Locking bars made of wire. Maxillofacial prosthetics. The word "orthopedics" comes from the Greek orthos direct and paidevo to form, train, so under, orthopedics. Treatment of fractures of the body of the lower jaw with toothless fragments
Ring tires.
The large contact surface of ring tires with teeth provides good tire stability. In addition, the non-coated chewing surface of the teeth makes it possible to control the ratio of dentition in the bite. Due to the fact that the production of high-quality ring tires is very laborious, recently, in medical institutions they have been used to fix the jaws in the complex surgical and orthopedic treatment of severe forms of malocclusion (progeny, open occlusion). For the treatment of patients with traumatic injuries of the jaw, ring tires are used less frequently. Distinguish standard and individual ring tires. The standard are devices or arcs of Schroeder and Engle. Individually made tires consist of rings and arcs soldered to the rings. If necessary, branches or hooks for intermaxillary fastening are soldered to the arches. Rings are soldered or stamped. An annular tire is a temporary construction, therefore grinding of teeth, even in the area of \u200b\u200bcontact points, is unacceptable. With close interdental contacts, teeth are separated by conservative methods (rubber strips or ligature wire).
Soldered tires.
Soldered rod (beam) Limberg tire.
Indications for use: treatment of jaw fractures with low clinical crowns of teeth, their insufficient number, and with tooth mobility. If necessary, the crowns in this tire are replaced by rings or turned into rings by crowns, cutting off their chewing surface. When intermaxillary traction is necessary, wire processes-hooks - rods 3-4 mm long are soldered to the rods, and the splint on the lower jaw is made of two parts, respectively, fragments. After the fragments are repaired, an impression is made from the lower jaw, on the resulting model both parts of the tire are soldered, making it single-jawed. Sometimes, the rectangular or oval-shaped tube-sleeves for extraoral levers are additionally soldered to the buccal surface of the crowns (rings).
Solid tires.
Indications for use: used for fractures of the lower jaw without displacement of fragments or their insignificant reposition within the dentition, when the teeth on the fragments are placed in parallel (without inclination). If there is a tilt of the teeth, collapsible solid tires are used. These tires are removable, so they can be additionally fixed with cement, special glue.
Multi-Link Solid Rail with Front Arcs. It is fixed to the orthopedic cap with the help of bandages (rubber rods).
Indications for use: treatment of fractures of the upper jaw with a sufficient number of stable teeth on the fragments.
Kappa tires.
Distinguish plastic and metal kappa tires , the latter are divided into stamped and cast.
Plastic Mouthguard Tires laboratory manufacturing.
Made of hot cured plastic. They are distinguished by high aesthetic qualities. However, due to the elasticity and fragility of the plastic, they are not used to fix the jaws with complete fractures.
Indications for use: tooth dislocations, fractures of the alveolar ridge, treatment of fractures of the lower jaw in children under 3 years old. In case there is a need for tooth removal, a hole is created in the mouthguard before fixation, taking into account better access to the pulp chamber. Fixing mouth guards on teeth with cement or quick-hardening plastic. Kappa is worn on the victim for 4-6 weeks along with the chin sling.
Metal Mouthguard Tires.
Indications for use: fixation of jaw fragments during bone grafting, fractures of the lower jaw within the dentition for single-jaw fixation. Splinting with metal mouthguards is only possible in patients who do not suffer from periodontal disease, with complete dentition or with small defects. It is advisable to use them for jaw fractures in patients with common diseases (tuberculosis), when enhanced nutrition is needed.
Tires of Courland V.Yu. for intraoral immobilization in fractures of the lower jaw (fixation: a) square, b) round tubes).
Each device consists of mouth guards, to which, on the vestibular side, levers with a lock are soldered: each lever is soldered in such a way that the middle of the lock coincides with the middle of the lower jaw. When opening the lock, it turns out that for each mouthguard placed on the teeth of each fragment, a metal plate of equal length equalizing the length of the shoulders of both fragments will be soldered. Thus, the apparatus manages to both repair and immobilize the fragments.
Metal stamped mouth guards.
Indications for use: if necessary, rigid fixation of fragments for a long period is used (for multiple fractures, fractures of the lower jaw with the formation of a defect). Kappa can be stamped from individual links for 3-5 teeth, followed by soldering the links into one mouthguard. To increase rigidity, a wire arc is soldered to the mouthguard on the one hand, more often with the oral one.
Gingival tires.
Weber's Gingival Tire.
The author made the tire from rubber, at present it is made from acrylic plastics, hot cured in laboratory conditions, and cold cured in the clinic. In the latter case, the mucous membrane of the alveolar bone is lubricated with petroleum jelly to avoid chemical burns with monomer. Use with full dentition or partial loss of teeth. If there is a defect in the dentition, artificial teeth can be welded onto the splint, thereby restoring its continuity. Then the Weber tire not only fixes the fragments, but also acts as a replacement prosthesis, and also prevents loosening of the teeth. Its disadvantages include the fact that it does not keep fragments from vertical displacement, time-consuming overlay and mobility that occurs over time. Therefore, recently abandoned its use.
Indications for use:
1) a fracture (crack) without displacement of fragments of the jaw;
2) in case of fractures with a slight displacement of fragments, if after reposition they do not return to their previous position;
3) during the follow-up of fractures, after the removal of the double jaw apparatus, when the consolidation of the fragments took place, but the callus is not yet reliable;
4) with insufficient number of teeth to fix the splint tires;
5) with mobility of the teeth remaining on the fragments.
6) when using the method of the surrounding suture in fractures of the lower jaw, fragments of kapron or wire ligatures are fixed to the Weber tire.
Inclined Weber Dental Tire.
Indications for use:
1) used to immobilize and prevent lateral displacement of fragments in fractures of the lower jaw outside the dentition, fracture of a branch or articular process due to the emphasis of an inclined plane on the vestibular surface of the teeth-antagonists of the upper jaw;
2) 
In addition, the Weber splint is used for significant defects of the lower jaw as a result of traumatic osteomyelitis, a gunshot wound, or after operations of the lower jaw resection for a tumor.
The tire is applied for a period of 2-3 months. The application of the tire can lead to the elimination of pronounced lateral displacement of the lower jaw after removing the tire.
Weber extra-buccal dental implant splint.
Indications: treatment of fractures of the upper jaw with a shift of the fragments down with an intact lower jaw.
Gingival splint M.M. Vankevich.
Indications for use: 1) in the treatment of fractures of the lower jaw with significant defects in the anterior section, to prevent displacement of the fragments forward, up and inward, due to the emphasis of inclined planes on the front edges of the branches or in the alveolar part of the lateral parts of the body; 2) in the treatment of fractures of the lower jaw with toothless alveolar processes or with the absence of a large number of teeth. 3) with bone grafting of the lower jaw to hold bone grafts.
Shina M.M.Vankevich can also be used in orthopedic treatment of fractures of the toothless lower jaw to repair fragments displaced in a transversal direction. To this end, the vertical processes of the apparatus are corrected using cold-cured plastic or using a sten, followed by its replacement with plastic. The rollers formed in this way put pressure on the fragments and gradually part them outwards. The disadvantages of the tire M.M. Vankevich refers to its bulkiness and inability to use while restricting the opening of the mouth.
Shina M.M. Vankevich as modified by A.I. Stepanov
In this apparatus, the maxillary base is replaced by a metal arc, like a clasp prosthesis, which makes the apparatus easier and more convenient, accelerates adaptation, improves hygiene, and does not change the taste.
Indications for use: the same as for M.M. Vankevich’s bus. Both devices are used in combination with the chin sling.
Tire tires.
Port Bus.
Indications for use: it is used for fractures of the toothless lower jaw without displacement of fragments, the patient has no removable dentures and teeth on the upper jaw. A prerequisite is unimpeded opening of the mouth.
Gunning tire (detachable)
Indications for use: used for fractures of the jaw in case of complete adentia or in the presence of 1-2 teeth, when there is limited opening of the mouth (post-traumatic contracture, TMJ disease, with sutures in the lips or cheeks).
Both tires are used as an immobilizing device only in combination with a chin sling bandage. The tires have a front feeding hole.
Limberg tire.
Indications for use: treatment of fractures of the lower jaw with full adentia and difficulty opening the mouth.
Tire Limberg in the modification of circle members of the Department of Orthopedic Dentistry KSMU: blanks (sleeves) for stamped metal crowns are used as locks.
The apparatus of A.M. Rarog.
Indications for use: for the treatment of toothless jaw fractures. It is made of wire by bending horizontal loops located across the toothless alveolar processes. These loops, worn on both sides of the jaw, are connected by an arc and placed on both sides. The device is held by the elasticity of the wire. It does not allow fragments to move and does not deprive the patient of the opportunity to open his mouth freely. The disadvantage of such tires is their indentation into the mucous membrane of the alveolar process and the formation of pressure sores. To protect the mucous membrane from injury N.I. Mikhelson recommends laying black gutta-percha under the wire, which allows the patient to use the devices for 12-14 days without harm to him.
At the Department of Orthopedic Dentistry of KSMU, it was proposed to use the alginate impression material Stomalgin-04 with improved clinical and technological properties for the manufacture of removable gingival tires at the stage of impression production.
The word "orthopedics" comes from the Greek orthos direct and paidevo to form, train, so that, in the exact sense, orthopedics should mean the correction of curvatures of various parts of the body. Maxillofacial orthopedics is a section of general orthopedics and deals with the correction and replacement of defects in all kinds of disorders of hard and soft tissues in the jaw and face.
Congenital acquired disorders (Congenital defects include: (Acquired defects result from: cleft hard and soft palate 1- transferred diseases (syphilis, lupus) and upper lip.) 2- injuries (industrial or domestic) 3- surgical interventions for various inflammatory processes, tumors, etc. Accordingly to each of the listed cases, the types of prostheses and the methods of their manufacture will be different.
The treatment of fractures aims to: - restore the anatomical integrity of the face - the full function of the affected organs. This is solved by repositioning the fragments into the correct position and keeping them in this state until the fracture heals. The main method of treating jaw fractures is currently orthopedic, which provides for the solution of medical problems with the help of tire devices.
