Classification of maxillofacial and facial prostheses. Methods of retention of maxillofacial and facial prostheses
The reduction of fragments of the jaw with repositioning devices is called long-term reposition. There are 2 types of manufacturing devices: Clinical and laboratory.1 Mouth guards For fractures mandible with displacement and stiffness of fragments, repairing regulating apparatuses are shown with extension of fragments with the help of wire tires and rubber rings or elastic wire tires and devices with screws. After fitting the prepared mouthguards in the mouth, they are made up with the model of the upper jaw along the occlusal surfaces and a plaster block is obtained...
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Introduction………………………………………………………………….….3 page
Chapter 1 Replicating devices………………………………………………4p.
- Mouthguards…………………….………………………………………….………4p.
- Shura apparatus..………..………………………………….…...……...5p.
- Katz apparatus………...…………………...……….………………....7p.
- Oksman's apparatus ……………………………………………………......8p.
- Brun's apparatus………………………………………………………...8p.
- Kappo-barbell apparatus of A. L. Grozovsky……………………...…9p.
Chapter 2. Fixing devices………..………………………………..10p.
2.1. Sheena Vankevich.………..…….………………..………………….....10p.
2.2. Weber bus….…………….………………….…………………....11p.
2.3. Apparatus of A. I. Betelman…………………………………….…..12p.
……………………………..13p.
2.5. Soldered tire on rings according to A. A. Limberg……………………...13str.
Chapter 3. Forming devices….………………………………..…...15p
Conclusion………………………………………………………...……… 16p.
References…...…………………………………………………...17p.
Introduction.
Maxillofacial orthopedics is a branch of orthopedic dentistry that studies the prevention, diagnosis and orthopedic treatment of injuries of the maxillofacial region that have arisen after trauma, wounds or surgical interventions for inflammatory processes and neoplasms.
In case of serious injuries (fractures) of the jaws, instrumental treatment is necessary, which mainly includes both fixing maxillofacial devices and repositioning (correcting) devices. Fixing devices are used for immobilization of non-displaced fragments and for fixation of corrected displaced fragments in case of jaw fractures. Basically, tires are classified as fixing devices.
Repositioning maxillofacial apparatuses, also called corrective ones, are intended for reduction (reposition) of fractures with displacement of fragments. The reduction of fragments of the jaw with repositioning devices is called long-term reposition.
There are 2 types of manufacturing devices: Clinical and laboratory.
In my work, I will describe the methods of manufacturing maxillofacial apparatuses in a dental laboratory.
Chapter 1
1.1 Mouthguards
In case of mandibular fractures with displacement and stiffness of fragments, repairing (regulating) devices with traction of fragments using wire splints and rubber rings or elastic wire splints and devices with screws are indicated. Tires are used in the presence of teeth on both fragments. Composite tires are bent separately for each fragment along the outer surface of the teeth from elastic stainless steel 1.21.5 mm thick with hooks on which rubber rings are applied for traction. Tires are fixed on the teeth with crowns, rings or wire ligatures. After establishing the fragments in the correct position, the control tires are replaced with fixing ones. It is advisable to use repairing devices, which, after moving the fragments, can be used as splinting. These apparatuses include the apparatus of Kurlyandsky. It consists of caps. Double tubes are soldered on the buccal surface of the kappa, into which rods of the appropriate section are inserted. For the manufacture of the apparatus, casts are taken from the teeth of each fragment and, according to the obtained models, stainless steel mouth guards are prepared for these groups of teeth. After fitting the prepared mouthguards in the mouth, they are made up with a model of the upper jaw along the occlusal surfaces and a plaster block is obtained, that is, a model. Kappas are placed along the occlusal surface of the opposite jaw to determine the direction of displacement of fragments and securely fix them after reposition. Double tubes are soldered to the kappa from the side of the vestibule of the mouth in a horizontal direction and rods are attached to them. Then the tubes are sawn between the trays and each tray is cemented separately on the teeth. After simultaneous reposition of the jaw fragments or traction with rubber rings, their correct position is fixed by inserting the rods into the tubes soldered to the kappa. For reposition, 1-2 springy archwires are used, which are inserted into the tubes, or screw devices. Arcs in the form of a loop, resembling a Coffin spring, are bent according to block models and, after fixing the kappa, are inserted into the tubes. Screw devices consist of a screw mounted in a protruding plate inserted into the tubes of one of the caps. A rigid plate bent in the direction of displacement of the fragments with a support platform for the screw is inserted into the tubes of the second kappa.
1.2 Schur apparatus.
The manufacture of the Schur apparatus begins with the removal of an impression from the abutment posterior teeth. Abutment crowns are made in the usual stamped way without tooth preparation and fit them in the oral cavity. Together with the crowns, an impression is taken from the lower jaw, a plaster working model is cast, on which the supporting crowns are located. A rod 2-2.5 mm thick and 40-45 mm long is prepared, ½ of this rod is flattened and, accordingly, a flat tube is prepared for it, which is soldered to the supporting crowns from the buccal side. On the lingual side, the supporting crowns are soldered with a 1 mm thick wire to strengthen the structure.
After checking the supporting part of the apparatus in the oral cavity, the flattened part of the rod is inserted into the tube, and the round protruding part is bent so that its free end, with the mouth closed and the fragment displaced, is located along the buccal tubercles of the teeth-antagonists of the upper jaw. In the laboratory, an inclined plane 10-15 mm high and 20-25 mm long is soldered to the round end of the rod along the flattened end of the rod in the tube.
On the working model, the inclined plane is set in relation to the antagonist tooth at an angle of 10-15 degrees. In the process of treatment, the inclined plane is brought closer to the abutment teeth by compressing the curved arch. Periodically (every 1-2 days), by approaching the inclined plane to its supporting part, the position of the fragment is corrected and the patient is taught to put the fragment of the lower jaw in a more and more correct position when closing the mouth. When the inclined plane comes close to its support, the fragment of the lower jaw will be set in the correct position. After 2-6 months of using this device, even in the presence of a large bone defect, the patient can freely, without an inclined plane, set the fragment of the lower jaw into the correct position. Thus, the Schur apparatus is distinguished by a good repositioning effect, small size and ease of use and manufacture.
More effective devices that are used for displacement of fragments to the median line include devices: Katz, Brun and Oksman.
1.3 Katz apparatus.
The Katz repositioning apparatus consists of crowns or rings, a tube and levers. In the usual way, orthodontic crowns or rings are stamped on the chewing teeth, an oval or quadrangular tube with a diameter of 3-3.5 mm and a length of 20-30 mm is soldered to the vestibular side.The appropriate shape is inserted into the tubeswire ends. The length of the stainless steel wire is 15cm and the thickness is 2-2.5mm. The opposite ends of the wire, bending around the corners of the mouth, form a bend in the opposite direction and come into contact with each other. Cuts are made at the touching ends of the wire. To reposition the fragments, the ends of the levers are separated and fixed with a ligature wire at the place of the cuts.The fragments are moved apart slowly and gradually (over several days or weeks) until they are compared in the correct position. Due to the elasticity of the wire, the movement of fragments is achieved.
With the help of the apparatus of A. Ya. Katz, it is possible to use fragments in the vertical and sagittal directions, rotate fragments around the longitudinal axis, as well as reliable fixation of fragments after their comparison.
1.4 Oxman apparatus
I. M. Oksman somewhat modified the repositioning apparatus of A. Ya. Katz. He soldered two (instead of one) parallel tubes to the supporting part of the apparatus on each side, and split the rear ends of the intraoral rods into two parts that enter both tubes on each side. This modification of the apparatus prevents fragments from rotating around the horizontal axis.
1.5 Brun's apparatus
Brun's apparatus consists of wire and crowns. One end of the wire is tied to the teeth or attached to the crowns (rings) put on the lateral teeth of the fragments. The opposite ends of the wire, bent in the form of levers, cross and stand outside the oral cavity. Rubber rings are pulled onto the ends of the wire bent in the form of levers. Rubber rings, contracting, move the fragments apart. The disadvantages of the apparatus include the fact that during its action, the posterior parts of the fragments are sometimes displaced towards the oral cavity or rotate around the longitudinal axis.
1.6 Kappo-rod apparatus A. L. Grozovsky
It consists of metal mouthguards for the teeth of fragments of the lower jaw, shoulder processes with holes for screws, two screws connected by a soldered plate. The device is used for the treatment of fractures of the lower jaw with a significant bone defect and a small number of teeth on fragments. Manufacturing. Partial casts are taken from fragments of the lower jaw, models are cast and mouthguards are stamped (soldered crowns, rings). They try on mouth guards on the abutment teeth and take casts from the fragments of the damaged lower jaw and the intact upper jaw. Models are cast, matched to the correct position and plastered in an occluder. Two tubes are soldered to the kappa of a small fragment (vestibularly and orally), and one tube is soldered to the kappa of a large fragment (vestibularly). Manufacture of expansion screw, rods with holes, nuts and screws. The mouthguards are cemented on the abutment teeth, a long lever with a platform is inserted into the oral tube of the small fragment, and a short lever with a nut for the expansion screw is inserted into the vestibular tube of the larger fragment. To fix the achieved position, other rods with matching holes for screws and nuts are inserted into the vestibular tubes.
Chapter 2 Fixing devices.
Fixing maxillofacial apparatuses include splints that fix jaw fragments in the correct position. Such devices manufactured by the laboratory method include: Tire Vankevich, Tire Stepanov, Tire Weber, etc.
2.1 Sheena Vankiewicz
In case of fractures of the lower jaw with a large number of missing teeth, treatment is carried out with a splint M. M. Vankevich. It is a periodontal splint with two planes that extend from the palatal surface of the splint to the lingual surface of the lower molars or the edentulous alveolar ridge.
Impressions are taken from the upper and lower jaws with an alginate mass, plaster models are cast, and central ratio jaws and plaster working models are fixed in the articulator. Then the frame is bent and a wax tire is modeled. The height of the planes is determined by the degree of mouth opening. When opening the mouth, the planes must remain in contact with the edentulous alveolar processes or teeth. After bus simulation,the technician attaches to her in the area chewing teeth a double-folded base wax plate 2.5-3.0 cm high, then the wax is replaced by plastic,. conducts polymerization. After replacing wax with plastic, the doctor checks it in the oral cavity, corrects the surfaces of the supporting planes with quick-hardening plastic or stens (thermoplastic impression mass), followed by replacing it with plastic. This splint can be used in mandibular bone grafting to hold bone grafts. Tire Vankevich was modified by A.I. Stepanov, who replaced the palatal plate with an arch (byugel).
2.2 Weber bus.
The splint is used for fixing fragments of the lower jaw after they have been compared and for post-treatment of fractures of the jaws. It covers the remaining dentition and gums on both fragments, leaving open occlusal surfaces and cutting edges of the teeth.
Manufacturing. They take casts from the damaged and opposite jaws, get models, make them in position central occlusion and plastered in an occluder. A frame is made of stainless wire with a diameter of 0.8 mm in the form of a closed arc. The wire should be separated from the teeth and the alveolar part (process) by 0.7-0.8 mm and held in this position by transverse wires passed in the area of interdental contacts. The places of their section with longitudinal wires are soldered. When using a tire for the treatment of fractures of the upper jaw in the lateral sections, oval-shaped tubes are soldered for the introduction of extraoral rods. Then a tire is modeled from wax, plastered into a cuvette in a direct way and the wax is replaced with plastic., after which it is processed.
