arm of the headband.
In case of lateral displacement of a fragment of the upper jaw, a metal rod is plastered on the opposite side of the displacement of the fragment to the lateral surface of the head plaster cast. Traction is carried out by elastic traction, as in the case of displacements of the upper jaw posteriorly. Fragment traction is performed under bite control. With vertical displacement, the apparatus is supplemented with traction in the vertical plane by means of horizontal extraoral levers, a supragingival plate splint and rubber bands (Fig. 233). The plate splint is made individually according to the impression of the upper jaw. From impression materials
Rice. 233. Lamellar gingival splint for fixing fragments of the upper jaw. a - view of the finished tire; b - the splint is fixed on the jaw and to the headband.
it is better to use alginate. According to the obtained plaster model, they start modeling the lamellar tire. It should cover the teeth and the mucous membrane of the gums both from the palatine side and from the vestibule of the oral cavity. The chewing and cutting surfaces of the teeth remain bare. Tetrahedral sleeves are welded to the side surface of the apparatus on both sides, which serve as bushings for extraoral levers. The levers can be made in advance. They have tetrahedral ends corresponding to the sleeves into which they are inserted in the anteroposterior direction. In the canine region, the levers form a bend around the corners of the mouth and, going outward, go towards the auricle. A loop-shaped curved wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. The levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband by means of rubber rings.
A similar splint can also be used to treat combined fractures of the upper and lower jaws. In such cases, hook loops are welded to the plate spike of the upper jaw, bent at a right angle upwards. Fixation of fragments of the jaws is carried out in two stages. At the first stage, fragments of the upper jaw are fixed to the head with the help of a splint with extraoral levers connected to the plaster cast with rubber bands (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled up to the splint of the upper jaw by means of an aluminum wire splint with hook loops fixed on the lower jaw.
Orthopedic treatment of mandibular fractures
Orthopedic treatment of fractures of the lower jaw, median or close to the midline, in the presence of teeth on both fragments, is carried out using a smooth aluminum wire arc. As a rule, wire ligatures going around the teeth should be fixed on the splint with closed jaws under bite control. Prolonged treatment of mandibular fractures with wire splints with intermaxillary traction can lead to the formation of scar bands and the occurrence of extra-articular contractures of the jaws due to prolonged inactivity of the temporomandibular joints. In this regard, there was a need for a functional treatment of injuries of the maxillofacial region, providing physiological rather than mechanical rest. This problem can be solved by returning to the undeservedly forgotten single jaw splint, to fixing jaw fragments with devices that preserve movement in the temporomandibular joints. Single-jaw fixation of fragments ensures early use of maxillofacial gymnastics as a therapeutic factor. This complex formed the basis for the treatment of gunshot injuries of the lower jaw and was called the functional method. Of course, the treatment of some patients without more or less significant damage to the mucous membrane of the oral cavity and the oral region, patients with linear fractures, with closed fractures of the lower jaw branch can be completed by intermaxillary fixation of bone fragments without any harmful consequences.
In case of fractures of the lower jaw in the area of the angle, at the place of attachment of the masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. With multi-comminuted fractures, damage to the mucous membrane, oral cavity and facial integument, fractures accompanied by a bone defect, etc., the wounded need single-maxillary fixation of fragments, which allow them to maintain movement in the temporomandibular joints.
A. Ya. Katz proposed a regulating apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin area. The apparatus consists of rings reinforced with cement on the teeth of a jaw fragment, oval-shaped sleeves soldered to the buccal surface of the rings, and levers originating in the sleeves and protruding from the oral cavity. By means of the protruding parts of the lever, it is possible to quite successfully adjust the fragments of the jaw in any plane and set them in the correct position (see Fig. 234).
Rice. 234. Replicating apparatus forreduction of fragments of the lower jaw.
l - Katz; 6 - Pomerantseva-Urbanskaya; a - Shelhorn; Mr. Porno and Psom; e - kappa-rod apparatus.
Of the other single-jaw devices for the treatment of fractures of the lower jaw, it should be noted the spring-loaded bracket made of stainless steel "Pomerantseva-Urbaiska. This author recommends the method of applying ligatures according to Schelgorn (Fig. 234) to regulate the movement of fragments of the jaw in the vertical direction. With a significant defect in the body of the lower jaw and a small number of teeth on fragments of the jaw, A. L. Grozovsky suggests using a kappa-rod repositioning apparatus (Fig. 234, e). The preserved teeth are covered with crowns, to which rods in the form of semi-arches are soldered. At the free ends of the rods there are holes where screws and nuts are inserted, which regulate and fix the position of the jaw fragments.
We proposed a spring-loaded apparatus, which is a modification of the Katz apparatus for repositioning mandibular fragments in case of a defect in the chin area. This is an apparatus of combined and sequential action: at first repositioning, then fixing, shaping and replacing. The op consists of metal trays with double tubes soldered to the buccal surface, and springy levers made of stainless steel 1.5–2 mm thick. One end of the lever ends with two rods and is inserted into the tubes, the other protrudes from the oral cavity and serves to regulate the movement of jaw fragments. Having set the jaw fragments in the correct position, they replace the extraoral levers fixed in the kappa tubes with a vestibular clip or a forming apparatus (Fig. 235).
The kappa apparatus undoubtedly has some advantages over wire splints. Its advantages lie in the fact that, being single-jawed, it does not restrict movements in the temporomandibular joints. With the help of this device, it is possible to achieve stable immobilization of jaw fragments and, at the same time, stabilization of the teeth of the damaged jaw (the latter is especially important with a small number of teeth and their mobility). Kappa apparatus without wire ligatures is used; the gum is not damaged. Its disadvantages include the need for constant monitoring, since cement resorption in kappas and displacement of jaw fragments are possible. To monitor the state of cement on the chewing surface kappas make holes (“windows”). For this reason, these patients should not be transported, since the decementation of the mouthguards along the way will lead to a violation of the immobilization of jaw fragments. Kappa devices have found wider use in pediatric practice for fractures of the jaws.
