The main task in the treatment of patients with fractures of the jaws is the provision of emergency and emergency care. Its solution includes the simultaneous implementation of the following main activities.

▲ Reposition - matching or moving a break off
kov to the correct position if there is an offset.
Reposition must be done under anesthesia
(local - conductor or common). Its implementation
are given before immobilization. For this, see
the stagnant fragments are compared and immediately fixed
ut. If we compare the displaced fragments of the same time
tno fails, they are repositioned gradually, during
some time with the help of an elastic hood
niya.

▲ Immobilization - fixing fragments in the right
nom position for the period necessary for their fusion
(consolidation), i.e. before the formation of strong bone mo
sols. On average, this period is 4-5 weeks for neo-
complicated course of healing of a fracture of the upper che
lusti and unilateral fracture of the lower jaw. At
bilateral mandibular fracture
fragments occurs somewhat later, in connection with which the timing
immobilization is 5-6 weeks.

▲ Drug treatment is aimed at preventing complications during the treatment period. Antibacterial drugs are prescribed for open fractures, drugs that improve the rheological properties of blood and tissue microcirculation, antihistamines, immunostimulants, and drugs that optimize osteogenesis.

▲ Physical therapies are used to
improve tissue trophism and prevent complications
ny.

▲ Timely resolution of the issue of therapeutic measures in relation to the tooth located in the fracture gap.

5.1. CONSERVATIVE METHODS OF IMMOBILIZATION

There are temporary ones, which include transport, medical (permanent) conservative methods of immobilization.

Temporary (transport) methods are divided into extra-oral (bandage, chin sling, etc.) and intra-oral (intermaxillary ligature fastening, splints with "whiskers", etc.).

Therapeutic (permanent) methods of immobilization are divided into surgical, non-laboratory (tooth standard and individual bent wire) splints and orthopedic (dentogingival, gingival) splints, devices, etc. of laboratory production.

5.2. TEMPORARY (TRANSPORT) IMMOBILIZATION

Indications for temporary immobilization:

Lack of conditions for the implementation of therapeutic immobility
lysis;

Lack of specialized personnel capable of performing
thread therapeutic immobilization;

Lack of time for therapeutic immobilization
zation. This is usually observed during the period of hostilities.
or other emergencies (earthquake,
rii with a large number of victims, etc.), when it is celebrated
a large flow of victims;

Severe general somatic condition (traumatic
shock, coma, intracranial hematoma, etc.), which is
as a temporary relative contraindication to pro
therapeutic immobilization.

Transport immobilization is indicated if it is necessary to transport a patient with a jaw fracture to a specialized institution.

Temporary immobilization is usually maintained for 1-3 days (the maximum time required to transport victims to a specialized institution or call a specialist), since it cannot be used to achieve the desired

buoyant immobility of fragments. Sometimes this period may be extended due to the severe general condition of the patient, in which therapeutic immobilization is temporarily contraindicated.

This assistance in most cases can be provided by junior or middle medical personnel, as well as in the form of self- and mutual assistance. Its principle is to fix the jaws with a bandage to the cranial vault for a certain time. Some types of temporary immobilization are performed only specialists(for example, intermaxillary ligature fastening).

5.2.1. Extraoral methods of temporary immobilization

A simple bandage (or kerchief) parieto-chin bandage. It is applied for fractures of the upper and lower jaws. In this case, a wide gauze bandage is used, the circular tours of which pass through the chin and parietal bones, bypassing the auricles alternately in front and behind. You can use a mesh sleeve, scarf or scarf for this purpose, but this is much worse, as it does not provide the necessary rigidity. An elastic bandage is also used, applying it without tension. Unlike a gauze bandage, it does not stretch after 1-2 hours and does not weaken the bandages. A simple bandage bandage is loosely held on the head and often slides on its own onto the forehead or back of the head.

Hippocratic chin bandage, on the contrary, it is very securely fixed on the head and does not require correction for several days. It is used for fractures of the upper and lower jaws. One or two horizontal rounds are made with a gauze bandage around the head in the fronto-occipital plane, always below the occiput. On the back of the neck, the tour passes to the chin, after which several vertical tours are applied without much pressure in the parietal-mental plane, bypassing the auricles in front and behind alternately. Further along the back surface of the neck, the next tour is transferred to the head and two more horizontal tours are applied in the fronto-occipital plane. The first horizontal tours in the fronto-occipital plane create a rough surface for the vertical tours, and the last tours fix the vertical tours, preventing them from slipping (Fig. 5.1).

This bandage can last a week. It is best to fix the end of the last round with adhesive tape, but you can tear the bandage along and tie the ends on the forehead so that the knot does not press when laying the head on the pillow.

Fig.5.1. Parieto-chin bandage according to Hippocrates.

Note: The bandage applied for a fracture of the lower jaw should not be tight, as in this case it can contribute to the displacement of fragments, difficulty breathing and even asphyxia. Therefore, the bandage for the lower jaw should only be supportive.

In case of a fracture of the upper jaw, a tight bandage is applied, which prevents additional trauma to the brain and its membranes and helps to reduce liquorrhea.

Standard soft chin sling Pomerantseva-Urbanskaya. It is used for fractures of the upper and lower jaws. The sling consists of a fabric chin pad, to which wide elastic bands are sewn on both sides, turning into fabric ribbons with holes for a lace. The cord connects the ends of the sling and serves to regulate its length in accordance with the size of the patient's head (Fig. 5.2). The bandage is simple and comfortable and can be reused after washing.

Standard bandage for transport immobilization- hard chin sling, used for fractures of the lower and upper jaws. It consists of a standard dimensionless cap (bandage) and a rigid chin sling with tongue-like protrusions and slots used to fix the rubber rings and the tongue of the victim, and

Fig.5.2. Standard soft chin sling Pomerantseva-Urbanskaya.

a special pocket located in the parietal part of the cap. The sling is filled with a cotton-gauze insert made of hygroscopic material, protruding beyond the sling, and placed under the broken lower jaw. Rubber rings are put on the tongue-like protrusions of the sling and slightly press the teeth of the lower jaw to the teeth of the upper jaw, fixing the fragments.

In order to avoid displacement of fragments of the lower jaw and create a threat of asphyxia, soft and hard slings should only keep fragments of the jaw from further displacement during transportation.

With established fractures of the upper jaw, the traction of the elastic elements should be increased in order to move the jaw upward.

also for the outflow of wound contents. The cap has loops for fixing long rubber rings made from rubber tubes.

To prevent squeezing the soft tissues of the face, cotton rolls are inserted into the pockets under the loops (Fig. 5.3).

The cap is put on the head and, with the help of ribbons, the length of its circumference is adjusted to the size of the head by pulling them up and then tying them in a knot on the forehead of the victim.

If the cap is large in depth, then put cotton wool in

Fig.5.3. Standard bandage for transport immobilization (hard chin sling).

174

5.2.2. Intraoral methods of temporary (transport) immobilization

Standard transport splint for immobilization of the upper jaw consists of a standard cap and a standard metal spoon splint with extraoral rods ("whiskers") firmly welded to the splint splint. The cap is fixed on the patient's head as described above.

