Functional disorders in maxillofacial injuries. Classification of damage to the maxillofacial region

Damage- violation of the integral structure at the cellular, tissue or organ level, resulting from the action of a damaging agent. Can be caused mechanical action, including firearms, physical factors– thermal damage, radiation damage; chemical factors- damage by acids, alkalis, toxic chemical agents.

Classification of damage depends on the nature, location, damaging factor, amount of damage, etc.

Classification (B. D. Kabakov)- division of damage into mechanical, in turn, subdivided by localization, nature and mechanism of damage, as well as combined damage, burns, frostbite, chemical and radiation damage.

♦ Damage can be isolated, ie. affecting only one anatomical region, single and multiple.

♦ Damage can be combined, single and multiple, if we are talking about damage to several anatomical regions by one damaging factor.

♦ Combined injury - simultaneous impact on tissues or organs of different mechanisms of action of damaging factors: mechanical and thermal effects on facial tissues; mechanical and radiation exposure; gunshot wound and chemical burn, etc.

Fractures of the bones of the facial skeleton

Fractures of the bones of the facial skeleton range from 5-6% to 7-9% of traumatic injuries of the skeleton. Fractures of the lower jaw account for up to 65-85% of the total number of facial tissue injuries; upper jaw - 4-6%; zygomatic bones and bones of the nose - respectively 7-9% and 4-7%.

Bone fractures resulting from the action of force on an intact bone are classified as traumatic, and fractures resulting from the action of force on a bone altered by a pathological process (tumor, cyst, osteomyelitis) are classified as pathological.

Fractures without breaking the integrity skin and mucous membranes are considered as closed. Fractures that are accompanied by a violation of the integrity of these tissues are open and primary infected.

The fracture that occurs at the site of the application of force is direct; on the opposite side (which applies more to fractures of the lower jaw) - reflected.

Depending on the strength, direction and place of impact, single, double, more often bilateral, sometimes multiple fractures occur.

The displacement of fragments depends on:

- traction forces of masticatory muscles;

-localization of the fracture and the number of fragments;

-strength and direction of impact; -mass (gravity) of the fragment.

Diagnosis of mandibular fracture and main, pathognomonic symptoms:

1. Determination of pathological mobility of fragments.

2. Displacement of fragments, leading to malocclusion.

3. Crepitation of fragments when they are displaced by fingers.

4. Symptom of loading along the axis or a symptom of indirect pain - the occurrence of pain in the area of ​​​​the fracture when pressing or tapping on the jaw away from the suspicious site for a fracture.

Radiographs of the lower jaw of patients with a fracture of the condylar process:

Unlike the only unpaired and movable lower jaw, all other bones of the facial skeleton that form the middle zone of the face are paired and immobile.

Given the complexity of the midface, the following is currently used classification of fractures of the maxillary bones:

♦ fracture of the lower type (subnasal) - Le Fort I

♦ fracture of the middle type (suborbital) - Le Fort II

♦ fracture by top type(subbasal) – Le Fort III

Fractures are also mostly open and primary infected. With fractures of this localization, meningeal symptoms, loss, clouding of consciousness, nausea, vomiting, blurred vision, emphysema of facial tissues with damage to the paranasal sinuses, and liquor leakage are possible. X-ray diagnostics difficult, therefore, it is preferable to use CT and other research methods.

The first type of fracture of the upper jaw (subnasal):

The second type of fracture of the upper jaw (suborbital):

The third type of fracture of the upper jaw (subbasal):

Determination of the mobility of fragments of the upper jaw in case of its fracture:

Grab the upper teeth with the fingers of one hand and carefully move the jaw in an anterior-posterior direction.

The zygomatic bone, consisting of a body and an arch, connects the bones of the facial and brain (temporal) skull into a single whole. According to the type of fracture, open and closed (without violating the bone walls of the sinus), comminuted fractures are described. By localization, fractures of the body of the zygomatic bone are possible, often combined with damage to the walls of the sinus, infraorbital nerve, eyeball, and fractures of the zygomatic arch in its middle third, accompanied by pain in the region of the temporal muscle and limitation of movements of the lower jaw. characteristic symptom fracture of the zygomatic bone is a retraction in the area of ​​​​the body and the arch, the occurrence of a painful sharp "step" along the infraorbital margin, a violation of sensitivity in the zone of innervation of the infraorbital nerve. “The sound of cracked peas” - with percussion of the teeth in the fracture zone (E.I. Malevich).

Appearance of a patient with a fracture of the left zygomatic bone:

X-ray of a patient with a fracture of the zygomatic bone on the right:

Reduction of the zygomatic arch using a single-pronged hook with a transverse handle (Limberg hook):

Treatment of bone fractures according to traumatological canons consists of two stages:

♦ transport immobilization of fragments with the introduction of painkillers to prevent secondary displacement of fragments, relieve pain, prevent the development of shock

♦ specialized care in a hospital, which provides for a number of measures for the treatment of the patient.

used for transport immobilization. how standard means: Entin's sling-sling, Pomerantseva-Urbanskaya's sling, ligature bonding of teeth, various spoon splints, and henchmen- bandage chin-parietal bandages, boards, pencils, spatulas. Direct treatment – includes includes a number of mandatory, necessary actions for the treatment of the fracture itself and therapeutic measures determined by individual characteristics victim, volume, nature of the injury, concomitant injuries and possible complications.