Fixing devices: By the method of fixing Removable Fixed (gear-gusset tires) (mouthguards, wire tires, caps) At the place of fixation Intraoral Extraoral (Vasiliev’s tire, mouthguards, (chin sling, wire braces) Rudko, Zbarga, etc.)
Fixing devices: When broken jaws, bone fragments are usually displaced. To create the conditions for the most rapid and correct bone fusion, fixation of fragments (immobilization) is required. This is achieved through the use of special fixing devices. chin sling First aid for fracture of the jaw consists in the application of a retaining bandage.
Fixing devices: In the future, these dressings are replaced with wire rails or more stable devices manufactured in the laboratory. a) splint splint b) ligature binding 1) smooth splint splint 2) smooth splint splint In case of fracture of the lower jaw, fragments can be temporarily fixed by ligating the antagonist teeth of the upper and lower jaw. It is useful to add fixation of the lower jaw to the chin sling to this bandage so that the attached teeth do not loosen due to the severity of the fragments. For this purpose, a chin sling is suitable 3. N. Pomerantseva-Urban. intermaxillary binding
Fixing devices: In case of fracture of the upper jaw, it is necessary to strengthen its fragments with an apparatus fixed by means of a head cap. When providing first aid, you can use for this purpose an ordinary plywood board by bandaging it to the head. There are standard metal tire spoons with extraoral processes attached to the orthopedic cap.
Fixing devices: Weber plate-gingival splint. Stages of manufacturing: 1) obtaining a gypsum model of the jaw; 2) creating a wire frame. (The framework is bent from an orthodontic wire 0.8 mm thick. It covers the dentition in the form of an arch with a vestibular and lingual (palatine) surface. The connecting rails of the occlusal plates (23 on each side) are soldered to the framework, which should be located on the contact points of the teeth The wire frame parts are soldered together, creating a single design.) 3) tire modeling with wax. The finished carcass is placed on the jaw model and the tire base is modeled from wax. 4) replacing the wax reproduction of the tire with plastic. 5) packaging, polymerization, finishing and polishing (carried out according to the rules for the creation of removable plate dentures)
Replacing apparatuses: If bone fragments were not fixed in a timely manner and displacement occurred, then they are set in the correct position with the help of reposition and repairing apparatuses. They develop a certain force acting on the fragments for both short and long time.
Replacing apparatuses: Vankevich tire. It is a resonating apparatus, which consists of a plastic gear-gingival tire with two planes extending from the palatine surface of the tire to the lingual surface of the lower molars or toothless alveolar ridge. Stages of manufacturing: 1) obtaining plaster models of the upper and lower jaw; 2) creation of wax bases with bite (occlusal) ridges on gypsum models of jaws 3) gypsum models of jaws in an articulator after determining the central ratio in the oral cavity 4) creation of a carcass and modeling of a tire from wax. The height of the planes is determined by the degree of opening of the mouth. The planes are prepared from doubled strips of wax 2.53.0 cm high, since when opening the mouth they must remain in contact with the teeth or with the toothless alveolar parts; 5) in the future, the technological process (gypsum molding, packaging, polymerization, finishing and polishing) is carried out according to the rules for creating removable plate prostheses.
Resonating apparatuses: Katz apparatus. The apparatus consists of two tooth splints fixed with rings on the teeth of fragments of the lower jaw. A quadrangular tube 1.53 mm in diameter and 15 cm long is soldered on the cervical surface of each tire. The free ends of the rods extending from the oral cavity to the outside form a loop enveloping the corner of the mouth and a second loop directed in the opposite direction. Extraoral rods are located one above the other. To dilute the fragments to the sides, the ends of the rods are pushed to a certain distance and connected by a ligature. Due to the elasticity of the rods, the movement of fragments is achieved.
Replacing devices: Shura device It is used for bilateral fracture of the upper jaw and limited mobility of fragments. The apparatus consists of a gypsum cap, to which two vertical rods 150 mm long are attached with gypsum, a single soldered tire to the upper jaw, with supporting crowns for fangs and the first molars on both sides. Flat or oval tubes for two extraoral rods are soldered to the tire from the buccal surface in the region of the first molar. Production steps: 1) obtaining gypsum models 2) creating support elements, which use orthodontic crowns 3) after checking the support elements, the doctor takes an impression with them, according to which the laboratory technician receives a gypsum model of the jaw. Supporting elements pass onto it; 4) preparation of supporting elements for soldering. On the gypsum model of the jaw, horizontal tubes are attached with sticky wax from the vestibular side of the crowns; 5) soldering of supporting elements with tubes 6) release from gypsum, bleaching and polishing of frame elements 7) receiving extraoral rods. 34 mm thick stainless steel rods are bent so that they easily enter the horizontal tube of the crowns, then exit outside the corners of the mouth and parallel to the occlusal plane are directed at right angles upward to the temporal region;
Replacing apparatuses: Courland apparatus. This apparatus consists of mouth guards, on the buccal surface of which double tubes are soldered, and from the corresponding rods. Stages of production: Impressions of teeth are taken from each fragment and, according to the obtained models, stainless steel mouthguards are prepared for a group of teeth (separately for one and the other fragment). After fitting the mouthguards in the mouth, casts are taken again along with mouthguards from the damaged jaw and from the opposite upper jaw. The resulting model of the lower jaw is sawn in the fracture region into two parts. Sawed parts of the model are made with the model of the upper jaw along the occlusal surfaces of the teeth of the upper and lower jaw in the position of the bite, glue them and gypsum into the occluder. To both mouth guards from the side of the vestibule of the mouth, double tubes are soldered in a horizontal direction and rods are attached to them. Then the tubes are cut between mouth guards, which are cemented in the mouth. After forcible reposition of fragments, jaw or traction with rubber rings, their position is fixed with rods and tubes soldered to the mouth guards.
Hippocrates and Celsus already have indications on the fixation of fragments of the jaw when it is damaged. Hippocrates used a rather primitive apparatus, consisting of two belts: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus, through a cord of hair, strengthened the fragments of the lower jaw by the teeth 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. The founder of military field surgery, the great Russian surgeon N.I. Pirogov, was the first to apply a rigid chin sling with a plaster cast for the treatment of fractures of the lower jaw. He also offered a drinker to feed the wounded with maxillofacial injuries.
During the Franco-Prussian War (1870–1871), plate-shaped tires became widespread in the form of a base attached to the teeth of the upper and lower jaw, with bite rollers made of rubber and metal (tin), in which there was an opening for eating in the region of the anterior section ( Guning - Port devices). The latter was used to fix fragments of the toothless lower jaw. In addition to these devices, a rigid chin sling was applied to patients to maintain jaw fragments, fixing it on the head. These devices, which are quite complex in design, could be made individually according to the imprints of the upper and lower jaw of the wounded in special denture laboratories and therefore were used mainly in rear medical institutions. Thus, by the end of the 19th century there was no military splinting and assistance with maxillofacial injuries was rendered very late.
In the first half of the 19th century, a method was proposed for fixing fragments of the lower jaw using a bone suture (Rogers). Bone suture for fractures of the lower jaw was also used during the Russo-Japanese War. However, at that time the bone suture did not justify itself due to the complexity of its use, and most importantly subsequent complications associated with the absence of antibiotics (development of jaw osteomyelitis, repeated displacement of fragments and malocclusion). Currently, the bone suture is improved and is widely used.
The prominent surgeon Yu. K. Shimanovsky (1857), rejecting the bone suture, combined a plaster cast in the chin with an intraoral "stick splint" to immobilize 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 - rubber.
The next stage in the development of methods for fixing jaw fragments is tooth splints. They contributed to the development of methods for the 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 tooth splints to fix jaw fragments.
Wire tires were widely used during the First World War and took a strong place, displacing further plate tires 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 arch can easily be bent out of the dental arch in the form of a single and double jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires turned out to be rational in the field. They do not require special denture equipment and support staff, therefore they have won universal recognition and are being applied with minor changes at present.
In the First World War in the Russian army, the sanitary service was poorly organized, and the service of the wounded in the maxillofacial region was particularly affected. Thus, in the maxillofacial hospital in Moscow organized by G.I. Wilga in 1915, the wounded arrived late, sometimes 2-6 months after the wound, without properly securing jaw fragments. As a result, the treatment time was lengthened and persistent deformities occurred with a malfunction of the masticatory apparatus.
After the Great October Socialist Revolution, all the shortcomings in the organization of the sanitary service were gradually eliminated. At present, good maxillofacial hospitals and clinics have been created in the Soviet Union. A harmonious doctrine of the organization of the sanitary service in the Soviet Army at the stages of medical evacuation of the wounded, including in the maxillofacial region, was developed.
During World War II, Soviet dentists significantly improved the quality of treatment for wounded in the maxillofacial region. Medical assistance was provided to them at all stages of evacuation starting from the military district. Specialized hospitals or maxillofacial units were deployed in the army and front areas. The same specialized hospitals were deployed in the rear areas for the wounded in need of longer treatment. Simultaneously with the improvement of the organization of the sanitary service, the methods of orthopedic treatment of jaw fractures were significantly improved. All this played a large role in the outcome of the treatment of maxillofacial wounds. So, according to D.A. Entin and V.D. Kabakov, the number of completely wounded with injuries to the face and jaw was 85.1%, and with isolated damage to the soft tissues of the face - 95.5%, whereas in the First World War (1914-1918) 41% of the wounded in the maxillofacial region were dismissed from the army by disability.
Classification of jaw fractures
Some authors base the classification of jaw fractures on the location of the fracture along the lines corresponding to the places of the weakest bone resistance and the ratio of fracture lines to the facial skeleton and skull.
I. G. Lukomsky divides the fractures of the upper jaw into three groups depending on the location and severity of the clinical treatment:
1) fracture of the alveolar process;
2) a suborbital fracture at the level of the nose and maxillary sinuses;
3) the fracture is orbital, or subbasal, at the level of the nasal bones, 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 difficult fractures of the upper jaw, accompanied by a fracture, separation of the nasal bones and the base of the skull. These fractures are sometimes bloated with death. It should be noted that fractures of the upper jaw are found not only in typical places. Very often, one type of fracture is combined with another.