Rice. 235. Repositioning apparatus (according to Oksman).
a - replicating; 6 - fixing; c - forming and replacing.
M. M. Vankevich proposed a plate splint covering the palatine and vestibular surface of the mucous membrane of the upper jaw. From the palatal surface of the tire depart downward, to the lingual surface of the lower molars, two inclined planes. When the jaws close, these planes push apart the fragments of the lower jaw, displaced in the lingual direction, and fix them in the correct position (Fig. 236). Tire Vankevich modified by A. I. Stepanov. Instead of a palatal plate, he introduced an arc, thus freeing part of the hard palate.
Rice. 236. Plastic splint for fixing fragments of the lower jaw.
a - according to Vankevich; b - according to Stepanov.
In case of a fracture of the lower jaw in the region of the angle, as well as in other fractures with displacement of fragments to the lingual side, tires with an inclined plane are often used, and among them a plate supragingival splint with an inclined plane (Fig. 237, a, b). However, it should be noted that a supragingival splint with an inclined plane can be useful only with a slight horizontal displacement of the jaw fragment, when the plane deviates from the buccal surface of the teeth of the upper jaw by 10-15°. With a large deviation of the plane of the tire from the teeth of the upper jaw, the inclined plane, and with it the fragment of the lower jaw (will be pushed downward. Thus, the horizontal displacement will be complicated by the vertical one. In order to eliminate the possibility of this position, 3. Ya. Shur recommends providing an orthopedic apparatus springy inclined plane.
Rice. 237. Dental splint for the lower jaw.
a - general view; b - tire with an inclined plane; c - orthopedic devices with sliding hinges (according to Schroeder); g - steel wire tire with a sliding hinge (according to Pomerantseva-Urbanskaya).
All of the described fixing and regulating devices retain the mobility of the lower jaw in the temporomandibular joints.
Treatment of mandibular body fractures with edentulous fragments
Fixation of fragments of the edentulous lower jaw is possible by surgical methods: bone suture, intraosseous pins, extraoral bone splints.
In case of a fracture of the lower jaw behind the dentition in the area of the angle or branch with a vertical displacement of a long fragment or a shift forward and towards the fracture, intermaxillary fixation with oblique traction should be used in the first period. In the future, to eliminate the horizontal displacement (shift towards the fracture), satisfactory results are achieved by using the Pomerantseva-Urbanskaya articulated splint.
Some authors (Schroeder, Brun, Gofrat, etc.) recommend standard tires with a sliding hinge, fixed on the teeth with the help of caps (Fig. 237, c). 3. N. Pomerantseva-Urbanskaya proposed a simplified design of a sliding hinge made of stainless wire 1.5-2 mm thick (Fig. 237, d).
The use of splints with a sliding hinge for fractures of the lower jaw in the area of the angle and branch prevents the displacement of fragments, the occurrence of deformations of facial asymmetry and is also the prevention of jaw contractures, because this splinting method preserves the vertical movements of the jaw and is easily combined with therapeutic exercises. A short fragment of a branch in case of a fracture of the lower jaw in the angle area is strengthened by skeletal traction with the help of elastic traction to a head plaster cast with a rod behind the ear, as well as a wire ligature around the angle of the jaw.
In case of a fracture of the lower jaw with one edentulous fragment, the extension of the long fragment and the fixation of the short one are carried out using a wire clamp with hook loops, fastened to the teeth of the long fragment with a flight to the alveolar process of the edentulous fragment (Fig. 238). Intermaxillary fixation eliminates the displacement of the long fragment, and the pelot keeps the edentulous fragment from displacement upward and to the side. There is no downward displacement of the short fragment, since it is held by the muscles that lift the lower jaw. The tire can be made of elastic wire, and the pilot can be made of plastic.
Rice. 238. Skeletal traction of the lower jaw in the absence of teeth.
In case of fractures of the body of the edentulous lower jaw, the simplest method of temporary fixation is the use of the patient's prostheses and fixation of the lower jaw with a rigid chin sling. In their absence, temporary immobilization can be carried out with a block of bite rollers made of thermoplastic mass with bases made of the same material. Further treatment is carried out by surgical methods.
plastic tires
In case of fractures of the jaws, combined with radiation injuries, the use of metal splints is contraindicated, since metals, as some believe, can become a source of secondary radiation, causing necrosis of the gingival mucosa. It is more expedient to make tires from plastic. M. R. Marey recommends that instead of a ligature wire, nylon threads be used to fix the splint, and a splint for fractures of the lower jaw is made of quick-hardening plastic along a pre-made aluminum groove of an arcuate shape, which is filled with freshly prepared plastic, applying it to the vestibular surface of the dental arch. After the plastic has hardened, the aluminum chute can be easily removed, and the plastic is firmly connected to the nylon threads and fixes the jaw fragments.
The method of overlaying plastic G. A. Vasiliev and co-workers. A nylon thread with a plastic bead is applied to each tooth on the vestibular surface of the tooth. This creates a more secure fixation of the ligatures in the tire. Then a splint is applied according to the method described by M, R. Marey. If necessary, intermaxillary fixation of fragments of the jaw in the appropriate areas, holes are drilled with a spherical burr and pre-prepared plastic spikes are inserted into them, which are fixed with freshly prepared quick-hardening plastic (Fig. 239). The spikes serve as a place for applying rubber rings for intermaxillary traction and fixation of jaw fragments.
Rice. 239. The sequence of manufacturing jaw splints from fast-hardening plastic.
a - fixation of beads; b - bending of the groove; in - groove; g - a smooth splint is applied to the jaw; d - tire with hook loops; e—fixation of the jaw.