The necessary components of the treatment of any damaged bone is the consistent implementation, using appropriate types of anesthesia, the following manipulations:

♦ Reposition of fragments, which can be manual, instrumental, one-stage, long, bloody.

♦ Fixation of fragments, which can be carried out by orthopedic (conservative) methods using various splints; surgical interventions in the form of osteosynthesis, when fragments are interconnected by various extraosseous, intra- and transosseous fixing devices from extra- and intraoral access.

♦ Immobilization of the lower jaw, ie. ensuring the rest of the jaw, turning off its movements.

In the treatment of fractures of the maxillary and zygomatic bones, the same principles are followed, using the orthopedic surgical technique in the first case. In case of fractures of the zygomatic bones, a bloody reposition of the fragments is performed with their fixation by various methods.

In parallel with the implementation of the necessary actions for the treatment of a bone fracture, the problem of treating a patient with a fracture is solved, namely:

♦ Creation of optimal conditions for the course of the process of reparative osteogenesis. In this case, it is necessary to take into account the age, gender of the patient, the staging of the process of bone formation, the pace and quality of which depend on the time elapsed after the injury, the presence of concomitant diseases, the type and quality of reposition and fixation, medical and geographical conditions, etc.

♦ Prevention of inflammatory complications and their treatment. To prevent the development of complications, it is necessary to determine the amount of therapy in each specific case, decide the fate of the tooth in the fracture gap, etc.

♦ Activities aimed at restoring the function of the damaged bone, restoring chewing.

Facial soft tissue injuries

Facial soft tissue injuries are enough frequent view damage in both peacetime and wartime. Depending on the type of wounding projectile, they can be: punctate, punctured, incised, linear torn, torn-bruised, torn-crushed, patchy, scalped, with or without soft tissue defect. Bitten wounds (by animals, humans) are also distinguished - they require special treatment and treatment tactics. Often, soft tissue damage is combined with a violation of the integrity of the vessels, including the main ones, of the nerves, which can lead to paresis (paralysis) of the facial muscles.

The soft tissues of the face are a complex, multi-component interweaving of various tissue structures, the trauma of which predetermines a special picture of damage, on the one hand, tactics and methods surgical intervention- with another. It must be taken into account that:

♦ A large amount of loose fiber, the presence of a dense capillary network, the elasticity of the skin leads to a significant rapidly developing tissue edema, especially in the infraorbital and oral regions.

♦ A dense capillary-venous network, salivary gland duct, muscle mass of the tongue in case of damage to the sublingual region and tongue, contribute to the occurrence of profuse, difficult to stop bleeding or significant swelling of the tissues of the sublingual region up to respiratory failure.

♦ Damage to soft tissues in the area of ​​distribution of peripheral branches facial nerve causes paralysis or paresis of the corresponding groups of facial muscles, which leads to facial disfigurement.

♦ The circular muscle of the mouth or orbital globe loses its closing function when it is damaged, which leads to constant salivation and maceration of the skin or to the development of conjunctivitis, blepharitis and other complications.

♦ The presence of glandular structures in the tissues of the face determines the risk of developing persistent salivary fistulas in case of damage to the parenchyma or ductal structures of the gland.

♦ The tissues of the submandibular region and the anterolateral surface of the neck contain large main vessels, damage to which can lead to death from acute blood loss or from an air embolism, it is also possible to develop a hematoma and stenotic asphyxia.

♦ During the period of wound healing, cicatricial constrictions can cause eversion of the eyelids, wings of the nose, lips with the development of salivation, lacrimation, in addition, disfigurement of the face occurs.

The healing process occurs in three main options: primary healing with the formation of a thin, inconspicuous elastic scar, secondary healing through the formation of connective tissue and the formation of a rough deforming scar with a transition sometimes to a keloid, and healing under the scab - characteristic of the healing of abrasions.

In the process of soft tissue healing, a number of successive phases are distinguished:

♦ Initial period of microbial contamination and wound cleansing (first 2 days).

♦ The period of degenerative-inflammatory changes - the development of purulent-necrotic complications is possible; in their absence, the processes of formation of granulation tissue are activated, lymphoid infiltration decreases, the number of fibroblasts increases, and a connective tissue matrix is ​​formed (3-5 days).

♦ The period of active growth of fibrous, epithelial tissue, wound retraction, formation of a primary scar (5-12 days).

♦ Completion of primary scar formation, disappearance of edema, tissue infiltration (12-18 days).

♦ Period of final scar formation (up to 0.5-1 year)

Appearance of a patient with a bitten wound of the nose and traumatic tissue amputation. The patient's appearance after plastic surgery(before stitches are removed):

Appearance of patients with post-traumatic cicatricial eversion of the lower eyelid:

a) front view; b) side view; c) front view.

Primary debridement(PHO)- the first surgical intervention performed according to primary indications in order to prevent wound infection. PST is carried out after appropriate preparation of the wound and surrounding tissues - cleansing, washing the wound, adequate anesthesia. PST consists of three components: wound dissection for revision; elimination of pockets, gaps; excision of non-viable, necrotic tissues and suturing. According to the timing: primary (in 1 day), delayed (2-3 days), late (over 2-3 days).