2.3 The apparatus of A. I. Betelman
It consists of several crowns (rings) soldered together, covering the teeth on fragments of the jaw and antagonist teeth. On the vestibular surface of the crowns of both jaws, tetrahedral tubes were soldered for the insertion of a steel bracket. The device is used in the presence of a defect in the lower jaw in the chin area with 2-3 teeth on each fragment.
Manufacturing. Casts are taken from the jaw fragments for the manufacture of crowns. They fit crowns on the teeth, take casts from the fragments of the jaw and from the upper jaw. Models are cast, compared in the position of central occlusion, and plastered into the occluder. The crowns are soldered together and horizontal quadrangular or oval tubes are soldered from the vestibular surface of the crowns of the upper and lower jaws. Two U-shaped brackets are made, 23 mm thick, according to the shape of the bushings. The apparatus is applied to the jaw, the fragments are placed in the correct position and fixed by inserting a staple.
2.4 Lamellar tire A. A. Limberg
The tire is used to treat fractures of edentulous jaws.
Manufacturing. Impressions are taken from each edentulous fragment of the lower jaw and intact edentulous upper jaw. Individual spoons are made for each fragment of the lower jaw and the upper jaw. Individual spoons are fitted, hard occlusal stencils are fixed on them, the central ratio is determined and fixed with the help of a chin “sling”. In this state, individual spoons of the lower jaw are fastened with quick-hardening plastic, removed from the oral cavity. Gypsum is put into an occluder, the wall rollers are removed and replaced with columns of quick-hardening plastic. Impose on the jaw tires and chin "sling".
2.5 Soldered tire on rings according to A. A. Limberg.
The tire is used to treat single linear fractures of the jaws in the presence of at least three supporting teeth on each fragment. Manufacturing. According to the casts, crowns (rings) are made for the abutment teeth, checked in the oral cavity, casts are taken from the fragments on the teeth of which there are crowns, and a cast from the opposite jaw. Models are cast in the laboratory, fragments with crowns are set in the correct ratio with the antagonist teeth and plastered into the occluder. Wires are soldered to the crowns vestibularly and orally; if the tire is used for intermaxillary traction, then hook hooks are soldered to the wire, curved towards the gum. The soldered splint on the lower jaw can be supplemented with an inclined plane in the form of a stainless steel plate on the vestibular side of the intact half of the jaw. After finishing, grinding and polishing, the splint is fixed on the abutment teeth with cement.
Chapter 3 Forming apparatuses.
Forming devices. After mechanical, thermal, chemical and other damage to the soft tissues of the oral cavity and the oral region, defects and cicatricial changes are formed. To eliminate them, after the wound has healed, plastic surgery is performed using the tissues of neighboring distant parts of the body. To immobilize the graft during its engraftment and to reproduce the shape of the restored part, various forming orthopedic devices and prostheses are used. Forming devices consist of fixing replacing and forming elements in the form of thickened bases against the areas to be formed. They can be removable and combined with a combination of fixed parts in the form of crowns and removable forming elements fixed on them. When plasticizing the transitional fold and vestibule of the oral cavity, for successful engraftment of the skin flap (thickness 0.2-0.3 mm), a rigid liner made of thermoplastic mass is used, which is applied to the edge of the splint or prosthesis facing the wound. For the same, a simple aluminum wire splint can be used, curved along the dental arch with loops for layering the thermoplastic mass. In case of partial loss of teeth and prosthetics with a removable prosthesis, a zigzag wire is soldered to the vestibular edge against the surgical field, on which a thermoplastic mass with a thin skin flap is layered. If the dentition against the surgical field is intact, then orthodontic crowns are made for 3-4 teeth, a horizontal tube is soldered vestibularly, into which a 3-shaped bent wire is inserted to layer the thermoplastic mass and the skin flap. In plastic surgery of the lips, cheeks, and chin, dental prostheses are used as forming devices, which replace defects in the dentition and bone tissue, splinting, supporting and forming a prosthetic bed.
Conclusion.
Further fixation of the device for splinting wandering fragments and further restoration of the jaw due to their fusion in the correct connection with each other depends on the timely and correct reposition and fixation of the jaw fragments.
A well-made device should not deliver severe pain carrier.
Successful treatment of a patient depends not only on the doctor, but also on a skilled dental technician.
Bibliography.
- Dental technique M. M. Rasulov, T. I. Ibragimov, I. Yu. Lebedenko
- Orthopedic dentistry
- V. S. Pogodin, V. A. Ponamareva Guidelines for dental technicians
- http://www.docme.ru/doc/96621/ortopedicheskaya-stomatology.-abolmasov-n.g.---abolmasov-n...
- E. N. Zhulev, S. D. Arutyunov, I. Yu. Lebedenko Oral and Maxillofacial Orthopedic Dentistry
Maxillofacial Orthopedics
For the first time, the fixation of fragments began to be carried out with the help of intra- and extra-oral bandages - at the end of the 18th and beginning of the 19th centuries.
Hippocrates in the treatment of fractures using the reposition of fragments, followed by splinting with a sling bandage.
The first specialist who applied a plaster cast for mandibular fractures - Pirogov
Injuries of the maxillofacial region.
Facial injury occurs both in peacetime and in wartime, of which 70% are injuries to the soft tissues of the face and 30% are combinations of injuries with damage to the bones of the facial region.
Damage includes 5 groups:
1. Gunshot
2. Non-firearms
3. Combined
5. Frostbite
According to etiology, they are divided into:
1. Traumatic (gunshot, non-gunshot)
2. Pathological - arise in connection with the pathological process in the jawbone
Fractures are:
2. Incomplete
3. Subperiosteal
Fractures can be either open or closed.
Depending on the line of fracture, there are:
1. Transverse
2. Longitudinal
4. Zigzag
According to the number of fragments:
1. Single
2. Double on one side
3. Double sided
4. Multiple (fragmentation)
Non-gunshot wounds
There are household, transport, industrial and so on.
Occur when struck directly on the wide surface of the jaw, fall, compression. For non-gunshot fractures, linear damage to the bone is characteristic, at low strength they occur in places of reduced strength, accompanied by minor functional impairments, bleeding, malocclusion, swelling.
Patients are treated on an outpatient basis.
With a fracture in the \ h, the condition is more severe. v \ h connects with many bones of the skull, so injuries are often combined with damage to the vessels and nerves of the brain and organs of vision.
gunshot wounds
They are divided according to the type of wounding weapon - bullet, fragmentation, beam.
By nature - through, tangent, blind.
Gunshot fractures are always accompanied by a violation of the jaw, nearby tissues. are always open, the inlets are torn. They are characterized by significant damage to blood vessels and nerves, if large vessels are damaged, there is severe bleeding. Often damaged salivary glands, tongue, subsequently a violation of the function of chewing, swallowing, speech, eating. The condition of the patients is severe due to the proximity of the vital organs of the skull.
Gunshot fractures in \ h are more dangerous.
In case of gunshot fractures, the central block of the face is damaged with the participation of the zygomatic and ethmoid bones.
General features of wounds
1. Teeth, jaws are damaged, bite is disturbed.
2. Injury to the face disfigures the appearance of a person (psychological trauma)
3. Wounding the face leaves scars for a long time
4. Wounds of the mouth and face heal faster due to good blood supply
5. There are fewer inflammatory processes
6. Fractures in \ h are sometimes combined with fractures of the base of the skull, these are very severe fractures.
Clinic and diagnosis of fractures
Recognition of gunshot wounds is not difficult, it is more difficult to diagnose non-gunshot fractures. To clarify the diagnosis, there are:
I. Main symptoms
1. Mobility of fragments by a certain biomanual technique
2. Creptation (crunch)
3. Malocclusion
If there is at least one of the symptoms, then we can talk about a broken jaw
II. Additional symptoms
2. Violation of chewing
3. Bleeding
4. Swelling
In case of a fracture of the upper jaw, there is observed: deformation, asymmetry of the face, lengthening of the face, hemorrhage in the conjunctiva (glasses symptom), nausea, vomiting, loss of consciousness.
Diagnostic method - X-ray.
Complication of fracture injuries.
1) Asphyxia, shock, blood loss
2) Osteomyelitis of the jaw in case of infection, inflammation
3) Violation appearance face, scars, asymmetry
4) Deformation of the bite, with improperly fused fractures
5) Violation of the integrity of the bones
6) Formation of a false joint, a protrusion of 1-2 cm of connective tissue between the fragments
7) Contracture - limitation of joint mobility
8) Ankylosis - immobility of the joint
9) Microstomy - narrowing of the oral fissure (small mouth opening)
Features of combined lesions of the maxillofacial region.
(trauma + radiation)
Exacerbation symptoms are observed:
1. Increased bleeding
2. Gets worse general state
3. Wound healing is slow
Stage 1 - the primary reaction to radiation (headache, dizziness, nausea, vomiting, abdominal pain, diarrhea, etc.)
Stage 2 - the latent period lasts 2-3 weeks, with light exposure, with strong exposure for several days. During this period, all necessary interventions (surgical, orthopedic) are carried out, steel prostheses are replaced with plastic ones, since metal was a source of radiation.
Stage 3 - the period of the peak of radiation sickness, all symptoms intensify, stomatitis, gingivitis, hair loss, anemia, heart failure develop vascular system, nervous system, suppuration, infection. Evacuation from the affected area, removal of radioactive isotopes from the skin and mucous membrane of wounds.
Classification of mandibular fractures according to Entin.
Entin divides non-gunshot fractures of the lower jaw according to their localization into fractures of the alveolar process.
Group 1 - median fracture, with and without displacement of fragments in the region of the incisors
Group 2 - lateral (mental) fracture in the area of the canine and premolar
Group 3 - angular (angular)
Group 4 - fracture of the coronoid process in the region of the branch of the n.h.
Group 5 - fracture of the articular process in the neck of the articular process.
Entin divides fractures of the mandible by nature: single, double, multiple, the displacement of fragments is due to muscle traction because all masticatory muscles and a number of facial muscles are attached in the area of the mandible.
Functional disorders - slight swelling, bleeding, malocclusion, treated on an outpatient basis.
Principles of treatment of jaw fractures.
Fracture treatment aims to restore anatomical integrity and full function as the ultimate goal.
Achieved:
1. Reposition - comparison of fragments in the correct position.
2. Immobilization - immobility of fragments and retention until healing.
Problems are solved surgically or orthopedically.
Reposition can be carried out: manually (under anesthesia), with the help of devices, surgically (bloody).