The splint-spoon is filled with iodoform gauze, inserted into the mouth of the victim and applied to the teeth of the upper jaw. Extra-oral rods are placed outside along the cheeks. For them, with the help of rubber rings or ribbons, the upper jaw is fixed to a standard cap. The extraoral rods significantly limit the movements of his head, the splint is not firmly fixed and displaced, which in turn can lead to displacement of the jaw fragments. Currently, this method is used extremely rarely - only when it is impossible to use other methods.

Intermaxillary ligature fastening- the most commonly used type of temporary immobilization of jaw fragments. This bond required by any dentist. Wire ligatures used for temporary immobilization should be soft and strong, easy to bend and not break with repeated bending, not oxidize, and be relatively inexpensive. This requirement is best met by bronze-aluminum wire with a diameter of 0.5-0.6 mm and stainless steel wire with a diameter of 0.4-0.5 mm. If it is not soft enough, it should be ignited and cooled slowly before use. Use pieces of wire 8-10 cm long.

To apply the intermaxillary ligature fastening, a set of the following tools is required: crampon forceps, hemostatic forceps without teeth such as Billroth or Pean, however, you can also use a Kocher clamp, scissors for cutting metal wire, anatomical tweezers.

The indications for the imposition of intermaxillary ligature fastening are the prevention of displacement of the reduced fragments and the elimination of intrawound injury during the transportation of the victim or during his examination, until the moment of therapeutic immobilization. Usually this period is no more than 1-3 days.

When applying intermaxillary ligature bonding, it is necessary to follow the general rules:

Movable teeth and teeth in the fracture gap
do not use for intermaxillary ligature fastening
nia;

use for this pair of stable antagonists

Twist the ends of the wire only clockwise
ke.

Developed big number methods of intermaxillary ligature fastening of fragments of the jaws. Some of them are currently only of historical or educational interest. Thus, the intermaxillary ligature fastening according to Silverman (the simplest) is easy to manufacture, but has a number of disadvantages: after twisting the ligatures, large wire balls and several thick wire “pigtails” are formed in the vestibule of the mouth, which injure the mucous membrane of the gums, cheeks and lips. In addition, in case of urgent need to open the patient's mouth (vomiting, coughing with copious sputum, etc.), it is rather difficult to cut the wire "pigtails" consisting of 8 wire ends.

After opening the mouth, the entire procedure for restoring the intermaxillary ligature fastening has to be repeated from the very beginning.

The intermaxillary ligature fastening according to Geikin is inconvenient in that it requires the use of lead pellets with holes, which, on the one hand, are absent in medical institutions, and on the other hand, are not environmentally friendly for

person.

In this paper, we present the most commonly used methods that we recommend to practitioners.

One such method is the Ivey method, described by him in 1922.

Intermaxillary ligature fastening according to Ivy is the most effective among other methods of intermaxillary ligature bonding. For the manufacture of this bond, two pairs of antagonist teeth are used on both sides of the fracture line. Crampon tongs take a piece of bronze-aluminum wire 10 cm long, fold it in the form of a "hairpin" so that one end is 1 - 1.5 cm longer than the other. Having changed the ends of the wire in places, they are twisted by turning 360 °. Thus, a loop with a diameter of about 2 mm is formed at the end of the “hairpin”. The ends of the wire are brought together and introduced from the vestibule of the mouth into the oral cavity through the interdental space of the selected pair of teeth, while the loop is located vestibularly in the interdental space. The long end of the wire is removed from the oral cavity into the vestibule through the distal interdental space, and the short end through the medial one, bending around the necks of adjacent teeth. The distal (long) end of the wire is passed through the loop and twisted with the short end. Cut off the end of the wire, leaving a tip 0.5 cm long, which is bent to the teeth. A similar bandage is applied to the antagonist teeth and to the teeth of the second fragment.

Further, if possible, the fragments are repositioned and immobilized, passing the third piece of wire through the antagonizing upper and lower loops, the ends of which are then twisted (Fig. 5.4). If it is necessary to open the patient's mouth, it is enough to cut 2 vertical wire ligatures passed through the loops. In this case, the main load-bearing structural elements (tooth wire loops) are not destroyed. To restore the intermaxillary fastening, it is enough to reinsert the wire ligatures into the loops and twist their ends.

The Ivy method is easy to manufacture, more elegant, functional and convenient than other methods; when it is used, coarse coils of wire are not formed in the vestibule of the mouth. It can be used in all cases of jaw fractures described above.

Intermaxillary ligature fastening according to Kazanyan less elegant and convenient compared to the Ivy method. Manufacturing technique: around two adjacent teeth of one fragment, a figure-eight ligature is carried out and its two ends are twisted in front of the mouth. The same manipulation is carried out on the antagonist teeth and on the teeth of another fragment. The free ends are twisted and cut off. Thus, the resulting "pigtail" consists of 4 ends of the wire (Fig. 5.5).

Fig.5.4. Intermaxillary ligature fastening according to Ivy.

Fig.5.5. Intermaxillary ligature fastening according to Kazanyan.

Fig.5.6. Intermaxillary ligature fastening according to Gotsko.

In case of a fracture of the upper jaw, the intermaxillary ligature fastening is supplemented by the imposition of a chin sling to prevent it from moving down when the lower jaw is lowered.

The disadvantages of the method are the presence of a thick wire “pigtail” in the vestibule of the mouth, which can injure the mucous membrane of the cheeks and lips, as well as the need to re-apply ligatures from the very beginning if they break during unwinding for examination and treatment of the oral cavity or after emergency cutting of ligatures in case of nausea or coughing with copious sputum.

Intermaxillary ligature fastening according to Gotsko. As a ligature, a polyamide thread is used, which is passed around the neck of the tooth and tied in a knot on the vestibular surface. Further, both ends of the thread are led through the interdental gap of the antagonist teeth into the oral cavity, then each end is brought out into the vestibule of the mouth (distal and medial), pulled up and tied together with a knot, immobilizing. The method is less traumatic, elegant and quite effective (Fig. 5.6).

5.3. REPOSITION AND PERMANENT (CURRENT) IMMOBILIZATION OF JAW FRAGMENTS WITH THE HELP OF NON-LABORATORY BRACES

5.3.1. Tooth individual wire splints

Tigerstedt tires. For more than 80 years, bent wire dental splints have been successfully used, developed back in the period of the First World War by a dentist in Kiev

Military hospital S.S. Tigerstedt (1915). They proposed a large number of different tire designs: a simple brace (now called a smooth brace tire), a support brace (a tire with hook loops), a retention brace (a tire with a spacer bend), various options for brackets with planes, tires with inclined planes and hinges , with levers of various principles of action for moving fragments in chronic fractures, fixation seals, anchor brackets, etc. As the author himself pointed out, his system allowed “...quickly, without casts, without models, without rings, nuts and screws, without soldering and stamping, without vulcanizing do whatever it takes."

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 trauma, simplicity, high efficiency and low cost of the materials used.

Over time, in the process of clinical selection, the following bent wire splints have been preserved and successfully used: a smooth brace splint, a splint with a spacer bend, a splint with toe loops and very rarely a splint with inclined plane.