With the development of an infectious process, suppuration is carried out secondary debridement (SDO)- taken according to secondary indications, due to the presence purulent process or insufficient radicalness of the previous treatment for the treatment of wound infection. According to the bill, WMO can be a primary intervention.

Types of seams:

♦ Primary blind suture, applied in the first 24-48-72 hours in the absence of inflammation in the wound.

♦ Primary delayed suture, applied at the same time with unexpressed inflammatory-infiltrative processes.

♦ A secondary early suture is applied to a granulating wound without excision of granulations on days 5-12 in the absence of inflammatory process.

♦ Secondary late suture is applied to the wound with excision of granulations for 12-20 days.

♦ Original, lamellar sutures, which are applied in case of extensive torn-bruised patchwork wounds in the presence of tissue edema and inflammatory infiltrate; they perform bringing together, directed, unloading and holding functions.

Tooth damage

Classification of damage to the teeth (G.M. Ivashchenko):

♦ Incomplete fractures of teeth (without opening the pulp):

Cracks in enamel and dentin; marginal fracture of the crown, detachment of enamel and dentin.

♦ Complete fracture of teeth (with opening of the pulp):

a) open (into the oral cavity) - fractures with a partial defect of the crown; fragmentation or defect of the crown; crushing or defect of the crown and root;

b) closed (while maintaining the integrity of the crown) - root fracture.

♦ Dislocations of teeth:

Incomplete (partial) dislocation of the tooth; dislocation of the tooth (separation) and separation of the edge of the alveolar process.

♦ Driving in teeth.

dislocation of the tooth- this is a displacement of the tooth in the hole to either side or into the spongy tissue of the jaw, which is accompanied by a rupture of the tissues surrounding the tooth. With incomplete dislocation, there is a displacement of the tooth to the lingual (palatal) or buccal side, but the tooth has not lost contact with the hole. Complaints of pain in the tooth, aggravated by touching it, its mobility and displacement in relation to other teeth. Local anesthesia, manual reduction of the tooth, its immobilization by ligature binding or a dental splint for a period of about 2 weeks. With complete dislocation, the tooth is completely dislocated from the hole and loses contact with it, but can only be held in it due to the adhesive properties of the two blood-moistened surfaces. In case of traumatic tooth extraction, the hole is made with a clot, the gum is torn. The walls of the socket are broken or may be missing, which makes it impossible to carry out the replantation of the tooth, which is indicated for complete dislocation.

Drawing of the anterior teeth of the upper jaw with a fracture (indicated by arrows) of the central incisors:

Treatment of a fractured tooth varies depending on its type. When a crown is broken off - without opening the pulp, grinding off sharp edges and restoring a tooth defect with a filling or inlay; if the pulp is opened, depulp the tooth, the canal is sealed and the defect is restored. In case of a root fracture in the apex area, promptly remove the broken off part of it with obligatory preliminary filling of the root canal, the bone defect is filled. The tooth is subject to removal in case of a root fracture below the neck of the tooth and in case of its longitudinal fracture. With a root fracture baby tooth with inflamed, necrotic pulp or periapical changes, its removal is indicated.

Classification of fractures of the alveolar process:

♦ partial - the fracture line passes through the outer compact plate and spongy substance;

♦ complete - the fracture line passes through the entire thickness of the alveolar process;

♦ detachment of the alveolar process;

♦ fracture of the alveolar process, combined with dislocation or fracture of the teeth;

♦ comminuted fracture.

fracture line passes above the tops of the roots of the teeth (on the upper jaw) or below them (on the lower jaw) and has an arched shape. Complaints of the patient on spontaneous pain in the area of ​​the injured jaw, aggravated by closing the teeth or biting on solid food. The patient cannot close his mouth. There is bleeding. Speech disorder.

On examination- swelling of the soft tissues of the oral region, bruises, abrasions, wounds on the skin; viscous saliva with an admixture of blood flows out of the mouth; there may be ruptures of the alveolar process and exposure of the bone or tops of the teeth. In children, along with the alveolar process, the follicles of permanent teeth are displaced, which can lead to their death. The treatment is carried out under local anesthesia, digital alignment of the broken fragment of the alveolar process is carried out. With a sufficient number of stable teeth, it is necessary to apply a smooth splint - a bracket. Held PHO wounds mucous membrane of the alveolar process. The splint is kept, depending on the type of fracture, for about 2-3 weeks, followed by a 2-3 week light diet. Mandatory oral hygiene.

Fracture of the alveolar process of the upper jaw:

16286 0

Classification.

I. Production.

• Industrial.
• Agricultural.

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

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

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

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

• radiation;
• chemical poisoning.

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

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

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

Karaganda State Medical University

Department of Surgical Dentistry

Topic: “Injuries to the maxillofacial region. Classification. Principles of diagnosis and treatment»

Discipline PHS 4302 "Propaedeutics of Surgical Dentistry"

Specialty 051302 "Dentistry"

Course: 4

Time (duration) 1 hour

Karaganda 2014

Approved at a meeting of the Department of Surgical Dentistry

"____"______ 20___ protocol No. ____

Head of the Department of Surgical Dentistry, Professor _______________ Kurashev A.G.