D.A. Entin divides non-gastric fractures of the lower jaw according to their localization into median, mental (lateral), angular (angular) and cervical (cervical). Relatively rarely, an isolated fracture of the coronoid process is observed. (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, tangent, single, multiple, penetrating and not penetrating into the oral cavity and nose, isolated with damage 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 bone defects, unilateral, bilateral and combined;
3) localization (within and outside the dentition);
4) by type of wounding weapon (bullet, fragmentation).
Fig. 226 Localization of typical fractures in the lower jaw.
Currently, this classification includes all facial injuries and has the following form.
I . Gunshot wounds
By type of damaged tissue
1. Wounds of soft tissues.
2.Wounds with bone damage:
A. The lower jaw
B. The upper jaw.
B. Both jaws.
G. Zygomatic bone.
D. Damage to several bones of the facial skeleton
II.Non-injuries and injuries
III.Burns
IV.Frostbite
By nature of damage
1. Cross-cutting.
2. Blind.
3. Tangents.
A. Insulated:
a) without damage to the organs of the face (tongue, salivary glands andother);
b) with damage to the organs of the face
B. Combined (simultaneous injuries of other areas of the body).
B. Single.
G. Multiple.
D. Penetrating the oral cavity and nose
E. Non-penetrating
By the look of a wounding weapon
1. Bullet.
2. Fragmented.
3. Beam.
Classification of orthopedic devices used to treat jaw fracture
Fixation of jaw fragments is carried out using various devices. It is advisable to divide all orthopedic devices into groups in accordance with the function, area of \u200b\u200bfixation, therapeutic value, design.
Division of devices according to function. The devices are divided into corrective (repairing), fixing, guiding, shaping, replacing and combined.
Regulatory (reponiating) devices are calledthat contribute to the reposition of bone fragments: constricting or stretching them to the correct position. These include aluminum wire rails with elastic traction, elastic wire brackets, devices with extraoral adjusting levers, devices for jaw breeding for 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 (such as the jaw) in a specific position are called fixative. These include a smooth wire clip, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw with bone grafting, etc.
Formative devices are called, which are the support of plastic material (skin, mucous membrane) or creating a bed for the prosthesis in the postoperative period.
Replacing devices include, replacing defects of the dentition formed after tooth extraction, filling defects in the jaw, parts of the face that arose after an injury, operations. They are also called dentures.
Combined devices includehaving several purposes, for example, fixing jaw fragments and forming a prosthetic bed or replacing a jaw bone defect and simultaneously forming a skin flap.
Division of devices at the place of fixation. Some authors divide devices for treating injuries of the jaw into intraoral, extraoral and intraoral. Intraoral devices include devices attached to the teeth or adjacent to the surface of the oral mucosa, extraoral devices are attached to the surface of the integumentary tissues outside the oral cavity (chin sling with a head bandage or extraoral bone and intraosseous spikes to fix jaw fragments), and intraoral - devices, one part of which is fixed inside and the other outside the oral cavity.
In turn, intraoral tires are divided into single-jaw and double-jawed. The former, regardless of their function, are located only within the same jaw and do not interfere with the movements of the lower jaw. Two-jaw apparatuses are simultaneously placed on the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.
Division of devices for therapeutic purposes. For therapeutic purposes, orthopedic devices are divided into main and auxiliary.
The main ones are fixing and correcting tires, used for injuries and deformations of the jaws and having independent medical value. These include replacement devices that make up 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.).
Ancillary devices are those that serve to successfully perform skin-plastic or osteoplastic operations. In these cases, the main type of medical care will be surgery, and auxiliary - orthopedic (fixation devices for bone grafting, shaping devices for face grafting, protective palatine plastic for grafting, etc.).
Division of devices by design.
By design, orthopedic devices and tires 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 and complex construction. The first (wire) bend directly in the patient and fix on the teeth.
The second, more complex (plate, cap, etc.) can be made in the denture laboratory.
In some cases, from the very beginning of treatment, permanent devices are used - removable and non-removable tires (prostheses), which at first serve to fix jaw fragments and remain in the mouth as a prosthesis after joint fragments.
Orthopedic devices consist of two parts - supporting and acting.
The supporting part is crowns, mouth guards, rings, wire arches, removable plates, head caps, etc.
The active part of the apparatus is rubber rings, ligatures, an elastic bracket, etc. The active part of the apparatus can be continuously acting (rubber traction) 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 the head part being a plaster head bandage with a metal rod. The bone fragment is stretched using elastic traction attached at one end to the jaw fragment by means of a wire ligature, and the other to the metal core of the head plaster cast.
FIRST SPECIALIZED ASSISTANCE FOR Fractures of the JAW (IMMOBILIZATION OF FRAGMENTS)
In wartime, transport tires, and sometimes ligature dressings, are widely used in the treatment of wounded in the maxillofacial region. Of transport tires, the most comfortable is a rigid chin sling. It consists of a headband with side rollers, a chin sling made of plastic and rubber rods (2-3 on each side).
A rigid chin sling is used for fractures of the lower and upper jaws. With fractures of the upper jaw and intact lower jaw and with teeth on both jaws, the use of the chin sling is indicated. The sling is attached to the head bandage with rubber bands with a significant traction, which is transmitted to the upper dentition and contributes to the reduction of the fragment.
In case of multi-fragmented fractures of the lower jaw, rubber traction should not be applied tightly connecting the "chin sling with the head bandage, in order to avoid significant displacement of the fragments.
3. N. Pomerantseva-Urban, instead of the standard rigid 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 soft slings is simpler than rigid, and in some cases more convenient for the patient.
Ya. M. Zbarg recommended a standard tire for fixing fragments of the upper jaw. Its splint consists of the intraoral part in the VDS of the stainless steel double wire arch, covering the dentition of the upper jaw on both sides, and the extraoral arms extending outward, directed posterior to the auricles. 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, extraoral rods - 3.2 mm. Dimensions
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Fig. 227. Standard Zbarga tires for immobilizing fragments of the upper jaw.
a - bus-arc; b - headband; in - connecting rods; e - connecting collars.
wire arc are regulated by extension and shortening of its palatine 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 of a standard tire for fixing fragments of the upper jaw, but only using the palatal plane of plastic. The latter is corrected by means of quick-hardening plastic.
Ligature tooth binding
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Fig. 228. Maxillary binding of teeth.
1 - according to Ivy; 2 - according to Geikin; .3 — but Wilga.
One of the easiest ways to immobilize jaw fragments that does not require much time is ligature tooth binding. As a ligature, a bronze-aluminum wire with a thickness of 0.5 mm is used. There are several ways to apply wire ligatures (according to Ivy, Wilga, Geikin, Limberg, etc.) (Fig. 228). Ligature binding is only temporary immobilization of jaw fragments (for 2-5 days) and is combined with the imposition of the chin sling.
Wire Tire Overlay
More rational immobilization of jaw fragments with the help of tires. Distinguish between simple special treatment and complex. The first is the use of wire rails. They are imposed, as a rule, in the army area, since a denture laboratory is not required for production. Complex orthopedic treatment is possible in those institutions where there is an equipped denture laboratory.
Before splinting, conduction anesthesia is performed, and then the oral cavity is treated with disinfectant solutions (hydrogen peroxide, potassium permanganate, furatsilin, chloramine, etc.). The wire splint should be curved along the vestibular side of the dentition so that it is adjacent to each tooth at least at one point, without imposing on the mucous membrane of the gums.
Wire rails 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 dentition defect. For intermaxillary traction, wire arches with hook loops on both jaws are used for A.I. Stepanov and P.I. It is recommended to use a smooth wire splint and pre-assembled mobile hook hooks made of brass for intermaxillary traction to produce a wire splint with hook loops, which are mounted on necessary section of the tire.
The method of applying ligatures
To fix the bus, 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. The ends of it with tweezers are inserted from the lingual side into two adjacent interdental spaces and removed from the vestibule side (one under the tire, the other above the tire). 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 mucous membrane of the gums. In order to save time, you can preliminarily hold a ligature between the teeth, bending one end down and the other up, then lay a splint between them and fix it with ligatures.
Indications for use of bent wire tires
A smooth arc of aluminum wire is indicated for fractures of the alveolar process of the upper and lower jaws, midline fractures of the lower jaw, as well as fractures of a different location, but within the dentition without vertical displacement of the fragments. In the absence of a part of the teeth, a smooth tire with a retention loop is used - an arc with a spacer.
The vertical displacement of fragments is eliminated by wire splints with hooked loops and intermaxillary traction using rubber rings. If a simultaneous reduction of jaw fragments is made, then wire slime is immediately attached to the teeth of both fragments. In the case of stiff and displaced fragments and the impossibility of simultaneously setting them up, 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 restoration of normal closure of the dentition. A rubber gasket is placed between the teeth of the short fragment and their antagonists to accelerate the correction of the bite.
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 a fragment of the lower jaw is displaced in two planes (vertical and horizontal), intermaxillary traction is shown. In case of a fracture of the lower jaw in the region of the angle with horizontal displacement of the long fragment towards the fracture, it is advisable to use a tire with a sliding hinge (Fig. 229, f). It differs in that it fixes 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, moves downward, and sometimes also posteriorly under the influence of muscle traction. In this case, often the side fragments are displaced towards each other. In such cases, it is convenient to immobilize jaw fragments in two stages. At the first stage, the lateral fragments are diluted and fixed with the help of a wire arch with the correct closure of the dentition, at the second stage, the middle fragment is pulled up using 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 using bent spikes of aluminum wire with a loop and a lining. The free end of the aluminum splint is strengthened on the teeth of the Other jaw fragment by wire ligatures.
.jpg)
Fig. 229. Tigerstedt wire rail.
a - smooth tire-arc; b - smooth tire with a spacer; in - bus with. hooks; g - tenon with hooks and an inclined plane; d - a tire with hooks and intermaxillary traction; e - rubber rings.
In case of fractures of the toothless lower jaw, if the patient has dentures, they can be used as tires for temporary immobilization of jaw fragments with the simultaneous application of a chin sling. To ensure food intake in the lower prosthesis, all 4 incisors are cut out and fed from the drinker through the formed opening of the patient.
Treatment of alveolar bone fractures
Fig. 231. Treatment of fractures of the alveolar ridge.
a - with a shift inward; b - with rearward displacement; in - with vertical displacement.