The following materials are required 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 cooled slowly); 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: crampon forceps, anatomical tweezers, Billroth hemostatic forceps (without teeth) or Kocher (with teeth), dental scissors for cutting metal, file. General rules when applying tooth splints:

Subcutaneously administer 0.5 ml of a 0.1% solution of atropine for convenience.
work in connection with a decrease in salivation;

Perform local anesthesia, preferably conductive;

Start flexing the splint on the left side of the jaw pain
leg (for left-handers - from the right); some authors reko
it is recommended to start bending the tire from the side of the
ma;

Bend the tire with the fingers of the left hand, holding the wire
loca in right hand crampon tongs (for lion
neck - vice versa);

Crampon tongs should be placed on the border of the wire
(blank) and the curved section of the tire, protecting it
from deformation;

After fitting the splint to the teeth, bend it only outward
mouth cavity;

The manufactured tire must necessarily adhere to each
home tooth at least at one point and located between
gingival margin and equator of the tooth;

Fix the tire to each tooth included in it
ligature wire;

Twist the ligature wire only in the direction
clockwise movement (as agreed by all doctors).
This ensures continuity in tire care,
tightening and loosening the ligature.

Start making a tire by bending a large toe hook or toe spike. When bending the tire, the aluminum wire is fixed with crampon tongs, and it is bent by pressing the wire with your fingers to the cheeks of the tongs to avoid deformation of the part of the tire fitted to the teeth. In the mouth, the tire is tried on, and it is bent outside the patient's mouth. To try on a curved section of the tire, it is applied to the patient's teeth and fixed with the fingers of the right hand in the area of ​​​​the large hook or hook spike, i.e. in the area of ​​the already manufactured tire. This condition is very important. Do not try on the splint by holding it by the section of wire protruding from the mouth, as this leads to incorrect placement of the splint on the teeth. Having made a splint on one half of the jaw, they proceed to bending it on the other half. In this case, the long end of the wire of the workpiece must be bent by 180 °, leaving its piece sufficient to make the second half of the tire.

Smooth busbar can be used to treat a fracture of the lower jaw, provided that the larger fragment has at least 4, and the smaller one has at least 2 stable teeth. In this case, the teeth located in the fracture gap are not taken into account.

Indications for applying a smooth brace:

Unilateral linear fracture of the mandible, race
placed within the dentition, without displacement or
with easily reducible fragments within the frontal
groups of teeth

Fractures of the alveolar part of the lower jaw and alveo
the lar process of the upper jaw;

Fractures and dislocations of teeth, when on both sides
sparse areas of the jaw have stable teeth;

Splinting of teeth in acute odontogenic osteomy
cast jaw and periodontitis;

Fractures of the upper jaw (when using methods
Adams, Dingman, etc.);

For the prevention of a pathological fracture of the lower jaw prior to certain operations (sequestrectomy, cystectomy, cystotomy, resection of part of the jaw, etc.).

Method for bending a smooth bus-bracket. If there is a displacement of the fragments, then before bending the splint it is necessary to ■ match them with your hands or temporarily fix them with a wire ligature for the teeth of the fragments. They take a piece of aluminum wire in the left hand and with the right hand, using kampon forceps, bend the toe hook, putting it on the wisdom tooth (or on any last tooth in the dentition). When making a hook, the wire should be bent at a small angle, each time grabbing new sections of the wire with tongs, successively stepping back from the end by 1-2 mm. The hook should tightly cover the distal and buccal surfaces of the last tooth, reach the middle of the crown of its lingual surface and be located between the equator and the edge of the gum. The lingual end of the hook is sharpened with a file at an angle of 45 ° for a smooth transition of the wire to the tooth surface and to avoid injury to the tongue.

Sometimes, instead of a toe hook, the bending of the tire begins with the manufacture of a toe spike, which enters the interdental space by 2/3 of the width of the tooth crown and does not protrude into the oral cavity, does not injure the interdental papilla.

After manufacturing, the hook is placed on the last tooth and the wire is grasped with forceps at the level of the middle of its crown from the vestibular side. In this case, the long end of the hook (the main part of the wire) will be significantly lowered down and not correspond to the projection of the dental arch (arc, or curve, Spee). The tongs, when applied to the wire, should be horizontal. With kampon tongs, remove the hook from the tooth and with the second finger of the left hand at the cheeks of the tongs, bend the wire up at a small angle. Try on the tire in the mouth, applying it to the teeth. If the angle of flexion was correct, then the wire would be between the equator of several teeth and the gum. If the wire is higher or lower, it must be bent down or up to the appropriate angle.

After making sure that the wire lies in the indicated projection of several teeth, it is grasped with forceps at the last point of contact with the tooth, removed and carefully removed from the mouth so as not to bend. Slightly loosening the fixation of the forceps, turn them on the wire with the handles down by 90 ° and bend the wire I away from you with the finger of your left hand to the next tooth at a small angle. A splint is inserted into the vestibule of the mouth and tried on to the teeth. If it turns out that after bending the wire to the tooth, the correctly curved section of the tire has moved away from the teeth, this is significant.

Fig.5.7. Smooth tire-bracket.

cheat that the wire was bent excessively. For correction, it is necessary to put forceps on the wire at the place of the last bend and bend it slightly away from the tooth, i.e. on yourself, and again try on the tire to the teeth, hooking it on the last tooth with a hook. If the position of the tire is correct, then again, with the cheeks of crampon forceps, they grab the tire at the place of the last touch to the tooth, remove the tire from the vestibule of the mouth and continue to bend in the direction of the occlusal plane until contact with the next tooth.

In a similar way, repeating the manipulations, they sequentially bend the entire tire to the required length and finish bending it at the second fragment with a hook spike, which is inserted into the interdental space (Fig. 5.7). To bend the spike, the wire is grasped with forceps exactly at the level of the back surface of the selected tooth, the splint is removed from the teeth and removed from the mouth. Slightly loosening the fixation of the forceps, turn them on the wire with their handles down by 90 ° and bend the wire I away from you with the finger of your left hand by 90 °. The excess wire is cut off, leaving the end for a spike measuring 3-6 mm. With the help of a file, the spike is processed, giving it the shape of a wedge so that it enters the interdental space. The size of the spike Should correspond to 2/3 of the size of the interdental gap. The spike should be just above the interdental papilla, not injure it and not protrude with a sharp end into the oral cavity.

Try on the finished tire in your mouth. To do this, it is first advisable to insert a spike into the interdental space, and then put the entire splint on the teeth, hooking the hook on the first tooth. A correctly made splint should easily, without effort, be superimposed on the dental arch. It should touch all the teeth at least at one point and be located between the equator of the tooth and the edge of the gum.

The finished tire is tied to each tooth bronze-aluminum-nium wire. To do this, the wire is grasped with tweezers or a clamp, departing from its end by 2-3 cm, and it is inserted from the vestibule of the mouth into the oral cavity through the interdental space. Next, the oral end of the wire is grasped with a clamp and it is brought out through another interdental space in the vestibule of the mouth, surrounding the tooth from the distal, lingual and medial sides. The wire should be below the equator of the tooth. The distal end of the wire is bent up, and the medial end is down. Between these ends (they should be approximately equal in size) a space is formed where the curved tire will subsequently be placed. When passing the wire into the oral cavity, it is necessary to protect the tongue from injury with the wire. To do this, with the second finger of the left hand, the wire is bent to the teeth as it moves into the oral cavity.