3. Branches n/h:

a) the actual branches;

b) articular process (base, neck, head);

c) coronoid process;

a) alveolar process;

b) jaw body without nasal and zygomatic bones.

c) jaw tea with nasal and zygomatic bones;

a) zygomatic bone with damage to the walls of the maxillary

sinus or no damage;

b) zygomatic bone and zygomatic arch;

c) zygomatic arch;
D. Fractures of the bones of the nose:

a) nasal septum in the cartilaginous region;

b) nasal septum in the bone and cartilage region;

c) nasal bones;

A.a) single;

b) double;

d) multiple;

b) bilateral;

b) with displacement of fragments;

b) combined;

1. with a traumatic brain injury;

2. with fractures of other bones of the facial skeleton and

other areas of the body;

3. with damage to the soft tissues of the face;

b) open;

d) not penetrating into the maxillary sinus;

A. Gunshots;

B Non-firearms;
II. Combined lesions.
III. Burns.
IV. Frostbite.
II-2. C A L S I F I C A T I O N E O G N E S R E L N S

R A N E N I J I P O D R E ZH D E N I Y C E L J U S T N O L I C E -

V O Y O B L A S T I.
I. Mechanical damage to the upper, middle, lower and

kovy areas of the face.

1. Injuries of soft tissues.

2. Injuries of the teeth and bones of the maxillofacial area.

a) dental trauma;

b) fractures n/h;

c) fractures in / h;

d) fractures of the zygomatic bone and zygomatic arch;

e) fractures of the bones of the nose;

A.a) ordinary;

b) double;

c) multiple;

B. a) unilateral;

b) bilateral;

B. a) without displacement of fragments;

b) with displacement of fragments;

G. a) isolated;

Fractures of other bones of the face and other areas of the body

With damage to the soft tissues of the face

E. a) closed;

b) open;

D. a) penetrating into the oral cavity;

b) do not penetrate into the oral cavity;

c) penetrating into the maxillary sinus;

d) not penetrating into the maxillary sinus;
According to the mechanism of damage:

A. gunshot;

B. non-gunshot;
II. Combined.
III. Burns
IV. Frostbite.

C L A S I P F I C A T I O N

H E L I S T N O L I C E V O Y

O B L A S T I.

a) bullet;

b) comminuted;

c) a fraction;

d) secondary projectiles;
2. By the number of damaging shells:

a) single;

b) multiple;
3. By the nature of the wound channel:

a) the blind

b) through;

c) tangents;

d) traumatic amputations-shots of the face;
4. According to the localization of damage to the soft tissues of the face, depending on the area of ​​the face, head, neck.
5. According to the nature of soft tissue injuries:

a) abrasions;

b) point;

d) gifted;

e) scalped;

e) torn-crushed, etc.

a) lower jaw;

b) upper jaw;

c) both jaws;

d) zygomatic bone;

e) nasal bones;

e) hyoid bone;

g) combined injuries of several facial bones;

a) incomplete fractures (cracks, perforated, marginal);

b) complete fractures (transverse, longitudinal, oblique, impacted, large-splintered, small-splintered, shattered, with a bone defect;
8. By the nature of the direction of the wound channel:

a) segmental;

b) contour;

c) diametrical;

d) rebound;
9. By the nature of the injury:

a) isolated;

b) combined;

c) multiregional;

a) non-penetrating;

b) penetrating (into the nasal cavity, paranasal sinuses, pharynx, larynx, esophagus, trachea, into several cavities at once);
11. In relation to the organs of the facial area:

a) no damage

b) with damage to the tongue, hard palate, soft palate,

salivary glands, blood vessels, nerves;

a) incomplete fractures;

b) complete fractures;
13. In relation to related areas and bodies;

a) no damage

b) with damage (TMJ, organs of vision, hearing, brain, spine, etc.).
14. In relation to damage to other areas of the body;

a) no damage

b) with damage (lower and upper limbs, chest, abdomen, pelvic organs, etc.).
15. According to the severity of the injury;

a) lungs;

b) average;

c) heavy;

d) terminal;

EXAMINATION METHODS

S O V R E J D E N I A M I ​​C L O.
I. Clinical

Examination of any patient should be carried out according to a specific, well-established system, strictly sequentially. Should be addressed Special attention on the nature of complaints, on anamnesis data, establishing the causes and circumstances of the occurrence

injury. This sequence and clarity is of particular importance when examining a patient with an injury who needs urgent assistance.

It is necessary to find out the time, place and circumstance of the injury, make a preliminary diagnosis and provide the first first aid and send the patient for medical assistance to the trauma center, clinic, hospital.

All data of the questioning and examination of the patient and the applied therapeutic measures should be documented and noted in the referral (especially the administration against tetanus serum).

The examination should include a survey, examination, palpation and special (instrumental) methods.

Interview. During the survey, first, the passport and front parts of the medical history are filled out, and then they begin to collect an anamnesis of the disease.