In fractures of the alveolar process of the upper or lower jaw, the fragment is usually fixed with a wire splint, most often smooth and single-jawed. When treating a non-gunshot fracture of the alveolar ridge, the fragment is usually set simultaneously 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 part of the alveolar ridge with the displacement of the fragment back, the wire arch 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 section of the alveolar ridge with its displacement to the lingual side, a spring steel wire 1.2–1.5 mm thick is used (Fig. 231, a). The arc is first attached by ligatures to the teeth of the healthy side, then the fragment is pulled by the ligatures to the free end of the arc. With vertical displacement of the fragment, 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 by 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 bracket with support loops directed back to the site of damage. The flap of the mucous membrane can also be fixed using celluloid or plastic palatine plate.
Orthopedic treatment of maxillary fractures
Fixing tires attached to the head bandage by elastic traction often cause displacement of the upper jaw fragments and malocclusion, which is especially important to remember when comminuted fractures of the upper jaw with bone defects. For these reasons, wire fixing tires without rubber traction have been proposed.
Ya. M. Zbarzh recommends two options for arching tires from aluminum wire to fix fragments of the upper jaw. In the first embodiment, they take a piece of aluminum wire 60 cm long, 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 observed:
1) during twisting, the angle formed by the long axes of the wire should be constant and not more than 45 °;
2) one process should have a clockwise direction of rotation, 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 hereafter 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 tire 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 embodiment, they are bent over the cheeks towards the auricles, and by means of connecting, vertically extending rods are attached to the headband. The lower ends of the connecting rods are bent upward 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 strengthened with gypsum on the head bandage, which makes lm more stable.
The posterior displacement of a fragment of the upper jaw can cause asphyxiation due to the closure of the lumen of the pharynx. In order to prevent this complication, it is necessary to pull the fragment forward. Traction and fixation of the fragment produced extraoral way. To do this, a headband is made and in its front section a tin plate with a soldered lever of 3-4 mm steel wire is gypsum plated or 3-4 twisted along the midline
Rice, 232. The sequence of manufacture of wire rails from aluminum wire (according to Zbargu).
and - the first option; b - the second option; f - fastening solid-bent aluminum wiretires with connecting rods.
aluminum wires soaked with a hook loop against the mouth gap. An aluminum wire bracket with hook loops is applied to the teeth of the upper jaw, or a supragingival lamellar spike with hook loops in the incisal region is used. By means of elastic traction (rubber ring), a fragment of the upper jaw is pulled to the lever of the head bandage.
With lateral displacements of a fragment of the upper jaw, the metal rod is gypsum 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 with posterior displacement of the upper jaw. Traction of the fragment is carried out under the control of the bite. With vertical displacement, the apparatus is supplemented with traction in a vertical plane by means of horizontal extraoral levers, a supragingival lamella, and rubber cords (Fig. 233). The plate splint is made individually according to the imprint of the upper jaw. From impression masses
Fig. 233. Lamellar gingival splint for securing fragments of the upper jaw. a - type of finished tire; b - the tire is fixed on the jaw and to the headband.
it is better to use alginate. Based on the obtained gypsum model, they begin modeling the plate 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 exposed. Quadrangular sleeves, which serve as bushings for extraoral levers, are welded to both sides of the apparatus. Levers can be made in advance. They have tetrahedral ends corresponding to the bushings into which they slide in the anteroposterior direction. In the area of \u200b\u200bthe canines, the levers form a bend around the corners of the mouth and, going outside, go towards the auricle. A loop-shaped curved wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. The levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband by means of rubber rings.
A similar splint can also be used to treat combined fractures of the upper and lower jaw. In such cases, hook loops bent at a right angle up are welded to the plate spike of the upper jaw. Fixation of jaw fragments is carried out in two stages. At the first stage, fragments of the upper jaw are fixed to the head using a tire with extraoral levers connected to the plaster cast with rubber rods (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled to the upper jaw splint by means of an aluminum wire bar with hook loops fixed to the lower jaw.
Orthopedic treatment of fractures of the lower jaw
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 to the patina with closed jaws under the control of the bite. Prolonged treatment of fractures of the lower jaw with wire splints with intermaxillary traction can lead to the formation of cicatricial cords and the appearance of extra-articular contractures of the jaws due to prolonged inactivity of the temporomandibular joints. In this regard, there was a need for functional treatment of injuries of the maxillofacial region, providing physiological, rather than mechanical rest. This problem can be solved by returning to the undeservedly forgotten single jaw splint, by fixing jaw fragments with devices that preserve movements in the temporomandibular joints. Single-jaw fixation of fragments provides 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 cavity, patients with linear fractures, and closed fractures of the lower jaw branch can be completed by intermaxillary fixation of fragments without any harmful consequences.
In case of fractures of the lower jaw in the corner, at the site of attachment of the masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. In case of multi-fragmented fractures, damage to the mucous membrane, oral cavity and face integuments, fractures accompanied by a bone defect, etc., the wounded need single-jaw fixation of fragments, which allows them to maintain movements in the temporomandibular joints.
A. Ya. Katz proposed a regulatory apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin. The apparatus consists of rings reinforced with cement on the teeth of a fragment of the jaw, oval 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).
Fig. 234. The reponing devices forreposition of fragments of the lower jaw.
l - Katz; 6 - Pomerantseva-Urban; a - Shelhorn; Mr. Pornoy and Psom; d - kappovo-rod apparatus.
Of the other single-jaw apparatuses for treating fractures of the lower jaw, it is worth noting the spring clamp of stainless steel »Pomerantseva-Urbaiskoy. This author recommends a method for applying ligatures according to Shelhorn (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 the fragments of the jaw, A. L. Grozovsky proposes the use of a kappa-rod replacement apparatus (Fig. 234, e). The surviving teeth are covered with crowns, to which rods in the form of half-arms 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 apparatus, which represents some modification of the Katz apparatus for reposition of fragments of the lower jaw in case of a defect in the chin region. This is an apparatus of combined and sequential action: at first it is reponizing, then fixing, shaping and replacing. The op consists of metal mouthguards, double tubes soldered to the buccal surface, and spring 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. After setting the jaw fragments in the correct position, replace the extraoral levers fixed in the mouthguards with a vestibular staple or a forming device (Fig. 235).
The kappovy device undoubtedly has some advantages over wire tires. Its advantages are that, being single-jawed, it does not limit movements in the temporomandibular joints. Using 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). The mouth guard is used without wire ligatures; the gum is not damaged. Its disadvantages include the need for constant monitoring, since it is possible to absorb cement in the mouthguards and the displacement of fragments of the jaw. To monitor the state of cement on chewing on top the mouthguards make holes (“windows”). For this reason, these patients should not be transported, since the disintegration of the mouthguards along the route will lead to a violation of the immobilization of jaw fragments. Mouthguards have found wider use in pediatric practice for jaw fractures.
Fig. 235. The reponing apparatus (according to Oxman).
a - reponiating; 6 - fixing; in - forming and replacing.
MM Vankevich proposed a plate splint covering the palatine and vestibular surfaces of the mucous membrane of the upper jaw. From the palatal surface of the tire extend downward, to the lingual surface of the lower molars, two inclined planes. When the jaws are closed, these planes push apart the fragments of the lower jaw, displaced in the lingual direction, and fix them in the correct position (Fig. 236). Shina Vankevich modified by A.I. Stepanov. Instead of a palatal plate, he introduced an arc, thus freeing part of the hard palate.
Fig. 236. A plastic bus bar for securing 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 corner, as well as in other fractures with the displacement of fragments to the lingual side, tires with an inclined plane are often used, and among them a plate-gingival 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 small horizontal displacement of a fragment of the jaw, with a deviation of the plane 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 down. Thus, horizontal displacement will be complicated by vertical. In order to eliminate the possibility of this position, 3. Ya. Shur recommends providing an orthopedic apparatus spring inclined plane.
Fig. 237. Tooth-gingival splint for the lower jaw.
a - general view; b - a tire with an inclined plane; c - orthopedic devices with sliding joints (according to Schroeder); g - steel wire bus then with a sliding hinge (along Pomerantseva-Urbanskaya).
All described fixing and regulating devices retain the mobility of the lower jaw in the temporomandibular joints.
Treatment of fractures of the body of the lower jaw with toothless fragments
The fixation of fragments of the toothless lower jaw is possible by surgical methods: by applying a bone suture, intraosseous pins, extraoral bone splints.
In case of a fracture of the lower jaw behind the dentition in the region of an angle or branch with a vertical displacement of a long fragment or a shift forward and towards the fracture in the first period, intermandibular fixation with oblique traction should be used. In the future, to eliminate horizontal displacement (shift towards the fracture), satisfactory results are achieved by using the Pomerantseva-Urban articulated tire.
Some authors (Schroeder, Brun, Gofrat, etc.) recommend standard tires with a sliding hinge mounted on the teeth using mouth guards (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 tires with a sliding hinge for fractures of the lower jaw in the area of \u200b\u200bthe angle and branch prevents the displacement of fragments, the occurrence of facial asymmetry deformations and is also a prevention of jaw contractures, because this splinting method preserves the vertical movements of the jaw and is easily combined with therapeutic exercises. A short fragment of a branch during a fracture of the lower jaw in the corner region is strengthened by skeletal traction using elastic traction to the head plaster cast with a rod behind the ear, as well as a wire ligature around the jaw angle.
In case of a fracture of the lower jaw with one toothless fragment, the long fragment is extended and the short one is fixed using a wire staple with hook loops fixed to the teeth of a long fragment with flight to the alveolar bone of the toothless fragment (Fig. 238). Intermaxillary fixation eliminates the displacement of a long fragment, and the pelot keeps the toothless fragment from moving up and to the side. A short fragment does not shift downward, since it is held by the muscles that raise the lower jaw. The tire can be made of resilient wire, and the pelot can be made of plastic.
Fig. 238. Skeletal traction of the lower jaw in the absence of teeth.
In case of fractures of the toothless lower jaw body, the simplest way of temporary fixation is to use the patient’s prostheses and fixation of the lower jaw through a rigid chin sling. In their absence, temporary immobilization can be carried out by a block of bite rollers from a thermoplastic mass with bases of the same material. Further treatment is carried out by surgical methods.