F. L. Gardashnikov proposed a universal elastic plastic tooth splint (Fig. 240) with mushroom-shaped rods for intermaxillary traction. The tire is strengthened with a bronze-aluminum ligature.
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Rice. 240. Standard tire made of elastic plastic (according to Gardashnikov)
a - side view; b - front view; c - mushroom-shaped process.
Orthopedic treatment of jaw fractures in children
Tooth trauma. Bruises of the facial area may be accompanied by trauma to one tooth or group of teeth. Tooth trauma is found in 1.8-2.5% of the examined schoolchildren. More often there is an injury to the incisors of the upper jaw.
When the enamel of a milk or permanent tooth is broken off, the sharp edges are ground with a carborundum head to avoid injury to the mucous membrane of the lips, cheeks, and tongue. In case of violation of the integrity of the dentin, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed on artificial dentin without its preparation. During this timethe formation of replacement dentin is expected. In the future, the crown is replaced with a filling or inlay to match the color of the tooth. In case of a fracture of the tooth crown with damage to the pulp, the latter is removed. After filling the root canal, the treatment is completed by applying an inlay with a pin or a plastic crown. When the crown of a tooth is broken off at its neck, the crown is removed, and the root is tried to be preserved in order to use it to strengthen the pin tooth.
When a tooth is fractured in the middle part of the root, when there is no significant displacement of the tooth along the vertical axis, they try to save it. To do this, put a wire splint on a group of teeth with a ligature bandage on the damaged tooth. In young children (up to 5 years old), it is better to fix broken teeth with a mouthguard made ofplastics. The experience of domestic dentists has shown that a tooth root fracture sometimes grows together in l "/g-2 months after splinting. The tooth becomes stable, and its functional value is completely restored. If the color of the tooth changes, electrical excitability sharply decreases, pain occurs during percussion or palpation in near the apical region, then the crown of the tooth is trepanned and the pulp is removed.
With bruises with root wedging into a broken alveolus, it is better to adhere to expectant tactics, bearing in mind that in some cases the tooth root is somewhat pushed out due to the developed traumatic inflammation. In the absence of inflammation after healing of the injury, the holes resort to orthopedic treatment.
If a permanent tooth has to be removed from a child during an injury, then the resulting defect in the dentition will be mixed with a fixed prosthesis with unilateral fixation or a sliding removable prosthesis with bilateral fixation in order to avoid bite deformation. Crowns, pin teeth can serve as supports. A defect in the dentition can also be replaced with a removable prosthesis.
With the loss of 2 or 3 front teeth, the defect is replaced using a hinged and removable denture according to Ilyina-Markosyan or a removable denture. When individual front teeth fall out due to a bruise, but with the integrity of their sockets, they can be replanted, provided that assistance is provided soon after the injury. After replantation, the tooth is fixed for 4-6 weeks with a plastic kappa. It is not recommended to replant milk teeth, as they may interfere with the normal eruption of permanent teeth or cause the development of a follicular cyst.
Treatment of dislocation of teeth and fracture of the holes .
In children under the age of 27, with bruises, dislocation of the teeth or fracture of the holes and the region of the incisors and displacement of the teeth to the labial or lingual side are observed. At this age, fixing the teeth with a wire arch and wire ligatures is contraindicated due to the instability of milk teeth and the small size of their crowns. In these cases, the method of choice should be to manually set the teeth (if possible) and secure them with a celluloid or plastic tray. The psychology of a child at this age has its own characteristics: he is afraid of the doctor's manipulations. The unusual environment of the office affects the child negatively. Preparation of the child and some caution in the behavior of the doctor are necessary. At first, the doctor teaches the child to look at the instruments (a spatula and a mirror and at the orthopedic apparatus) as if they were toys, and then he carefully proceeds to orthopedic treatment. Techniques for applying a wire arch and wire ligatures are rough and painful, so preference should be given to mouthguards, the imposition of which the child tolerates much more easily.
How to make a kappa Pomerantseva-Urbanskaya .
After a preparatory conversation between the doctor and the child, the teeth are smeared with a thin layer of petroleum jelly and an impression is carefully taken from the damaged jaw. On the resulting plaster model, the displaced teeth are broken at the base, set in the correct position and glued with cement. On the model prepared in this way, a mouthguard is formed from wax, which should cover the displaced and adjacent stable teeth on both sides. The wax is then replaced with plastic. When the mouthguard is ready, the teeth are manually set under appropriate anesthesia and the mouthguard is fixed on them. In extreme cases, you can carefully not completely apply a mouth guard and invite the child to gradually close the jaws, which will help set the teeth in their sockets. A kappa for fixing dislocated teeth is strengthened with artificial dentin and left in the mouth for 2-4 weeks, depending on the nature of the damage.
Fractures of the jaws in children. Jaw fractures in children occur as a result of trauma due to the fact that children are mobile and careless. Fractures of the alveolar process or dislocation of teeth are more often observed, less often fractures of the jaws. When choosing a treatment method, it is necessary to take into account some age-related anatomical and physiological features of the dental system associated with the growth and development of the child's body. In addition, it is necessary to take into account the psychology of the child in order to develop the correct methods of approaching him.
Orthopedic treatment of mandibular fractures in children.
In the treatment of fractures of the alveolar process or the body of the lower jaw, the nature of the displacement of bone fragments and the direction of the fracture line in relation to the dental follicles are of great importance. Fracture healing proceeds faster if its line runs at some distance from the dental follicle. If the latter is on the fracture line, it may become infected and complication of a jaw fracture with osteomyelitis. In the future, the formation of a follicular cyst is also possible. Similar complications can develop when the fragment is displaced and its sharp edges are introduced into the tissues of the follicle. In order to determine the ratio of the fracture line to the dental follicle, it is necessary to produce x-rays in two directions - in profile and face. In order to avoid layering of milk teeth on permanent images, it should be taken with a half-open mouth. In case of a fracture of the lower jaw at the age of up to 3 years, a plastic palatine plate with imprints of the chewing surfaces of the dentition of the upper and lower jaws (tire-kappa) in combination with a chin sling can be used.