The complex of treatment systems includes:
1. Primary processing wounds
2. Reposition and fixation of fragments
3. Infection control measures
4. Bone grafting
5. Soft tissue plasty
6. Measures to combat contractures
7. Solving problems of false joints, microstomy
Dislocations and fractures of teeth
Often there are in the frontal area in \ h, as a result of a blow or fall, when biting off food, you can dislocate adjacent teeth when removing teeth with the root. There is a partial or complete rupture of tissues, periodontal fibers and damage to the neurovascular bundle. Visible swelling, hemorrhage, abrasions in the mouth. The mouth is sometimes half-open, the gum mucosa can be torn, one of the walls of the alveolus is broken, a defect in the dentition occurs, the teeth are turned, tilted.
Treatment:under local anesthesia the dislocated tooth is repositioned, its immobilization is reliably ensured by a plastic splint – kappa.
Fractured teeth
Causes: similar to that of a dislocation, the fracture can be longitudinal or transverse. Crown fracture:
1. Within the enamel or dentin without violating the integrity of its cavity.
2. With exposed coronal pulp.
3. Complete breakage of the crown at the level of the neck.
root fracture
Occurs in the middle of the upper and lower third root. When the root is fractured, a defect of a different shape is visible, the crown sometimes acquires a color from pink to purple. The x-ray shows the fracture lines of the tooth root.
Treatment: in case of a crown fracture without opening the cavity, sharp edges should be ground off and the defect should be eliminated with an inlay or filling. If the pulp is exposed, then it is removed, the canal is sealed and the broken part is restored. When the crown of the tooth is completely broken off, the root is not removed, it is used for tooth pins or stump tabs.
Restoration devices.
These include wire or plastic tires for intermaxillary tension, devices with screws, with extraoral levers, springy loops, and inclined planes. They act on the principle of tension, pressure on the displaced fragments. They consist of supporting parts and active ones.
1. Tigerstedt tire No. 3 with toe loops
2. Sheena Vankevich
3. Weber bus No. 3, 5
4. Katz apparatus
5. Apparatus of Courland
6. Grozovsky's apparatus
For tension and reduction of stiff fragments with chronic fractures, the following devices are used:
1. Katz apparatus with extra-oral levers for the lower jaw. It is used in the presence of a bone defect. It consists of rings to the buccal surfaces of which tubes are soldered for out-of-mouth levers. The levers are removed from the oral cavity by bending around the corner of the mouth forming a pneumatic loop and the second one is directed in the opposite direction. The katz apparatus is activated by retraction to the sides outside the oral rods. The rods are wide, they are pulled together with a ligature.
2. The apparatus of Courland is used for fractures within the dentition. It consists of mouthguards on the buccal surfaces of which are soldered double tubes or corresponding rods. Mouthguards are made, fitted in the oral cavity, I take casts from HF and LF. The mandibular model is sawn into 2 parts in the area of the fracture and made up in the bite in the occluder. By soldering the twin tubes horizontally, the rods are picked up, then the tubes are sawn and the kappa is cemented. A springy archwire is installed for reposition in the form of a loop. After its removal, the rods are inserted into the tubes.
3. Grozovsky's apparatus at low frequencies. It is used for a small number of teeth on both fragments. The apparatus consists of a mouthguard with soldered flat tubes and shoulder processes with holes for screws. The repanning device consists of out-of-mouth rods into which bushings are inserted, on one rod there is a nut for fixing the pushing screw, and on the other a support platform. Reposition takes 2-3 days, tightening the screw. Then put on the fixing processes.
Resection devices.
Devices replacing defects in the dentition, filling jaw defects after surgery.
The goal is to restore the function sometimes to keep the fragments from displacement and the soft tissues of the face from sinking.
1. Direct or immidate prostheses. Made before surgery and injected into the oral cavity after resection.
2. Subsequent, post-resection - are made in the near future or in the distant after 2-3 months. The domestic specialist who was the first to propose a replacement prosthesis for resection of half of the HF was Oksman. He proposed a 3-stage manufacturing method for HF.
Stage 1 - manufacturing of the fixing part
Stage 2 - manufacturing of the resection part, after casting the HF model with a fixing plate, the resection borders are marked on the model. The extreme tooth is cut to the level of the neck to close the mucosal bone in this place. The remaining teeth are cut to the level of the base of the alveolar process from the vestibular side and palatine to the middle of the sky. They clean the plate at the junction, set the teeth, model, polymerize, etc.
Stage 3 - the manufacture of the opturating part or the transformation of a temporary prosthesis into a permanent one. As the wound heals, the tampons are removed and the palatal part of the prosthesis is covered with a roller of self-hardening plastic to obtain impressions of the edges of the cavity and to separate the oral and nasal cavities. After 1-2 minutes, they are taken out and processed.
Making a prosthesis during resection of half of the mandible, stage 2. Difficulty in more complex fixation, since the replacement part is on one side, the more massive one does not have bone support. The healthy part is displaced midline, occlusion is broken. This position can be fixed by scars. To prevent this complication, an inclined plane is installed on the fixing plate.
Stage 1 - the manufacture of crowns, a fixing plate with clasps and an inclined plane.
Stage 2 - the manufacture of the resection part. The basis is thickened outward and lengthened behind the dentition to maintain soft tissues in the area of the jaw angle.
Forming devices.
Apply with damage to the soft tissues of the oral cavity and in the oral region. They serve as a support for soft tissues, replace defects in the dentition of the bone, form a plastic material, form a bed for the prosthesis, and prevent the formation of scars. Without them soft tissues wrinkle, sink down, the face loses its natural shape, so they need to be made before surgery. Forming devices consist of fixing, replacing and forming elements in the form of thickened bases against the areas to be formed. They can be removable and combined, with combinations in the form of crowns and removable forming elements fixed on them.
1. When plasticizing the transitional fold in the vestibule of the oral cavity, a thermal mass is layered on the edge of the prosthesis or splint facing the wound. It is possible to use a wire splint by bending it along the dental arch with loops for layering the thermomass.
2. In case of partial loss of teeth in prosthetics with removable dentures, a zigzag-shaped wire is soldered to the vestibular edge against the surgical field on the wire on which the thermal mass is layered.
3. Shaping apparatus according to Schur. A domestic specialist who was the first to develop a replacement prosthesis for the complete removal of the upper jaw Shur. The post-resection devices include the combined Schur prosthesis. Shur recommends that the forming prosthesis of the upper jaw be made with finger-like processes in its posterior part, pockets (niches) are created in the posterior parts of the cheeks by skin grafting, this ensures the fixation of the prosthesis in its posterior part, the anterior part of the prosthesis is fixed with a special extraoral rod attached to the gypsum head bandage. In the future, the front part of the prosthesis is fixed by scars formed around the prosthesis in the post-resection period. A prosthesis of this design can be used after unilateral and bilateral resection of the edentulous upper jaw. Its manufacture and skin grafting is carried out 3-4 months after the resection of the upper jaw by the method of remote prosthetics. With extensive jaw defects and a large volume of the forming prosthesis or with microstomy, they are made folding or collapsible.
Facial prostheses.(ecto)
Traumatic defects of the face are eliminated plastic surgery, but if the patients are weakened, exhausted, they make facial prostheses, distinguish between prostheses of the lips, cheeks, eyes, chin, nose, ear. They are used as temporary before surgery and permanent. Requirements:
1. Restore the shape, contour of the face.
2. Dyeing and color should match the fabrics
3. Tightly adhere to the edges of the defect at rest and during function
4. Fixation must be secure
For the manufacture of Ecto prostheses, it is necessary to take an impression of the entire face. The patient is given a horizontal position, tubes are inserted into the nose. I lubricate my eyebrows with Vaseline, I cover my mustache, beard, head and neck with a napkin . I cover my face with plaster 1-1.5 cm. then the impression is taken forward and slightly down to avoid a hematoma on the back of the nose. They put it in water for 15-20 minutes and cast the model. The prosthesis is modeled from wax, plasticine, focusing on the second half, photo, etc. The modeled composition is lubricated with petroleum jelly and a cast is taken from it, isolated, wax 1-1.5 mm thick is poured, removed, and a layer of wax 5-10 mm is applied to the plaster mask at the edges of the defect and the wax composition of the prosthesis is glued to it. Try on the face, adjust and replace with the appropriate plastic. Fastening is provided by a spectacle frame with the help of plates covering the darts. And the lower part of the nose enters the bottom of the nasal openings by means of a spring.
Orbit prosthesis.
A wax model of the prosthesis is created on the mask; an eye prosthesis is mounted on the inner surface of the eyelids, then it is carefully separated to the wax, eyebrows and eyelashes are glued. Gypsum and replaced with plastic, processed. An eye is attached to the back wall of the orbit, fixed on the face with brackets and a spectacle frame. The prosthesis of the auricle is made of elastic plastic, modeled from wax, the color is selected. At total absence ear use the auditory opening to make a prosthesis with an appendage included in it. This contributes to the attachment of the lower part of the prosthesis. The upper part of the prosthesis is reinforced with a spring thrown to the opposite side of the head. In cases of severe facial injuries, there is a need for simultaneous prosthetics of the jaws and facial tissues, facial prostheses are connected on one side with the help of hinges or magnets with jaw prostheses on the other on a spectacle frame. To strengthen the ear prosthesis, it is better to use springs. Facial ecto prostheses are fixed - with a spectacle frame. Egmos 12 plastic is used.
Maxillofacial Orthopedics
It is a section of orthopedic dentistry that deals with the issues of the clinic, diagnosis and treatment of injuries and defects of the maxillofacial region resulting from a trauma of gunshot or non-gunshot origin, or past diseases, defects of the soft palate, TB of the palate and lips.
CL orthopedics consists of two parts:
1. Maxillofacial traumatology - surgical diagnostics(operational methods for fixing fragments)
2. Maxillofacial prosthetics
1. Restore the anatomical integrity of the maxillofacial region, the contours of the face, the integrity of the bones
2. Restore functions: chewing, eating, speaking.
The main tasks of maxillofacial orthopedics
1. Prosthetics of patients with congenital and acquired defects of the face and jaws
2. Creation of orthopedic structures for the correct compilation of fragments, for the correction of incorrectly fused fragments, for the elimination of the consequences of injuries (scars, contractures)
3. Production of orthopedic structures in the preparation of patients for surgery and to ensure the most favorable conditions in post. operating period.
4. Manufacture of special prostheses during bone and facial operations and soft tissue plasty
5. Treatment of diseases of masticatory muscles and TMJ
20448 0
Treatment of damage to the maxillofacial region is carried out by conservative, operative and combined methods.
main method conservative treatment are orthopedic devices. 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 (Scheme 4). 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.
Scheme 4
Classification of fixing devices
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 the dental wire splint (Fig. 237) is a wire bent in the shape of the 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 teeth).
With the mobility of the teeth, a sharp atrophy of the alveolar bone, it is not possible to ensure reliable stability of 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 shown, in which the fixing ability of the structure is enhanced by increasing the fit area of the splinting part in the form of covering the gums and the alveolar process (Fig. 238). At total loss 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 (Fig. 239). 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 (Fig. 240). The good fixing ability of this tire is due to a reliable, almost immovable connection of all structural elements. The splinting arc is soldered to a ring or to a metal crown, which is fixed with phosphate cement on the abutment teeth. 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 tires appeared (Fig. 241). 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.
Rice. 241. Tire made of fast hardening plastic.
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 (Fig. 242).