Apply in a similar way wire ligatures on all teeth included in the splint. All distal ends are bent up, and the medial ends are bent down. After the ligatures are applied, the tire is fixed. For this, a splint is placed on the teeth by inserting it between the ends of the wire ligatures. The upper and lower ends of the wire ligature of each tooth are twisted clockwise, capturing them with a clamp at a distance of 2-2.5 cm from the vestibular surface of the crown. In order not to confuse the upper end of one ligature with the lower end of the other, they must be shaken before twisting. With this movement of one end in the oral-vestibular direction, the paired end of the same ligature moves synchronously.

Twisted ligatures are cut to a length not exceeding 5 mm, and the ends are bent to the teeth towards the midline on the upper jaw below, on the lower - above the splint. It is necessary to ensure that the ends of the ligatures do not injure the adjacent mucous membrane.

You can fix the splint to your teeth and another way. To do this, the splint is fixed on the teeth with a spike and a hook. The wire ligature is bent in the form of a "hairpin" and its ends are inserted from the oral cavity into the medial and distal interdental spaces of the same tooth. In this case, one end of the wire (for example, medial) passes under the tire, and the other (distal) - above the tire. The wire is not twisted

to the end, leaving the tire movable to facilitate subsequent ligatures. Similarly, ligatures are applied to all teeth. However, this method often causes significant difficulties when, as a rule, the upper end of the ligature, which abuts against the inner surface of the tire, is carried out. Twist all ligatures tightly, cut and bend the ends to the teeth, as indicated above.

Before removing the tire, loosen the ligatures and check the lack of mobility of the fragments by shaking them.

The splint is removed after 4-5 weeks. To do this, the ends of the wire ligatures are slightly untwisted with crampon tongs counterclockwise, one or both of them are cut with scissors to cut the metal, and the wire is removed from the interdental space. If the ligature is stuck, it must be slightly shifted towards the gums, pushed into the oral cavity and then removed. The tire is removed from the teeth, the gum is treated with a 3% hydrogen peroxide solution and 1% iodine solution.

After applying a smooth brace, the patient may be advised to wear a soft chin sling to limit mouth opening. The patient needs to take liquid or pureed food. The doctor should regularly examine the patient 2-3 times a week. At the same time, it is necessary to control the state of bite, the strength of fixation of bone fragments with a splint, the state of tissues in the area of ​​the fracture (the presence or absence of inflammation), the state of the teeth in the fracture gap. When loosening the tire on the teeth, it is necessary to tighten the ligatures, twisting them clockwise. If at the same time the ligature bursts, it is replaced with a new one.

Of particular importance is the condition of the oral cavity. The patient must be taught hygiene measures to prevent gingivitis. To this end, he should brush his teeth and the splint with toothpaste and brush 2 times a day (morning and evening), remove food debris with a toothpick after each meal, and rinse his mouth with antiseptic solutions 3-5 times a day.

Tactics of the doctor in the presence of teeth located in the fracture gap. Teeth, or rather their roots, located in the fracture gap, are the cause of the inflammatory process in the bone wound or traumatic osteomyelitis. Until now, there is no consensus among specialists about medical tactics in relation to these teeth. Some believe that early extraction of teeth in the fracture gap is a guarantee and prevention of various complications. So, N.M. Mikhelson (1956) pointed out that if immobilization is not carried out in the first hours or days after injury, then the only prevention of the development of traumatic osteomyelitis is tooth extraction

Let's consider some aspects of this issue.

Supporters early tooth extraction from the gap of the fracture, they mistakenly see only in it the main cause of traumatic osteomyelitis. Experimental studies on animals [Shvyrkov M.B., 1987] using biochemical, morphological and radioisotope methods, contrast microangiography and determination of the mental status of the patient showed that the cause of all complications, including traumatic osteomyelitis, lies much deeper and is programmed on the genetic level (see Chapter 8 for more on this).

A tooth located in the fracture gap, of course, is a conductor of microorganisms to the bone wound. However, not every wound, when infected, suppurates. This is often forgotten and it is believed that without adequate therapy, the consolidation of fragments can be complicated by traumatic osteomyelitis. However, this complication does not occur in a number of patients, although the reasons for this phenomenon have not yet been studied enough.

There may be one or two teeth in the fracture gap. In this case, various options are noted: the fracture line can pass through the entire periodontium or part of it, it is possible to expose only the apical part of the tooth in the fracture gap, sometimes a root fracture is detected in its various sections or in the area of ​​bifurcation. The tooth in the fracture gap may be on larger or smaller fragments. It is not possible to speak about the viability of the pulp of such teeth in the early period of injury, since their electrical excitability, determined by EDI, always decreases significantly and recovers no earlier than 10-14 days from the moment of injury, and sometimes later. Therefore, dynamic EDI is shown to address the issue of pulp viability.

Some authors believe that if, along with high numbers of EDI, there is paresthesia of the lower lip and chin, then dynamic EDI is not required. It is enough to control the pain or tactile sensitivity of the lips.

Clinical practice shows that teeth with a bare root, even with a live pulp or filled ones, slow down the process of consolidation of fragments, since bone beams grow from only one fragment and do not fuse with the root of the tooth. In this case, there is a direct indication for the early removal of such teeth. The proof of the correctness of this statement is the presence of mobility of fragments after the usual time required for consolidation, i.e. after 4-5 weeks.

Teeth in a fracture gap with periapical chronic lesions are always potentially dangerous due to the possibility of inflammatory complications, so the early removal of such teeth is highly advisable.

Teeth located in the fracture gap require special attention. on the distal fragment, and above all the wisdom tooth. These teeth, when using conservative methods of immobilization, are of great importance in preventing the upward movement of the loose distal fragment. It should be especially noted that an attempt to remove such a tooth on a small fragment in the first 1-3 days after the fracture is always associated with significant difficulties, since it is impossible to firmly hold the fragment by hand when the tooth is dislocated with forceps. In this case, the ends of the fragments rub against each other, which is unacceptable. Additional injury to the inferior alveolar nerve can sometimes lead to its crushing and (or) rupture. Possible damage to the ligamentous apparatus of the temporomandibular joint and even its dislocation. To prevent a purulent inflammatory process in the fracture area, antibiotic therapy is prescribed for 8-10 days.

After 12-14 days, after the formation of primary callus and subsidence of acute inflammation caused by trauma, such teeth can be removed with less difficulty due to the development of chronic periodontitis, accompanied by a decrease in the strength of edematous collagen ligaments of the tooth (collagen fibers swell in an acidic environment and lose strength), and resorption of the walls of the hole. But even in this case, a strong fixation of a small fragment is required, since there is a danger of not only damaging the lower alveolar nerve, but also destroying the fragile newly formed primary callus.

Thus, the doctor's tactics in relation to the teeth in the fracture gap are varied and depend on many reasons that must be taken into account in practical work.