Technique for the manufacture of a plate splint-kappa.
After some psychological preparation of a small patient, an impression is taken from the jaws (first from the top, then from the bottom). The resulting model of the lower jaw is sawn into two parts at the fracture site, then they are made up with the plaster model of the upper jaw in the correct ratio, glued with wax and plastered into the occluder. After that, a well-heated semi-circular wax roller is taken and placed between the teeth of plaster models in order to obtain an imprint of the dentition. The latter should be at a distance of 6-8 mm from each other. The wax roller with the plate is checked in the mouth and, if necessary, it is corrected. Then the plate is made of plastic according to the usual rules. This apparatus is used together with a chin sling. The child uses it for 4-6 weeks until the fusion of the jaw fragments occurs. When feeding a child, the device can be temporarily removed, then immediately put it back on. Food should only be given in liquid form.
In children with chronic osteomyelitis, pathological fractures of the lower jaw are observed. To prevent them, as well as the displacement of fragments of the jaw, especially after sequestrotomy, splinting is shown. From a wide variety of tires, preference should be given to the Vankevich tire in Stepanov's modification (see Fig. 293, a) as more hygienic and easily portable.
Impressions from both jaws are taken before sequestrotomy. Plaster models are plastered into the occluder in the position of central occlusion. The palatine plate of the tire is modeled with an inclined plane downward (one or two depending on the topography of a possible fracture), to the lingual surface of the chewing teeth of the lower jaw. It is recommended to fix the device with arrow-shaped clasps.
With fractures of the jaw at the age of 21/2 to 6 years, the roots of milk teeth are already formed to one degree or another and the teeth are more stable. The child at this time is easier to persuade. Orthopedic treatment can often be carried out using stainless steel wire splints 1-1.3 mm thick. Tires are strengthened with ligatures to each tooth along the entire length of the dentition. For low crowns or tooth decay by caries, plastic mouthguards are used, as already described above.
When applying wire ligatures, it is necessary to take into account some anatomical features of the teeth of the milk bite. Milk teeth, as you know, are low, have convex crowns, especially in chewing teeth. Their large circle is located closer to the neck of the tooth. As a result, wire ligatures applied in the usual way slip off. In such cases, special techniques for applying ligatures are recommended: a ligature covers the tooth around the neck and twists it, forming 1-2 turns. Then the ends of the ligature are pulled over and under the wire arc and twisted in the usual way.
In case of jaw fractures at the age of 6 to 12 years, it is necessary to take into account the peculiarities of the dentition of this period (resorption of the roots of milk teeth, eruption of crowns of permanent teeth with immature roots). Medical tactics in this case depends on the degree of resorption of milk teeth. With complete resorption of their roots, the dislocated teeth are removed, with incomplete resorption, they are splinted, keeping them until the eruption of permanent teeth. When the roots of milk teeth are broken, the latter are removed, and the defect in the dentition is replaced with a temporary removable prosthesis to avoid bite deformation. For immobilization of fragments of the lower jaw, it is advisable to use a soldered splint, and as supporting teeth it is better to use the 6th teeth as more stable and milk canines, on which crowns or rings are applied and connected with a wire arc. In some cases, the manufacture of a mouthguard for a group of chewing teeth with hook loops for intermaxillary fixation of jaw fragments is shown. At the age of 13 years and older, splinting is usually not difficult, since the permanent teeth are already well-formed.
The presence of gaps between the teeth to some extent violates the appearance of the patient and speech. Three reasons are the discrepancy between the size of the teeth and the size of the jaw, the absence of teeth, the incorrect position of individual teeth (protrusion, rotations). If there are gaps between the teeth with the correct ratio of the dentition, treatment is usually not performed or resorted to prosthetics; if tremas are observed with upper and lower prognathism, open bite, treatment of the underlying anomaly causes their elimination.
A diastema is a gap (from 1 to 6 mm or more) between the central incisors, which is observed more often in the upper and less often in the lower jaw. It violates the appearance, and sometimes the speech of the patient. Often the diastema is accompanied by a strongly developed frenulum of the upper lip, which attaches to the crest of the alveolar part, where it joins the incisive papilla. The roots of the upper central incisors are covered with bone of sufficient thickness or are clearly outlined (as if separated from each other), forming a groove between themselves, into which the frenulum of the upper lip is woven. On the radiograph in the region of the central incisors, a wide dense palatal suture is usually observed. Sometimes in the anterior section the palatine suture is split and fibers of the connective tissue of the frenulum of the upper lip penetrate there. This diastema is most often observed in the intact dentition. Some authors argue that such a diastema is inherited.
The treatment of diastema and fixing its results is associated with significant difficulties, since the space between the central incisors is filled not only with bone, but also with the connective tissue of a highly developed frenulum of the upper lip. When the teeth are moved, the connective tissue is compressed, but not rebuilt, and after removing the equipment, the teeth return to their original place. The convergence of the teeth also leads to compression of the gingival mucosa, which straightens after treatment and causes a recurrence of the anomaly.
In order to ensure the success of the treatment, it is necessary to first move the frenulum of the upper lip, excise the connective tissue of the palatine suture, disrupt the density of the bone tissue between the incisors (perform corticotomy). After the convergence of the teeth, it is sometimes useful to also excise the excess mucous membrane and the enlarged incisive papilla. Some authors indicate that with the gradual approach of the teeth, atrophy of the frenulum and fibrous cord occurs; therefore, they do not recommend surgery.
A diastema is also a gap between the central incisors, formed as a result of partial adentia (most often the lateral incisors), anomalies in the shape and size of the teeth, retention of the teeth and their location between the roots of the central incisors.