Rice. 242. Tooth splint made of an alloy with shape memory,
a - general form tires; b - fixing devices; in — the loop providing a compression of fragments.
Fixing devices used in osteoplastic operations are a dental structure consisting of a system of soldered crowns, connecting locking sleeves, and rods (Fig. 243).
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 (Fig. 244).
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 (Fig. 245).
Rice. 245. Structure inside the extraoral apparatus.
rehearsal apparatus
Distinguish between simultaneous and gradual reposition. Simultaneous 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 (Fig. 246). With closed jaws, it also serves as a fixing device for fractures of the lower jaws with edentulous fragments.
Rice. 246. Tire Vankevich.
a — view of the model of the upper jaw; b — reposition and fixation of fragments in case of damage to the edentulous lower jaw.
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 restorative surgical interventions and in the process of them.
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 (Fig. 247).
Rice. 247. Forming apparatus (according to A.I. Betelman). The fixing part is fixed on the upper teeth, and the forming part is located between the fragments of the lower jaw.
Replacement devices (prostheses)
Prostheses used in maxillofacial orthopedics can be divided into dentoalveolar, maxillary, facial, 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 positive influence 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 (Fig. 248).
Replacement devices also include orthopedic devices used for palate defects. This is primarily a protective plate - used in the plastic 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 (Fig. 249).
Rice. 249. Apparatus of combined action.
Dental, dentoalveolar and maxillary prostheses, in addition to the replacement function, often serve as a forming apparatus.
Results of orthopedic treatment maxillofacial injuries largely depend on the reliability of fixation devices.
When solving this problem, the following rules should be followed:
To use as much as possible the preserved natural teeth as a support, connecting them into blocks, using the known methods of splinting teeth;
. make maximum use of the retention properties of the alveolar processes, bone fragments, soft tissues, skin, cartilage that limit the defect (for example, the 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 right choice and the use of these devices adequately to clinical situations make it possible to achieve success in the orthopedic treatment of injuries of the maxillofacial region.
Orthopedic dentistry
Edited by Corresponding Member of the Russian Academy of Medical Sciences, Professor V.N. Kopeikin, Professor M.Z. Mirgazizov
CLASSIFICATION OF COMPLEX MAXILLOFACIAL APPARATUS
Fastening of fragments of the jaws is carried out using various orthopedic devices. All orthopedic devices are divided into groups depending on the function, area of fixation, therapeutic value, design, manufacturing method and material.
By function:
Immobilizing (fixing);
Repositioning (correcting);
Corrective (guides);
Formative;
Resection (replacement);
Combined;
Prostheses for defects of the jaws and face.
Place of fixation:
Intraoral (single jaw, double jaw, intermaxillary);
extraoral;
Intra- and extraoral (maxillary, mandibular).
For medical purposes:
Basic (having an independent therapeutic value: fixing, correcting, etc.);
Auxiliary (serving for the successful implementation of skin-plastic or bone-plastic operations).
By design:
Standard;
Individual (simple and complex).
According to the manufacturing method:
Laboratory production;
Non-laboratory production.
According to materials:
plastic;
metal;
Combined.
Immobilizing devices are used in the treatment of severe fractures of the jaws, insufficient number or absence of teeth on fragments. These include:
Wire tires (Tigerstedt, Vasiliev, Stepanov);
Tires on rings, crowns (with hooks for fragments traction);
Mouthguard tires:
V metal - cast, stamped, soldered;
V plastic; - removable tires of Port, Limberg, Weber, Vankevich, etc.
Repositioning devices that promote the reposition of bone fragments are also used for chronic fractures with stiff jaw fragments. These include:
Repositioning devices made of wire with elastic intermaxillary traction, etc.;
Devices with intraoral and extraoral levers (Kurlyandsky, Oksman);
Repositioning devices with a screw and a repulsive platform of Kurlyandsky, Grozovsky);
Repositioning apparatus with a pelotom on an edentulous fragment (Kurlyandskogo and others);
Repositioning apparatus for edentulous jaws (Guning-Port splints).
Fixing devices are called devices that help hold fragments of the jaw in a certain position. They are subdivided:
For extraoral:
V standard chin sling with head cap;
V standard tire according to Zbarzh and others.
Intraoral:
*V tooth bars:
Wire aluminum (Tigerstedt, Vasiliev, etc.);
Soldered tires on rings, crowns;
plastic tires;
Fixing dental devices;
* tooth-gingival tires (Weber and others);
* gum tires (Port, Limberg);
Combined.
Guides (corrective) are called devices that provide a bone fragment of the jaw with a certain direction with the help of an inclined plane, a pilot, a sliding hinge, etc.
For wire aluminum tires, the guide planes are bent simultaneously with the tire from the same piece of wire in the form of a series of loops.
For stamped crowns and mouth guards, inclined planes are made of a dense metal plate and soldered.
For cast tires, the planes are modeled from wax and cast along with the tire.
On plastic tires, the guide plane can be modeled simultaneously with the tire as a whole.
In case of insufficient number or absence of teeth in the lower jaw, tires according to Vankevich are used.
Forming devices are called devices that are the support of plastic material (skin, mucous membrane), create a bed for the prosthesis in the postoperative period and prevent the formation of cicatricial changes in soft tissues and their consequences (displacement of fragments due to constricting forces, deformations of the prosthetic bed, etc.). According to the design, the devices can be very diverse, depending on the area of damage and its anatomical and physiological features. In the design of the forming apparatus, a forming part and fixing devices are distinguished.
Resection (replacement) devices are called devices that replace defects in the dentition formed after the extraction of teeth, filling defects in the jaws, parts of the face that arose after injury, operations. The purpose of these devices is to restore the function of the organ, and sometimes to keep fragments of the jaw from moving or soft tissues of the face from retraction.
Combined devices are called devices that have several purposes and perform various functions, for example: fixing fragments of the jaw and forming a prosthetic bed or replacing a defect in the jawbone and simultaneously forming a skin flap. A typical representative of this group is the kappa-rod device of combined sequential action according to Oxman for fractures of the lower jaw with a bone defect and the presence of a sufficient number of stable teeth on fragments.
Prostheses used in maxillofacial orthopedics are divided into:
On the dentoalveolar;
jaw;
Facial;
Combined;
During resection of the jaws, prostheses are used, which are called post-resection prostheses.
Distinguish between immediate, immediate and distant prosthetics. In this regard, the prostheses are divided into operational and postoperative. Replacement devices also include orthopedic devices used for palate defects: protective plates, obturators, etc.
Prostheses for defects of the face and jaws are made in case of contraindications to surgical interventions or in case of persistent unwillingness of patients to undergo plastic surgery.
If the defect captures a number of organs at the same time: nose, cheeks, lips, eyes, etc., a facial prosthesis is made in such a way as to restore all the lost tissues. Facial prostheses can be fixed with spectacle frames, dentures, steel springs, implants, and other devices.
Orthopedic treatment for false joints (Oxman method):
Prosthetics for a false joint has its own characteristics. The denture, regardless of fixation (ie, removable or non-removable), in place of the false joint must have a movable connection (preferably hinged).
Impressions are taken from each fragment, a basis with clasps and an inclined plane or an extragingival splint with an inclined plane are made on plaster models.
The bases are fitted to the jaw fragments so that the inclined plane holds them when the mouth is opened, then the area of the jaw defect is filled on both sides (vestibular and oral) with an impression material that is inserted without a spoon.
Based on this impression, a single prosthesis is prepared, which is, as it were, a spacer between the fragments of the lower jaw, preventing them from approaching when the mouth is opened (in this case, the inclined planes are removed).
The central occlusion is determined on a rigid plastic base, after which the prosthesis is made in the usual way.
It should be noted that hinged prostheses do not restore chewing function to the same extent as conventional prostheses. The functional value of prostheses will be much higher if they are made after osteoplasty. Radical treatment of a false joint is only surgical, by osteoplasty.
Orthopedic treatment for improperly fused jaw fragments:
With improperly fused fractures of the jaws and a small number of remaining teeth that are out of occlusion, removable dentures with a duplicated dentition are made. The remaining teeth are used to fix the prosthesis with support-retaining clasps.
When the dental arch of the lower jaw is deformed due to the inclination of one or more teeth to the lingual side, it is difficult to prosthetic the defect of the dentition with a removable plate or arc prosthesis, since the displaced teeth interfere with its application. In this case, the design of the prosthesis is changed in such a way that in the area of displaced teeth, a part of the base or arch is located on the vestibular, and not on the lingual side. Support-retaining clasps or occlusive pads are applied to the displaced teeth, which allow the chewing pressure to be transferred through the prosthesis to the abutment teeth and prevent their further displacement to the lingual side.
In case of incorrectly fused fractures with a shortening of the length of the dental arch and jaw (microgenia), a removable prosthesis is made with a duplicating row of artificial teeth, which creates the correct occlusion with antagonists. Displaced natural teeth, as a rule, are used only for fixing the prosthesis.
Orthopedic treatment for microstomy:
With prosthetics, the best result is obtained only after the expansion of the oral fissure by surgery. In those cases when the operation is not indicated (the age of the patient, the state of health, systemic scleroderma), prosthetics are performed with a narrowed oral fissure and encounter great difficulties in orthopedic manipulations.
When prosthetics of defects in the dentition with bridges or other fixed structures, conduction anesthesia is difficult. In these cases, other types of anesthesia are used. The preparation of abutment teeth during microstomy is inconvenient for both the doctor and the patient. Sick teeth should be separated not with metal discs, but with shaped heads on turbine or contra-angle tips, without damaging intact neighboring teeth. Removal of the impression is complicated due to the difficulty of introducing a spoon with an impression mass into the oral cavity and removing it from there in the usual way. In patients with a defect in the alveolar process, it is difficult to remove the impression, since it has a large volume. When prosthetics are fixed with fixed dentures, impressions are taken with partial spoons, with removable structures - with special collapsible spoons. If there are no such spoons, then you can use the usual standard spoon, sawn into two parts. The technique consists in sequentially obtaining an impression from each half of the jaw. It is advisable to make an individual tray from a collapsible impression and use it to obtain the final impression. In addition, the impression can be taken by first placing the impression material on the prosthetic bed and then covering it with an empty standard tray. It is also possible to form an individual wax tray in the oral cavity, make a plastic one on it and get the final impression with a hard tray.
With a significant decrease in the oral fissure, the determination of central occlusion in the usual way using wax bases with bite ridges is difficult. When removing the wax base from the oral cavity, its deformation is possible. For this purpose, it is better to use bite rollers and bases made of thermoplastic mass. If necessary, they are shortened.
The degree of reduction of the oral fissure affects the choice of prosthesis design. To facilitate insertion and removal in patients with microstomia and defects in the alveolar process and the alveolar part of the jaws, the design of the prosthesis should be simple. With a significant microstomy, collapsible and hinged removable dentures are used. However, these constructs should be avoided. It is better to reduce the boundaries of the prosthesis, narrow the dental arch and use flat artificial teeth. Improving the fixation of a removable prosthesis when its base is shortened is facilitated by a telescopic fastening system. In the process of getting used to removable dentures, the doctor must teach the patient how to insert the denture into the oral cavity.