Tire With spacer bend. Indications for use:

Fracture of the lower jaw within the dentition with de
defect of bone tissue no more than 4-5 cm;

(jcomments on)Treatment of victims with jaw fractures consists of repositioning and immobilization of jaw fragments, as well as drug treatment and physiotherapy.
Reposition involves matching or moving the bone fragments of the facial skeleton to the correct position. If it is not possible to match the displaced fragments at once, they are repositioned gradually, over several days, using elastic traction.
Immobilization means fixing the fragments in the correct position for the period necessary for their fusion (consolidation), i.e. before the formation of bone marrow. On average, this period is 4-5 weeks for an uncomplicated course of healing of a fracture of the upper jaw and a unilateral fracture of the lower jaw. With the immobilization time can increase up to 5-6 weeks.
Medical and physiotherapy it is necessary to prevent the development of complications during the period of fragment consolidation (antibacterial, anti-inflammatory, antihistamines; drugs that improve the rheological properties of blood and tissue microcirculation, immunostimulants, drugs that optimize osteogenesis).
In addition, the issue of the advisability of preserving the teeth in the fracture gap and the need for therapeutic measures in relation to these teeth is necessarily resolved.

Types of conservative methods of immobilization of jaw fragments

There are temporary methods of immobilization (including transport) and permanent (therapeutic).
Temporary methods of fixing fragments of the jaws are divided into:
- extraoral (bandage, chin sling, impromptu bandages using improvised means);
- intraoral (methods of intermaxillary ligature fastening, different in design of the splint-spoon with a "mustache").
Permanent (therapeutic) methods of immobilization are divided into:
- non-laboratory splints (individual splints made of metal or other material, standard splints);
- laboratory-made tires (Weber's dental splint, simple or with an inclined plane, Vankevich and Vankevich-Stepanov's tires, various dental kappa devices, Port's supragingival splint).

Temporary (transport) immobilization

Indications for the imposition of temporary (transport) immobilization:
- lack of conditions for the implementation of permanent (therapeutic) immobilization and the need to transport the victim to a specialized medical facility;
- lack of specialized personnel who are able to carry out permanent immobilization;
- lack of time required for permanent (therapeutic) immobilization. This usually happens during the period of hostilities or during other emergency situations(earthquake, accidents with a large number of victims, etc.), when there is a large flow of victims and injured with trauma at the same time;
- severe general somatic condition (traumatic shock, coma, intracranial hematoma, etc.), which is a temporary relative contraindication for therapeutic immobilization.
Temporary immobilization is imposed for a period of not more than 3-4 days (the maximum time required to transport the victims to a specialized institution or call a specialist to the patient), since it cannot be used to achieve the required long-term immobility of fragments. In exceptional cases, this period is extended due to the severe general condition of the patient, in which therapeutic immobilization is temporarily contraindicated.
Temporary immobilization can be performed both outside the medical institution and in a specialized clinic. If it is superimposed on the time of transportation of the victim to a medical facility, then it is called "transport". Usually, temporary immobilization is imposed by junior or middle medical staff, as well as in the form of self- or mutual assistance. Some methods are performed only by specialists (intermaxillary ligature bonding).

Extraoral methods of temporary (transport) immobilization.

- Simple bandage parieto-chin bandage. It is applied for fractures of the upper and lower jaw. A wide gauze bandage is used, the circular tours of which are carried out through the chin and parietal bones. You can use improvised material: a scarf, scarf, etc., which is less convenient. A simple bandage bandage is not firmly held on the head, and it must be touched up often.
- securely fixed on the head and does not require correction. It is used for fractures of the upper and lower jaws.

Apply to the lower jaw. It consists of a chin sling, to which wide elastic bands are sewn on both sides, turning into fabric ribbons with holes for a lace. The sling is convenient and versatile, but is not used for fractures of edentulous jaws and the absence of dentures.

(hard chin sling) for fractures of the lower and upper jaws. This bandage consists of a standard dimensionless cap and a rigid chin sling with slots and protrusions used to fix the rubber rings and the tongue of the victim, as well as to drain the wound contents. Intraoral methods of temporary (transport) immobilization.

- Standard transport splint for immobilization of the upper jaw. It consists of a standard cap and a standard metal splint-spoon with extraoral rods ("whiskers") firmly fixed to the splint-spoon.
- Intermaxillary ligature fastening. Most often used in clinical practice. For immobilization, wire ligatures are used, which should be easy to bend, not oxidize, and be inexpensive. This requirement is met by a bronze-aluminum wire with a diameter of 0.5-0.6 mm.
For the imposition of intermaxillary ligature fastening, pieces of bronze-aluminum wire 7-10 cm long and instruments (crampon forceps, billroth-type hemostatic clamps, scissors for cutting metal wire, anatomical tweezers) are taken.
Indications for the imposition of intermaxillary ligature fastening is to prevent displacement of fragments and eliminate intra-wound injury during the transportation of the victim and during his examination, until the moment of therapeutic immobilization.
General rules observed when applying intermaxillary ligature fastening: immobilization is carried out under local anesthesia, tartar is first removed, mobile teeth and teeth located in the fracture gap are not used for intermaxillary ligature fastening, stable antagonist teeth are used, wire ligatures are twisted clockwise.
There are a large number of different ways of intermaxillary ligature fastening of fragments of the jaws.

Methods of intermaxillary ligature fastening.

- Silverman. A bronze-aluminum ligature is drawn around each of the two adjacent teeth and twisted, then the ends of these two ligatures are also twisted. The same is done in the area of ​​antagonist teeth. The upper wire flagellum is twisted with the lower one, and the end is cut off. Advantages: ease of manufacture. Disadvantages: after twisting the ligatures in the vestibule of the mouth, thick wire flagella are formed that injure the mucous membrane; if necessary, open the patient's mouth and cut the thick wire flagella, which is quite difficult. After examining the oral cavity, the design has to be redone.

The most commonly used in clinical practice, as a rule, in all cases of jaw fractures. In case of a fracture of the upper jaw, the intermaxillary ligature fastening is supplemented by the imposition of a chin sling to prevent its downward displacement during involuntary lowering of the lower jaw. Advantages: simplicity and efficiency, the ability to quickly open the mouth if necessary, without violating the integrity of the structure. Intermaxillary ligature fastening according to Kazanyan is less convenient compared to the Ivy method. The technique differs in that a ligature in the form of a "figure eight" is carried out around the adjacent teeth of one fragment and its two ends are twisted in the vestibule of the mouth. The same manipulation is carried out on the antagonist teeth and on the teeth of another fragment. The free ends are twisted and cut off. Thus, the common end of the wire (flagellum) consists of four ends. The disadvantages of the method are the presence of a thick wire tourniquet in the vestibule of the mouth, which can injure the mucous membrane, as well as the need to reapply ligatures in case of breakage or after emergency cutting of ligatures.

- Intermaxillary ligature fastening according to Gotsko.

A polyamide thread is used as a ligature. It is carried out around the neck of the tooth and tied in a knot on its vestibular surface. Further, both ends of the thread are passed through the interdental space of the antagonists from the vestibule - into the oral cavity, then each end is removed from the cavity to the vestibule of the mouth (distal and medial), pulled up and tied together with a knot, immobilizing. Advantage: low trauma, high efficiency.

