Traumatic injuries of the maxillofacial region. Injuries to the forehead Incorrect position of the fetus

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Classification.

I. Production.

• Industrial.
• Agricultural.

II. Non-production.

• Household:
  • transport;
  • street;
  • sports;
  • others.

Types of damage to the maxillofacial region.

I. Mechanical damage.

By localization.

• Soft tissue injury:
  • language;
  • major salivary glands;
  • large nerve trunks;
  • large vessels.
• Bone injury:
  • lower jaw;
  • upper jaw;
  • cheekbones;
  • nose bones;
  • damage to two or more bones.

By the nature of the injury:

• through;
• the blind;
• tangents;
• penetrating into the oral cavity;
• non-penetrating into the oral cavity;
• penetrating into the maxillary sinuses and nasal cavity.

According to the mechanism of damage:

• bullet;
• comminuted;
• ball;
• arrowhead elements.

II. Combined damage

• radiation;
• chemical poisoning.

III. Burns.

IV. Frostbite.

Damage is divided into:

• isolated;
• single;
• isolated multiple;
• combined isolated;
• combined multiples.

Associated injury- damage to two or more anatomical regions by one or more damaging agents.

Combined injury- damage resulting from the impact of various traumatic factors.

fracture- partial or complete violation of the continuity of the bone.


Traumatic damage to teeth

Distinguish between acute and chronic trauma. Acute tooth injury occurs when a large force is applied to the tooth simultaneously, resulting in a bruise, dislocation, fracture of the tooth, more common in children, mainly the anterior teeth of the upper jaw are injured.

Chronic tooth injury occurs when a force is weak in magnitude for a long time.

Etiology: fall on the street, hit by objects, sports injury; among the factors predisposing to injury, malocclusion is noted.

Features of the examination of a patient with acute dental trauma: an anamnesis is obtained from the victim, as well as from the person accompanying him, the number and exact time of the injury, the place and circumstances of the injury, how much time has passed before going to the doctor; when, where and by whom the first medical aid was provided, its nature and volume. Find out if there was a loss of consciousness, nausea, vomiting, headache (maybe a traumatic brain injury), find out the presence of vaccinations against tetanus.

Features of the external examination: note the change in the configuration of the face due to post-traumatic edema; the presence of hematomas, abrasions, ruptures of the skin and mucous membranes, discoloration of the skin of the face. Also pay attention to the presence of abrasions, tears on the mucous membrane of the vestibule and oral cavity. Carefully inspect the injured tooth, radiography and electrodontometry of the injured and adjacent teeth.

Injury to the anterior teeth leads to such consequences as a violation of aesthetics due to the absence of a tooth, occlusion, the development of the Popov-Godon symptom (protrusion of a tooth that has lost its antagonist), as well as speech disorders.


Classification of acute trauma to the tooth.

1. Bruised tooth.

2. Tooth dislocation:

• incomplete: without displacement, with displacement of the crown towards the adjacent tooth, with rotation of the tooth around the longitudinal axis, with displacement of the crown in the vestibular direction, with displacement of the crown towards the oral cavity, with displacement of the crown towards the occlusal plane;
• hammered;
• full.

3. Cracked tooth.

4. Tooth fracture (transverse, oblique, longitudinal):

• crowns in the enamel zone;
• crowns in the zone of enamel and dentin without opening the tooth cavity;
• crowns in the zone of enamel and dentin with opening of the tooth cavity;
• tooth in the area of ​​enamel, dentin and cementum.
• root (in the cervical, middle and apical thirds).

5. Combined (combined) injury.

6. Injury of the tooth germ.


bruised tooth- closed mechanical damage to the tooth without violating its anatomical integrity.

Patohistology: periodontal fibers are damaged, ischemia, tear or rupture of part of the periodontal fibers, especially in the area of ​​the apex of the tooth, is observed; reversible changes develop in the pulp. The neurovascular bundle can be completely preserved, partial or complete rupture can be observed. With a complete rupture of the neurovascular bundle, hemorrhage into the pulp and its death is observed.

The clinical picture of a tooth injury: there are constant aching pains in the tooth, pain when biting and vertical percussion of the tooth, a feeling of a “grown tooth”, staining and darkening of the tooth crown in pink, tooth mobility, swelling, hyperemia of the gum mucosa in the area of ​​the injured tooth; no radiological changes.

Treatment: anesthesia, rest of the tooth until pain stops when biting on the tooth (elimination of solid food for 3-5 days, reduction of contact with antagonist teeth by grinding them off; anti-inflammatory treatment: physiotherapy.


D.V. balls
"Dentistry"

CONVENTIONAL ABBREVIATIONS

CT - computed tomography

PHO - primary surgical treatment

FTL - physiotherapy treatment

MFR - maxillofacial region

THEME #1
INJURY OF THE MAXILLOFACIAL REGION IN CHILDREN

The frequency of injuries of the maxillofacial region in children. Facial wounds: classification, clinic, features, treatment. Damage to the bones of the facial skeleton, especially in childhood, damage to the teeth, trauma to the oral cavity. Fracture of the lower jaw, dislocation of the lower jaw. Fracture of the upper jaw, zygomatic bone and zygomatic arch.

Purpose of the lesson.

To get acquainted with the types of injuries of the maxillofacial region in childhood, the principles of treatment and dispensary observation, the outcomes of injuries. Learn how to provide first aid and care for children who have suffered an injury to the maxillofacial region. Determine the role of the pediatrician in further monitoring of patients.

Injuries to the maxillofacial region (MAF) in children, according to N. G. Damier (1960), occur in 8% of cases in relation to all injuries in childhood. Most often in children there is an injury to the soft tissues of the face and oral cavity. Usually this is the result of domestic injuries (on the street, in a traffic accident, while playing sports), there are also cases of gunshot injuries. Insufficient supervision of the child, non-observance of traffic rules by children often lead to injury. The age factor determines the nature of the damage, which is associated with anatomical features at a certain age. The smaller the child, the greater the layer of subcutaneous fat and the more elastic the bones of the facial skeleton, therefore, bone damage is less common than soft tissue injury (bruises, bruises, abrasions, wounds). With the appearance of the lower central incisors, various wounds of the tongue become possible, the child can bite the tongue, for example, during a fall. With age, when the child begins to take various objects into his mouth, there is a possibility of getting a wound of the mucous membrane and palate. In children 3-5 years old, as a result of a fall, dislocations and fractures of the teeth occur, usually in the frontal part of the jaw. Fractures of the bones of the face are more common in older children, but can also occur in newborns with obstetric care.

Medical care provided to children can be divided into emergency and specialized. Emergency care is provided in the institution where the patient enters, it is aimed at eliminating factors that threaten the life of the child - shock, asphyxia, bleeding. Transport mobilization is underway. Specialized care consists in the primary surgical treatment of wounds and in the therapeutic immobilization of fragments, if soft tissue damage is combined with damage to the bones of the facial skeleton.

Wounds classified as isolated when there is only soft tissue damage, and combined when soft tissue damage is combined with damage to the bones of the facial skeleton and teeth. There are wounds single and multiple, penetrating(in the mouth, nose, eye socket, skull) and non-penetrating,With defect and no defect fabrics. By the nature of the wounding object, they are cut,stab,tattered, bruised,bitten which is more common in childhood. firearms wounds in children are less common.

The negative features of the wounds of the maxillofacial region include:

1. Disfigurement of the face.

2. Violation of the function of speech and chewing.

3. Risk of damage to vital organs - the brain, eyes, hearing organs, upper respiratory tract, large vessels and nerves.

4. The likelihood of damage to the teeth, which, being carious, are an additional infectious, and sometimes injuring factor.

5. Difficulty in making a diagnosis due to a mismatch between the type of victim and the severity of the injury.

6. Features of care: most of these patients need special care and nutrition. Nutrition is carried out from the drinker with liquid food, in extremely severe conditions - through a probe.

The positive features include:

1. Increased regenerative capacity of facial tissues.

2. Resistance of tissues to microbial contamination.

These features are due to the richness of the blood supply and innervation. In case of damage to the oral region, despite the leakage of saliva, ingestion of food, wounds regenerate well due to the presence in the oral region of a significant amount of connective tissue with low differentiated cellular elements, which are the potential for tissue regeneration.

Cosmetic considerations in the treatment of facial wounds dictate the use of gentle surgical techniques. Primary surgical treatment of facial wounds is most effective in the first 24 hours after injury. However, when antibiotics are used, and also taking into account the peculiarities of the maxillofacial region, primary surgical treatment can be performed within 36 hours from the moment of injury. Before treatment of wounds, a thorough x-ray examination should be carried out to diagnose possible bone damage. Primary surgical debridement (PSW) includes: wound dressing, bleeding control, removal of foreign bodies, wound revision (with examination of the walls and bottom of the wound), excision of non-viable edges and its layer-by-layer suturing.