With a significant microstomy, collapsible or folding dentures using hinged devices are sometimes used. A folding prosthesis consists of two lateral parts connected by a hinge and an anterior locking part. In the oral cavity, it moves apart, is installed on the jaw and strengthened by the anterior locking part. The latter is a block of the anterior group of teeth, the base and pins of which fall into the tubes located in the thickness of the halves of the prosthesis.
Collapsible prostheses consist of separate parts. In the oral cavity, they are made up and fastened into a single whole with the help of pins and tubes. You can make a conventional prosthesis, but to facilitate the introduction and removal of it from the mouth through a narrowed oral fissure, the dental arch of the prosthesis should be narrowed, while using the telescopic fastening system as the most reliable.
Orthopedic treatment of defects of the hard and soft palate:
Treatment of acquired defects consists in their elimination by performing bone and soft tissue plasty. Orthopedic treatment of such defects is carried out in the presence of contraindications to surgical treatment or the patient's refusal from surgery.
In the case of congenital defects of the palate, the treatment of patients in all civilized countries is carried out by interdisciplinary working groups according to a pre-planned comprehensive program. Such groups usually include: geneticist, neonatologist, pediatrician, surgeon (maxillofacial surgeon), pediatric surgeon, plastic surgeon, anesthesiologist, orthodontist, speech therapist, orthopedic dentist, psychiatrist.
Rehabilitation of this group of patients consists in eliminating the defect, restoring the functions of chewing, swallowing, recreating the appearance and phonetics.
The orthodontist treats the patient from birth to the post-pubertal period, conducting periodic treatment according to the indications.
Currently, usually in the first week after the birth of a child, according to indications, he is undergoing cheiloplasty or correction of the deformity of the upper jaw using the McNeil method. This method is aimed at eliminating the incorrect location of the unfused processes of the upper jaw in the anteroposterior direction (with a unilateral cleft) or in the transversal direction (with a bilateral cleft). To do this, the newborn is put on a protective plate with extraoral fixation to the head cap. The plate is periodically (once a week) cut along the cleft line, and its halves are moved in the desired direction by 1 mm. The components of the plate are connected with quick-hardening plastic. This creates pressure on the palatine process in the right direction and ensures its constant movement. Thus, the correct dental arch is formed. The method is indicated until teething (5-6 months).
Already in Hippocrates and Celsus there are indications of the fixation of fragments of the jaw when it is damaged. Hippocrates used a rather primitive device, consisting of two straps: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus, using a cord of hair, strengthened the fragments of the lower jaw by the teeth standing on both sides of the fracture line. At the end of the 18th century, Ryutenik and in 1806 E. O. Mukhin proposed a “submandibular splint” for fixing fragments of the lower jaw. A hard chin sling with a plaster bandage for the treatment of fractures of the lower jaw was first used by the founder of military field surgery, the great Russian surgeon N. I. Pirogov. He also offered a drinker for feeding the wounded with maxillofacial injuries.
During the Franco-Prussian War (1870-1871), lamellar splints became widespread in the form of a base attached to the teeth of the upper and lower jaws, with bite rollers made of rubber and metal (tin), in which there was a hole in the region for eating. anterior section(Gooning-Port apparatuses). The latter was used to fix fragments of the edentulous lower jaw. In addition to these devices, a hard chin sling was applied to the patients to support the fragments of the jaw, fixing it on the head. These devices, quite complex in design, could be made individually according to the impressions of the upper and lower jaws of the wounded in special dental laboratories and therefore were used mainly in the rear medical institutions. Thus, by the end of the 19th century, there was still no military field splinting, and assistance for maxillofacial wounds was provided with a great delay.
In the first half of the 19th century, a method was proposed for fixing fragments of the lower jaw with a bone suture (Rogers). A bone suture for fractures of the lower jaw was also used during the Russo-Japanese War. However, at that time, the bone suture did not justify itself due to the complexity of its use, and most importantly, the subsequent complications associated with the lack of antibiotics (development of osteomyelitis of the jaw, repeated displacement of fragments and malocclusion). Currently, the bone suture has been improved and is widely used.
Prominent surgeon Yu. K. Shimanovsky (1857), rejecting a bone suture, combined a plaster cast in the chin area with an intraoral "stick splint" for immobilizing jaw fragments. Further improvement of the chin sling was carried out by Russian surgeons: A. A. Balzamanov proposed a metal sling, and I. G. Karpinsky - a rubber one.
The next stage in the development of methods for fixing jaw fragments are dental splints. They contributed to the development of methods for early immobilization of jaw fragments in front-line military sanitary institutions. Since the 90s of the last century, Russian surgeons and dentists (M. I. Rostovtsev, B. I. Kuzmin, etc.) have used dental splints to fix jaw fragments.
Wire splints were widely used during the First World War and took a firm place, later replacing plate splints in the treatment of gunshot wounds of the jaws. In Russia, aluminum wire tires were put into practice during the First World War by S. S. Tigerstedt (1916). Due to the softness of aluminum, the wire arc can be easily bent into the dental arch in the form of a single and double jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires proved to be rational in a military field situation. They do not require special prosthetic equipment and support staff, therefore they have won universal recognition and are currently used with minor changes.
During the First World War, the medical service in the Russian army was poorly organized, and the care of the wounded in the maxillofacial region suffered especially. So, in the maxillofacial hospital organized by G. I. Vilga in 1915 in Moscow, the wounded arrived late, sometimes 2-6 months after the injury, without proper fixation of jaw fragments. As a result, the duration of treatment was prolonged and persistent deformities occurred with a violation of the function of the masticatory apparatus.
After the Great October Socialist Revolution, all the shortcomings in the organization of the sanitary service were gradually eliminated. Good maxillofacial hospitals and clinics have now been set up in the Soviet Union. A coherent doctrine of the organization of the sanitary service in Soviet army at the stages of medical evacuation of the wounded, including in the maxillofacial region.
During the Great Patriotic War, Soviet dentists significantly improved the quality of treatment of the wounded in the maxillofacial region. Health care turned out to them at all stages of the evacuation, starting with the military district. Specialized hospitals or maxillofacial departments were deployed in the army and front-line areas. The same specialized hospitals were deployed in the rear areas for the wounded in need of more long-term treatment. Simultaneously with the improvement of the organization of the sanitary service, the methods of orthopedic treatment of fractures of the jaws were significantly improved. All this played a big role in the outcomes of treatment of maxillofacial wounds. So, according to D. A. Entin and V. D. Kabakov, the number of completely healed wounded with damage to the face and jaw was 85.1%, and with isolated damage to the soft tissues of the face - 95.5%, while in the First World War (1914-1918) 41% of those wounded in the maxillofacial region were dismissed from the army due to disability.
Classification of fractures of the jaws
Some authors base the classification of jaw fractures on the localization of the fracture along the lines corresponding to the places of the weakest bone resistance, and the ratio of the fracture lines to the facial skeleton and skull.
I. G. Lukomsky divides fractures of the upper jaw into three groups depending on the location and severity of clinical treatment:
1) fracture of the alveolar process;
2) suborbital fracture at the level of the nose and maxillary sinuses;
3) orbital fracture, or subbasal, at the level of the nasal bones, the orbit and the main bone of the skull.
By localization, this classification corresponds to those areas where fractures of the upper jaw most often occur. The most severe are fractures of the upper jaw, accompanied by a fracture, separation of the nasal bones and the base of the skull. These fractures are sometimes pumped up by death. It should be pointed out that fractures of the upper jaw occur not only in typical places. Very often one type of fracture is combined with another.
D. A. Entin divides non-gunshot fractures of the lower jaw according to their localization into median, mental (lateral), angular (angular) and cervical (cervical). An isolated fracture of the coronoid process is relatively rare. (fig. 226).
D. A. Entin and B. D. Kabakov recommend a more detailed classification of jaw fractures, consisting of two main groups: gunshot and non-gunshot injuries. In turn, gunshot injuries are divided into four groups:
1) by the nature of the damage (through, blind, tangential, single, multiple, penetrating and not penetrating into the mouth and nose, isolated with and without damage to the palatine process and combined);
2) by the nature of the fracture (linear, comminuted, perforated, with displacement, without displacement of fragments, with and without defect of the bone, unilateral, bilateral and combined;
3) by localization (within and outside the dentition);
4) according to the type of injuring weapon (bullet, fragmentation).
Rice. 226 Localization of typical fractures in the lower jaw.
Currently, this classification includes all facial injuries and has the following form.
I . gunshot wounds
Type of damaged tissue
1. Wounds of soft tissues.
2. Wounds with bone damage:
A. Mandible
B. Upper jaw.
B. Both jaws.
G. Zygomatic bone.
D. Damage to several bones of the facial skeleton
II. Non-fire wounds and damage
III. Burns
IV. Frostbite
According to the nature of the damage
1. Through.
2. Blind.
3. Tangents.
A.Insulated:
a) without damage to the organs of the face (tongue, salivary glands and others);
b) with damage to the organs of the face
B. Combined (simultaneous injuries to other areas of the body).
B. Single.
D. Multiple.
D. Penetrating into the mouth and nose
E. Non-penetrating
By the type of weapon that hurts
1. Bullets.
2. Fragmentation.
3.Ray.
Classification of orthopedic devices used for the treatment of jaw fractures
Fixation of fragments of the jaws is carried out using various devices. It is advisable to divide all orthopedic devices into groups in accordance with the function, area of fixation, therapeutic value, design.
Division of devices according to function. Apparatuses are divided into corrective (reponing), fixing, guiding, shaping, replacing and combined.
Regulatory (reponing) devices are called, contributing to the reposition of bone fragments: tightening or stretching them until they are placed in the correct position. These include wire aluminum splints with elastic traction, wire elastic braces, devices with extraoral control levers, devices for spreading the jaw with contractures, etc.
Guides are mainly devices with an inclined plane, a sliding hinge, which provide a certain direction to the bone fragment of the jaw.
Devices (spikes) that hold parts of an organ (for example, the jaw) in a certain position are called fixing devices. These include a smooth wire clamp, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw during bone grafting, etc.
Forming devices are called, which are the support of the plastic material (skin, mucous membrane) or create a bed for the prosthesis in the postoperative period.
Substitutes include devices, replacing the defects of the dentition, formed after the extraction of teeth, filling the defects of the jaws, parts of the face that arose after an injury, operations. They are also called prostheses.
Combined devices include that have several purposes, for example, fixation of fragments of the jaw and the formation of a prosthetic bed or replacement of a defect in the jawbone and at the same time the formation of a skin flap.
Division of devices according to the place of fixation. Some authors divide devices for the treatment of jaw injuries into intraoral, extraoral and intra-extraoral. To intraoral devices are attached to the teeth or adjacent to the surface of the oral mucosa, to extraoral - adjacent to the surface of the integumentary tissues outside the oral cavity (chin sling with a headband or extraoral bone and intraosseous spikes for fixing jaw fragments), to intra-extraoral - devices, one part of which is fixed inside, and the other outside the oral cavity.