The anamnesis can be collected from the words of the patient, as well as those accompanying him. The medical documents available to the patient (referral, act of accident, extract from the medical history, etc.) can also be used. With special criticality should be treated the data of the anamnesis of the victims who are in a state of intoxication. It is necessary to find out when, where and under what circumstances the injury was received, the nature of the injury (industrial, household, sports, street, agricultural), if possible, to clarify the mechanism of injury, the nature of the injuring object, the patient's condition at the time of injury. At the same time, the year, month, day, hour (and, if possible, minutes) of the injury must be accurately indicated. In special cases for data forensic medical examination(in case of domestic injury) it is necessary to indicate the last name, first name, patronymic of the person who caused the injury, or witnesses.

It is necessary to find out whether the patient lost consciousness, whether he remembers what happened (retrograde anamnesia), whether there was vomiting, what sensations the patient was accompanied by an injury (char-r and duration of pain, the state of breathing, swallowing and speech), whether the character of pain and complaints has changed, what worries the patient at present

time.

When clarifying all these circumstances, it is necessary to strictly observe the rules of medical deontology. In a serious condition of the patient, the initial survey should be reduced as far as possible, but all the necessary data should be entered in the medical history, as an addition to the anamnesis on the day the information was received.

All data of the anamnesis of the disease and life, as well as past illnesses and injuries should be carefully recorded in the medical history.

About with m o t r. In an objective examination, first of all, it is necessary to evaluate general state: the state of consciousness, the cardiovascular system (harp pulse, and the magnitude blood pressure) and respiratory system(frequency and character of breathing), internal organs, musculoskeletal system, skin (for this patient must be undressed).

Particular attention should be paid to determining the state of the central nervous system according to the degree of involvement of cerebral symptoms.

When starting to inspect the area of ​​damage, first of all, the condition of the outer integument is established: discoloration of the skin due to abrasions and bruises, asymmetry of the face, edema and swelling of soft tissues. In the presence of burns, their localization, character, size are noted. All this must be described accurately (specify dimensions in centimeters).

A change in bite (the ratio between the teeth in / h and n / h) is the main sign of jaw fractures.

On examination, attention should be paid to the presence of fresh defects in the teeth (the state of the hole), dislocations and fractures of the teeth, character, localization, size of damage to the mucous membrane and soft tissues of the oral cavity, the condition of the gums in the region of the fracture line.

It is mandatory to examine the eyes and nose, especially the eyeballs.

When examining the nose, they find out the presence of deformation (curvature, retraction, etc.), impaired nasal breathing, character of discharge from the nasal passages (blood, mucus, cerebrospinal fluid).

P a l p a c and i. After the inspection, they begin palpation, which should also be consistent and methodical and starts from a known intact area.

With the help of palpation, the presence of edema or infiltration, their consistency, boundaries, and the place of greatest pain are determined.

Palpation in front of the tragus, and fingers inserted into the external auditory canals and pressed against their anterior wall, help determine the mobility of the articular head. The emptiness of the articular cavity may indicate a dislocation or fracture of the head.

You should not try to determine the crepitus of fragments. You can resort to the study of the load on the chin, while the patient indicates pain at the fracture site.

When examining the / h, it is necessary to carefully palpate the entire jaw, determining the painful points at the place of its connection with other bones of the facial skeleton. To clarify the nature of the fracture of the bones of the facial skeleton, the direction and degree of displacement of the fragments, the location of the tooth and fracture gap, the clinical examination must be supplemented with an x-ray.
II. X ray.

X-ray diagnostics of fractures of the facial bones and possible combined injuries of the bones of the skull are based on the identification of classic symptoms: fracture planes, displacement of fragments, emphysema, hemosinus, as well as changes in the linearity of the image of the structural elements of the facial skeleton in the form of their angular or step-like deformation, discontinuity (asymmetry, etc. ).

The main method of x-ray examination in facial trauma is radiography (electroradiography). Pictures in lateral projections are especially important for determining possible combined injuries of the skull bones, as well as for characterizing the displacement of fragments of the facial bones. Tomography (orthopantomography) and radiography with direct magnification of the image are of great practical importance for clarifying the diagnosis of injuries of the maxillofacial region.

AT last years in clinical practice began to use computed tomography well. It is effective in the study of the nasal cavity, paranasal sinuses, walls and cavity of the orbit, the main and ethmoid bones, mandibular joints.

Computed tomography reveals changes in thin bone structures and musculo-fascial disorders, usually associated with bone lesions, which cannot be detected with traditional x-ray examination and tomography. Computed tomograms clearly show complex damage to the orbit and the ethmoid bone, hematomas, low-contrast and small foreign bodies, wound channel and other changes, which facilitates the determination of the nature of the lesion and the planning of surgical intervention in case of trauma to the maxillofacial region.

At the same time, it was found that computed tomography in the standard projection, it is not always possible to detect a fracture with a maximum displacement of fragments in the direction perpendicular to the plane of the examined section.

The main method of X-ray examination for gunshot wounds of the face is radiography or electro-radiography of this area in standard projections, as well as with the help of sighting images and tomography.

Combined wounds of the face and neck.

With combined injuries of the face and neck, visible damage to the eye and initial clinical manifestations do not always correspond to the severity and volume of the true destruction hidden in the depths of the altered tissues. In this case, X-ray examination allows you to most accurately determine the volume and nature of the damage, as well as their localization.

In modern clinical medicine data obtained using objective diagnostic methods occupy a leading place. The subjective approach in assessing the patient's condition, although not completely excluded, gives way to accurate, quantifiable

methods. These include laboratory (including microbiological, functional, radiozaton methods of research and diagnostics.
L a b o r a to r o n methods

and research.