Therapeutic (permanent) immobilization with non-laboratory splints

Teeth individual wire splints Tigerstedt. Types of Tigerstedt tires:
- smooth bus-bracket;
- bus-bracket with spacer bend;
- tire with hook loops.

Tires are made of aluminum wire d = 1.8-2.0 mm and 12-15 cm long. They are tied to the teeth with the help of bronze-aluminum wire d = 0.5-0.6 mm. The tire is bent individually for each patient using kampon forceps. General rules for applying dental splints. 0.5 ml of a 0.1% solution of atropine is injected subcutaneously to reduce salivation, splinting is carried out under local anesthesia, it is necessary to remove tartar for free passage of the ligature into the interdental space, bend the splint from the side of the fracture, try it on the teeth in the mouth, and bend it outside the oral cavity, the tire should be adjacent to the neck of each tooth at least at one point, the tire is tied to each tooth with a ligature wire, which is twisted clockwise.
Splint making begins by bending a large toe hook that wraps around the first tooth, or a toe spike inserted into the interdental space. To try on a tire, it is applied to the teeth in the mouth.

It is used to treat fractures of the lower jaw, provided that the larger fragment contains at least four, and the smaller one contains at least two stable teeth.

Indications for use: linear fractures of the lower jaw, located within the dentition, without displacement or with easily reducible fragments, fractures of the alveolar process, fractures and dislocations of teeth, tooth mobility in acute odontogenic osteomyelitis and periodontitis, fractures of the upper jaw (Adams and Dingman methods), to prevent pathological mandibular fracture.
After treatment, before removing the splint, the ligatures are loosened and the absence of fragment mobility is checked by shaking them. The splint is removed after 4-5 weeks. The patient needs to take liquid food. The doctor should regularly examine the patient 2-3 times a week. At the same time, it is necessary to control the state of bite, the strength of fixation of fragments, the state of tissues and teeth in the fracture gap. When the fixation of the splint on the teeth is weakened, it is necessary to tighten the ligatures by twisting them. If at the same time the ligature bursts, it is replaced with a new one.
The patient is taught hygiene measures to prevent the development of gingivitis. To this end, the patient should brush the teeth and the splint with toothpaste and brush 2 times a day, remove food debris with a toothpick after each meal, and rinse the mouth with antiseptic solutions 3-5 times a day.

The spacer bend prevents lateral displacement of fragments.

Indications for use: fracture of the lower jaw within the dentition and the presence of a bone defect of no more than 2-4 cm, fracture of the lower jaw without displacement or with easily reducible fragments, if the fracture gap passes through the alveolar part, devoid of teeth.

The tire is used most often to treat fractures of the jaws. Two splints are made with hook loops for the teeth of the upper and lower jaws.

Indications for use: fractures of the lower jaw outside the dentition, within the dentition - in the absence of four on a larger fragment, on a smaller one - two stable teeth, fractures of the lower jaw with difficult-to-reset fragments that require traction, bilateral, double and multiple fractures of the lower jaw, fracture of the upper jaw (with the obligatory use of a chin sling), simultaneous fractures of the upper and lower jaws.
During the manufacture of the tire, its toe loop should be at an angle of 45 ° with respect to the gum. Toe loops are bent on the tire so that they are located in the area of ​​the 6th, 4th and 2nd teeth. If the patient does not have these teeth, then toe loops are made in the area of ​​other teeth that have antagonists. Usually, 3-4 toe loops are bent on the splint adjacent to the teeth of the larger fragment, and 2-3 toe loops of the smaller one. The base of the loop must be within the crown of the tooth.
If the displacement of fragments is large and it is difficult to bend one splint on both fragments, splints can be made and fixed on each of the fragments. After their reposition, rubber rings are put on the toe loops at an angle so that they create compression of the fragments, which significantly prevents their movement.
Periodically (2-3 times a week), the patient is examined, ligatures are tightened, rubber rings are changed, the vestibule of the mouth is treated with antiseptic solutions, and the bite is monitored.
10-25 days after the splint is applied, an X-ray examination is performed to control the position of the fragments.
After the fusion of fragments, before removing the splints, it is necessary to remove the rubber rings and let the patient walk for 1-2 days without fixation, taking soft food. If the fragments are not displaced, the tires are removed. If there is a slight change in bite, then the rubber traction is retained for another 10-15 days.

Splinting according to the method of A.P. Vikhrova and M.A. Slepchenko.

The authors proposed to use a polyamide thread to reinforce the attachment of the splint to the teeth. To do this, take a bronze-aluminum wire ligature, fold it in the form of a hairpin and insert both ends of it into one interdental space from the mouth towards the vestibule of the mouth. The ligature is tightened so that a small loop is formed on the lingual surface of the interdental spaces. Do a similar procedure in the area of ​​all interdental spaces. They take a polyamide thread with a diameter of 1 mm and pass it through all the loops on the lingual side, the ends of the thread are brought out in the vestibule of the mouth behind the last teeth on both sides. Next, a previously made splint is placed on the teeth so that it is located between the two ends of the same bronze-aluminum ligatures, which were then twisted. According to the authors, the advantages of their method are as follows: a stronger bonding of fragments, a reduction in the time of fixing the splint, and the absence of trauma to the gingival mucosa.

Tooth standard splints.

Good manual skills are required to make custom wire splints. Their production requires a lot of time and frequent fitting to the dental arch. It is especially difficult to bend them in case of bite anomalies, teeth dystopia, etc. Considering the above, standard splints were proposed, which are manufactured in the factory, do not need to bend the toe loops and simplify splinting.
In Russia, standard band tires were proposed by V.S. Vasiliev. The bar is made of a thin flat metal band 2.3 mm wide and 134 mm long, which has 14 hook loops. The tire easily bends in the horizontal plane, but does not bend in the vertical plane. The Vasiliev tire is cut to the required size, bent along the dental arch so that it touches each tooth at least at one point, and is tied to the teeth with a ligature wire. The advantage of the tire in the speed of its imposition. The disadvantage is the impossibility of its bending in the vertical plane, which does not allow to avoid injury to the mucous membrane in the lateral parts of the jaws due to the discrepancy between the spear curve and the Spee curve. For single-jaw splinting, this tire is not suitable due to its low strength.
Abroad, there are various designs of standard tires made of steel wire (Winter tires) and polyamide materials that can be bent in any plane. Tires are produced with pre-made toe hooks.

Therapeutic immobilization of jaw fragments using laboratory splints

Laboratory-made splints are classified as orthopedic immobilization methods. They perform both an independent function of immobilization, and can be an additional device for various surgical methods of fastening fragments.
Removable orthopedic structures include dentogingival splints (a simple or inclined plane Weber dentogingival splint, Vankevich splint, Vankevich-Stepanov splint) and a Porta supragingival splint.
Non-removable orthopedic structures include mouth guard splints with fixing elements of various modifications.
Indications for the use of laboratory-made tires:
- severe damage to the jaws with significant defects in bone tissue, in which jaw bone grafting is not performed;
- the presence of concomitant diseases in the victim ( diabetes, stroke, etc.), in which the use of surgical methods of immobilization is contraindicated;
- refusal of the patient from the operational fixation of fragments;
- the need for additional fixation of fragments simultaneously with the use of wire tires.
For the manufacture of laboratory splints, conditions are necessary: ​​a dental laboratory, special materials. Dental work is carried out by dental technicians.