When treating a diastema, attention should be paid to the location of the central incisors in relation to the midline (they can be located asymmetrically), the degree of formation of their roots, the position, shape of the roots and their slope, the width of the diastema. This allows you to select the appropriate hardware.
To eliminate the diastema, removable (plates with springs, vestibular arches, levers) or fixed (Angle apparatus, crowns with levers, hooks, springs, rubber traction) orthodontic appliances are used (Fig. 186). The gaps formed after the convergence of the central incisors are filled with removable or non-removable prostheses. After surgery and moving the central and lateral incisors to the midline, the latter are often covered with jacket crowns. This makes it possible to avoid relapse, improve the appearance and speech of the patient. In the lower jaw, the diastema is most often closed with a fixed prosthesis.
Due to the wide variety of anomalies of individual teeth and their combinations, the recommended orthodontic appliances should be selected and, if necessary, modified according to the clinical picture and age of the patient. When eliminating anomalies of individual teeth, orthodontic measures are often combined with surgical and prosthetic measures. In older patients who do not want to undergo long-term treatment, if the existing irregularities injure the psyche or impair speech, anomalies of individual teeth are eliminated by prosthetics.
It is advisable to identify and eliminate anomalies of individual teeth in childhood in order to contribute to their more correct eruption and thus the formation of dental arches.
The various varieties and forms of dentoalveolar anomalies described here are not always found in their pure form. More often in the clinic one has to deal with combined or combined anomalies
Yami. So, in one patient, an open bite can be detected, combined with a narrowing of the dental arches, an anomaly in the position of individual teeth, enamel hypoplasia, in another, hyperplasia of the lower jaw is observed with a simultaneous dorsal position of the upper jaw. At the same time, the underdevelopment of the anterior part of the upper jaw, the close position (crowding) of the anterior upper teeth, the presence of a diastema and three lower dentition are diagnosed. Mixed forms of anomalies are characterized by a complex clinical picture. They complicate diagnosis and complicate treatment.
^ MAXILLOFACIAL ORTHOPEDICS
It is one of the sections of orthopedic dentistry and includes:
1) orthopedic treatment of jaw fractures and their consequences; 2) prosthetics for congenital and acquired defects of the face and skull; 3) elimination of deformities of the dentition by orthopedic methods; 4) orthopedic measures in reconstructive surgery of the face and jaws; 5) treatment of diseases of masticatory muscles and temporomandibular joints.
The purpose of maxillofacial orthopedics is the rehabilitation of patients with defects in the dentition. To achieve this goal, the following is carried out: 1) study of the frequency, etiopathogenesis, clinic and diagnosis of defects and deformities of the dentoalveolar system; 2) methods of prosthetics are being developed for defects in the face and jaws; 3) prevention of post-traumatic and postoperative deformities of the face and jaws is carried out.
When describing the methods of orthopedic treatment, one or another apparatus will always be named, the classification of which we consider it useful to give in advance.
^ CLASSIFICATION OF DEVICES USED IN MAXILLOFACIAL ORTHOPEDICS
All orthopedic devices should be divided into groups according to their purpose, method of fixation and technology.
According to their purpose, the devices are divided into corrective (reponing), fixing (holding), guiding, replacing, shaping, separating and combined. In the treatment of jaw fractures, corrective, fixing, guiding orthopedic devices are used. Orthopedic devices are called corrective or repositioning, with the help of which fragments are installed
Get into the correct position. These include wire and plastic splints for intermaxillary traction, devices with screws, with extraoral control levers.
Guides include devices with inclined planes or a sliding hinge, which provide bone fragments with a certain direction. These include tires Vankevich, Weber, wire tires with Schroeder hinges, Pomerantseva-Urbanskaya.
Devices that hold fragments of the jaw in the correct position and ensure their immobility are called fixing devices. These include various dental splints (smooth wire brace, aluminum wire splints with spacers, extraoral devices for fixing mandibular fragments). Fixing devices are also used to hold fragments of the lower jaw after its resection.
In the plastic compensation of soft tissue defects of the face, devices are used that serve as a support for the plastic material. They are called shapers. With the help of these devices, a bed is also created for removable dentures on the edentulous lower jaw during operations aimed at improving the conditions for fixing the prosthesis.
After resection of the jaws or in case of jaw defects of traumatic origin, devices are used that replace the lost tissues. They are called substitutes. These, for example, include prostheses used after resection of the jaws, called resection prostheses.
Disconnecting devices include devices that separate the oral and nasal cavities. They are called obturators. Dissociating devices also include a protective palatine plate and devices used in the plastic elimination of acquired defects in the hard palate.
Combined devices perform several functions. In case of jaw fractures, the devices reposition the fragments and immobilize them. During plastic surgery, devices can hold fragments of the lower jaw and form the lower lip.
According to the method of fixation, maxillofacial apparatuses can be divided into intraoral, extraoral and intra-extraoral. Intraoral devices are located in the oral cavity and are fixed on the teeth and alveolar part. Extraoral are located outside the oral cavity, on the tissues of the face and head. Intra-extraoral devices include devices, one part of which is fixed inside and the other outside the oral cavity. Intraoral appliances can be located within one jaw and are called single-jaw or on both jaws (double-jaw appliances, splints).
Devices and splints used in maxillofacial orthopedics, according to the method of their manufacture, can be standard or individual. In turn, individual devices are prepared by the doctor directly.
Venno at the operating table (chair) or in the dental laboratory. Apparatus and tires can be made of plastic and metal alloys. The latter are bent, cast, soldered and combined.
^ ORTHOPEDIC TREATMENT OF JAW FRACTURES
Injuries to the face and jaws can be gunshot and non-gunshot origin. There are the following main types of non-gunshot injuries of the maxillofacial region:
1) isolated injuries of soft tissues with violation of the integrity of the skin of the face and oral mucosa (penetrating into the oral cavity);
2) damage to the soft tissues and bones of the face with a violation of the integrity of the skin or oral mucosa or closed damage to the bones of the facial skeleton;
3) damage to the soft tissues and bones of the face (open and closed), combined with damage to other areas of the body.