In turn, intraoral splints are divided into single-jawed and double-jawed. The former, regardless of their function, are located only within one jaw and do not interfere with the movements of the lower jaw. Two-jaw devices are applied simultaneously to the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.
Division of devices for medical purposes. According to the therapeutic purpose, orthopedic devices are divided into basic and auxiliary.
The main ones are fixing and correcting splints, used for injuries and deformities of the jaws and having independent therapeutic value. These include replacement devices that compensate for defects in the dentition, jaw and parts of the face, since most of them help restore the function of the organ (chewing, speech, etc.).
Auxiliary devices are those that serve to successfully perform skin-plastic or osteoplastic operations. In these cases, the main type of medical care will be surgical intervention, and the auxiliary one will be orthopedic (fixing devices for bone grafting, shaping devices for facial plastic surgery, protective palatal plastic surgery for palate plastic surgery, etc.).
Division of devices by design.
By design, orthopedic devices and splints are divided into standard and individual.
The first include the chin sling, which is used as a temporary measure to facilitate the transportation of the patient. Individual tires can be of simple or complex design. The first (wire) ones are bent directly at the patient and fixed on the teeth.
The second, more complex ones (plate, cap, etc.) can be made in a dental laboratory.
In some cases, from the very beginning of treatment, permanent devices are used - removable and non-removable splints (prostheses), which at first serve to fix the jaw fragments and remain in the mouth as a prosthesis after the fragments have fused.
Orthopedic devices consist of two parts - supporting and acting.
The supporting part is crowns, mouthguards, rings, wire arches, removable plates, head caps, etc.
The active part of the device is rubber rings, ligatures, an elastic bracket, etc. The active part of the device can be continuously operating (rubber rod) and intermittent, acting after activation (screw, inclined plane). Traction and fixation of bone fragments can also be carried out by applying traction directly to the jawbone (the so-called skeletal traction), with a head plaster bandage with a metal rod serving as the supporting part. The traction of the bone fragment is carried out with the help of elastic traction, attached at one end to the jaw fragment by means of a wire ligature, and at the other end to the metal rod of the head plaster bandage.
FIRST SPECIALIZED AID FOR JAW FRACTURES (IMMOBILIZATION OF FRAGMENTS)
In wartime, in the treatment of wounded in the maxillofacial region, transport tires, and sometimes ligature bandages, are widely used. From transport tires the most comfortable is a hard chin sling. It consists of a headband with side rollers, a plastic chin sling and rubber bands (2-3 on each side).
Rigid chin sling is used for fractures of the lower and upper jaws. In case of fractures of the body of the upper jaw and intact lower jaw, and in the presence of teeth on both jaws, the use of a chin sling is indicated. The sling is attached to the headband with rubber bands with significant traction, which is transmitted to the upper dentition and contributes to the reduction of the fragment.
In case of multi-comminuted fractures of the lower jaw, rubber bands connecting the chin sling with the head bandage should not be tightly applied, in order to avoid significant displacement of the fragments.
3. N. Pomerantseva-Urbanskaya, instead of the standard hard chin sling, proposed a sling that looked like a wide strip of dense material, into which pieces of rubber were sewn on both sides. The use of a soft sling is easier than a hard one, and in some cases more comfortable for the patient.
Ya. M. Zbarzh recommended a standard splint for fixing fragments of the upper jaw. Its splint consists of an intraoral part in the vnds of a double stainless steel wire arc, covering the dentition of the upper jaw on both sides, and outwardly extending extraoral levers directed posteriorly to the auricles. The extraoral levers of the tire are connected to the head bandage using connecting metal rods (Fig. 227). The diameter of the wire of the inner arc is 1-2 mm, the diameter of the extraoral rods is 3.2 mm. Dimensions
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Rice. 227. Standard tires Zbarzha for immobilization of fragments of the upper jaw.
a - bus-arc; b - headband; c - connecting rods; e - connecting clamps.
wire arch are regulated by extension and shortening of its palatal part. The tire is used only in cases where manual reduction of fragments of the upper jaw is possible. M. 3. Mirgazizov proposed a similar device for a standard splint for fixing fragments of the upper jaw, but only using a plastic palatal plane. The latter is corrected with a quick-hardening plastic.
Ligature bonding of teeth
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Rice. 228. Intermaxillary bonding of teeth.
1 - according to Ivy; 2 - according to Geikin; .3—but Wilga.
One of the simplest ways of immobilization of jaw fragments, which does not require much time, is ligature binding of teeth. A bronze-aluminum wire 0.5 mm thick is used as a ligature. There are several ways to apply wire ligatures (according to Ivy, Wilga, Geikin, Limberg, etc.) (Fig. 228). Ligature binding is only a temporary immobilization of fragments of the jaw (for 2-5 days) and is combined with the imposition of a chin sling.
Wire busbar overlay
More rational immobilization of fragments of the jaw with splints. Distinguish between simple special treatment and complex. The first is the use of wire tires. They are imposed, as a rule, in the army area, since the manufacture does not require a dental laboratory. Complex orthopedic treatment is possible in those institutions where there is an equipped prosthetic laboratory.
Before splinting spend conduction anesthesia, and then treat the oral cavity with disinfectant solutions (hydrogen peroxide, potassium permanganate, furatsilin, chloramine, etc.). The wire splint should be curved along the vestibular side of the dentition so that it is adjacent to each tooth at least at one point, without imposing on the gingival mucosa.
Wire tires have a variety of shapes (Fig. 229). Distinguish between a smooth wire splint-bracket and a wire splint with a spacer corresponding to the size of the defect in the dentition. For intermaxillary traction, wire arcs with hook loops on both jaws are used for A.I. Stepanov and P.I. desired section of the tire.
The method of applying ligatures
To fix the tire, wire ligatures are used - pieces of bronze-aluminum wire 7 cm long and 0.4-0.6 mm thick. The most common is the following method of conducting ligatures through the interdental spaces. The ligature is bent in the form of a hairpin with ends of various lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and removed from the vestibule (one under the splint, the other over the splint). Here the ends of the ligatures are twisted, the excess spiral is cut off and bent between the teeth so that they do not damage the gum mucosa. In order to save time, you can first hold the ligature between the teeth, bending one end down and the other up, then lay the tire between them and secure it with ligatures.
Indications for the use of bent wire bars
A smooth arc made of aluminum wire is indicated for fractures of the alveolar process of the upper and lower jaws, median fractures of the lower jaw, as well as fractures of other localization, but within the dentition without vertical displacement of fragments. In the absence of a part of the teeth, a smooth splint with a retention loop is used - an arc with a spacer.
The vertical displacement of fragments is eliminated with wire splints with hook loops and intermaxillary traction using rubber rings. If the jaw fragments are simultaneously reduced, then the wire slime is immediately attached to the teeth of both fragments. With stiff and displaced fragments and the impossibility of their simultaneous reduction, the wire splint is first attached with ligatures to only one fragment (long), and the second end of the splint is attached with ligatures to the teeth of another fragment only after the normal closure of the dentition is restored. Between the teeth of a short fragment and their antagonists, a rubber gasket is placed to speed up the bite correction.
In case of a fracture of the lower jaw behind the dentition, the method of choice is the use of a wire spike with intermaxillary traction. If the fragment of the lower jaw is displaced in two planes (vertical and horizontal), an intermaxillary traction is shown. In case of a fracture of the lower jaw in the area of the angle with a horizontal displacement of a long fragment towards the fracture, it is advisable to use a splint with a sliding hinge (Fig. 229, e). It differs in that it fixes the fragments of the jaw, eliminates their horizontal displacement and allows free movement in the temporomandibular joints.
With a bilateral fracture of the lower jaw, the middle fragment, as a rule, is displaced downwards, and sometimes also backwards under the influence of muscle traction. In this case, often the lateral fragments are displaced towards each other. In such cases, it is convenient to immobilize the jaw fragments in two stages. At the first stage, the lateral fragments are bred and fixed with a wire arch with the correct closure of the dentition, at the second, the middle fragment is pulled up with the help of intermaxillary traction. Having set the middle fragment in the position of the correct bite, it is attached to a common tire.
In case of a fracture of the lower jaw with one toothless fragment, the latter is fixed with a bent spike made of aluminum wire with a loop and lining. The free end of the aluminum tire is fixed on the teeth of another fragment of the jaw with wire ligatures.
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Rice. 229. Wire bus according to Tigerstedt.
a - smooth tire-arc; b - a smooth tire with a spacer; in - bus with. hooks; g - a spike with hooks and an inclined plane; e - splint with hooks and intermaxillary traction; e - rubber rings.
In case of fractures of the edentulous lower jaw, if the patient has dentures, they can be used as splints for temporary immobilization of jaw fragments with simultaneous application of a chin sling. To ensure the intake of food in the lower prosthesis, all 4 incisors are cut out and the patient is fed from a drinker through the hole formed.
Treatment of fractures of the alveolar process
Rice. 231. Treatment of fractures of the alveolar process.
a - with an inward displacement; b - with posterior displacement; c - with vertical displacement.
In case of fractures of the alveolar process of the upper or lower jaw, the fragment, as a rule, is fixed with a wire splint, most often smooth and single-jawed. In the treatment of a non-gunshot fracture of the alveolar process, the fragment is usually set at the same time under novocaine anesthesia. The fragment is fixed with a smooth aluminum wire arc 1.5–2 mm thick.
In case of a fracture of the anterior alveolar process with a displacement of the fragment back, the wire arc is attached with ligatures to the lateral teeth on both sides, after which the fragment is pulled anteriorly with rubber rings (Fig. 231, b).
In case of a fracture of the lateral part of the alveolar process with its displacement to the lingual side, a springy steel wire 1.2-1.5 mm thick is used (Fig. 231, a). The arc is first attached with ligatures to the teeth of the healthy side, then the fragment is pulled with ligatures to the free end of the arc. When the fragment is vertically displaced, an aluminum wire arc with hook loops and rubber rings is used (Fig. 231, c).
In case of gunshot injuries of the alveolar process with crushing of the teeth, the latter are removed and the defect in the dentition is replaced with a prosthesis.
In case of fractures of the palatine process with damage to the mucous membrane, a fragment and a flap of the mucous membrane are fixed with an aluminum clip with support loops directed back to the site of damage. The mucosal flap can also be fixed with a celluloid or plastic palatal plate.
Orthopedic treatment of fractures of the upper jaw
Fixation splints, attached to the headband with elastic traction, often cause displacement of fragments of the upper jaw in and deformities of the bite, which is especially important to remember in case of comminuted fractures of the upper jaw with bone defects. For these reasons, wire fixing splints without rubber traction have been proposed.
Ya. M. Zbarzh recommends two options for bending splints made of aluminum wire for fixing fragments of the upper jaw. In the first option, a piece of aluminum wire 60 cm long is taken, its ends15 cm long, each is bent towards each other, then these ends are twisted in the form of spirals (Fig. 232). In order for the spirals to be uniform, the following conditions must be met:
1) during twisting, the angle formed by the long axes of the wire must be constant and not more than 45°;
2) one process must have the direction of the turns clockwise, the other, on the contrary, counterclockwise. The formation of twisted processes is considered complete when the middle part of the wire between the last turns is equal to the distance between the premolars. This part is further the front part of the tooth splint.