The toilet of the wound is carried out after anesthesia with antiseptic drugs (furatsilin, an aqueous solution of chlorhexidine, catapol, octenisept, etc.). Only mechanical treatment of the wound with these solutions matters, which significantly reduces the risk of purulent inflammation. A wound revision is carried out in all cases, which, with knowledge of the anatomy, makes it possible to detect damage to important anatomical structures and carry out their speedy full-fledged surgical restoration. This avoids serious consequences, and in some cases disability. So, for example, unnoticed damage to the branches of the facial nerve leads to persistent paralysis of the facial muscles and sometimes it is impossible to restore the function of the nerve. Unnoticed damage to the muscles of the face leads to a violation of facial expressions or chewing function, and damage to the salivary glands (especially the parotid) can cause the formation of salivary fistulas.

When examining the oral cavity, the size of the rupture of the mucous membrane, the presence of damage to the tongue are determined. The stab wound should be dissected to the bottom so that it is possible to carry out a full revision of the wound to identify damage to important anatomical structures and subsequently restore them. The peculiarity of the treatment of facial wounds depends on the time elapsed since the injury, as well as the nature and location of the damage. Wounds of the oral cavity, tongue, oral region, the area of ​​the corners of the mouth, the corner of the eye, the wings of the nose are sutured without excision of the edges. Economic excision is done only when the edges of the wound are severely crushed. A primary blind suture is applied, which gives a good cosmetic result and prevents displacement and eversion in the area of ​​the corners of the mouth, eyes, and wings of the nose. In all areas of the face and neck, when suturing wounds, all damaged structures (mucosa, muscles, skin with subcutaneous tissue) are restored in layers until drainage. If the branches of the facial nerve, blood vessels and nerves of the neck are damaged, their mandatory restoration is necessary.

If the wound is without a tissue defect, it is closed by simply bringing the edges together (towards oneself). If the direction of the wound did not follow the course of the natural folds of the face, it is desirable to carry out primary plastic surgery using figures of counter triangular flaps, especially in the area of ​​the inner corner of the eye, the nasolabial groove, in places where the relief changes from convex to concave, etc. If there is a defect, primary plastic using nearby tissues, by moving the pedicled flap or counter triangular flaps. In cases associated with traumatic amputation of a tissue area (tip of the nose, auricle), it is necessary to deliver the amputated tissue segment to the hospital under conditions of cold ischemia, which allows replantation with a good cosmetic result or use of parts of these tissues for plastic restoration of the defect.

Bite wounds occupy a special place in pediatric practice. These are most often gross injuries of soft tissues with trauma to important anatomical structures. These wounds are always accompanied by massive microbial contamination, crushing of the edges. It is generally accepted that bitten wounds almost always fester and suturing them is useless. But with a carefully performed PST of the wound in a short time after the injury (up to 12-24 hours) and the use of antibiotic therapy, the occurrence of complications practically does not occur. This allows you to get a good result in the treatment of such severe injuries.

To obtain a good cosmetic result, the use of a suitable suture material is essential. So, muscles and fiber are more often restored with absorbable suture material (catgut, vicryl), for skin sutures, an artificial prolene monofilament thread from 5/0 to 7/0 is used. Such a suture material does not cause an inflammatory reaction, unlike nylon and silk, and avoids rough scars. For extensive, deep and bitten wounds, drainage of the wound with thin strips of glove rubber is often used. Seamless convergence of the edges of the wound with the help of strips of an adhesive patch should not be used, especially on actively moving surfaces of the face, since, being saturated with the contents of the wound and saliva, the patch does not hold the edges of the wound, they diverge and subsequently form a rough scar. With a smooth course of the wound process and in the absence of tension, the sutures on the face can be removed on the 4th - 7th day after the operation. Further, according to indications, scar massage with contractubex and FTL is prescribed. Sutures in the tongue are applied with a long-term absorbable suture material and removed no earlier than the 10th day.

Tooth damage: bruises are the most common, resulting in a slight mobility of the teeth. If the pulp is damaged, the tooth becomes dark in color. When dislocated, its position changes. Sometimes there is an embedded or impacted dislocation, the type depends on the direction of the acting force. With an impacted dislocation, the tooth is displaced towards the body of the jaw. A tooth fracture can occur in any department (root, crown), in this case, they try to save a permanent tooth. Impacted dislocation does not require treatment, the tooth after 6 months. restored in the dental arch. With significant tooth mobility, splinting is necessary. In the case of a complete dislocation of a permanent tooth, reimplantation is possible.

Damage to the bones of the facial skeleton can be observed from the moment of birth - these are injuries during obstetric care during childbirth. Most often, a fracture of the body of the lower jaw occurs along the midline, the condylar process of the head of the lower jaw, or the zygomatic arch. Often, trauma to the bones of the face remains unrecognized and only its consequences are diagnosed: deformity of the bones of the face, dysfunction of the temporomandibular joint. According to G. A. Kotov (1973), fractures of the jaws in childhood account for 31.3% of injuries of the maxillary fossa.

Fracture of the lower jaw. Often in children, subperiosteal fractures are observed, most often they occur in the lateral sections of the lower jaw. As a rule, these are non-displaced fractures. Fractures of the "green stick" or "willow" type are complete fractures localized in the region of the condylar processes.

Traumatic osteolysis is observed when the head of the mandibular joint is torn off. It can be compared with the epiphysiolysis of long tubular bones. Fractures of the lower jaw in older children are more common in typical places: in the midline, at the level of premolars, in the area of ​​the angle of the lower jaw and the neck of the articular process. Fractures localized within the dentition are always open, since the mucous membrane is torn at the time of injury. Closed are subperiosteal fractures and fractures localized in the branch and neck of the articular process of the lower jaw. The fracture line can pass at the location of the tooth germ of the permanent tooth, which, despite the injury, in most cases does not die, and therefore it is not removed. If the tooth germ becomes necrotic, it separates spontaneously, like a sequester. Milk teeth that are in the fracture line are removed.

With fractures of the lower jaw, children complain of pain at the site of injury, difficulty in speech, inability to chew and close teeth. An external examination reveals asymmetry of the face, a half-open mouth, a hematoma at the site of injury. Examination from the oral cavity makes it possible to detect a rupture of the mucous membrane, malocclusion, and damage to the tooth. Bimanual examination determines the pathological mobility of fragments. To clarify the diagnosis, an X-ray examination is performed.

When providing first aid in a polyclinic, a child is given temporary, or transport, immobilization, for which a hard chin sling is used or a soft bandage is applied. In the emergency room, it is possible to bind the fragments with a wire passed through the interdental spaces. In the hospital, fragments are repositioned, if necessary, and therapeutic immobilization is applied using wire splints or cap splints made of quick-hardening plastic. To apply dental splints, there must be a sufficient number of teeth on all fragments. In addition, the choice of fixation method depends on age. The height of the crowns of milk teeth is much less than that of permanent teeth, and the length of the roots is also small. Therefore, wire splints under the age of 3 years are almost impossible to apply. In children in this age group, it is better to use soft chin-head bandages with intermaxillary pads or cap splints made of quick-hardening plastic. At the age of 9 - 10 years, metal splints are used, for fractures with displacement - two-jaw with the imposition of intermaxillary traction. An operative method of fixation is indicated if there is no possibility of using orthopedic methods (tires). The most rational at present is the imposition of a bone suture or fixation with titanium miniplates. After a fracture of the lower jaw, especially in the area of ​​the articular process, stiffness in the joint, or ankylosis, may develop, as well as a lag in the growth of the lower jaw, which is clinically expressed in malocclusion. In this regard, dispensary observation of the child for 5-6 years is necessary.

Dislocation of the lower jaw. It is more common in older children and is predominantly anterior - unilateral or bilateral. Anterior dislocation occurs when you try to open your mouth wide - screaming, yawning, wanting to bite off too much of a piece of food.

clinical picture. The wide-open mouth does not close, salivation, immobility of the lower jaw are observed. By palpation, the heads of the articular processes are determined under the zygomatic arches. With unilateral dislocation, the mouth is half open and the lower jaw is displaced to the healthy side, the bite is broken on the side of the dislocation. In this case, an x-ray examination is also necessary, since the dislocation can be combined with a fracture of the neck of the articular process.

Treatment. With a fresh dislocation, reduction can be performed without anesthesia. If the dislocation is chronic, that is, several days have passed after the injury, then infiltration anesthesia of the masticatory muscles is performed to relieve muscle tension or under general anesthesia.