Weber's simple dentogingival splint.

It can be used alone or as one of the main elements when using the surrounding suture method for mandibular fractures. The Weber splint is used for significant mandibular defects as a result of traumatic osteomyelitis or after mandibular resection operations for a tumor. In these cases, prolonged wearing of the splint (within 2-3 months) can lead to the elimination of a pronounced lateral displacement of the lower jaw after the removal of the splint. Weber's splint is prepared in a laboratory way, having previously taken casts from fragments of the jaws. To prevent lateral displacement of fragments, an inclined plane is made on it in the region of the molars. It is possible to make a splint directly in the patient's mouth from quick-hardening plastic.

Tire Vankevich and Tire Vankevich-Stepanova.

They are tooth-supported splints supported by alveolar ridge upper jaw and hard palate. It has two downward-facing inclined planes in the lateral sections, which abut against the anterior edges of the branches or into the alveolar part of the lateral sections of the body of the lower jaw, mainly from the lingual side and do not allow the fragments of the lower jaw to move forward, up and inward.
The Vankevich splint is used to fix and prevent lateral and rotational displacement of fragments of the lower jaw, especially with significant defects, due to the emphasis of inclined planes on the front edges of the jaw branches.
Tire Vankevich in Stepanov's modification differs in that instead of the maxillary base there is a metal arc, like a clasp prosthesis.
The Porta bus is used in case of a fracture of the edentulous lower jaw without displacement of fragments and the absence of removable dentures and teeth in the upper jaw in the patient.
The splint consists of two base plates for each jaw in the form of complete removable dentures, rigidly connected to each other in the position of central occlusion. There is a hole in the front section of the tire for eating. The Porta splint is used in combination with wearing a chin sling bandage.

Mouth guards with fixing elements.

It is used to immobilize fragments of the lower jaw in the presence of a defect in the bone tissue within the dentition, when there is a sufficient number of stable supporting teeth on the fragments. These splints consist of metal caps fitted to the teeth of the lower jaw. The caps are soldered together and fixed on the teeth of each fragment. With the help of various locks (pins, levers, etc.), after their reposition, the fragments are fixed for the period necessary for consolidation. The teeth used for splinting are not prepared.

Doctor's tactics in relation to the teeth located in the fracture gap.

The roots of the teeth located in the fracture gap are the cause of the development of the inflammatory process. Until now, there is no consensus among specialists about medical tactics in relation to these teeth. Some believe that early extraction of teeth in the fracture gap is the basis for preventing the development of various complications. Others believe that these teeth must be preserved.
Proponents of early tooth extraction from the fracture gap see only in it the cause of traumatic osteomyelitis.
Experimental studies (Shvyrkov M.B., 1987) showed that the cause of complications, including traumatic osteomyelitis, is programmed at the genetic level.
The tooth in the fracture gap is a conductor of microorganisms to the bone wound. However, not every wound, being infected, suppurates, therefore, it is believed that if adequate therapy is not carried out, the consolidation of fragments can be complicated by the development of traumatic osteomyelitis. This complication does not occur in some patients, but the reasons for this phenomenon have not yet been studied enough.
The fracture gap can pass through the entire periodontium or part of it, only the apical part of the tooth may be exposed, sometimes there is a root fracture in its various sections or in the area of ​​bifurcation. The tooth in the fracture gap may be on a larger or smaller fragment. It is not possible to speak reliably in the early post-traumatic period about the viability of the pulp of such teeth, since their sensitivity, determined by EDI, always decreases and recovers no earlier than 10-14 days from the moment of injury, and sometimes later. Clinical practice shows that teeth with exposed roots slow down the process of consolidation of fragments, since bone trabeculae grow only from one fragment to another and do not fuse with the root of the tooth. In this case, there is an absolute indication for early extraction of teeth.
Teeth in the fracture gap with periapical chronic foci of infection are always potentially dangerous in terms of the development of inflammatory complications, therefore, early extraction of such teeth is indicated.
The molars located on the distal fragment deserve special attention. They, when using conservative methods of immobilization, are important to prevent upward displacement of the loose distal fragment. An attempt to remove such a tooth on a small fragment in the first days after the injury is associated with significant difficulties due to the impossibility of firmly holding this fragment by hand when dislocating the tooth with forceps. Additional trauma to the inferior alveolar nerve or its rupture is possible. Often there is damage to the TMJ or its dislocation. In this case, to prevent a purulent inflammatory process in the fracture area, antibiotic therapy is prescribed for 1-2 weeks. After 12-14 days, after the formation of primary callus, such teeth are removed with less difficulty due to the development of chronic periodontitis, accompanied by a decrease in the strength of periodontal fibers and resorption of the walls of the hole.
Absolute indications (according to most authors) for early tooth extraction from the fracture gap:
- the presence of teeth in the fracture gap with pathological changes(fracture or dislocation of the root, cement exposure, tooth mobility, the presence of granuloma in the periapical tissues);
- a tooth in the fracture gap, which maintains inflammation, despite ongoing drug therapy;
- teeth interfering with comparison of fragments.
In doubtful cases, it is advisable to resolve the issue in favor of removing the tooth from the fracture gap immediately or at the first signs of the development of an inflammatory process in the area of ​​jaw fragments. Leaving the tooth not removed, the doctor takes responsibility for the possible consequences.

A simple bandage (or kerchief) parieto-chin bandage. It is applied for fractures of the upper and lower jaws. For manufacturing, a wide gauze bandage is used, the circular tours of which pass through the chin and parietal bones, bypassing the auricles alternately in front and behind. You can use improvised material for this purpose: a scarf, a scarf, strips of dense matter, which is less convenient. An elastic bandage is also used, which is used without tension. Unlike a gauze bandage, it does not stretch after 1-2 hours and does not weaken the bandages. A simple bandage bandage is not firmly held on the head, often, weakening, slips to the forehead or back of the head and requires constant correction.

The Hippocrates parieto-chin bandage is securely fixed on the head, does not require correction at the time of immobilization. It is used for fractures of the upper and lower jaws. When it is applied, first with a gauze bandage, 1-2 horizontal tours are made around the head in the fronto-occipital plane below the occiput. On the back of the neck, the tour passes to the chin, after which several vertical tours are applied without much pressure in the parieto-chin plane.

sti, bypassing alternately the auricles in front and behind. Further along the back surface of the neck, the next tour is transferred to the head and 2 more horizontal tours are applied in the fronto-occipital plane. The first horizontal tours in the fronto-occipital plane create a rough surface for the vertical tours, and the last tours secure the vertical tours, preventing them from slipping (Fig. 8-1). At the end of the last round, the bandage is fixed with adhesive plaster or tied on the forehead to prevent its pressure on the underlying tissues when the head is laid on the pillow. This Hippocratic bandage must be supportive and not tight in case of a fracture of the lower jaw, otherwise it can lead to displacement of its fragments, difficulty breathing or asphyxia. In case of a fracture of the upper jaw, the bandage should be tight, which prevents additional trauma to the brain and its membranes and will help reduce liquorrhea.