Blood investigations. necessary and important diagnostic method. Hematopoietic organs are very sensitive to pathological influences, including fractures. These changes and the restructuring of the bone tissue itself, the response

of the whole organism to injury: Injury of the maxillofacial area; complicated by significant blood loss; reflected in the clinical analysis of blood.

In the course of fracture healing, it is very important biochemical research blood, including the determination of indicators of protein, total protein, protein fractions, amino acids and carbohydrate (hexosamines, lactic and other acids, glycogen) metabolism.

These studies have great importance and with a complicated course of a fracture; so, with traumatic osteomyelitis, in addition to high leukocytosis, the ESR and other parameters increase, dysproteinemia is noted in the blood serum, which is expressed in hypoalbuminemia and hyperglobunemia. V.N. Bulyaev et al. (1975)

proposed a test for the activity of alkaline phosphatase of blood leukocytes, which in the initial stages of inflammatory complications changes earlier than leukocytosis appears.

The results of the study of hydroxyproline and amino acids, which are part of collagen, are also characteristic.

Determining the content of neuroamino acids and glycoproteins in serum as indicators of protein metabolism can also be of diagnostic value.

Investigation of urine. In uncomplicated isolated trauma of the maxillofacial area, it is rarely possible to detect changes in the urine. However, with extensive trauma, combined fractures, state of shock when kidney function is impaired, the amount of urine excreted and its composition may change. With wounds and fractures complicated by the inflammatory process, kidney function is also impaired. The relative density of urine changes, substances that are not normally found in it (sugar, protein and

etc.), bacteriuria, leukocyturrria, hematuria can join this. The physical and chemical properties of urine are very important. In addition, urinalysis can provide significant indications of drug absorption.

Microbiological research. A significant role in the course of the wound process, fracture healing, and the development of purulent-inflammatory complications belongs to the microbial factor. The main source of purulent-inflammatory processes is gram-positive staphylococci and a number of gram-negative aerobes.

It is necessary that the processing of crops takes place no later than 1-2 hours after the collection of the material. The sampling of the material must be carried out with special swabs and cotton balls.

I m m u n o l o g i c h i c h i n e d o v a n y.

The complex examination of the patient includes: determining the number of T-lymphocytes (E-rock) and their response to PHA (phytohemagglutinin); determination of the number in lymphocytes and their function on lipopolysaccharide (LPS), as well as on the spectrum of immunoglobulin Jg G, Jg M, Jg A

serum; determination of the level of antigenemia by the reaction of aggregate-agglutination and antibodies to toxins of staphylococcus and streptococcus; assessment of the function of neutrophils by their phagocytic activity; determining the level of complement components (C3 and C4) by radial immunodiffusion; determination of individual proteins of the inflammatory complex.

F unk t t i a n a l d a g n o s t i a . It serves to identify functional disorders and control the restoration of lost functions, its task is not only to identify these disorders and their severity, but also to give these disorders

quantitative characteristic, i.e. objectify observations.

There are many methods of functional diagnostics and monitoring of the state of the masticatory apparatus. Of these, Gelman's test, with which you can conduct a comparative assessment of the restoration of chewing function. Then mastication according to Rubinov gained worldwide distribution. However, this technique does not always allow an objective assessment of the data obtained.

Functional research methods include tendomechanomyography, proposed by I.S. Rubinov (1954) and modified by V.Yu. Kurlyandsky and S.D. Fedorov (1968). With the help of special strain gauges, an impulse is obtained, which amplifies the recorders on the oscilloscope.

However, one of the most modern and informative diagnostic methods is electromyography, which allows for observations throughout the treatment process. The principle of electromyography is based on the ability to record potential fluctuations resulting from the occurrence

stimulation in muscle fibers. In addition, this ability of the muscle to excite allows you to stimulate the muscle with impulses.

current. The recording is carried out using an electromyograph, which is based on an oscilloscope.

Allocate global electromyography, which is carried out using skin electrodes; local, carried out using needle electrodes; stimulation, which allows you to determine the speed of propagation of excitation along the nerve. The clinic uses electromyography in two versions: with the help of skin and needle electrodes. The former are used to record the potentials of muscle groups, the latter to record more local processes.

With injuries of the maxillofacial region, as A.A. Prokhonchukov et al. (1988), electromyography serves for an objective assessment of the degree of impairment and, accordingly, the restoration of the masticatory muscles.

Measurement of the tone of the masticatory muscles can be carried out using tonometry. Muscle tone is measured in myotons (m.t.) and examined with an electromyotonometer. At the same time, the average values ​​of the resting tone of tension are normally 46 and 80 mt, respectively. With the imposition of tires, these figures increase.

P o l i r o gr a f i i . electrochemical method to determine the trophic potential of soft tissues and the level of redox processes in them.

Using the polarographic method, it is possible to measure oxygen tension in tissues (Po2) and determine its average values. The method is based on recording current-voltage curves that reflect the dependence of the current strength on voltage, which in turn depends on the polarization process at the working electrode. This method allows, if necessary, to perform plastic surgery of MFR defects, to select flaps with optimal regenerative capabilities.