Dislocation reduction technique. The patient is seated on a chair. The assistant stands behind the child and holds his head. The doctor is to the right or in front of the patient. The doctor wraps the thumbs of both hands with gauze and puts them on the chewing surfaces of the lower large molars on the right and left. The rest of the fingers cover the jaw from the outside. Then three consecutive movements are made: pressing down with the thumbs, they lower the head to the level of the articular tubercles. Without stopping the pressure, the jaw is displaced posteriorly, moving the heads into the articular cavities. The last movement anteriorly and upwards completes the reduction, which is accompanied by a characteristic click. After that, the mouth closes and opens freely. With unilateral dislocation, these movements are performed with the free hand. Immobilization after reduction is carried out with a soft circular bandage or scarf for 5-6 days. Assign a sparing diet.

Fracture of the upper jaw in childhood occurs after 4 years. In children, the alveolar process is most often damaged with dislocation of the teeth in the frontal section.

clinical picture. With fractures of the alveolar process, swelling, soreness, and a violation of the closure of the teeth are observed. Crepitus is determined by palpation. X-ray examination allows us to clarify the nature of the fracture. In older children, fractures are possible along the lines of “weakness” - Lefort 1, Lefort 2, Lefort 3. With a Lefort 1 fracture, the fracture line runs from the piriform opening parallel to the alveolar process (on both sides) to the tubercle of the upper jaw. With this fracture, swelling, pain, and bleeding from the nose are noted. There is no malocclusion. With a Lefort 2 fracture, the clinical picture is more severe. The fracture line passes through the root of the nose, the inner wall of the orbit and along the zygomatic-maxillary suture from both sides. There is bleeding from the nose due to damage to the ethmoid bone, malocclusion and lengthening of the face due to displacement of the anterior section, diplopia. The most severe is considered a fracture of the Lefort 3 type, when the fracture line passes through the root of the nose, the zygomatic bone (on both sides) and the pterygopalatine fossa.

A fracture of the upper jaw may be combined with a fracture of the base of the skull.

Clinical picture: pain, swelling, liquorrhea, bleeding from the nose and ears, malocclusion. Transport immobilization is carried out by applying a Limberg splint or a Limberg plank attached to a support head cap. For therapeutic immobilization, dental wire splints or splints made of quick-hardening plastic are used, with displacement of fragments - with extraoral rods fixed on the supporting head cap. Surgical treatment is carried out by the imposition of titanium miniplates. Children who have suffered a fracture of the jaw are under dispensary observation. If there is a tendency to deformity (narrowing of the maxillary arch, malocclusion), orthodontic treatment becomes necessary.

Fracture of the zygomatic bone and zygomatic arch occurs more often in older children. In 4% of cases, the maxillary sinus is damaged.

Clinical picture depends on the location of the fracture and the degree of displacement of fragments. Immediately after the fracture, the retraction of the zygomatic region is visible, which after 2–4 hours is masked by soft tissue edema. An irregularity is palpated at the infraorbital margin - a symptom of a "step". If the fracture line passes through the inferoorbital foramen and the inferiororbital nerve is compressed, then numbness of the area of ​​the side wall of the nose and upper lip appears on the corresponding side. If the walls of the maxillary sinus are damaged, bleeding from the nose is observed, subcutaneous air emphysema on the face is possible. With a fracture of the zygomatic arch, opening the mouth is difficult due to the infringement of the coronoid process of the lower jaw and the tendon of the temporal muscle attached to it. X-ray examination confirms the clinical diagnosis. The fracture is reduced under general anesthesia by an extraoral or intraoral method. The intraoral method is used in case of a combination of a fracture of the zygomatic bone and the zygomatic arch, the presence of fragments in the maxillary sinus and damage to its walls. In children, the extraoral method is more often used, using the Limberg hook. At the edge of the displaced fragment, a skin puncture is made with a scalpel. With a hemostatic clamp, the tissues are bluntly stratified to the bone. Then a Limberg hook is inserted into the wound, which is used to grab the edge of the displaced fragment and lift it up. Immobilization is not required. Late complications are facial deformity and paresthesia, which require surgical treatment.

Situational tasks

Task number 1. A child has a penetrating wound in the oral cavity with a tissue defect. What method of wound treatment should be applied in this case?

Task number 2. The patient has a stab wound in the submandibular region, edema, hematoma. How will you treat the wound of this localization?

Task number 3. The patient has a half-open mouth, closing of the teeth is impossible, swelling in the lower jaw and in the submandibular region. How to make a diagnosis, what research method will you use? What first aid will you provide and how will you transport the patient?

Task number 4. The child's mouth is open, the lower jaw is motionless, salivation, speech is impossible. What is your presumptive diagnosis? What will you do to confirm the diagnosis? When confirming the diagnosis, what should be done as an emergency?

Task number 5. The patient has bleeding from the nose, a hematoma in the upper half of the face on the right or left. When viewed from the oral cavity, there is no malocclusion. What is your presumptive diagnosis? What examination should be prescribed to the patient? What needs to be applied during transportation?

Task number 6. The patient's condition is grave. Bleeding and liquorrhea from the nose, malocclusion. When questioning complaints of double vision. What is your presumptive diagnosis? What examination method should be used? What emergency assistance will you provide? What type of care will be provided to him in the hospital?

Literature

Aleksandrov N. M. Clinical operative maxillofacial surgery. - L .: Medicine, 1985.

Kovaleva N. N. Trauma of the maxillofacial region in children // G. A. Bairov. Traumatology of childhood. - L .: Medicine, 1976.

Kolesov A. A. Dentistry of children's age. - M .: Medicine, 1985 .

Kotov G. A. Fractures of the jaws in children: Ph.D. dis. … cand. honey. Sciences. - L., 1973.

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Epidemiology

At the age of 3-5 years, soft tissue injury prevails, at the age of over 5 years - bone injury and combined injuries.

Classification

Injuries of the maxillofacial region (MAF) are:

• isolated - damage to one organ (dislocation of the tooth, trauma of the tongue, fracture of the lower jaw);
• multiple - varieties of trauma of unidirectional action (dislocation of the tooth and fracture of the alveolar process);
• combined - simultaneous injuries of functionally multidirectional action (fracture of the lower jaw and craniocerebral injury).

Soft tissue injuries of the face are divided into:

• closed - without violating the integrity of the skin (bruises);
• open - with violation of the skin (abrasions, scratches, wounds).

Thus, all types of injuries, except for bruises, are open and primarily infected. In the maxillofacial region, open also includes all types of injuries passing through the teeth, airways, nasal cavity.

Depending on the source of injury and the mechanism of injury, wounds are divided into:

• non-firearms:

- bruised and their combinations;
- torn and their combinations;
- cut;
- bitten;
- chopped;
- chipped;

• firearms:

- splintered;
- bullet;

• compression;
• electrical injury;
• burns.

By the nature of the wound are:

• tangents;
• through;
• blind (as foreign bodies there may be dislocated teeth).

Etiology and pathogenesis

A variety of environmental factors determine the cause of childhood injuries. Birth injury- occurs in a newborn with a pathological birth act, features of the obstetric benefit or resuscitation. With birth trauma, injuries of the TMJ and lower jaw are often encountered. domestic injury- the most common type of childhood trauma, which accounts for more than 70% of other types of injuries. Domestic trauma prevails in early childhood and preschool age and is associated with the fall of the child, blows against various objects.

Hot and poisonous liquids, open flames, electrical appliances, matches and other items can also cause household injuries. street injury(transport, non-transport) as a kind of household injury prevails in children of school and senior school age. Transport injury is the heaviest; as a rule, it is combined, this type includes cranio-maxillofacial injuries. Such injuries lead to disability and can be the cause of death of the child.

Sports injury:

• organized - happens at school and in the sports section, is associated with improper organization of classes and training;
• unorganized - violation of the rules of sports street games, in particular extreme ones (roller skates, motorcycles, etc.).

Training and production injuries are the result of violations of labor protection rules.

burns

Among those burned, children aged 1-4 years predominate. At this age, children tip over vessels with hot water, take an unprotected electric wire into their mouths, play with matches, etc. Typical localization of burns is noted: head, face, neck and upper limbs. At the age of 10-15 years, more often in boys, burns of the face and hands occur when playing with explosives. Frostbite of the face usually develops with a single, more or less prolonged exposure to temperatures below 0 C.

Clinical signs and symptoms

Anatomical and topographical features of the structure of the maxillofacial region in children (elastic skin, a large amount of fiber, well-developed blood supply to the face, incompletely mineralized bones, the presence of growth zones of the bones of the facial skull and the presence of teeth and tooth rudiments) determine the general features of the manifestation of injuries in children.