In the second option, they take a piece of aluminum wire of the same length as in the previous case, and bend it so that the intraoral part of the splint and the remains of the extraoral part are immediately determined (Fig. 232, b), after which they begin to twist the extraoral rods, which, as in the first variant, they are bent over the cheeks towards the auricles and are attached to the headband by means of connecting, vertically extending rods. The lower ends of the connecting rods are bent upwards in the form of a hook and connected with a ligature wire to the process of the tire, and the upper ends of the connecting rods are reinforced with plaster on the head bandage, which gives the lm greater stability.
Displacement of a fragment of the upper jaw posteriorly can cause asphyxia due to the closure of the lumen of the pharynx. In order to prevent this complication, it is necessary to pull the fragment anteriorly. Traction and fixation of the fragment is performed by an extraoral method. To do this, a head bandage is made and in its anterior part a plate of tin with a soldered lever made of steel wire 3-4 mm thick is plastered or 3-4 twisted
Fig, 232. The sequence of manufacturing wire tires from aluminum wire (according to Zbarzh).
a - the first option; b - the second option; e - fastening of solid-bent aluminum wiretires using connecting rods.
aluminum wires, which are hooked with a toe loop against the oral fissure. A brace made of aluminum wire with hook loops is applied to the teeth of the upper jaw or a supragingival lamellar spike with hook loops in the area of the incisors is used. By means of an elastic traction (rubber ring), a fragment of the upper jaw is pulled up to the arm of the headband.
In case of lateral displacement of a fragment of the upper jaw, a metal rod is plastered on the opposite side of the displacement of the fragment to the lateral surface of the head plaster cast. Traction is carried out by elastic traction, as in the case of displacements of the upper jaw posteriorly. Fragment traction is performed under bite control. With vertical displacement, the apparatus is supplemented with traction in the vertical plane by means of horizontal extraoral levers, a supragingival plate splint and rubber bands (Fig. 233). The plate splint is made individually according to the impression of the upper jaw. From impression materials
Rice. 233. Lamellar gingival splint for fixing fragments of the upper jaw. a - view of the finished tire; b - the splint is fixed on the jaw and to the headband.
it is better to use alginate. According to the obtained plaster model, they start modeling the lamellar tire. It should cover the teeth and the mucous membrane of the gums both from the palatine side and from the vestibule of the oral cavity. The chewing and cutting surfaces of the teeth remain bare. Tetrahedral sleeves are welded to the side surface of the apparatus on both sides, which serve as bushings for extraoral levers. The levers can be made in advance. They have tetrahedral ends corresponding to the sleeves into which they are inserted in the anteroposterior direction. In the area of the fangs, the levers form a bend around the corners of the mouth and, going outward, go towards auricle. A loop-shaped curved wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. The levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband by means of rubber rings.
A similar splint can also be used to treat combined fractures of the upper and lower jaws. In such cases, hook loops are welded to the plate spike of the upper jaw, bent at a right angle upwards. Fixation of fragments of the jaws is carried out in two stages. At the first stage, fragments of the upper jaw are fixed to the head with the help of a splint with extraoral levers connected to the plaster cast with rubber bands (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled up to the splint of the upper jaw by means of an aluminum wire splint with hook loops fixed on the lower jaw.
Orthopedic treatment of mandibular fractures
Orthopedic treatment of fractures of the lower jaw, median or close to the midline, in the presence of teeth on both fragments, is carried out using a smooth aluminum wire arc. As a rule, wire ligatures going around the teeth should be fixed on the splint with closed jaws under bite control. Prolonged treatment of fractures of the lower jaw with wire splints with intermaxillary traction can lead to the formation of scar bands and the occurrence of extra-articular contractures of the jaws due to prolonged inactivity of the temporomandibular joints. As a result, there was a need for functional treatment damage to the maxillofacial region, providing physiological rather than mechanical rest. This problem can be solved by returning to the undeservedly forgotten single jaw splint, to fixing jaw fragments with devices that preserve movement in the temporomandibular joints. Single-jaw fixation of fragments ensures early use of maxillofacial gymnastics as a therapeutic factor. This complex formed the basis for the treatment of gunshot injuries of the lower jaw and was called the functional method. Of course, the treatment of some patients without more or less significant damage to the oral mucosa and oral region, patients with linear fractures, with closed fractures of the lower jaw branch can be completed by intermaxillary fixation of bone fragments without any harmful consequences.
In case of fractures of the lower jaw in the area of the angle, at the place of attachment of the masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. With multi-comminuted fractures, damage to the mucous membrane, oral cavity and facial integument, fractures accompanied by a bone defect, etc., the wounded need single-maxillary fixation of fragments, which allow them to maintain movement in the temporomandibular joints.
A. Ya. Katz proposed a regulating apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin region. The apparatus consists of rings reinforced with cement on the teeth of a jaw fragment, oval-shaped sleeves soldered to the buccal surface of the rings, and levers originating in the sleeves and protruding from the oral cavity. By means of the protruding parts of the lever, it is possible to quite successfully adjust the fragments of the jaw in any plane and set them in the correct position (see Fig. 234).
Rice. 234. Replicating apparatus forreduction of fragments of the lower jaw.
l - Katz; 6 - Pomerantseva-Urbanskaya; a - Shelhorn; Mr. Porno and Psom; e - kappa-rod apparatus.
Of the other single-jaw devices for the treatment of fractures of the lower jaw, it should be noted the spring-loaded bracket made of stainless steel "Pomerantseva-Urbaiska. This author recommends the method of applying ligatures according to Schelgorn (Fig. 234) to regulate the movement of fragments of the jaw in the vertical direction. With a significant defect in the body of the lower jaw and a small number of teeth on fragments of the jaw, A. L. Grozovsky suggests using a kappa-rod repositioning apparatus (Fig. 234, e). The preserved teeth are covered with crowns, to which rods in the form of semi-arches are soldered. At the free ends of the rods there are holes where screws and nuts are inserted, which regulate and fix the position of the jaw fragments.
We proposed a spring-loaded apparatus, which is a modification of the Katz apparatus for repositioning mandibular fragments in case of a defect in the chin area. This is an apparatus of combined and sequential action: at first repositioning, then fixing, shaping and replacing. The op consists of metal trays with double tubes soldered to the buccal surface, and springy levers made of stainless steel 1.5–2 mm thick. One end of the lever ends with two rods and is inserted into the tubes, the other protrudes from the oral cavity and serves to regulate the movement of jaw fragments. Having set the jaw fragments in the correct position, they replace the extraoral levers fixed in the kappa tubes with a vestibular clip or a forming apparatus (Fig. 235).
The kappa apparatus undoubtedly has some advantages over wire splints. Its advantages lie in the fact that, being single-jawed, it does not restrict movements in the temporomandibular joints. With the help of this apparatus, it is possible to achieve stable immobilization of jaw fragments and, at the same time, stabilization of the teeth of the damaged jaw (the latter is especially important with a small number of teeth and their mobility). Kappa apparatus without wire ligatures is used; the gum is not damaged. Its disadvantages include the need for constant monitoring, since cement resorption in kappas and displacement of jaw fragments are possible. To monitor the state of cement on the chewing surface kappas make holes (“windows”). For this reason, these patients should not be transported, since the decementation of the mouthguards along the way will lead to a violation of the immobilization of jaw fragments. Kappa devices have found wider use in pediatric practice for fractures of the jaws.
Rice. 235. Repositioning apparatus (according to Oksman).
a - replicating; 6 - fixing; c - forming and replacing.
M. M. Vankevich proposed a plate splint covering the palatine and vestibular surface of the mucous membrane of the upper jaw. From the palatal surface of the tire depart downward, to the lingual surface of the lower molars, two inclined planes. When the jaws close, these planes push apart the fragments of the lower jaw, displaced in the lingual direction, and fix them in the correct position (Fig. 236). Tire Vankevich modified by A. I. Stepanov. Instead of a palatal plate, he introduced an arc, thus freeing part of the hard palate.
Rice. 236. Plastic splint for fixing fragments of the lower jaw.
a - according to Vankevich; b - according to Stepanov.
In case of a fracture of the lower jaw in the region of the angle, as well as in other fractures with displacement of fragments to the lingual side, tires with an inclined plane are often used, and among them a plate supragingival splint with an inclined plane (Fig. 237, a, b). However, it should be noted that a supragingival splint with an inclined plane can be useful only with a slight horizontal displacement of the jaw fragment, when the plane deviates from the buccal surface of the teeth of the upper jaw by 10-15°. With a large deviation of the plane of the tire from the teeth of the upper jaw, the inclined plane, and with it the fragment of the lower jaw (will be pushed downward. Thus, the horizontal displacement will be complicated by the vertical one. In order to eliminate the possibility of this position, 3. Ya. Shur recommends providing an orthopedic apparatus springy inclined plane.
Rice. 237. Dental splint for the lower jaw.
a - general view; b - tire with an inclined plane; c - orthopedic devices with sliding hinges (according to Schroeder); g - steel wire tire with a sliding hinge (according to Pomerantseva-Urbanskaya).
All of the described fixing and regulating devices retain the mobility of the lower jaw in the temporomandibular joints.
Treatment of mandibular body fractures with edentulous fragments
Fixation of fragments of the edentulous mandible is possible surgical methods: imposition of a bone suture, intraosseous pins, extraoral bone splints.
In case of a fracture of the lower jaw behind the dentition in the area of the angle or branch with a vertical displacement of a long fragment or a shift forward and towards the fracture, intermaxillary fixation with oblique traction should be used in the first period. In the future, to eliminate the horizontal displacement (shift towards the fracture), satisfactory results are achieved by using the Pomerantseva-Urbanskaya articulated splint.
Some authors (Schroeder, Brun, Gofrat, etc.) recommend standard tires with a sliding hinge, fixed on the teeth with the help of caps (Fig. 237, c). 3. N. Pomerantseva-Urbanskaya proposed a simplified design of a sliding hinge made of stainless wire 1.5-2 mm thick (Fig. 237, d).
The use of splints with a sliding hinge for fractures of the lower jaw in the area of the angle and branch prevents the displacement of fragments, the occurrence of deformations of facial asymmetry and is also the prevention of jaw contractures, because this splinting method preserves the vertical movements of the jaw and is easily combined with techniques therapeutic gymnastics. A short fragment of a branch in case of a fracture of the lower jaw in the angle area is strengthened by skeletal traction using elastic traction to a head plaster cast with a rod behind the ear, as well as a wire ligature around the angle of the jaw.
In case of a fracture of the lower jaw with one edentulous fragment, the extension of the long fragment and the fixation of the short one are carried out using a wire clamp with hook loops, fastened to the teeth of the long fragment with a flight to the alveolar process of the edentulous fragment (Fig. 238). Intermaxillary fixation eliminates the displacement of the long fragment, and the pelot keeps the edentulous fragment from displacement upward and to the side. There is no downward displacement of the short fragment, since it is held by the muscles that lift the lower jaw. The tire can be made of elastic wire, and the pilot can be made of plastic.
Rice. 238. Skeletal traction of the lower jaw in the absence of teeth.