An oxygen test is used to determine the oxygen tension. It is carried out using an oxygen mask, through which the patient breathes oxygen. Against the background of this functional test, colorography is performed. The same method can also determine the volumetric velocity of blood flow. The technique is based on the electrochemical oxidation of hydrogen. In case of soft tissue injuries, if necessary, free skin grafts should be used to clarify the level of trophic capabilities of tissues using this method. This can be done by compiling polarographic data and redox determination results.

potential (ORP). For this definition of ORP, use functional tests as in polarography. It is an important indicator that makes it possible to judge the process of oxygen utilization by tissues.

Another common method of functional research and functional diagnostics is rheography - a method for studying the blood supply to tissues and, consequently, their viability. It is based on registering changes in the complex resistance of tissues when a high current passes through them.

frequencies. Resistance depends on the speed of blood flow and blood filling. Rheographs record these fluctuations, which makes it possible to judge the viability of tissues. This is especially important when performing plastic surgery.

In maxillofacial traumatology, rheography can be used to assess the effect of local anesthesia. Since anesthesia causes vasospasm, the decrease in the amplitude of the rheogram can be used to judge the effectiveness of anesthesia. In addition, this method can serve to identify possible vascular disorders in jaw fractures and to clarify the duration rehabilitation period as well as the effectiveness of the treatment.

In addition to rheography, photoplethysmography is used - relatively new method studies of the degree of blood filling of tissues depending on sound vibrations. Changes in tissue blood supply are recorded using complex electron-optical devices - photoplethysmographs. They use powerful light sources and lasers. Photoplethysmography uses light transmission and light reflection.

In recent years, thermal imaging has been used, since it has been proven that a correlation is determined between pathological processes and the temperature of certain areas of body surfaces. Thermal imaging allows you to observe individual areas human body in the infrared region of the spectrum. This method is absolutely harmless and has a high diagnostic resolution, especially in vascular lesions.

Ultrasound also finds its application. By sending oscillation pulses with a frequency of 0.8-20 mGu, it is possible to carry out echolocation and thus form an idea of ​​the state of the tissues of the size of the pathological focus, the presence of an inflammatory process. Ultrasound is also used for the development of pathological processes in bone tissue, since the speed of its conduction along the bone varies depending on its condition.

According to T.E. Khorkova, T.M. Oleinikov (1980) and others, in fractures and osteomyelitis, a decrease in the speed of propagation of ultrasound along the bone is detected.

In particular, in case of fractures of the h/h, osteometry reveals a sharp decrease in speed on the damaged side.

R a d i o s o t o p n a i a g n o s t i a . To study the dynamics of metabolic processes in bone tissue under the conditions of the functioning of the body, radioactive isotopes are used, which are sources of gamma-ray studies. In particular, in maxillofacial traumatology they are used for diagnostic monitoring of fracture healing processes, prediction of inflammatory complications, as well as for monitoring ongoing treatment.

Based on the results of radiometric studies, graphs are constructed that reflect the dynamics of accumulation and excretion of the isotope in the process of fracture healing. The curve of accumulation and excretion of the drug is characterized by the presence of two rises in the level of radioactivity.

By 5-7 days, the first rise in radioactivity is determined, and its occurrence is explained by the formation of a new vascular network and the activation of neoplasm processes. The second rise in the radioactivity of the isotope corresponds to 21-24 days from the moment of injury. This peak of radioactivity indicates the beginning of restructuring

primary bone callus, which is accompanied by an increase in bone tropism for calcium ions.

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  Illustrative material

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  Literature

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  Control questions (feedback)

1. 
   Methods of surgical treatment:

B. Osteosynthesis with a Kirschner wire.

B. Osteosynthesis with miniplates.

D. Osteosynthesis with shape memory structure.

Facial injuries are open and closed. open injuries are accompanied by protrusion of bone fragments of the maxillofacial region (MAF) of the skull into the wound surface.

Injuries to the maxillofacial area occur due to the mechanical impact of a blunt object. In percentage terms, injuries of the maxillofacial area are divided into: domestic - 62%; transport - 17%; production - 12%; street - 5%; sports - 4%.

The maxillofacial region has a powerful vascular network and a large array of loose subcutaneous tissue, so injuries of the maxillofacial area are accompanied by significant swelling, hemorrhages, and an apparent discrepancy between the size of the wound and the amount of bleeding. Often, facial injuries are combined with injuries of the facial nerve and parotid salivary gland, injuries of the lower jaw - with damage to the nerves of the larynx, pharynx and large vessels.

Urgent care with injuries of the maxillofacial region:

• relief (if necessary) of signs of acute respiratory and cardiovascular failure;
• to prevent asphyxia, the victim is laid face down, turning his head to one side;
• carry out sanitation of the oral cavity;
• in case of a threat of obstructive asphyxia, an S-shaped air duct is installed to the victim;
• bleeding is stopped with a pressure bandage, tight tamponade of the wound, the imposition of a hemostatic clamp;
• a pressure bandage is applied to the site of soft bruises;
• the victim is admitted to a hospital.

Tooth damage

With injuries of the maxillofacial area, the following dental injuries occur: crown fracture, tooth dislocation, tooth root fracture.