Injuries of the soft tissues of the face in children are accompanied by:

• extensive and rapidly growing collateral edema;
• hemorrhages in the tissue (by type of infiltrate);
• the formation of interstitial hematomas;
• Bone injuries of the "green line" type.

Dislocated teeth can be embedded in soft tissues. More often this happens with an injury to the alveolar process of the upper jaw and the introduction of a tooth into the area of ​​​​the tissues of the nasolabial sulcus, cheek, bottom of the nose, etc.

bruises

With bruises, there is an increasing traumatic swelling at the site of injury, a bruise appears, which has a cyanotic color, which then acquires a dark red or yellow-green hue. The appearance of a child with a bruise often does not correspond to the severity of the injury due to increasing edema and forming hematomas. Bruises in the chin area can lead to damage to the ligamentous apparatus of the temporomandibular joints (reflected). Abrasions, scratches are primarily infected.

Signs of abrasions and scratches:

• pain;
• violation of the integrity of the skin, oral mucosa;
• edema;
• hematoma.

Wounds

Depending on the location of the wounds of the head, face and neck, the clinical picture will be different, but common signs for them are pain, bleeding, infection. With wounds of the perioral region, tongue, floor of the mouth, soft palate, there is often a danger of asphyxia with blood clots, necrotic masses. Concomitant changes in the general condition are traumatic brain injury, bleeding, shock, respiratory failure (conditions for the development of asphyxia).

Burns of the face and neck

With a small burn, the child actively reacts to pain by crying and screaming, while with extensive burns, the general condition of the child is severe, the child is pale and apathetic. Consciousness is completely preserved. Cyanosis, small and rapid pulse, cold extremities, and thirst are symptoms of a severe burn indicating shock. Shock in children develops with a much smaller area of ​​damage than in adults.

In the course of a burn disease, 4 phases are distinguished:

• burn shock;
• acute toxemia;
• septicopyemia;
• convalescence.

Frostbite

Frostbite occurs mainly on the cheeks, nose, auricles, and the back surfaces of the fingers. A red or bluish-purple swelling appears. In the heat on the affected areas, itching is felt, sometimes a burning sensation and soreness. In the future, if cooling continues, scratches and erosions form on the skin, which can become secondarily infected. There are disorders or complete cessation of blood circulation, impaired sensitivity and local changes, expressed depending on the degree of damage and the associated infection. The degree of frostbite is determined only after some time (bubbles may appear on the 2-5th day).

There are 4 degrees of local frostbite:

• I degree is characterized by circulatory disorders of the skin without irreversible damage, i.e. without necrosis;
• II degree is accompanied by necrosis of the superficial layers of the skin to the growth layer;
• III degree - total necrosis of the skin, including the growth layer, and the underlying layers;
• at IV degree, all tissues die, including bone.

G.M. Barer, E.V. Zoryan

Maxillofacial Orthopedics is one of the sections of orthopedic dentistry and includes a clinic, diagnosis and treatment of injuries of the maxillofacial region resulting from injuries, injuries, surgical interventions for inflammatory processes, neoplasms. Orthopedic treatment can be independent or used in combination with surgical methods.

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

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

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

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

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

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

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

• Dislocations of the tooth

dislocation of the tooth- This is a displacement of the tooth as a result of an acute injury. Dislocation of the tooth is accompanied by a rupture of the periodontal, circular ligament, gum. There are dislocations complete, incomplete and impacted. In the anamnesis, there are always indications of a specific cause that caused the dislocation of the tooth: transport, household, sports, industrial trauma, dental interventions.

What causes damage to the maxillofacial area

• Tooth fractures

• False joints

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

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

• Contracture of the mandible

Contracture of the lower jaw can occur not only as a result of mechanical traumatic injuries of the jaw bones, soft tissues of the mouth and face, but also from other causes (ulcer-necrotic processes in the oral cavity, chronic specific diseases, thermal and chemical burns, frostbite, myositis ossificans, tumors and etc.). Here, contracture is considered in connection with an injury to the maxillofacial region, when contractures of the lower jaw occur as a result of incorrect primary treatment of wounds, prolonged intermaxillary fixation of jaw fragments, and untimely use of physiotherapy exercises.

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

• Tooth fractures

• Contracture of the mandible

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

Symptoms of Injury to the Maxillofacial Region

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

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

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

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

The second group of signs are: the absence of teeth on fragments of the jaws or the presence of teeth with diseased periodontal disease; pronounced cicatricial changes in the soft tissues of the mouth and oral region (microstomy), the absence of the bone base of the prosthetic bed with extensive jaw defects; pronounced violations of the structure and function of the TMJ.

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

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

Knowing that each type of occlusion is characterized by its own signs of physiological wear of the teeth, it is possible to determine the type of occlusion in the victim before the injury. For example, in an orthognathic bite, wear facets will be on the cutting and vestibular surfaces of the lower incisors, as well as on the palatal surface of the upper incisors. With progeny, on the contrary, there is abrasion of the lingual surface of the lower incisors and the vestibular surface of the upper incisors. For a direct bite, flat abrasion facets are characteristic only on the cutting surface of the upper and lower incisors, and with an open bite, abrasion facets will be absent. In addition, anamnestic data can also help to correctly determine the type of bite before damage to the jaws.

• Dislocations of the tooth

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

• Tooth fractures

• Fractures of the lower jaw

Of all the bones of the facial skull, the lower jaw is most often damaged (up to 75-78%). Among the reasons in the first place are transport accidents, then domestic, industrial and sports injuries.

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

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

• Contracture of the mandible

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

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

Cicatricial contractures, depending on which tissues are affected: skin, mucous membrane or muscle, are called dermatogenic, myogenic or mixed. In addition, there are contractures temporo-coronary, zygomatic-coronary, zygomatic-maxillary and intermaxillary.

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

• prevention of the development of rough scars by correct and timely treatment of the wound (maximum convergence of the edges with suturing, with large tissue defects, stitching of the edge of the mucous membrane with the edges of the skin is shown);
• timely immobilization of fragments, if possible, using a single-jaw splint;
• timely intermaxillary fixation of fragments in case of fractures in the places of attachment of muscles in order to prevent muscle hypertension;
• the use of early therapeutic exercises.

Diagnosis of Injuries of the Maxillofacial Region

• Dislocations of the tooth

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

• Tooth fractures

The most common fractures of the alveolar process of the upper jaw with predominant localization in the region of the anterior teeth. Their causes are traffic accidents, bumps, falls.

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

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

Palpation and percussion of each tooth, determination of its position and stability make it possible to recognize damage. To determine the defeat of the neurovascular bundle of teeth, electroodontodiagnostics is used. The final conclusion about the nature of the fracture can be made on the basis of x-ray data. It is important to establish the direction of displacement of the fragment. Fragments can move vertically, in the palatingual, vestibular direction, which depends on the direction of impact.

Treatment of fractures of the alveolar process is mainly conservative. It includes fragment reposition, its fixation and treatment of damage to soft tissues and teeth.

• Fractures of the lower jaw

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

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

Treatment of injuries of the maxillofacial region

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

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

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

Recovery times vary. Despite the tendency of surgeons to perform the operation as early as possible, it is necessary to withstand a certain time when the patient remains with an unrepaired defect or deformity in anticipation of surgical treatment, plastic surgery. The duration of this period can be from several months to 1 year or more. For example, reconstructive surgery for facial defects after lupus erythematosus is recommended to be carried out after a stable elimination of the process, which is about 1 year. In such a situation, orthopedic methods are indicated as the main treatment for this period. In the surgical treatment of patients with injuries of the maxillofacial region, auxiliary tasks often arise: creating a support for soft tissues, closing the postoperative wound surface, feeding patients, etc. In these cases, the use of the orthopedic method is shown as one of the auxiliary measures in complex treatment.

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

Orthopedic devices, their classification, mechanism of action

Treatment of damage to the maxillofacial region is carried out by conservative, operative and combined methods.

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

According to the place of attachment, the devices are divided into intraoral (single jaw, double jaw and intermaxillary), extraoral, intra-extraoral (maxillary, mandibular).

According to the design and manufacturing method, orthopedic appliances can be divided into standard and individual (outside laboratory and laboratory production).

Fixing devices

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

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

With the mobility of the teeth, a sharp atrophy of the alveolar bone, it is not possible to ensure reliable stability of the fragments with dental splints due to the imperfection of the fixing part of the apparatus itself.

In such cases, the use of tooth-gingival splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of ​​​​fitting of the splinting part in the form of covering the gums and the alveolar process. With complete loss of teeth, the intra-alveolar part (retainer) of the apparatus is absent, the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained. However, the fixing capacity of such devices is extremely low.