With fractures of the body of the edentulous lower jaw, the most in a simple way temporary fixation are the use of the patient's prostheses and the fixation of the lower jaw by means of a rigid chin sling. In their absence, temporary immobilization can be carried out with a block of bite rollers made of thermoplastic mass with bases made of the same material. Further treatment is carried out by surgical methods.
plastic tires
In case of fractures of the jaws, combined with radiation injuries, the use of metal splints is contraindicated, since metals, as some believe, can become a source of secondary radiation, causing necrosis of the gingival mucosa. It is more expedient to make tires from plastic. M. R. Marey recommends that instead of a ligature wire, nylon threads be used to fix the tire, and a splint for fractures of the lower jaw is made of quick-hardening plastic along a prefabricated aluminum groove of an arcuate shape, which is filled with freshly prepared plastic, applying it to the vestibular surface of the dental arch. After the plastic has hardened, the aluminum chute can be easily removed, and the plastic is firmly connected to the nylon threads and fixes the jaw fragments.
The method of overlaying plastic G. A. Vasiliev and co-workers. A nylon thread with a plastic bead is applied to each tooth on the vestibular surface of the tooth. This creates a more secure fixation of the ligatures in the tire. Then a splint is applied according to the method described by M, R. Marey. If necessary, intermaxillary fixation of fragments of the jaw in the appropriate areas, holes are drilled with a spherical burr and pre-prepared plastic spikes are inserted into them, which are fixed with freshly prepared quick-hardening plastic (Fig. 239). The spikes serve as a place for applying rubber rings for intermaxillary traction and fixation of jaw fragments.
Rice. 239. The sequence of manufacturing jaw splints from fast-hardening plastic.
a - fixation of beads; b - bending of the groove; in - groove; g - a smooth splint is applied to the jaw; d - tire with hook loops; e—fixation of the jaw.
F. L. Gardashnikov proposed a universal elastic plastic tooth splint (Fig. 240) with mushroom-shaped rods for intermaxillary traction. The tire is strengthened with a bronze-aluminum ligature.
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Rice. 240. Standard tire made of elastic plastic (according to Gardashnikov)
a - side view; b - front view; c - mushroom-shaped process.
Orthopedic treatment of jaw fractures in children
Tooth trauma. Bruises of the facial area may be accompanied by trauma to one tooth or group of teeth. Tooth trauma is found in 1.8-2.5% of the examined schoolchildren. More often there is an injury to the incisors of the upper jaw.
When the enamel of a milk or permanent tooth is broken off, the sharp edges are ground with a carborundum head to avoid injury to the mucous membrane of the lips, cheeks, and tongue. In case of violation of the integrity of the dentin, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed on artificial dentin without its preparation. During this timethe formation of replacement dentin is expected. In the future, the crown is replaced with a filling or inlay to match the color of the tooth. In case of a fracture of the tooth crown with damage to the pulp, the latter is removed. After filling root canal the treatment is completed by applying an inlay with a pin or a plastic crown. When the crown of a tooth is broken off at its neck, the crown is removed, and the root is tried to be preserved in order to use it to strengthen the pin tooth.
When a tooth is fractured in the middle part of the root, when there is no significant displacement of the tooth along the vertical axis, they try to save it. To do this, put a wire splint on a group of teeth with a ligature bandage on the damaged tooth. In young children (up to 5 years old), it is better to fix broken teeth with a mouthguard made ofplastics. The experience of domestic dentists has shown that a fracture of the tooth root sometimes grows together in l "/g - 2 months after splinting. The tooth becomes stable, and its functional value is completely restored. If the color of the tooth changes, electrical excitability sharply decreases, pain occurs during percussion or palpation in near the apical region, then the crown of the tooth is trepanned and the pulp is removed.
With bruises with root wedging into a broken alveolus, it is better to adhere to expectant tactics, bearing in mind that in some cases the tooth root is somewhat pushed out due to the developed traumatic inflammation. In the absence of inflammation after healing of the injury, the holes resort to orthopedic treatment.
If a permanent tooth has to be removed from a child due to an injury, then the resulting defect in the dentition will be mixed with a fixed prosthesis with unilateral fixation or a sliding removable prosthesis with bilateral fixation in order to avoid deformation of the bite. Crowns, pin teeth can serve as supports. A defect in the dentition can also be replaced with a removable prosthesis.
With the loss of 2 or 3 front teeth, the defect is replaced using a hinged and removable denture according to Ilyina-Markosyan or a removable denture. When individual front teeth fall out due to a bruise, but with the integrity of their sockets, they can be replanted, provided that assistance is provided soon after the injury. After replantation, the tooth is fixed for 4-6 weeks with a plastic kappa. It is not recommended to replant milk teeth, as they may interfere with the normal eruption of permanent teeth or cause the development of a follicular cyst.
Treatment of dislocation of teeth and fracture of the holes .
In children under the age of 27, with bruises, dislocation of the teeth or fracture of the holes and the region of the incisors and displacement of the teeth to the labial or lingual side are observed. At this age, fixing the teeth with a wire arch and wire ligatures is contraindicated due to the instability of milk teeth and the small size of their crowns. In these cases, the method of choice should be to manually set the teeth (if possible) and secure them with a celluloid or plastic tray. The psychology of a child at this age has its own characteristics: he is afraid of the doctor's manipulations. The unusual environment of the office affects the child negatively. Preparation of the child and some caution in the behavior of the doctor are necessary. At first, the doctor teaches the child to look at the instruments (a spatula and a mirror and at the orthopedic apparatus) as if they were toys, and then he carefully proceeds to orthopedic treatment. Techniques for applying a wire arch and wire ligatures are rough and painful, so preference should be given to mouthguards, the imposition of which the child tolerates much more easily.
How to make a kappa Pomerantseva-Urbanskaya .
After a preparatory conversation between the doctor and the child, the teeth are smeared with a thin layer of petroleum jelly and an impression is carefully taken from the damaged jaw. On the resulting plaster model, the displaced teeth are broken at the base, set in the correct position and glued with cement. On the model prepared in this way, a mouthguard is formed from wax, which should cover the displaced and adjacent stable teeth on both sides. The wax is then replaced with plastic. When the mouthguard is ready, the teeth are manually set under appropriate anesthesia and the mouthguard is fixed on them. In extreme cases, you can carefully not completely apply a mouthguard and invite the child to gradually close the jaws, which will help set the teeth in their sockets. A kappa for fixing dislocated teeth is strengthened with artificial dentin and left in the mouth for 2-4 weeks, depending on the nature of the damage.
Fractures of the jaws in children. Jaw fractures in children occur as a result of trauma due to the fact that children are mobile and careless. Fractures of the alveolar process or dislocation of teeth are more often observed, less often fractures of the jaws. When choosing a treatment method, it is necessary to take into account some age-related anatomical and physiological features dental system associated with the growth and development of the child's body. In addition, it is necessary to take into account the psychology of the child in order to develop the correct methods of approaching him.
Orthopedic treatment of mandibular fractures in children.
In the treatment of fractures of the alveolar process or the body of the lower jaw great importance have the character of displacement of bone fragments and the direction of the fracture line in relation to the dental follicles. Fracture healing proceeds faster if its line runs at some distance from the dental follicle. If the latter is located on the fracture line, it may become infected and complication of a jaw fracture with osteomyelitis. In the future, the formation of a follicular cyst is also possible. Similar complications can develop when the fragment is displaced and its sharp edges are introduced into the tissues of the follicle. In order to determine the ratio of the fracture line to the dental follicle, it is necessary to produce x-rays in two directions - in profile and face. To avoid layering of milk teeth on permanent images, it should be done with a half-open mouth. In case of a fracture of the lower jaw at the age of up to 3 years, a plastic palatine plate with imprints of the chewing surfaces of the dentition of the upper and lower jaws (tire-kappa) in combination with a chin sling can be used.
Technique for the manufacture of a plate splint-kappa.
After some psychological preparation of a small patient, an impression is taken from the jaws (first from the top, then from the bottom). The resulting model of the lower jaw is sawn into two parts at the fracture site, then they are made up with a plaster model of the upper jaw in the correct ratio, glued with wax and plastered into the occluder. After that, a well-heated semi-circular wax roller is taken and placed between the teeth of plaster models in order to obtain an imprint of the dentition. The latter should be at a distance of 6-8 mm from each other. The wax roller with the plate is checked in the mouth and, if necessary, it is corrected. Then the plate is made of plastic according to the usual rules. This apparatus is used together with a chin sling. The child uses it for 4-6 weeks until the fusion of the jaw fragments occurs. When feeding a child, the device can be temporarily removed, then immediately put it back on. Food should only be given in liquid form.
In children at chronic osteomyelitis observed pathological fractures of the lower jaw. To prevent them, as well as the displacement of fragments of the jaw, especially after sequestrotomy, splinting is shown. From a wide variety of tires, preference should be given to the Vankevich tire in Stepanov's modification (see Fig. 293, a) as more hygienic and easily portable.
Impressions from both jaws are taken before sequestrotomy. Plaster models are plastered into the occluder in the position of central occlusion. The palatal plate of the tire is modeled with an inclined plane downward (one or two depending on the topography of a possible fracture), to the lingual surface of the chewing teeth of the lower jaw. It is recommended to fix the device with arrow-shaped clasps.
With fractures of the jaw at the age of 21/2 to 6 years, the roots of milk teeth are already formed to one degree or another and the teeth are more stable. The child at this time is easier to persuade. Orthopedic treatment can often be carried out using stainless steel wire splints 1-1.3 mm thick. Tires are strengthened with ligatures to each tooth along the entire length of the dentition. For low crowns or tooth decay by caries, plastic mouthguards are used, as already described above.
When applying wire ligatures, it is necessary to take into account some anatomical features of the teeth of the milk bite. Milk teeth, as you know, are low, have convex crowns, especially in chewing teeth. Their large circle is located closer to the neck of the tooth. As a result, wire ligatures applied in the usual way slip off. In such cases, special techniques for applying ligatures are recommended: a ligature covers the tooth around the neck and twists it, forming 1-2 turns. Then the ends of the ligature are pulled over and under the wire arc and twisted in the usual way.
In case of jaw fractures at the age of 6 to 12 years, it is necessary to take into account the peculiarities of the dentition of this period (resorption of the roots of milk teeth, eruption of crowns of permanent teeth with immature roots). Medical tactics in this case depends on the degree of resorption of milk teeth. With complete resorption of their roots, the dislocated teeth are removed, with incomplete resorption, they are splinted, keeping them until the eruption of permanent teeth. When the roots of milk teeth are broken, the latter are removed, and the defect in the dentition is replaced with a temporary removable prosthesis to avoid bite deformation. For immobilization of fragments of the lower jaw, it is advisable to use a soldered splint, and as supporting teeth it is better to use the 6th teeth as more stable and milk canines, on which crowns or rings are applied and connected with a wire arc. In some cases, the manufacture of a mouthguard for a group of chewing teeth with hook loops for intermaxillary fixation of jaw fragments is shown. At the age of 13 years and older, splinting is usually not difficult, since the permanent teeth are already well-formed.