A fracture of the crown of the tooth is accompanied by pain, the presence of sharp edges of the remains of the tooth, the exposed pulp of the tooth or root canal, and bleeding is possible. With a dislocation, the tooth comes out of the hole and becomes pathologically mobile. With an impacted dislocation, the crown is displaced inside the alveolar process.

Emergency care for dental injuries consists in anesthesia with a 2% solution of novocaine, a cotton ball soaked in 1 g of carboxylic acid, 3 g of camphor and 2 ml of ethyl alcohol is applied to the opened pulp stump.

A completely dislocated tooth is removed from the socket, after which it is replanted into the same socket. An incompletely dislocated tooth is set and fixed to the adjacent teeth with a metal ligature.

Fracture of the alveolar process of the lower jaw

With a fracture, the alveolar process of the lower jaw is mobile, there is bleeding from the gums, buccal mucosa, lips, nosebleeds. In case of damage maxillary sinus frothy blood comes out of the wound.

Emergency care is to remove from the mouth to prevent possible aspiration and asphyxia blood clots, scraps of mucous, freely lying fragments of the alveolar process. Local anesthesia is carried out with a 2% solution of novocaine, the victim is hospitalized in a medical hospital, where a permanent fixation of the fracture site is carried out and measures are taken to preserve the teeth.

Fracture of the body of the mandible

Such fractures are considered open, primarily infected, since the fracture occurs within the dentition with damage to the mucosa. Most often, the fracture line lies at the level of the canines and mental foramina, in the region of the lower 8th tooth and the angle of the jaw.

In case of fractures of the lower jaw, the mobility of the opening of the mouth is limited, the bite is disturbed, there is abundant salivation, bleeding, fragments of the lower jaw are pathologically mobile, multiple fractures may be accompanied by asphyxia due to retraction of the tongue.

The first aid is to remove foreign bodies from the mouth, if necessary, an S-shaped air duct is inserted into the mouth in order to prevent the retraction of the tongue and the development of ARF. Anesthesia is performed with a 50% solution of analgin intramuscularly in a volume of 2-4 ml, if it is ineffective, narcotic analgesics. The victim is hospitalized in the department of maxillofacial surgery. For the duration of transportation, with the help of a sling-like bandage, temporary immobilization of the damaged jaw is carried out.

Dislocation of the lower jaw

Dislocation of the lower jaw can occur with maximum mouth opening, trauma, insertion of an endotracheal tube, gastric tube, expander.

With a dislocation of the lower jaw, the head of the articular process of the lower jaw is displaced outside the articular cavity, while the victim cannot close his mouth, he has salivation, he feels pain in the temporomandibular joint. With a bilateral dislocation, the chin is shifted down, with a one-sided dislocation - to the healthy side.

Dislocation of the mandible is treated by reduction. The patient is given anesthesia, and is seated on a low chair so that his head rests on the headrest and is at the level elbow joint doctor.

The doctor sets his thumbs in the retromolar region of both sides of the lower jaw, with the rest of his fingers he covers the outer surface of the jaw from the corner to the chin. After that, the jaw is pressed down with the thumbs, after which the chin section is sent up with the rest of the fingers.

After reduction of the dislocation, a fixing sling bandage is applied to the patient for a period of 10-12 days.

Fracture of the upper jaw

There are three types of fractures of the upper jaw:

1. Fracture of the body of the upper jaw above the alveolar process from the base of the piriform to pterygoid processes - bleeding from the mucous membrane of the mouth and nose, lengthening of the middle zone of the face, hemorrhage into the conjunctiva, eyelids, violation of the closing of the teeth.
2. Complete detachment of the upper jaw - the symptoms are the same, but the symptom of "points" is more pronounced, when the entire upper jaw with the root of the nose is pathologically mobile without movement of the zygomatic bones. There may be a combined fracture of the upper jaw with a fracture of the base of the skull with symptoms of irritation of the meninges.
3. Complete detachment of the bones of the facial skull - characterized by a serious condition of the patient with pronounced signs of damage to the base of the skull.

Emergency care is to eliminate signs of acute respiratory and cardiovascular failure, cold in place. Anesthesia is carried out with a 2% solution of promedol in a volume of 2 ml. The damaged jaw is immobilized with a parieto-chin or sling bandage, the victim is transported in a lying position on his side to a medical facility.

Fracture of the zygomatic bone

The victim feels pain and numbness in the wing of the nose and upper lip on the injured side, a feeling of pressure in the eyes. Examination reveals a symptom of "glasses", restriction of movement of the lower jaw, nosebleeds often develop. Palpation determines the unevenness along the lower orbital edge.

Emergency care consists in adequate anesthesia, cold in place. The victim is admitted to the hospital.

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CONVENTIONAL ABBREVIATIONS

CT - computed tomography

PHO - primary surgical treatment

FTL - physiotherapy treatment

MFR - maxillofacial region

THEME #1
INJURY OF THE MAXILLOFACIAL REGION IN CHILDREN

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

Purpose of the lesson.

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

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

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

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

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

1. Disfigurement of the face.

2. Violation of the function of speech and chewing.

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

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

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

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

To positive features must be attributed:

1. Increased regenerative capacity of facial tissues.

2. Resistance of tissues to microbial contamination.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Situational tasks

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

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

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

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

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

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

Literature

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

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

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

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