From the point of view of biomechanics, the most optimal design is a soldered wire splint. It is mounted on rings or on full artificial metal crowns. The good fixing ability of this tire is due to a reliable, almost immovable connection of all structural elements. The sinizing arch is soldered to a ring or to a metal crown, which is fixed on the abutment teeth with the help of phosphate cement. With ligature binding with an aluminum wire arch of teeth, such a reliable connection cannot be achieved. As the tire is used, the tension of the ligature weakens, the strength of the connection of the splinting arc decreases. The ligature irritates the gingival papilla. In addition, there is an accumulation of food residues and their decay, which violates oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that occur during orthopedic treatment of jaw fractures. Soldered tires are devoid of these disadvantages.

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

Tire designs are constantly being improved. By introducing executive loops into the splinting aluminum wire arc, they try to create compression of fragments in the treatment of mandibular fractures.

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

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

Extraoral devices consist of a chin sling (gypsum, plastic, standard or individual) and a head cap (gauze, plaster, standard from strips of a belt or ribbon). The chin sling is connected to the head cap with a bandage or elastic traction.

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

AST. rehearsal apparatus

Distinguish between simultaneous and gradual reposition. One-moment reposition is carried out manually, and gradual reposition is performed by hardware.

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

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

Forming devices

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

By 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, it is possible to distinguish the forming part of the fixing devices.

Replacement devices (prostheses)

Prostheses used in maxillofacial orthopedics can be divided into dentoalveolar, maxillary, facial, combined. During resection of the jaws, prostheses are used, which are called post-resection prostheses. Distinguish between immediate, immediate and distant prosthetics. It is legitimate to divide prostheses into operating and postoperative.

Dental prosthetics is inextricably linked with maxillofacial prosthetics. Achievements in the clinic, materials science, technology for the manufacture of dentures have a positive impact on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid clasp prostheses have found application in the construction of resection prostheses, prostheses that restore dentoalveolar defects.

Replacement devices also include orthopedic devices used for palate defects. First of all, this is a protective plate - it is used for plastic surgery of the palate, obturators - are used for congenital and acquired defects of the palate.

Combined devices

For reposition, fixation, formation and replacement, a single design is appropriate, capable of reliably solving all problems. An example of such a design is an apparatus consisting of soldered crowns with levers, locking locking devices and a forming plate.

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

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

When solving this problem, the following rules should be followed:

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

Clamps, rings, crowns, telescopic crowns, mouth guards, ligature binding, springs, magnets, spectacle frames, sling bandage, corsets can be used as fixing devices for maxillofacial apparatuses. The correct choice and use of these devices adequately to clinical situations allow success in the orthopedic treatment of injuries of the maxillofacial region.

Orthopedic methods of treatment for injuries of the maxillofacial region

Dislocations and fractures of teeth

• Dislocations of the tooth

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

• Tooth fractures

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

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

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

In case of fractures at the neck of the tooth, often resulting from cervical caries, often associated with an artificial crown that does not tightly cover the neck of the tooth, removal of the broken part and restoration with the help of a stump pin tab and an artificial crown is indicated.

A root fracture is clinically manifested by tooth mobility, pain when biting. On radiographs of the teeth, the fracture line is clearly visible. Sometimes, in order to trace the fracture line along its entire length, it is necessary to have x-rays obtained in various projections.

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

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

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

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

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

• Fractures of the alveolar process

Treatment of fractures of the alveolar process is mainly conservative. It includes fragment reposition, its fixation and treatment of damage to soft tissues and teeth.

Fragment reposition with fresh fractures can be carried out manually, with chronic fractures - by the method of bloody reposition or with the help of orthopedic devices. When the broken off alveolar process with teeth is displaced to the palatal side, reposition can be performed using a dissociating palatal plate with a screw. The mechanism of action of the apparatus consists in the gradual movement of the fragment due to the pressing force of the screw. The same problem can be solved by using an orthodontic appliance by stretching the fragment to the wire arch. In a similar way, it is possible to reposition a vertically displaced fragment.

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

Fragment fixation can be carried out with any tooth splint: bent, wire, soldered wire on crowns or rings, made of quick-hardening plastic.

• Fractures of the body of the upper jaw

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

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

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CHAPTER 1

GENERAL INFORMATION ABOUT INJURY OF THE MAXILLOFACIAL REGION, STATISTICAL DATA, CLASSIFICATION

Patients with injuries of the maxillofacial region account for about 30% of all patients treated in hospitals for maxillofacial surgery. The frequency of facial injuries is 0.3 cases per 1000 people, and the proportion of all maxillofacial trauma among injuries with bone damage in the urban population ranges from 3.2 to 8%. According to Yu.I. Bernadsky (2000), the most common are fractures of the bones of the face (88.2%), soft tissue injuries - in 9.9%, burns of the face - in 1.9%.

There is a predominance of injuries of the maxillofacial region in men compared to women. The number of traumatic injuries increases during the summer period and on holidays.

Classification of injuries of the maxillofacial region.

1. Depending on the circumstances of injury, the following types of traumatic injuries are distinguished: industrial and non-productive (domestic, transport, street, sports) injuries.

2. According to the mechanism of damage (the nature of the damaging factors), there are:

mechanical (firearms and non-firearms),

thermal (burns, frostbite);

· chemical;

radiation;

combined.

3. Mechanical damage in accordance with the "Classification of damage to the maxillofacial region" are divided depending on:

a) localization (injuries to the soft tissues of the face with damage to the tongue, salivary glands, large nerves, large vessels; injuries to the bones of the lower jaw, upper jaw, zygomatic bones, nasal bones, two bones or more);

b) the nature of the injury (through, blind, tangential, penetrating and non-penetrating into the oral cavity, maxillary sinuses or nasal cavity);

c) damage mechanism (firearms and non-firearms, open and closed).

There are also: combined lesions, burns and frostbite.

It is necessary to distinguish between the concepts of combined and combined trauma.

Associated injury is damage to at least two anatomical regions by one or more damaging factors.

Combined injuries a is damage caused by exposure to various traumatic agents. In this case, the participation of the radiation factor is possible.

In traumatology, there are open and closed damage. Open diseases include those in which there is damage to the integumentary tissues of the body (skin and mucous membrane), which, as a rule, leads to infection of damaged tissues. With a closed injury, the skin and mucous membrane remain intact.

The nature of the injury to the face, the clinical course and outcome depend on the type of injuring object, the strength of its impact, the localization of the injury, as well as on the anatomical and physiological features of the area of ​​injury.

Features of primary surgical treatment of facial wounds.

early surgical treatment of the wound up to 24 hours from the onset of injury;

final surgical treatment of the wound in a specialized institution;

The edges of the wound are not excised, only obviously non-viable tissues are cut off;

narrow wound channels are not completely dissected;

foreign bodies are removed from the wound, but the search for foreign bodies located in hard-to-reach places is not undertaken;

Wounds penetrating the oral cavity must be isolated from the oral cavity by applying blind sutures. It is necessary to protect the bone wound from the contents of the oral cavity;

· on the wounds of the eyelids, wings of the nose and lips, the primary suture is always applied, regardless of the timing of the surgical treatment of the wound.

When suturing wounds on the lateral surface of the face, drainage is introduced into the submandibular region.

At injury penetrating into the oral cavity First of all, the mucous membrane is sutured, then the muscles and skin.

At lip wounds the muscle is sutured, the first suture is superimposed on the border of the skin and the red border of the lip.

At damage to the soft tissues of the face, combined with bone trauma, first, the bone wound is treated. At the same time, fragments not associated with the periosteum are removed, the fragments are repositioned and immobilized, the bone wound is isolated from the contents of the oral cavity. Then proceed to the surgical treatment of soft tissues.

At wounds penetrating into the maxillary sinus, produce an audit of the sinus, form an anastomosis with a lower nasal passage, through which the iodoform tampon is removed from the sinus. After that, the surgical treatment of the wound of the face is carried out with layer-by-layer suturing.

When damaged salivary gland first, sutures are applied to the parenchyma of the gland, then to the capsule, fascia and skin.

When damaged duct conditions should be created for the outflow of saliva into the oral cavity. To do this, a rubber drainage is brought to the central end of the duct, which is removed into the oral cavity. The drainage is removed on the 14th day. The central excretory duct can be sutured on a polyamide catheter. At the same time, its central and peripheral sections are compared.

Crushed submandibular salivary gland may be removed during the primary surgical treatment of the wound, and the parotid, due to the complex anatomical relationship with the facial nerve, cannot be removed due to injury.