Damage to the bones of the face is diverse. In order to statistically process the materials of clinical observations, diagnosis and treatment of fractures, B.D. Kabakov, V.I. Lukyanenko and P.Z. Arzhantsev give a working classification of facial bone injuries:
I. Damage to teeth (upper and lower jaw):
II. Fractures of the lower jaw:
A. By nature:
Single |
Double g single sided
Multiple J or bilateral B. By localization:
Alveolar part
Chin part of the body of the jaw
Lateral part of the body of the jaw
jaw angle
Branches of the jaw (actually branches, bases or necks of the condylar process, coronoid process).
III. Fractures of the upper jaw:
Alveolar process
Body of jaw without nasal and zygomatic bones
Body of jaw with nasal bones (craniocerebral separation).
IV. Fractures of the zygomatic bone and arch: i
The zygomatic bone with damage to the walls of the maxillary sinus or without damage
The zygomatic bone and arch
zygomatic arch
V. Fractures of the nasal bones
(with or without displacement of fragments)
VI. Combined injuries of several bones of the face
(both jaws, lower jaw, zygomatic bone, etc.).
VII. Combined injuries of the face and other areas of the body.
Gunshot fractures of the bones of the face are comminuted in nature, have different localization and occur at the site of the direct action of the injuring projectile, and not along the lines of weak points. V.Yu. Kurlyandsky divided them into 4 groups:
1. Fractures of the alveolar process (partial fracture or defect, complete detachment or defect).
2. Suborbital fractures (fracture or defect within the dentition with opening of the maxillary sinus of the maxillary cavity) and palate defect, unilateral fracture with opening of the maxillary cavity and defect of the palate, bilateral fracture with opening of the maxillary cavities, perforated fracture.
3. Subbasal fractures (tearing off the entire upper jaw or tearing off and crushing it).
4. Fractures of individual bones of the facial skeleton (fracture or defect of the nasal bones, fracture or defect of the zygomatic bone).
The treatment of fractures has two ultimate goals: restoration of anatomical integrity and restoration of the full function of the affected organ. This is solved by: 1) matching the fragments to the correct position (reposition) and 2) holding them in this position until the fracture heals (immobilization). Both of these tasks are solved by orthopedic or surgical methods.
Reposition of jaw fragments can be carried out manually after anesthesia, with the help of devices and surgically (bloody or open reduction). The main method of treating jaw fractures at present is the orthopedic method, which involves solving medical problems with the help of splints. The system of measures for the rehabilitation of patients with injuries of the maxillofacial region also includes physiotherapy and therapeutic exercises. Treatment of gunshot fractures of the jaws includes: 1) primary wound treatment, 2) reposition and immobilization of fragments, 3) measures to combat infection, 4) bone grafting, 5) soft tissue plasty, 6) measures to prevent contractures.
^ First aid for jaw fractures (transport immobilization)
The first medical aid for fractures of the jaw is to temporarily fix the fragments in a stationary state. This is necessary to stop bleeding or prevent it, as well as to stop pain. Temporary splinting of fragments is one of the means of dealing with shock. Medical care for fractures of the jaws in wartime is provided at the stages of evacuation of the wounded to the maxillofacial region. In peacetime, the transport immobilization of fragments is carried out before the provision of specialized care to the patient by doctors of district hospitals and ambulance stations.
Transport tires are used to create immobility of fragments. The most common and simple is the hard chin sling. It is used for a short period (2-3 days) for fractures of the upper and lower jaws, when there is a sufficient number of teeth holding the interalveolar height. The rigid chin sling consists of a head band and a plastic chin sling. A layer of cotton wool is placed in the sling and attached with rubber bands to the headband with sufficient traction.
For immobilization of fragments of the lower jaw and fractures of the alveolar process of the upper jaw, ligature binding of the jaws is also used. The ligature is bronze-aluminum wire 0.5 mm thick. There are several ways to apply wire ligatures according to Ivy, Wilga, Geikin, Limberg, and others (Fig. 209). Ligature binding of the jaws should be combined with the imposition of a chin sling.
Rice. 209. Intermaxillary tooth binding: a - according to Ivy; b - according to Geikin; c - according to Wilga.
In case of fractures of the edentulous jaws, removable dentures of patients can be used as a transport splint, if the atrophy of the alveolar processes is moderate, and the occlusion of artificial teeth is good. However, in this case, the imposition of a chin sling is mandatory.
^ Specialized care for jaw fractures
Orthopedic treatment of fractures of the alveolar process
Most often, fractures of the alveolar process of the upper jaw are observed. They can be with or without offset. The direction of displacement of the fragment is determined by the direction of the acting force. Basically, the fragments are displaced backwards or towards the midline.
For fractures of the alveolar process without displacement, a single-jaw aluminum splint (smooth wire clip) is used (Fig. 210). It bends along the dentition from the vestibular side and is fixed to the teeth with a ligature wire. In case of fresh fractures with displacement, the fragments are reduced simultaneously under anesthesia and fixed with a single-jaw wire splint. If the patient does not contact the doctor in time, the fragments become stiff and it is not possible to set them at the same time. In these cases, intraoral and extraoral traction is used.
Rice. 210. Wire tires according to Tigerstedt: a - a smooth bus-bracket; b - a smooth tire with a spacer; in - a tire with hooks; g - a tire with hooks and an inclined plane; e - splint with hooks and intermaxillary traction; e - rubber rings.