Plastic tires
In case of jaw fractures, combined with radiation injuries, the use of metal tires 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 using kapron threads instead of ligature wire to fasten the tire, and the tire for lower jaw fractures - from quick-hardening plastic according to a pre-made aluminum arcuate gutter, which is filled with freshly prepared plastic, laying it on the vestibular surface of the dental arch. After hardening of the plastic, the aluminum trough is easily removed, and the plastic is firmly connected to the nylon threads and fixes jaw fragments.
The plastic overlay method G. A. Vasiliev and employees. A kapron thread with a bead of plastic on the vestibular surface of the tooth is applied to each tooth. This creates a more reliable fixation of ligatures in the tire. Then impose a tire according to the method described by M, R. Marey. If necessary, intermaxillary fixation of jaw fragments in the corresponding areas is drilled with a spherical bore hole and pre-prepared spikes of plastic 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.
Fig. 239. The sequence of manufacture of jaw tires from quick-hardening plastic.
a - fixation of beads; b - bending the groove; in - groove; g - a smooth splint imposed on 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 reinforced with a bronze-aluminum alloy.
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Fig. 240. Standard tire made of elastic plastic (according to Gardashnikov)
a is a side view; b - front view; in - a mushroom shoot.
Orthopedic treatment of jaw fractures in children
Tooth injury. Bruises of the facial area may be accompanied by trauma to one tooth or group of teeth. A tooth injury is found in 1.8-2.5% of the examined schoolchildren. More often, an injury to the maxillary incisors is observed.
When breaking off the enamel of a milk or permanent tooth, 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 dentin, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed on artificial dentin without preparation of it. During this timefor me, the formation of replacement dentin is assumed. In the future, the crown is replaced with a seal or tab to match the color of the tooth. When a tooth crown fractures with damage to the pulp, the latter is removed. After filling the root canal, treatment is completed by applying a tab with a pin or crowns made of plastic. When a tooth crown is broken off, the crown is removed from its neck, and the root is tried to be preserved in order to use it to strengthen the pin tooth.
When a tooth fractures in the middle part of the root, when there is no significant tooth displacement along the vertical axis, they try to save it. To do this, apply a wire splint to a group of teeth with a ligature bandage on a damaged tooth. In young children (up to 5 years old), the fixation of broken teeth is best done using mouthguards fromplastics. The experience of domestic dentists has shown that a tooth root fracture sometimes heals after l "/ g — 2 months after splinting. The tooth becomes stable and its functional value is fully restored. If the tooth changes color, the electrical excitability decreases sharply, pain occurs during percussion or palpation in near the apical region, then the tooth crown is trepaned and the pulp is removed.The corpus canal is sealed with cement and thus preserves the tooth.
In case of bruises with root sticking into a broken alveolus, it is better to adhere to expectant tactics, bearing in mind that in some cases the tooth root is ejected somewhat due to the developed traumatic inflammation. In the absence of inflammation after healing the injury, the holes resort to orthopedic treatment.
If a child has to remove a permanent tooth during an injury, then the resulting dentition defect is kneaded with a fixed prosthesis with one-sided fixation or a sliding removable prosthesis with two-sided fixation to avoid malocclusion. Crowns, pin teeth can serve as supports. A defect in the dentition can also be replaced by a removable denture.
In case of loss of 2 or 3 anterior teeth, the defect is replaced with an articulated and removable denture according to Ilyina-Markosyan. In case of loss of individual front teeth due to bruising, but with the integrity of their holes, they can be re-implanted, provided that assistance is provided soon after the injury. After replantation, the tooth is fixed for 4-6 weeks with a plastic mouthguard. Re-implantation of milk teeth is not recommended, as they may interfere with the normal eruption of permanent teeth or cause the development of a follicular cyst.
Treatment of tooth dislocation and hole fracture .
In children under the age of 27 years with bruises there is a dislocation of the teeth or a breakdown of the holes and the incisors and the displacement of the teeth in the labial or lingual side. At this age, tooth fixation using a wire arc 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 the reduction of teeth manually (if possible) and fixing them with a mouthguard made of celluloid or plastic. The psychology of a child at this age has its own characteristics: he is afraid of the manipulations of a doctor. The unusual environment of the office acts on 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 instruments (spatula and mirror and at the orthopedic apparatus) like toys, and then carefully proceeds to orthopedic treatment. Methods for applying a wire arc and wire ligatures are rough and painful, so preference should be given to mouth guards, the application of which the child tolerates is much easier.
A method of manufacturing mouthguards Pomerantseva-Urban .
After a preparatory conversation between the doctor and the child, the teeth are smeared with a boggy layer of petroleum jelly and the impression is carefully removed from the damaged jaw. On the obtained gypsum model, the displaced teeth are cracked at the base, set them in the correct position and glued with cement. On the model thus prepared, a mouthguard is formed from wax, which should cover the displaced and adjacent stable teeth on both sides. Then the wax is replaced with plastic. When the kappa is ready, the teeth under appropriate anesthesia are manually adjusted and the kappa is fixed on them. In an extreme case, you can carefully not fully apply a mouthguard and suggest that the child gradually close his jaw, which will help establish the teeth in their holes. 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.
Jaw fractures in children. Jaw fractures in children occur as a result of trauma due to the fact that children are mobile and careless. More often, fractures of the alveolar ridge or dislocation of the teeth are observed, less often jaw fractures. When choosing a treatment method, it is necessary to take into account some age-related anatomical and physiological features of the dentition, 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 techniques for approaching him.
Orthopedic treatment of fractures of the lower jaw in children.
In the treatment of fractures of the alveolar ridge or lower jaw body, the nature of the displacement of bone fragments and the direction of the fracture line with respect to the dental follicles are of great importance. Fracture healing proceeds faster if its line passes at a certain distance from the dental follicle. If the latter is on the line of fracture, its infection and complication of a jaw fracture with osteomyelitis are possible. In the future, the formation of a follicular cyst is also possible. Similar complications can develop with the displacement of the fragment and the introduction of its sharp edges in the tissues of the follicle. In order to determine the ratio of the fracture line to the dental follicle, it is necessary to produce x-rays in two directions - in profile and face. In order to avoid the layering of milk teeth on permanent images should be done with a half-open mouth. In case of fracture of the lower jaw under the age of 3 years, a palatal plastic plate with imprints of the chewing surfaces of the dentition of the upper and lower jaws (splint-kappa) in combination with the chin sling can be used.
The technique of manufacturing 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 at the fracture in two parts, then they are made up with the gypsum model of the upper jaw in the correct ratio, glued with wax and gypsum in an occluder. After that, they take a well-heated semicircular wax roller and put it between the teeth of the gypsum models to get an imprint of the dentition. The latter should be at a distance of 6-8 mm from each other. A wax roller with a plate is checked in the mouth and, if necessary, corrected. Then the plate is made of plastic according to the usual rules. This apparatus is used together with the chin sling. The child uses it for 4-6 weeks before the time when the fusion of jaw fragments occurs. When feeding a baby, the device can be temporarily removed, then immediately re-lay it. Food should only be given in liquid form.
In children with chronic osteomyelitis, pathological fractures of the lower jaw are observed. To prevent them, as well as the displacement of jaw fragments, especially after sequestrotomy, splinting is indicated. From a wide variety of tires, one should give preference to the Vankevich tire in the Stepanov modification (see Fig. 293, a) as more hygienic and easily tolerated.
Impressions from both jaws are removed prior to sequestrotomy. Plaster models are gypsum plated into the occluder in a central occlusion position. The palatine plate of the tire is modeled with a downward plane (one or two, depending on the topography of a possible fracture), to the lingual surface of the chewing teeth of the lower jaw. The fixation of the device is recommended using swept clasps.
In case of jaw fractures from the age of 21/2 to 6 years, the roots of milk teeth are to some extent already formed and the teeth are more stable. The child at this time is easier to convince. Orthopedic treatment can often be carried out using stainless steel wire tires 1-1.3 mm thick. Tires are strengthened with ligatures to each tooth throughout the entire dentition. For low crowns or tooth decay, caries made of plastic are used, as already described above.
When applying wire ligatures, it is necessary to take into account some anatomical features of the teeth of a milk bite. Milk teeth, as you know, are low, have convex crowns, especially in chewing teeth. Their large circumference is located closer to the neck of the tooth. As a result, the wire ligatures, applied in the usual way, slip off. In such cases, special methods of applying ligatures are recommended: the 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 them in the usual way.
For jaw fractures aged 6 to 12 years, it is necessary to take into account the features of the dentition of this period (resorption of the roots of milk teeth, teething crowns of permanent teeth with unformed roots). Medical tactics in this case depends on the degree of resorption of primary teeth. With complete resorption of their roots, dislocated teeth are removed, with incomplete - splint, keeping them until eruption of permanent teeth. If the roots of the milk teeth are broken, the latter are removed, and the dentition defect is replaced with a temporary denture to avoid malocclusion. To immobilize the 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 fangs, on which crowns or rings are applied and connected with a wire arc. In some cases, the manufacture of mouth guards for a group of chewing teeth with hook loops for intermaxillary fixation of jaw fragments is indicated. At the age of 13 years and older, splinting is usually not difficult, since the roots of the permanent teeth are already quite formed.
splinting
proposed by S.S. Tigerstedt during the First World War (1916). IN
1967 V.S. Vasiliev developed a standard stainless steel strip tire with ready hooks (Fig. 12
-2).
Fig. 12
-2.
Tires for splinting in jaw fractures: a
- bent wire rail
S.S. Tigerstedt; b
- standard tape splint for intermaxillary fixation according to V.S. Vasiliev
Distinguish
bent tires
from wire:
smooth tire
- a bracket;
smooth tire with a spacer;
tire with hook loops;
a tire with hook loops and an inclined plane;
splint with hook loops and intermaxillary traction. For
splintingthe following tools are needed:
krampon forceps;
pliers;
anatomical and dental tweezers;
needle holder;
clamp;
dental mirror;
file for metal;
coronal scissors.
Of
materials
necessary:
1.5 aluminum wire
-
2 mm in segments of 25 cm;
5 bronze-aluminum or copper wire
-
6 cm, 0.40.6 cm thick;
rubber drain pipe with hole 4
-
6 mm for rubber rings;
dressing.