At large through defects soft tissues of the face, the convergence of the edges of the wound almost always leads to pronounced deformities of the face. Surgical treatment of wounds should be completed with their “sheathing”, connecting the skin with the mucous membrane with sutures. Subsequently, plastic closure of the defect is performed.

With an extensive injury to the lower third of the face, the bottom of the mouth, the neck, a tracheostomy is necessary, and then intubation and primary surgical treatment of the wound.

Wound in the infraorbital region with a large defect is not sutured on itself parallel to the infraorbital margin, but is eliminated by cutting out additional flaps (triangular, tongue-shaped), which are moved to the defect site and fixed with the appropriate suture material.

After the primary surgical treatment of the wound, it is necessary to carry out the prophylaxis of tetanus.

TOOTH INJURIES

Tooth injury- this is a violation of the anatomical integrity of the tooth or its surrounding tissues, with a change in the position of the tooth in the dentition.

Cause of acute trauma to the teeth: falling on hard objects and hitting the face.

Most often, incisors are subject to acute trauma of the teeth, mainly on the upper jaw, especially during prognathism.

Classification of traumatic injuries of teeth.

I. WHO classification of injuries.

Class I. Contusion of the tooth with minor structural damage.

Class II. Uncomplicated fracture of the crown of the tooth.

Class III. Complicated fracture of the crown of the tooth.

Class IV. Complete fracture of the crown of the tooth.

Class V. Coronal root longitudinal fracture.

Class VI. Fracture of the root of the tooth.

Class VII. Dislocation of the tooth is incomplete.

Class VIII. Complete luxation of the tooth.

II. Classification of the clinic of pediatric maxillofacial surgery of the Belarusian State Medical University.

1. Bruised tooth.

1.1. with rupture of the neurovascular bundle (NB).

1.2. without breaking the SNP.

2. Dislocation of the tooth.

2.1. incomplete dislocation.

2.2. with a break in the SNP.

2.3. without breaking the SNP.

2.4. complete dislocation.

2.5. impacted dislocation

3. Tooth fracture.

3.1. fracture of the crown of the tooth.

3.1.1. within the enamel.

3.1.2. within the dentin (with opening of the tooth cavity, without opening of the tooth cavity).

3.1.3. fracture of the crown of the tooth.

3.2. fracture of the tooth root (longitudinal, transverse, oblique, with displacement, without displacement).

4. Injury of the tooth germ.

5. Combined tooth injury (dislocation + fracture, etc.)

INJURED TOOTH

Tooth injury - traumatic damage to the tooth, characterized by concussion and / or hemorrhage into the pulp chamber. When a tooth is bruised, the periodontium is primarily damaged in the form of a rupture of part of its fibers, damage to small blood vessels and nerves, mainly in the apical part of the tooth root. In some cases, a complete rupture of the neurovascular bundle is possible at its entrance to the apical foramen, which, as a rule, leads to the death of the dental pulp due to the cessation of blood circulation in it.

Clinic.

The symptoms of acute traumatic periodontitis are determined: pain in the tooth, aggravated by biting, pain during percussion. In connection with the swelling of periodontal tissues, there is a feeling of "promotion" of the tooth from the hole, its moderate mobility is determined. At the same time, the tooth retains its shape and position in the dentition. Sometimes the crown of a damaged tooth turns pink due to hemorrhage in the pulp of the tooth.

An x-ray examination is required to exclude a fracture of its root. When a tooth is bruised, a moderate expansion of the periodontal gap can be detected on the radiograph.

creating conditions for the rest of the damaged tooth, removing it from occlusion by grinding the cutting edges of the teeth;

mechanically sparing diet;

In case of pulp death – extirpation and canal filling.

Pulp viability is monitored by

electroodontodiagnostics in dynamics within 3-4 weeks, as well as on the basis of clinical signs (darkening of the tooth crown, pain during percussion, the appearance of a fistula on the gums).

DISTRUCTIONS OF THE TEETH

dislocation of the tooth- traumatic injury to the tooth, as a result of which its connection with the hole is broken.

A tooth luxation most often occurs as a result of a blow to the crown.

tooth. More often than others, the frontal teeth on the upper jaw and less often on the lower jaw are exposed to dislocation. Dislocations of premolars and molars occur most often with the careless removal of adjacent teeth using an elevator.

Distinguish:

incomplete dislocation (extrusion),

Complete dislocation (avulsion)

Impacted dislocation (intrusion).

With incomplete dislocation, the tooth partially loses its connection with the tooth socket,

becomes mobile and displaced due to rupture of periodontal fibers and violation of the integrity of the cortical plate of the alveolus of the tooth.

With a complete dislocation, the tooth loses its connection with the socket of the tooth due to a rupture.

all periodontal tissues, falls out of the hole or is held only by the soft tissues of the gums.

In impacted dislocation, the tooth is embedded in the spongy

substance of the bone tissue of the alveolar process of the jaw (immersion of the tooth into the hole).

Incomplete dislocation of teeth

Clinic. Complaints about pain, tooth mobility, change in position

zheniya it in the dentition, violation of the function of chewing. When examining the oral cavity, incomplete dislocation of the tooth is characterized by a change in the position (displacement) of the crown of the injured tooth in different directions (orally, vestibularly, distally, towards the occlusal plane, etc.). The tooth may be mobile and sharply painful on percussion, but not displaced outside the dentition. The gum is edematous and hyperemic, its ruptures are possible. Due to the rupture of the circular ligament of the tooth, periodontal tissues and damage to the alveolar wall, pathological dentogingival pockets and bleeding from them can be determined. When a tooth is dislocated and its crown is displaced orally, the root of the tooth, as a rule, is displaced vestibularly, and vice versa. When a tooth is displaced towards the occlusal plane, it protrudes above the level of neighboring teeth, is mobile and interferes with occlusion. Very often, the patient has a concomitant injury to the soft tissues of the lips (bruise, hemorrhage, wound).

With incomplete dislocation of the tooth, the expansion of the periodontal gap and some “shortening” of the root of the tooth are determined radiographically if it is displaced orally or vestibular.

Treatment of incomplete dislocation.

Reposition of the tooth

fixation with a kappa or a smooth bus-bracket;

sparing diet;

inspection after 1 month;

When establishing the death of the pulp - its extirpation and canal filling.

Immobilization or fixation of teeth is carried out in the following ways:

1. Ligature tying of teeth (simple ligature tying, continuous in the form of a figure eight, tying teeth according to Baronov, Obwegeser, Frigof, etc.). Ligature binding of teeth is shown, as a rule, in permanent occlusion in the presence of stable, adjacent teeth (2-3 on both sides of the dislocated one). For ligature binding of teeth, thin (0.4 mm) soft bronze-aluminum or stainless steel wire is usually used. The disadvantage of these methods of splinting is the impossibility of their use in temporary occlusion for the above reasons. In addition, the application of wire ligatures is a rather laborious process. At the same time, this method does not allow sufficiently rigid fixation of dislocated teeth.

2. Bus-bracket (wire or tape). A tire is made (bent) from stainless wire from 0.6 to 1.0 mm. thick or standard steel tape and fixed to the teeth (2-3 on both sides of the dislocated one) using a thin (0.4 mm) ligature wire. A brace is shown in permanent occlusion, usually with a sufficient number of adjacent teeth that are stable.

Disadvantages: invasiveness, laboriousness and limited use in temporary bite.

3. Tire kappa. It is made, as a rule, from plastic in one visit, directly in the patient's oral cavity after the teeth are repositioned. Disadvantages: separation of the bite and the difficulty of conducting EOD.

4. Tooth-gingival splints. Shown in any occlusion in the absence of a sufficient number of supporting, including adjacent teeth. They are made of plastic with reinforced wire, laboratory-made after taking an impression and casting a jaw model.

5. The use of composite materials, with the help of which wire arcs or other splinting structures are fixed to the teeth.

Immobilization of dislocated teeth is usually carried out within 1 month (4 weeks). At the same time, it is necessary to strictly observe oral hygiene to prevent inflammatory processes and damage to the enamel of splinted teeth.

Complications and outcomes of incomplete dislocation: shortening of the tooth root,

obliteration or expansion of the root canal with the formation of an intrapulpal granuloma, stopping the formation and growth of the root, curvature of the tooth root, changes in the periapical tissues in the form of chronic periodontitis, root cysts.

Complete dislocation of teeth.

Complete dislocation of the tooth (traumatic extraction) occurs after a complete rupture of the periodontal tissues and the circular ligament of the tooth as a result of a strong blow to the tooth crown. The frontal teeth in the upper jaw (mainly the central incisors) are most often affected, and less often in the lower jaw.