For fractures in the lateral sections of the alveolar process, you can use the springy Angle arch, which is adjusted in such a way as to move the teeth along with the alveolar process in the direction necessary to restore normal occlusion. So, for example, when the fragment is displaced in the palatal direction, the arc fits snugly against the teeth of the healthy side, but is separated from the teeth of the damaged alveolar process. After applying ligatures, the elastic arc will move
Push the teeth of the damaged side outward, i.e. in the correct position (Fig. 211).
Rice. 211. Treatment of fractures of the alveolar process with displacement inward (a), posteriorly (b) and vertical displacement (c).
Fig.212. Bent wire splint Zbarzha for the treatment of fractures of the upper jaw: a first option; b - the second option; c - fixing the tires.
With included fractures of the alveolar process and its fractures in the anterior part of the dental arch, a stationary wire steel arch with a thickness of 1.2 - 1.5 mm is used. The arc is tied to the teeth of the healthy side, and the fragment is pulled to the arc with rubber rings or a ligature.
^ Orthopedic treatment of fractures of the upper jaw
Fractures of the upper jaw can be unilateral or bilateral. There are three types of fractures of the upper jaw (Fore I, II, III). In addition, there may be impacted fractures of the upper jaw, and sometimes its complete separation. The main symptom of a fracture of the upper jaw with displacement is a violation of the closure of the teeth in the form of an open bite.
Treatment of fractures of the upper jaw with pronounced mobility of fragments consists in manual reduction of fragments and their fixation in the correct position. For the treatment of bilateral fractures of the upper jaw, wire splints are used, which have an intraoral part fixed to the teeth and an extraoral part connected to a head plaster cast. A similar splint for the treatment of fractures of the anterior part of the upper jaw was proposed by Ya M. Zbarzh (Fig. 212). It is prepared in the following way. An aluminum wire 75-80 cm long is taken. On each side, its ends 15 cm long are bent towards each other and twisted in the form of a spiral. The angle between the long axes of the wire should not exceed 45°. The turns of one process go clockwise, and the other - counterclockwise. The formation of twisted processes is considered complete when the middle part of the wire between the last turns is equal to the distance between the premolars. This part is further the front part of the tooth splint. The side parts are bent from the free ends of the wire. The intraoral part of the splint is strengthened with a ligature wire to the teeth after the fragments have been reduced. The extraoral processes are bent up to the head so that they do not touch the skin of the face. After that, a plaster bandage is applied, into which the ends of the wire processes are plastered.
For the treatment of fractures of the upper jaw according to type I and II, Ya.M. Zbarzh developed a standard set consisting of a splint-arc, a supporting head bandage and connecting rods (Fig. 213). The device allows you to simultaneously set and fix fragments. The tire-arc is a double steel arc covering the dentition of the upper jaw on both sides. The size of the wire arch is regulated by extension and shortening of its palatal part. Extraoral rods depart from the arc, directed back to the auricles. Extraoral rods connect-
Yutsya with a headband using connecting metal rods M.Z. Mirgazizov proposed a similar device for a standard splint for fixing fragments of the upper jaw, not only using a plastic palatine plate
Treatment of fractures of the upper jaw with downward displacement of fragments with an intact lower jaw can be carried out using the Weber Type I dentogingival splint (Fig. 214). It consists of a wire frame and a plastic base that encloses and covers the hard palate and sockets for extraoral nails. The incisal edges and chewing surfaces of the teeth are left open to control occlusion. The frame is bent from orthodontic wire with a diameter of 0.8 mm.
Rice. 213. Standard kit for treatment of upper jaw fractures
It covers the dentition in the form of an arc from the vestibular and palatal surfaces. In order for the splint to rest on the teeth and not damage the gingival margin, bars are soldered to the frame, which should be located at the contact points of the teeth. Tetrahedral tubes are soldered to the frame, which will hold the extraoral rods. The soldered frame is placed on the jaw model and a splint is modeled from wax. A model with a wax reproduction is plastered into a cuvette and the wax is replaced with plastic. It is possible to make a dental splint according to another technical
Rice. 214. Dental splint for fixation of fragments of the upper jaw
Nology. Make a wire frame with tubes. Place it on the model and model a tire made of quick hardening plastic. The polymerization is carried out in a vulcanizer. The bus base is translucent. This allows you to see the places of compression of the mucous membrane under the tire.
Obtaining an impression for the manufacture of a tire has its own characteristics. They consist in the danger of displacement of fragments during the removal of the impression. Impressions are obtained with alginate masses, which have the ability to stick to the mucous membrane. With a rough removal of the impression from the oral cavity, fragments can be displaced. Therefore, before removing the impression, it is necessary to bend one of its edges, thereby opening the access of air under the impression.
Rice. 215. Apparatus for repositioning fragments of the upper jaw according to Schur.
With a bilateral fracture of the upper jaw and limited mobility of the fragments, the reduction and fixation of the latter is carried out with the help of splints. For this purpose, Z.Ya. Shur proposed an apparatus with counter rods (Fig. 215). It consists of: 1) a plaster cap, into which two vertical rods 150 mm; 2) a single soldered splint for the upper jaw with abutment crowns for the canines and first molars on both sides. Flat tubes with a section of 2x4 mm and a length of 15 are attached to the tire from the buccal side in the region of the first molar mm; 3) two extraoral rods with a cross section of 3 mm and a length of 200 mm. The soldered splint is cemented on the teeth of the upper jaw. A plaster cap is formed on the patient's head and at the same time short rods are vertically cast into it on both sides so that they are located somewhat behind the lateral edge of the orbit and descend downward to the level of the wings of the nose. Extraoral rods are inserted into the tubes and bent along the buccal surface of the tooth. In the area of the canine, they are directed backward, at the level of the short upper rod they bend towards it. Movement of the jaw fragments is achieved by changing the direction of the extraoral rods. After setting the jaw in the correct position, the ends of the levers are tied with a ligature.