Before applying the tire, you need to free the patient’s mouth from the remains of food masses, plaque, broken teeth, bone fragments, blood clots with gauze balls soaked in a 3% hydrogen peroxide solution, followed by irrigation with potassium permanganate 1 ÷ 1000. If necessary, anesthesia is performed.
When fitting and applying
aluminum tires
(fig. 12
-
3) it is necessary to adhere to certain requirements.
The splint should be curved along the vestibular surface of the dentition so that it is adjacent to each tooth at least at one point. It is not necessary to bend it along the contours of the tooth crowns.
The splint should not rest against the gingival mucosa to prevent pressure sores.
The ends of the tire are bent in the form of a hook around a distally located tooth in the shape of an equator or in the form of a spike and inserted into the interdental space of the distal teeth from the vestibular side.
Fig. 12
-3.
Types of wire tires: a
-
smooth tire
-
bracket; b
-
tire according to Schelhorn; in
-
wire rail with sliding joint according to Pomerantseva
-
Urban g
-
smooth
fractured wire splint
The arch is bent with fingers along the dentition with frequent correction in the oral cavity, avoiding repeated bending.
Forced pressing of the tire to the teeth is unacceptable in order to avoid pain and displacement of fragments.
If there is a defect in the dentition on the tire, a loop in the shape of the letter P is bent, the upper crossbar of which corresponds to the width of the defect and faces the oral cavity.
The loops are bent with krampon forceps. The distance between the loops is not more than 15 mm,
2-
3 loops on each side. The hook loop should be no more than 3 mm long and bent at an angle of 45 ° to the gum. Loops should not injure the oral mucosa.
The tire is fixed with ligatures to as many teeth as possible. The ligatures are twisted clockwise, the excess is cut off and bent towards the center so that they do not injure the mucous membrane.
Smooth tire
-
staple
shown:
in case of fractures of the alveolar ridge, if simultaneous reduction of fragments is possible;
with median fractures of the lower jaw without vertical displacement of fragments;
with fractures within the dentition, if it is not accompanied by a vertical displacement of fragments;
with bilateral and multiple fractures of the lower jaw within the dentition, when a sufficient number of teeth is preserved on each fragment.
With the same indications, standard V.C. tires can be used Vasilieva.
A smooth tire with a spacer is used for fractures with a defect in the dentition.
With a vertical displacement of fragments in the event of a fracture, tires with hook loops are used within the dentition.
Tires with intermaxillary traction are used to treat fractures behind the dentition. In the treatment of fractures with vertical displacement of fragments, direct intermaxillary rubber traction is used. For the treatment of fractures with displacement of fragments in two planes, an oblique intermandibular traction is indicated.
In case of fractures of the lower jaw with a small number of teeth on the fragments or in their complete absence, extraoral extraoral devices V.F. Rud
- to, Ya.M. Zbarga.
In order to simplify the manufacturing technique of tooth splints and improve fixation of fragments of the lower jaw, it is proposed to use quick-hardening plastic, the main indication for the use of which is fixing bone fragments after they are installed in the correct position.
In case of fractures in the lateral sections, in case of osteomyelitis of the lateral section, in order to prevent displacement of fragments in the case of a pathological fracture during surgery, a stable inclined plane is used, which is 2
-
3 crowns made on the lateral teeth of the intact side, or a brazed tire, from the vestibular side of which a stainless steel plate is soldered. The plate rests on the vestibular surface of the teeth
- antagonists of the upper jaw. Its edge should not be higher than the necks of the teeth of the upper jaw with closed teeth, so as not to injure the mucous membrane. The plate is soldered to the crowns of the lower teeth just below the equator, so as not to interfere with the closure of the teeth.
In bilateral fractures of the lower jaw with a displacement of the median fragment downward, the lateral fragments are diluted and fixed in the correct position with a steel wire arch, and the short fragment is pulled up using the maxillary traction. Treatment ends with a smooth tire
- a bracket after setting all fragments in the correct closure of the teeth.
In case of a fracture of the lower jaw with one toothless fragment, it is fixed with a bent tire with a loop and a thermoplastic lining. A fragment with teeth is strengthened by wire ligatures to the teeth of the upper jaw.
For the treatment of single fractures of the lower jaw with complete mobility of fragments in the case of an insignificant number of teeth on the fragments or mobility of all teeth, weber's removable gingival splint is used (Fig. 12
-
4). This splint covers the entire remaining dentition and gum on both fragments,
leaving the chewing and cutting surfaces of the teeth open. It can be used to treat fractures of the lower jaw.
Fig. 12
-4.
Weber Bus: a
-
the step of manufacturing the wire frame of the tire; b
-
finished tire
For fractures of the toothless lower jaw and the absence of teeth on the upper, devices are used
Gunning
-
Porta, Limberg in combination with chin sling (Fig. 12
-5).
Among the fractures of the upper jaw, fractures of the alveolar process are more often noted. They can be without bias and with bias. The direction of displacement of the fragment is due to the direction of the acting force. Mostly fragments are shifted back or to the midline.
First aid treatment
alveolar bone fracturescomes down to setting the fragment in the correct position and applying a sling or external dressing to the teeth
- antagonists tightly closed. An elastic sling-like dressing can be successfully applied.
Simple specialized treatment of fractures of the alveolar bone is carried out with a smooth aluminum or steel splint
- a bracket. The fragment is repaired first
Fig. 12
-5.
Apparatus used to treat jaw fractures in the complete absence
teeth: a
-
gunning machine
-
Porta b
-
limberg apparatus
with hands and with closed teeth, bend the tire with hands
- a bracket on the upper dentition. Then, wire ligatures in the form of hairpins are inserted between all teeth and their ends are brought out in front of the mouth. The tire is fixed to the teeth of the intact side, asking the patient to close their teeth in the correct position, impose a sling, and then attach the fragment to the tire
- bracket. The sling is removed after the staples are fully fixed. If there are contraindications to the tire
- bracket, make a complete tire with the location of the supporting crowns on the teeth of the undamaged area and the fragment.
At
maxillary fractures
(suborbital and subbasal) with the free mobility of fragments, first aid comes down to setting the fragments in the correct position and fixing them to the head cap. For this purpose, standard devices are used: tires
- spoons of Entin, Limberg, a rigid chin sling. Sagittar dressings are effective if the lower jaw is not damaged and there are at least 6 on both jaws
-
8 pairs of teeth
- antagonists. Standard tires
- spoons are placed on 1
-
2 days Their main disadvantages include: bulkiness, poor fixation of fragments, lack of hygiene, inability to follow the correct installation of a damaged upper jaw, since the tire
- a spoon covers the entire dentition.
Simple specialized treatment
reduced to the simultaneous reduction and fixation of fragments in the correct position. For this, individual wire tires are used: solid-bent and composite. Inside
- and extraoral processes
- levers connected to the tires are mounted in a gypsum cap. For the treatment of fractures of the anterior jaw Zbarg proposed a one-piece aluminum wire tire (Fig. 12
-6).
For the treatment of fractures of the upper jaw type Le Fort I and II Ya.M. Zbarg has developed a standard tire kit
- arches, supporting dressings and connecting rods, which can simultaneously fix and adjust the fragments. Complex specialized treatment of upper fracture
Fig. 12
-6.
The device for the treatment of fractures of the upper jaw according to Ya.M. Zbarzhu: a
-
head
gypsum cap; b
-
bent wire splint with extraoral processes,
fixed to the head cap
the jaw with a downward shift with the free mobility of the fragment (suborbital fracture) and the integrity of the lower jaw is carried out by the method inside
- oral fixation with Weber’s tire with extraoral levers attached by means of elastic traction to the head bandage. It covers the teeth and the mucous membrane of the gums around the dentition from the palatine and vestibular sides.
Tubes are welded into the side sections on both sides, into which the rods are inserted to connect with the head bandage. TO
gingival deficiencies
tires should include cumbersomeness, overlapping of the mucous membrane of the alveolar ridge and hard palate, the need to obtain a complete impression from the upper jaw, poor fixation of the fragment. In order to eliminate the shortcomings
Z.Ya. Schur proposed replacing the Weber tire with a single soldered bus with tetrahedral tubes in the side sections to strengthen the extraoral rods in them. The outer ends of the rods are connected rigidly to the gypsum cap by the opposing rods coming from the gypsum cap vertically downward.
In the treatment of simultaneous fracture of the upper and lower jaw, a gingival splint with extraoral rods is shown.
- mustache and hooks for intermaxillary fixation of fragments of the lower jaw, fixed to a soft head cap, proposed by A.A. Limberg.
With timely immobilization of jaw fragments during non-gunshot fractures, they grow together after 4
-
5 weeks Usually after 12
-
Fifteen days after the injury, the primary bone callus can be found in the form of a dense formation along the fracture line. The mobility of bone fragments is markedly reduced. End 4
-5th week, and sometimes fragments mobility disappears earlier with a decrease in compaction in the fracture area
- secondary bone marrow is formed.
In an X-ray examination, the gap between the bone fragments can be determined up to 2 months after the clinical healing of the fracture.
Treatment tires can be removed after the clinical mobility of the fragments has disappeared. The healing time for gunshot fractures is significantly increased.
Comprehensive rehabilitation treatment of fractures is carried out under the control of radiography, myography and laboratory research methods.
12.2. CLASSIFICATION OF COMPLEX JUST
-
FACIAL APPLIANCES
Fixation of jaw fragments is carried out using various orthopedic devices. All orthopedic devices are divided into groups depending on function, area of \u200b\u200bfixation, therapeutic value, design, manufacturing method and material.
By function:
- immobilizing (fixing);
- reponing (correcting);
- corrective (guides);
- formative;
- resection (replacement);
Combined
- dentures for defects in the jaw and face.
At the place of fixation:
- intraoral (single-jawed, double-jawed, intermaxillary);
- extraoral;
- inside
- and extraoral (maxillary, mandibular).
For medical purposes:
- basic (having independent medical value: fixing, correcting, etc.);
- auxiliary (serving for the successful implementation of skin
- plastic or bone
- plastic surgery).
By design:
- standard;
- individual (simple and complex).