Clinical picture: when examining the oral cavity, there is no tooth in the dentition and there is a hole of a dislocated tooth that is bleeding or filled with a fresh blood clot. Often there are concomitant damage to the soft tissues of the lips (bruises, wounds of the mucosa, etc.). When contacting a dentist, dislocated teeth are often brought "in the pocket". To draw up a treatment plan, it is necessary to assess the condition of the dislocated tooth (the integrity of the crown and root, the presence of carious cavities, a temporary tooth or a permanent one, etc.).

Treatment of complete dislocation consists of the following steps.

Pulp extirpation and canal filling;

· replantation;

fixation for 4 weeks with a kappa or a smooth splint;

mechanically sparing diet.

It is necessary to examine the tooth socket and assess its integrity. X-ray, with a complete dislocation of the tooth, a free (empty) tooth socket with clear contours is determined. If the socket of the dislocated tooth is destroyed, then the boundaries of the alveoli are not determined radiologically.

Indications for tooth replantation depend on the age of the patient, his

general condition, the condition of the tooth itself and its socket, from whether the tooth is temporary or permanent, the root of the tooth is formed or not.

Tooth replantation is the return of the tooth to its own socket. Distinguish immediate and delayed tooth replantation. With simultaneous replantation in one visit, a tooth is prepared for replantation, its root canal is sealed and the actual replantation is carried out, followed by splinting it. In delayed replantation, the avulsed tooth is washed, immersed in saline with an antibiotic, and placed temporarily (until replantation) in the refrigerator. After a few hours or days, the tooth is trepanned, sealed and replanted.

The operation of tooth replantation can be divided into the following stages:

1. Preparation of the tooth for replantation.

2. Preparation of the tooth socket for replantation.

3. The actual replantation of the tooth and its fixation in the hole.

4. Postoperative treatment and observation in dynamics.

1-1.5 months after the tooth replantation operation, the following types of tooth engraftment are possible:

1. Engraftment of the tooth according to the type of primary tension through the periodontium (syndesmosis). This is the most favorable, periodontal type of fusion, depending mainly on the preservation of the viability of periodontal tissues. With this type of union on the control radiograph, a periodontal gap of uniform width is determined.

2. Engraftment of the tooth according to the type of synostosis or bone fusion of the tooth root and the wall of the hole. This occurs with the complete death of periodontal tissues and is the least favorable type of fusion (tooth ankylosis). With ankylosis of the tooth, the periodontal gap is not visible on the control radiograph.

3. Engraftment of the tooth according to the mixed (periodontal-fibrous-bone) type of fusion of the tooth root and the wall of the alveolus. On the control radiograph with such an adhesion, the line of the periodontal fissure alternates with areas of its narrowing or absence.

In the remote period (several years) after tooth replantation, resorption (resorption) of the root of the replanted tooth may occur.

Operative methods of treatment.

1. Suspension of the upper jaw to the orbital edge of the frontal bone according to Faltin-Adams.

At a fracture:

In the lower type, the upper jaw is fixed to the lower edge of the orbit or to the edge of the piriform opening;

On the middle type - to the zygomatic arch;

In the upper type - to the zygomatic process of the frontal bone;

Operation steps:

· A wire splint with two toe loops facing down is placed on the upper jaw.

· An undamaged section of the upper outer edge of the orbit is exposed, in which a hole is made. A thin wire or polyamide thread is passed through it.

Both ends of the ligature with a long needle are passed through the thickness of the soft tissues so that they come out in the vestibule of the oral cavity at the level of the first molar.

After the fragment is repositioned to the correct position, the ligature is fixed by the hook of the dental splint.

This operation is carried out on both sides.

· If it is necessary to correct the bite, a splint with hook loops is applied to the lower jaw and intermaxillary rubber traction or parieto-chin sling.

2. Fronto-maxillary osteosynthesis according to Chernyatina-Svistunov indicated for fractures of the upper jaw in the middle and upper type.

Fragments are fixed not to the splint, but to the zygomatic-alveolar crest.

3. Fixation of fragments of the upper jaw with Kirschner's wires according to Makienko.

4. Osteosynthesis of fractures of the upper jaw with titanium mini-plates.

In case of a fracture of the lower type, osteosynthesis is carried out in the area of ​​the zygomatic-alveolar ridge and along the edge of the piriform opening through intraoral incisions.

In case of a fracture of the middle type, mini-plates are applied along the zygomatic-alveolar ridge, as well as along the lower edge of the orbit and in the region of the bridge of the nose.

In case of a fracture of the upper type, osteosynthesis is shown in the region of the bridge of the nose, the upper outer corner of the orbit and the zygomatic arch.

· For the prevention of traumatic maxillary sinusitis, a revision of the maxillary sinus is performed, an anastomosis with a lower nasal passage is applied, the defect is closed with local tissues to separate the oral cavity from the sinus.

FRACTURES

Classification of non-gunshot fractures of the zygomatic bone and arch:

1. Fractures of the zygomatic bone (with and without displacement of fragments).

2. Fractures of the zygomatic arch (with and without displacement of fragments).

Displaced fractures of the zygomatic bone are usually open.

Fractures of the zygomatic arch are most often closed.

Clinic of fractures of the zygomatic bone (zygomatic-maxillary complex).

The following symptoms are identified:

Severe swelling of the eyelids and hemorrhage in the tissue around one eye, which leads to a narrowing or closure of the palpebral fissure.

Bleeding from the nose (from one nostril).

· Limited mouth opening due to blockage of the coronoid process of the lower jaw, displaced zygomatic.

Anesthesia or paresthesia of soft tissues in the zone of innervation of the infraorbital nerve on the side of the injury (upper lip, wing of the nose, infraorbital region, etc.).

· Violations of binocular vision (diplopia or double vision) due to the displacement of the eyeball.

Retraction, determined by palpation in the zygomatic region.

· Pain and "step" symptom on palpation along the infraorbital margin, upper outer margin of the orbit, along the zygomatic arch and along the zygomatic-alveolar crest.

Clinic of fractures of the zygomatic arch:

Damage to the soft tissues of the zygomatic region (edema, wounds, hemorrhages), which masks the retraction in the zygomatic region.

Limited mouth opening due to blockage of the coronoid process of the lower jaw by a displaced zygomatic arch.

Lack of unilateral lateral movements of the mandible.

Retraction, pain and a symptom of "steps" on palpation in the area of ​​the zygomatic arch.

X-ray examination.

X-rays of the paranasal sinuses and zygomatic bones are studied in the naso-chin (semi-axial) and axial projections.

Defined:

Violation of the integrity of the bone tissue at the junction of the zygomatic bone with other bones of the facial and cerebral skull;

Darkening of the maxillary sinus on one side as a result of hemosinus in fractures of the zygomatic bone.

Treatment.

Patients are treated in a hospital.

In case of fractures of the zygomatic bone and arch without significant displacement of fragments and dysfunction, conservative treatment is carried out, restriction of solid food intake.

Indications for reposition of fragments of the zygomatic arch and bone:

Deformation of the face due to retraction of tissues in the zygomatic region,

violation of sensitivity in the zone of innervation of the infraorbital and zygomatic nerve, diplopia,

Disturbance of movements of the lower jaw.

Fractures of the bones of the nose

Occur when falling or a strong blow to the bridge of the nose. The displacement of bone fragments depends on the strength and direction of the traumatic factor.

Classification.

Allocate fractures of the bones of the nose with displacement and without displacement of bone fragments, as well as impacted fractures of the bones of the nose.

All displaced nasal fractures are open fractures, as they are accompanied by ruptures of the nasal mucosa and profuse epistaxis.

40% of patients with fractures of the bones of the nose have a traumatic brain injury.

Clinical symptoms of a fracture of the bones of the nose:

Deformation of the external nose in the form of a lateral curvature of it or a saddle depression.

· Nose bleed.

Difficulty in nasal breathing.

Damage to the skin of the back of the nose.

Swelling of the eyelids and hemorrhage in the tissue around the eyes (a symptom of glasses).

Pain, crepitus and mobility of bone fragments, determined by palpation in the area of ​​the back of the nose.

Displacement of the bone and cartilage of the nasal septum, which is detected during anterior rhinoscopy.

For the final diagnosis of a fracture, an X-ray of the bones of the nose is shown in frontal and lateral projections.

Treatment.

First aid- stop bleeding (anterior or posterior tamponade).

Reposition of fragments under local anesthesia with the help of a hemostatic clamp introduced into the upper nasal passage or a special elevator, which lifts the displaced bones, forming the contours of the back of the nose with the index and thumbs of the left hand. The nasal passages are plugged.