Treatment of unilateral fractures of the upper jaw with stiff fragments is carried out using wire splints with intermaxillary traction. A Tigerstedt splint with hook loops is bent onto the lower jaw. On the upper jaw, a wire splint with hook loops is bent only on the healthy side, and on the fragment, the splint remains smooth and is not fixed with ligatures. After strengthening the tire on the healthy side, an intermaxillary rubber traction is applied, and a rubber gasket is installed between the lowered fragment of the upper jaw. After reduction of the fragment, the free end of the splint on the upper jaw is tied to the teeth.
With a complete detachment of the upper jaw with its displacement back and with an impacted fracture, the traction of the fragment is carried out using a steel wire rod, one end attached to a plaster head bandage, and the other end to an intraoral splint.
^ Orthopedic treatment of mandibular fractures
Mandibular fractures occur along the line of weakness and have a typical localization (Fig. 216). Gunshot fractures, on the contrary, have a different location. Fractures of the lower jaw most often occur with displacement of fragments, which is explained by the traction of the masticatory muscles attached to them.
Rice. 216. Typical localization of mandibular fractures.
The choice of the method of orthopedic treatment of fractures of the lower jaw depends on the localization of the fracture line, the degree and direction of displacement of fragments, the presence of teeth in the jaw and the state of their periodontium, and the nature of occlusion disorders.
In the presence of teeth on the jaw, a slight displacement of fragments and fractures within the dentition, single-jaw wire splints are used. Fractures outside the dentition or significant displacement of fragments require the use of splints with toe loops for intermaxillary traction. For the first time, aluminum wire tires were used by the doctor of the Kyiv hospital S.S. Tigershtedt in 1916. (fig.210). Deep overbite with a vertical or retruded position of the anterior teeth limits the use of wire splints.
^ Fig. 217. Standard tape splint for intermaxillary fixation according to Vasiliev, a - general view of the splint; b - bus on the model (part of the ligatures removed).
The technique of imposing a wire bus. The wire bus is bent from aluminum wire with a diameter of 1.8 mm. The tire is bent outside the oral cavity, constantly trying it on the dentition. The imposition of the tire is carried out after conduction anesthesia. It should fit snugly around each tooth. In the absence of a part of the teeth, a spacer or retention loop is bent in it. The hook loops are bent with crampon tongs. The ends of the splint should cover the last teeth. To fix it, a bronze-aluminum wire 6–7 cm long and 0.4–0.6 mm thick (ligature) is used. The tire should be located between the equator of the tooth and the gum, without causing damage to the latter. The ligature is bent in the form of a hairpin with ends of various lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and removed from the vestibule (one under the splint, the other over the splint). The ends of the ligatures are twisted and bent into the interdental space. The ligature should not cause damage to the gums. After 2-3 days, it is twisted.
Bent wire bars take a long time to bend. In 1967, V.S. Vasiliev developed a standard stainless steel tooth splint with ready-made toe hooks (Fig. 217).
Treatment of fractures of the lower jaw with edentulous alveolar parts or with the absence of a large number of teeth is carried out by M.M. Vankevich's splint (Fig. 218a). It is a tooth-gingival splint with two planes that extend from the palatal surface of the splint to the lingual surface of the lower molars or the edentulous alveolar ridge.
Rice. 218. Removable splints for fixing edentulous fragments of the lower jaw: a - Vankevich splint; b - Stepanov's tire.
^ Tire technology. Alginate impression mass is used to take impressions from the upper and lower jaws. The central ratio of the jaws is determined and the model is plastered into the occluder. Measure the degree of opening of the mouth. The frame is bent and a wax tire is modeled. The height of the planes is determined by the degree of mouth opening. The planes when opening the mouth must maintain contact with the edentulous alveolar processes or teeth. Wax is replaced with plastic. This tire can be used
Called also for bone grafting of the lower jaw to hold bone grafts. Tire Vankevich was modified by A.I. Stepanov, who replaced the palatal plate with an arc (Fig. 2186).
For fractures of the lower jaw outside the dentition, a dentogingival splint with an inclined plane on the lower jaw and wire splints with sliding hinges (Pomerantseva-Urbanskaya) are used (Fig. 219).
^ Plastic tires. With the advent of plastics in the practice of orthopedic dentistry, the latter began to be used in the treatment of fractures of the lower jaw. Various tire modifications made of fast-hardening plastic were proposed by G.A. Vasiliev, I.E. Koreiko, M.R. Ma-rey, Ya.M. Zbarzh. Rapid hardening plastic tire is formed
Rice. 219. Tires for the treatment of mandibular fractures outside the dentition: a, b - Weber's tooth-gingival splint; c - orthopedic apparatus with a sliding hinge according to Schroeder; g - wire tire with a sliding hinge Pomerantseva-Urbanskaya.
On a metal template of an arched shape. Preliminarily, a polyamide thread with plastic beads is strengthened on the teeth. With this method, you can get a smooth tire and a tire with hook loops (Fig. 220).
F.M. Gardashnikov proposed a universal plastic tooth splint with mushroom-shaped rods for intermaxillary traction. The tire is strengthened with a bronze-aluminum ligature (Fig. 221).
A fast-hardening plastic splint can be prepared in the form of a kappa directly in the patient's mouth. It is necessary to protect the gingival margin from plastic burns with wax. E.Ya.Vares suggested making mouthguards by stamping from sheet polymethyl methacrylate in a special mold.
Rice. 220. Scheme of manufacturing a plastic splint for the treatment of fractures of the lower jaw:
A - fixation of beads; b - formation of a groove; c - groove; g - the tire is imposed on the jaw;
D - tire with hook loops; e - fixation of the jaws.
Plastic tires have the following disadvantages: 1) reinforcing plastic tires with polyamide thread is not stable enough due to stretching of the latter; 2) plastic splints in the form of mouthguards change occlusion, are bulky, damage the gingival papillae and violate oral hygiene.