According to the manufacturing method:
- laboratory manufacturing;
- off-laboratory manufacturing.
According to the materials:
- plastic;
- metal;
- combined.
Immobilizing devices are used in the treatment of severe jaw fractures, insufficient or missing teeth on the fragments. These include:
- tires made of wire (Tigerstedt, Vasiliev, Stepanova);
- tires on rings, crowns (with hooks for stretching fragments);
- tires
- mouthguards:
V metal
- cast, stamped, soldered;
V
plastic;
Removable tires of Port, Limberg, Weber, Vankevich, etc.
Replacing devices that contribute to the reposition of bone fragments are also used for chronic fractures with stiff jaw fragments. These include:
- reponing devices made of wire with elastic intermaxillary traction, etc .;
- devices with inside
- and extraoral levers (Courland, Oaks
- mana);
- reponing devices with a screw and a repelling platform (Chickens
- landsky, Grozovsky);
- Replacing devices with a pelot for a toothless fragment (Kurlyandsko
- go and others);
- repair devices for toothless jaws (Gunning tires
-
Porta).
Fixing devices are devices that help to keep jaw fragments in a certain position. They are divided into:
- on extraoral:
V standard chin sling with a head cap;
Vstandard tire according to Zbarg and others.
- intraoral:
■ V
tooth tires:
aluminum wire (Tigerstedt, Vasiliev, etc.);
soldered tires on rings, crowns;
plastic tires;
fixing tooth devices;
■
gearing tires (Weber and others);
■
spring tires (Porta, Limberg);
- combined.
Guides (corrective ones) are called devices that provide a certain direction to the bone fragment of the jaw using an inclined plane, a pelot, a sliding hinge, etc.
-
For aluminum wire tires, the guide planes bend 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, planes are modeled from wax and cast along with the tire.
-
On plastic tires, the guide plane can be simulated simultaneously with the tire as a whole.
-
In case of insufficient or missing teeth on the lower jaw, tires are used according to
Vankevich.
Formative devices are called, which are the support of plastic material (skin, mucous membrane), creating a bed for the prosthesis in the postoperative period and preventing the formation of cicatricial changes in soft tissues and their consequences (displacement of fragments due to the compressive forces, deformations of the prosthetic bed, etc.). By design, the devices can be very diverse depending on the area of \u200b\u200bdamage and its anatomical
- physiological features. In the design of the forming apparatus, the forming part and fixing devices are distinguished.
Resectional (replacement) devices are called, replacing dentition defects formed after tooth extraction, filling defects in the jaw, parts of the face that arose after an injury, operations. The purpose of these devices
- restore the function of the organ, and sometimes keep fragments of the jaw from displacement or soft tissues of the face from falling.
Combined devices are those that have several purposes and perform various functions, for example: fixing jaw fragments and forming a prosthetic bed or replacing a jaw bone defect and simultaneously forming a skin flap.
A typical representative of this group is Kappovo.
- a barbell apparatus of combined sequential action according to Oksman for fractures of the lower jaw with a bone defect and the presence of a sufficient number of stable teeth on the fragments.
Dentures used in maxillary
- facial orthopedics, are divided:
- on dentoalveolar;
- jaw;
- facial;
- combined;
- when resecting the jaw, prostheses are used, which are called post-resection.
There are direct, near and distant prosthetics. In this regard, prostheses are divided into operating and postoperative. Orthopedic devices used for defects in the palate also belong to replacement devices: protective plates, obturators, etc.
Prostheses for defects in the face and jaw are made in case of contraindications to surgical interventions or in the case of persistent unwillingness of patients to perform plastic surgery.
If a defect captures a number of organs at the same time: nose, cheeks, lips, eyes, etc., the facial prosthesis is made in such a way as to restore all the lost tissue. Face prostheses can be fixed with spectacle frames, dentures, steel springs, implants and other devices.
12.3. TREATMENT METHOD FOR MOBILE Fractures
Simple specialized treatment of fractures of the lower jaw with limited mobility and stiffness of the fragments is carried out by various devices that are well fixed on the jaw and have sufficient resistance to muscle traction. Limited mobility of the fragments is observed in case of untimely first aid or its incorrect conduct. If the patient seeks help after 2
-
3 weeks after the fracture, the position of the fragments is almost always incorrect.
With single fractures with horizontal displacement of fragments to the midline, the most common, as well as for the treatment of fractures with freely moving fragments, are S. Tigerstedt with hook loops.
In case of fractures within the dentition with stiff fragments, tires with hook loops are made on the upper jaw and a large fragment of the lower jaw, rubber traction is installed, and on a small fragment between the teeth
- antagonists place a pad for crushing it. After a consistent comparison of fragments, the tire is removed and treatment is completed with a single smooth tire. In some cases, it is advisable to leave the free end of the wire in the area of \u200b\u200bthe small fragment, and after correcting the position of the fragments, bend it to the teeth of the small fragment and fix it with a ligature.
With bilateral and multiple fractures along with Tiger tires
- stedta tires with vertical P
- and G
- shaped bends, to which fragments are pulled by ligatures. In case of fractures of the lower jaw with a shortened dentition or in the presence of a toothless fragment, a Tigerstedt tire with hook loops is applied to the large fragment and upper jaw, and a pelot is made on the toothless fragment. In case of fractures behind the dentition, Tigerstedt tires with intermaxillary traction are applied, which are preserved even after correcting the position of the fragments.
Mandatory in this case is the appointment of myogymnastics.
For the treatment of single fractures and fractures with a bone defect in the anterior section, the apparatus A.Ya. Katz with intraoral spring levers. It consists of supporting elements.
- mouth guards or crowns to which a flat or quadrangular tube is soldered from the vestibular side, and two rods. The advantage of the Katz apparatus is that it is possible to move fragments in any direction: parallel expansion or convergence of fragments, movement of fragments in the sagittal and vertical directions, extension or displacement only in the region of ascending branches and jaw angles, rotation of fragments around sagittal (longitudinal) axes.
With complete separation of the upper jaw with stiff fragments (subba
- zalnaya fracture) with displacement posteriorly and turning around the transverse axis for simple specialized treatment apply traction to the shaft, fortified to a plaster cast. The rod is made of steel
wire, its free end ends with a loop. A wire splint with hook loops is applied to the teeth of the upper jaw. By means of rubber traction, the displaced jaw is pulled to a lever mounted on a headband.
With unilateral complete separation of the upper jaw, when a sufficient number of teeth on both jaws has been preserved, repositions of the stiff fragment are achieved by intermaxillary traction. A splint with hook loops is applied to the lower jaw, and the upper splint is attached only on the healthy side, where the hook loops are made. On the sore side, the end of the tire is smooth and remains free. Rubber traction is applied between the hook loops, and between the teeth on the fracture side
- elastic gasket. After reposition of the fragment, the tire is fixed to the teeth of the diseased side.
12.4. ORTHOPEDIC METHODS OF TREATMENT WITH FALSE JOINTS
To the consequences of maxillary
- Facial trauma also includes non-consolidated jaw fractures or a false joint (pseudoarthrosis). The most characteristic sign of an overgrown fracture is the mobility of jaw fragments. During the Great Patriotic War, about 10% of fractures of the lower jaw ended in the formation of a false joint. These were fractures mainly with a bone defect.
Topic: Production of tires and tire prostheses. Tire manufacturing demonstration (Vankevich, Tigerstedt).
The purpose of the lesson: to teach students the features of orthopedic treatment of traumatic injuries of the maxillofacial region. To characterize and determine indications for the use of splinting, repairing and shaping devices. To study the clinical and laboratory stages of their manufacture.
^ Questions necessary for mastering the topic:
The muscular system of the maxillofacial region.
Features of blood supply and innervation of the maxillofacial region.
Test questions:
Devices used in maxillofacial orthopedics, their classification, indications for use.
Classification of fixing devices.
Stages of manufacturing Weber tires, Port tires.
Shina Vankevich. Indications. Stages of manufacturing.
Tigerstedt tires. Indications. Stages of manufacturing.
Characterization and clinical and laboratory stages of the manufacture of tires and prostheses used in fractures of the upper jaw (Gunning, Oksman).
Classification of devices used in maxillofacial orthopedics:
By function:
Fixing (provide functional stability of fragments).
Replacing (provide a gradual reposition of fragments).
Formative (provide temporary maintenance of the shape of the face, create rigid support, prevent cicatricial changes in soft tissues, deformation of the prosthetic bed, etc.).
Replacing (perform the function of replacing congenital and acquired defects).
Combined (a single design for reposition, fixation, formation and replacement).
Intraoral (single-jawed, double-jawed, intermaxillary).
Extraoral.
Inside the extraoral.
Standard.
Customized.
Intraoral:
Tooth splints (aluminum wire splint, brazed wire splint on rings (crowns), plastic tires, fixation of dentition devices for osteoplastic surgery);
Tooth gingival splint (Weber splint);
Gingival (monoblock, Port bus).
Extraoral (chin sling with a head cap).
Combined (bent wire aluminum splint with a head cap for the treatment of fractures of the upper jaw).