The imposition of an external fixing bandage (tire) for fixing bone fragments for 8-10 days (gauze collodion bandage or plaster).

COMPLICATIONS OF PERSONAL INJURIES

The following types of complications of injuries of the maxillofacial region are distinguished:

1. Direct (asphyxia, bleeding, traumatic shock).

2. Immediate complications (suppuration of wounds, abscess and phlegmon of soft tissues, traumatic osteomyelitis, traumatic maxillary sinusitis, secondary bleeding due to thrombus melting, sepsis).

3. Long-term complications (cicatricial deformity of soft tissues, soft tissue defects, adentia and death of the rudiments of permanent teeth, jaw deformity, incorrectly fused jaw fracture, malocclusion, bone tissue defects, false joint, jaw growth retardation, ankylosis and other diseases of the temporomandibular joint).

TRAUMATIC SHOCK

traumatic shock- the general reaction of the body to severe damage, in the pathogenesis of which the central place is occupied by a violation of tissue circulation, a decrease in cardiac output, hypovolemia and a drop in peripheral vascular tone. There is ischemia of vital organs and systems (heart, brain, kidneys).

Traumatic shock occurs as a result of severe polytrauma, severe bone injuries, crushing of soft tissues, extensive burns, combined trauma to the face and internal organs. With such injuries, severe pain occurs, which is the root cause of traumatic shock and disruption of the interconnected functions of the circulatory, respiratory and excretory organs.

During shock, erectile and torpid phases are distinguished. The erectile phase is usually short-term, manifested by general anxiety.

The torpid phase is divided into 3 degrees according to the severity of clinical manifestations:

1 degree - mild shock;

Grade 2 - severe shock;

Grade 3 - terminal state.

For the 1st degree of the torpid phase, the following are characteristic: indifference to the environment, pallor of the skin, pulse 90-110 beats per minute, systolic pressure 100-80 mm. rt. Art., diastolic - 65-55 mm. rt. Art. The volume of circulating blood is reduced by 15-20%.

At grade 2 shock, the victim's condition is severe, the skin is pale with a grayish tint, although consciousness is preserved, indifference to the environment increases, the pupils react poorly to light, reflexes are lowered, the pulse is frequent, heart sounds are muffled. Systolic pressure - 70 mm. rt. Art., diastolic - 30-40 mm. rt. Art., is not always caught. The volume of circulating blood is reduced by 35% or more. Breathing is frequent, shallow.

The terminal state is characterized by: loss of consciousness, pale gray skin, covered with sticky sweat, cold. The pupils are dilated, weakly or completely unresponsive to light. Pulse, blood pressure are not determined. Breathing is barely noticeable. The volume of circulating blood is reduced by 35% or more.

Treatment.

The main objectives of the treatment:

local and general anesthesia;

stop bleeding;

Compensation for blood loss and normalization of hemodynamics;

maintaining external respiration and combating asphyxia and hypoxia;

temporary or transport immobilization of a jaw fracture, as well as timely surgical intervention;

correction of metabolic processes;

Satisfying hunger and thirst.

When providing first aid at the scene of an accident, reducing bleeding can be achieved by finger pressure on the damaged blood vessel. Effective general anesthesia is achieved by using non-narcotic analgesics (analgin, fentanyl, etc.) or neuroleptanalgesia (droperidol, etc.). Local anesthesia - conduction or infiltration. With the threat of asphyxia, subcutaneous administration of morphine (omnopon) is contraindicated. In cases of respiratory depression, the victims inhale carbon dioxide, ephedrine is injected subcutaneously.

BRONCHOPULMONAL COMPLICATIONS

Bronchopulmonary complications develop as a result of prolonged aspiration of infected oral fluid, bone, blood, vomit. With gunshot wounds of soft tissues and bones of the face, bronchopulmonary complications are more common than with injuries of other areas.

Predisposing factors for the development of bronchopulmonary complications:

constant salivation from the oral cavity, which, especially in winter, can lead to significant hypothermia of the anterior surface of the chest;

· blood loss;

· dehydration;

malnutrition;

weakening of the body's defenses.

The most common complication is aspiration pneumonia. It develops 4-6 days after the injury.

Prevention:

timely provision of specialized assistance;

antibiotic therapy;

prevention of aspiration of food during feeding;

mechanical protection of the chest organs from wetting with saliva;

· breathing exercises.

ASPHYXIA

Clinic of asphyxia. The breathing of the victims is accelerated and deepened, auxiliary muscles participate in the act of breathing, when inhaling, the intercostal spaces and the epigastric region sink down. The breath is noisy, with a whistle. The face of the victim is cyanotic or pale, the skin becomes gray in color, the lips and nails are cyanotic. The pulse slows down or quickens, cardiac activity falls. The blood takes on a dark color. Victims often experience excitation, restlessness is replaced by loss of consciousness.

Types of asphyxia in the wounded in the face and jaw and treatment according to G.M. Ivashchenko

Indications for tracheostomy:

damage to the maxillofacial region in combination with severe craniocerebral trauma, causing loss of consciousness and respiratory depression;

The need for prolonged artificial ventilation of the lungs and systematic drainage of the tracheobronchial tree;

Injuries with detachment of the upper and lower jaws, when there is a significant aspiration of blood into the respiratory tract and their drainage cannot be provided through the endotracheal tube;

after extensive and severe operations (resection of the lower jaw with a one-stage Crail operation, excision of a cancerous tumor of the root of the tongue and the floor of the mouth).

In the postoperative period, due to impaired swallowing and a reduced cough reflex, as well as due to a violation of the integrity of the muscles of the floor of the mouth, such patients often experience retraction of the tongue, blood constantly flows into the trachea mixed with saliva, and a large amount of fluid accumulates in the trachea and bronchi amount of mucus and sputum.

There are the following types of tracheostomy:

Upper (imposition of a stoma above the isthmus of the thyroid gland);

Medium (imposition of a stoma through the isthmus of the thyroid gland);

lower (imposition of a stoma below the isthmus of the thyroid gland);

The lower one is shown only in children, the middle one is practically not produced.

Tracheostomy technique(according to V. O. Bjork, 1960).

The patient lies on his back with a roller under the shoulder blades and the head thrown back as much as possible.

· An incision is made in the skin and subcutaneous tissue 2.5-3 cm long along the midline of the neck, 1.5 cm below the cricoid cartilage.

· In a blunt way, the muscles are stratified and the isthmus of the thyroid gland is pushed up or down, depending on the anatomical features. In the first case, to prevent pressure on the tracheostomy tube, the isthmus capsule is fixed to the upper skin flap.

In the anterior wall of the trachea, a flap is cut out from the second or from the second and third rings of the trachea, with the base turned downwards. To avoid injury to the cricoid cartilage by the tracheostomy tube, the first tracheal ring is retained.

The apex of the flap is fixed with one catgut suture to the dermis of the lower skin flap.

A tracheostomy cannula of the appropriate diameter with a replaceable inner tube is inserted into the stoma. The diameter of the outer cannula should correspond to the opening in the trachea.

Removal of the tracheostomy tube (decannulation) is usually performed on the 3-7th day, after making sure that the patient can breathe normally through the glottis, the stoma is then pulled together with a strip of adhesive tape. As a rule, it closes on its own after 7-10 days.

Cricoconicotomy indicated for asphyxia when there is no time for tracheostomy and intubation is not possible.

Operation technique:

Rapid dissection (simultaneously with the skin) of the cricoid cartilage and thyroid cricoid ligament.

The edges of the wound are bred with any instrument suitable for this purpose.

A narrow cannula is temporarily inserted into the wound and the trachea is drained through it.

BLEEDING

bleeding called the outflow of blood from a blood vessel in violation of the integrity of its walls.

Depending on the place where the blood is poured after the injury, there are:

interstitial bleeding - the blood leaving the vessels, impregnating the tissues surrounding the damaged vessel, causes the formation of petechiae, ecchymosis and hematomas;

external bleeding - the outflow of blood on the surface of the body;

Internal bleeding - the outflow of blood into any cavity of the body.

According to the source of the outflow of blood from the vessel, they distinguish arterial, venous, capillary and mixed bleeding.

According to the time factor of the outflow of blood, there are:

primary;

secondary early (in the first 3 days after injury).

The reasons: eruption of the ligature of the vessel, slippage of the ligature from the vessel, technical errors of hemostasis, improvement of central and peripheral hemodynamics as a result of the patient's exit from the state of circulatory insufficiency;

secondary late (on the 10-15th day after injury).

The reasons: purulent fusion of a thrombus and vessel wall, DIC, followed by blood hypocoagulation.

Criteria for assessing the severity of blood loss.