^ Scheme of OOD on the topic: "Clinical and laboratory stages of the manufacture of tires and tire prostheses"
| Name of tire, prosthesis | Materials, tools necessary for manufacturing. Manufacturing steps | Indications |
| Tigerstedt tire smooth | 2 mm aluminum wire, 0.3 mm bronze-aluminum wire, krampon forceps, file | With easily straightened fractures of the alveolar process of the upper jaw and the presence of at least 2-3 stable teeth on the fragments |
| Tigerstedt tire with spacer bend | Also In the area of \u200b\u200bmissing teeth, a spacer bend is made | With fractures in the area of \u200b\u200bthe toothless jaw |
| Tigerstedt tire with hook loops | Also | If necessary, rubber traction |
| Shina Vankevich | Acrylic plastic base, if necessary, artificial teeth, pellets for the lower jaw | For various fractures of the lower jaw for fixation and reposition |
| Tire made of stamped crowns connected by two tubes and two pins | Consists of 2 stamped mouth guards (1X18H9T steel) for chewing groups of teeth, on the mouth guard on the lingual and vestibular sides 2 soldered tubes, on the other 2 shafts | One-sided jaw fracture |
| Open vestibular palatine plate with bushings for extraoral rods | The device is strengthened by extraoral rods on an orthopedic gypsum cap | With fractures of the upper jaw with a defect and a small number of supporting teeth |
| Cap tire with a sleeve on which a supporting buccal plate is fixed with a rod | The plate is created by free modeling, the reference point for its size and shape is the intact jaw. In the middle of the surface adjacent to the cheek, a 1 mm high bead is modeled, which forms a channel in the scar tissue and serves as a support for the prosthesis | With a unilateral fracture of the upper jaw with a defect and a sufficient number of supporting teeth |
| Limberg Ring Tire | Sleeves (rings) soldered to crowns or rings of an arch of orthodontic wire 1.5–2 mm thick. Fixing rings on stable teeth, taking casts with rings, casting models, soldering tires, bleaching, polishing, fixing on teeth. | For fractures of the upper jaw with insufficient teeth, low clinical crowns |
| An open supragingival splint with a closing loop fixed by extraoral rods on an orthopedic gypsum cap | A model is cast according to the cast, on which the size of individual fragments is clearly outlined. On the vestibular surface of the tire set cannulas for extraoral rods. On extraoral rods, 2–3 hinges are bent on each side for attaching aluminum wire to the head gypsum cap | Bilateral fracture of the upper jaw with a large number of teeth on the jaw and the absence of a palate defect |
| Standard Zbarga Kit | Steel intraoral wire splint, extraoral mandrel, supporting head bandage, side metal straps, 4 connecting rods, 8 connecting clamps, ligature wire, clamps, crown scissors. Tire preparation using forceps and pliers in accordance with the individual anatomical features of the dentition. Fixation of the intraoral wire splint to the teeth with ligature wire. The application of a supporting head bandage. With a toothless jaw, a splint bar is used as a base on which a plate of self-hardening plastic can be applied | Subbasal fractures of the upper jaw with displacement in the presence of a large number of teeth (superimposed for 2-3-5 weeks). Combined fractures of the upper and lower jaw (on the lower jaw a wire splint with hook loops). |
| Gunning tire Limberg tire | Collapsible, mounted on the teeth with clasps. Spikes are made on the occlusal surface of the lower jaw of the tire, on the occlusal surface of the upper part of the recess for them. After the next tire insertion and fixation with the chin sling of the lower jaw, a lock forms. | Fractures of the lower jaw subject to the presence of one or more teeth that do not allow the Port splint to be inserted |
| Port Bus | Impression material, base wax, gypsum, spirit lamp, wax spatula, 2 cuvettes, impression spoons. Taking impressions, making bases with occlusal rollers, determining the central jaw ratio, the gypsum model in the occluder, modeling the tire with a wax monoblock with a hole in the frontal area of \u200b\u200b1.5 x 2.5 cm for eating. Replacing wax with plastic. Used in conjunction with a sling bandage | With fractures of the toothless upper and lower jaws without displacement |
| Upper jaw reposition apparatus | Steel rod 2.5–3 mm thick, soldered to a plate 30 cm long. Aluminum wire 2 mm thick, rubber rod, gypsum, bandage. Reposition of fragments of the upper jaw forward is achieved by an extraoral rod, mounted on a gypsum cap. A pre-prepared intraoral tire is pulled to it. When piling up the fragments, a tooth splint with a loop is installed. Reposition up is achieved by applying a rubber traction between the gypsum cap and extraoral rods. With a unilateral displacement of the jaw, a good reposition can be obtained by installing a rubber gasket between the teeth of the fragment and antagonists. The pull is carried out between the soft head with a hat and a sling. | Fractures of the upper jaw with displacement |
^ The manufacture of tires Vankevich M.M.
Tire Vankevich consists of the upper base, which is fixed on the upper jaw. With a toothless upper jaw, the splint represents the basis of the prosthesis, which is fixed on the jaw due to adhesion and the valve area. In the presence of teeth, the basis is made in the form of a Weber tire. Vertical processes are welded to this base, which are lowered down, touch the outer surfaces of the lingual surfaces of the fragments of the lower jaw and, thus, hold the fragments in the correct position.
If the treatment was carried out correctly and movable fragments with single teeth can be divorced and set in the correct position, the tire is made immediately with the supporting planes.
For toothless fragments, the mold is first made and the maxillary plastic template is checked. To install each fragment in the correct position, a buffer of softened impression mass is attached to the surface of the template opposite to it. When the patient presses the allotted fragment to the upper jaw, the outer surface of the buffer is contoured according to the surface of the removed fragment. Upon completion of molding and finishing, the impression mass is replaced with plastic AKP-7.
When fragments are fused in the wrong position, a maxillary splint is made with a supporting plane for one of them at its maximum abstraction, without taking into account the displacement of the other fragment. After the trial wear of the tire, it is installed on gypsum (cast), then after hardening of the gypsum, the checked supporting plane with a minimum part of the maxillary tire is sawn off and drawn up on the model. On the majority of the tire removed from the model, a support for the fragment is formed on the other hand, also at its maximum retraction and without taking into account the position of the other fragment. After welding, this second shaped portion of the tire is tested by test wear. Then, both separately tested parts are installed on a gypsum cast and welded together. In this form, with a wide standing of the supporting planes, the tire can be superimposed only after the complete fragmentation of the fragments by surgical intervention.
Vankevich intraoral apparatus for repositioning and securing fragments of the lower jaw: A - apparatus on the model; B - without a model.
Apparatus for intraoral fixation of fragments of a toothless lower jaw in the absence of chewing teeth on the upper jaw (according to the author): A - details of the apparatus; B - apparatus on the model.
^ Tigerstedt tire manufacturing.
For more than 80 years, bent wire tooth splints have been successfully used, developed even during the First World War by the dentist of the Kiev military hospital S.S. Tigerstedt (1915). He was offered a large number of different tire designs: a simple bracket (now called a smooth tire-bracket), a support bracket (a tire with hook loops), a retention bracket (a tire with a spacer bend), various versions of brackets with planes, tires with inclined planes and hinges , with levers of various principles of action for moving fragments during chronic fractures, fixation seals, anchor braces, etc. As the author himself pointed out, his system allowed “... quickly, without casts, without models, without rings, nuts and screws, without soldering and tampovki without vulcanization to do everything you need. "
Tigerstedt tires have made a real revolution in domestic and foreign traumatology. This was due to the fact that this method of therapeutic immobilization is characterized by relatively low invasiveness, simplicity, high efficiency and low cost of the materials used.
Over time, in the process of clinical selection, the following bent wire tooth splints have been preserved and successfully used: a smooth splint-splint, splint with spacer bend, splint with snag loops, and very rarely, an oblique splint.
The following materials are necessary for the manufacture of tooth-tires: aluminum wire with a diameter of 1.8–2 mm and a length of 12–15 cm (in case of high rigidity, it must be calcined and slowly cooled); bronze-aluminum wire with a diameter of 0.5-0.6 mm or stainless steel wire with a diameter of 0.4-0.5 mm; tools: krampon forceps, anatomical forceps, hemostatic clamp Billroth (without teeth) or Kocher (with teeth), dental scissors for cutting metal, file.
General rules for applying splint tires:
Subcutaneously administer 0.5 ml of a 0.1% atropine solution for ease of work in connection with a decrease in salivation;
Perform local anesthesia, better conductor;
Start bending the tire on the left side of the patient’s jaw (for left-handed people - on the right); some authors recommend starting to bend the tire from the side of the fracture;
Bend the tire with the fingers of the left hand, holding the wire in the right hand with krampon tongs (for the left-handed people - vice versa);
Place krampon forceps at the border of the wire (billet) and the curved section of the tire, protecting it from deformation;
After fitting the tire to the teeth, bend it only outside the oral cavity;
The manufactured tire must always be adjacent to each tooth at least at one point and located between the gingival margin and the tooth equator;
Fix the tire to each tooth included in it with ligature wire;
Twist the ligature wire only in the clockwise direction (all doctors have agreed).
This ensures continuity in caring for the tire, pulling up and loosening the ligature.
Start manufacturing tires by bending a large hook or hook. When bending the tire, the aluminum wire is fixed with krampon forceps, and it is bent by pressing the wire with your fingers to the cheeks of the forceps to avoid deformation of the tire section fitted to the teeth. In the mouth, try on the tire, and bend it outside the patient's mouth. To try on a curved section of a tire, it is applied to the patient’s teeth and fixed with the fingers of his right hand in the area of \u200b\u200ba large hook or hook, i.e. in the area of \u200b\u200ban already manufactured tire. This condition is very significant. You can not try on the tire, holding it by the wire section protruding from the mouth, as this leads to improper placement of the tire on the teeth. Having made a tire on one half of the jaw, they proceed to bending it on the other half. In this case, the long end of the workpiece wire must be bent 180 °, leaving a piece of it sufficient for the manufacture of the second half of the tire.
Tigerstedt wire rail: a - wire arc and ligature; b - the position of the arc with defects; in - hook loops; g - shear limiter; d - rubber rings and intermaxillary traction.
^ Situational Tasks
The patient is 72 years old. Fracture of the toothless upper jaw. The radiograph revealed a subbasal fracture. Determine the method of orthopedic treatment.
A 25-year-old patient was delivered to a dental clinic with a suborbital fracture of the upper jaw on the right. Explain the options for orthopedic treatment.
The patient is 50 years old. He entered the clinic with a fracture of the upper jaw of Le Fort 1. There are partial defects in the dentition on the jaw. Clinical tooth crowns are small. Justify an orthopedic treatment plan.
55-year-old patient, simultaneous fracture of the upper and lower toothless jaws. Make an orthopedic treatment plan.
A 20-year-old patient was admitted with an unexplained fracture of the upper jaw. On the jaw there are partial defects in the dentition. Justify an orthopedic treatment plan.
The patient is 38 years old. He was admitted with a diagnosis of a fracture of the body of the lower jaw with displacement. On the jaw there are partial defects in the dentition. Create and justify an orthopedic treatment plan.
Literature
Lecture material of the Department of Orthopedic Dentistry BSMU.
Gavrilov E.I., 0ksman I.M. Orthopedic dentistry. 1978, S.401–408, 411–417.
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