Standard soft chin sling Pomerantseva-Urbanskaya. It is used for fractures of the upper and lower jaws. It consists of a fabric chin sling, to which wide elastic bands are sewn on both sides, turning into fabric ribbons with holes for a lace. The latter connects the ends of the sling and serves to regulate its length in accordance with the size of the patient's head (Fig. 8-2). The Pomerantseva-Urban sling is simple, convenient and can be reused after washing.

Rice. 8-1. Hippocratic chin bandage

Rice. 8-2. Standard Soft Chin Sling Pomerantseva-Urbanskaya

be called. It is not used for fractures of edentulous jaws and the simultaneous absence of dentures.

Standard dressing for transport immobilization (hard chin sling) for fractures of the lower and upper jaws. This dressing for transport immobilization consists of a standard dimensionless cap (bandage) and a rigid chin sling with slots and tongue-like protrusions used to fix the rubber rings and the tongue of the victim, as well as to drain the wound contents (Fig. 8-3). The cap has loops for fixing long rubber rings made from rubber tubes. To prevent squeezing of the soft tissues of the face, cotton rolls are inserted into the pockets under the loops. The cap is put on the head and by tightening the ribbons, the length of its circumference is adjusted to the size of the head, followed by tying them in a knot on the forehead of the victim. If the cap is large in depth, then put cotton wool in a special pocket located in its parietal part. A hard sling is filled with a cotton-gauze insert made of hygroscopic material, protruding beyond the sling, and placed on a broken lower jaw. Rubber rings are put on the tongue-like protrusions of the sling and slightly press the teeth of the lower jaw to the teeth of the upper jaw, fixing the fragments.

In order to avoid displacement of fragments of the lower jaw and create a threat of asphyxia, soft and hard slings should only keep fragments of the jaw from further displacement during transportation. In case of fractures of the upper jaw, the traction of the elastic elements should be increased in order to move the jaw upward.

Treatment of victims with fractures of the jaws consists of:

1. Fragment repositions.

2. Fragment immobilization.

3. Medical treatment and physiotherapy.

Reposition involves matching or moving fragments of bones of the facial skeleton to the correct position when they are displaced. If it is not possible to match the displaced fragments at once, they are repositioned gradually, over several days, using elastic traction.

Immobilization means fixing fragments in the correct position for the period necessary for their fusion (consolidation), that is, until the formation of callus. On average, this period is 4-5 weeks for an uncomplicated course of healing of a fracture of the upper jaw and a unilateral fracture of the lower jaw. With a bilateral fracture of the lower jaw, the immobilization period can increase up to 5-6 weeks.

Reposition, as well as subsequent immobilization of fragments, is carried out under anesthesia (local or general).

Medical and physiotherapy it is necessary to prevent the development of complications during the period of fragment consolidation (antibacterial, anti-inflammatory, antihistamines; drugs that improve the rheological properties of blood and tissue microcirculation, immunostimulants, drugs that optimize osteogenesis).

In addition, the issue of the advisability of keeping the teeth in the fracture gap and the need for therapeutic measures in relation to these teeth is necessarily resolved.

1. Types of conservative methods of immobilization.

Distinguish temporary methods of immobilization (including transport) and permanent(medical).

Temporary Methods for fixing fragments of the jaws are divided into:

- extraoral(bandage, chin sling, impromptu bandages using improvised means),

- intraoral(various methods of intermaxillary ligature fastening, different in design of the splint-spoon with a "mustache").

Permanent(therapeutic) methods of immobilization are divided into: Non-laboratory A-tires(individual splints made of metal or other material, standard splints).

B-tires of laboratory production(Weber's tooth-gingival splint, simple or with an inclined plane, Vankevich and Vankevich-Stepanova tires, various dental kappa devices, Port's gingival splint).

2. Temporary (transport) immobilization.

Indications for the imposition of temporary (transport) immobilization:

The absence of conditions for the implementation of permanent (therapeutic) immobilization and the need to transport the victim to a specialized medical facility,

The lack of specialized personnel who can carry out permanent immobilization,

Lack of time required for permanent (therapeutic) immobilization. This usually happens during the period of hostilities or in other emergency situations (earthquake, accidents with a large number of victims, etc.), when a large flow of victims and wounded with trauma is noted at the same time,

Severe general somatic condition (traumatic shock, coma, intracranial hematoma, etc.), which is a temporary relative contraindication for permanent (therapeutic) methods of immobilization.

Temporary immobilization is imposed for a period of not more than 4 days (the maximum time required to transport the victims to a specialized institution or call a specialist to the patient), since it cannot be used to achieve the required long-term immobility of fragments of a broken jaw. In exceptional cases, this period is extended due to the extremely difficult general condition of the patient, in which permanent (therapeutic) immobilization is temporarily contraindicated.

Temporary immobilization can be performed at any stage of providing assistance to the victim: both outside the medical institution and in a specialized clinic. If it is applied to transport the patient to a medical facility, then it is called "transport". In most cases, temporary immobilization is provided by junior or middle medical personnel, as well as in the form of self- and mutual assistance. Its principle is to fix fragments of the lower jaw to the upper jaw or vice versa using various methods. Some methods are usually performed only by specialists (for example, intermaxillary ligature bonding).

2.1. Extraoral methods of temporary (transport) immobilization.

simple bandage(or scarf) parieto-chin bandage. It is applied for fractures of the upper and lower jaws. For manufacturing, a wide gauze bandage is used, the circular tours of which pass through the chin and parietal bones, bypassing the auricles alternately in front and behind. You can use improvised material for this purpose: a scarf, scarf, strips of dense matter, which is less convenient. An elastic bandage is also used, which is used without tension. Unlike gauze bandage, it does not stretch after 1-2 hours and does not weaken bandages. A simple bandage bandage is not firmly held on the head, often, weakening, slips onto the forehead or back of the head and requires constant correction.

Hippocratic chin bandage is much more securely fixed on the head and does not require correction at the time of immobilization. It is used for fractures of the upper and lower jaws. The method of its application: one or two horizontal tours are made with a gauze bandage around the head in the fronto-occipital plane below the occipital protuberance. On the back of the neck, the tour passes to the chin, after which several vertical tours are applied without much pressure in the parietal-chin plane, bypassing the auricles in front and behind alternately. Further along the back surface of the neck, the next tour is transferred to the head and two more horizontal tours are applied in the fronto-occipital plane. The first horizontal tours in the fronto-occipital plane create a rough surface for the vertical tours, and the last tours fix the vertical tours, preventing them from slipping (Fig. 51). It is better to fix the end of the last round of the bandage with adhesive tape or tie it on the forehead so that the knot does not press on the underlying tissues when laying the head on the pillow. It should be noted that the Hippocratic bandage applied for a fracture of the lower jaw should only be supportive, but not tight, since in this case it can contribute to the displacement of fragments, difficulty breathing or asphyxia. In case of a fracture of the upper jaw, the bandage should be tight, which prevents additional trauma to the brain and its membranes and will help reduce liquorrhea.

Rice. 51. Parietal-chin bandage according to Hippocrates.

Standard soft chin sling Pomerantseva-Urbanskaya. It is used for fractures of the upper and lower jaws. It consists of a fabric chin sling, to which wide elastic bands are sewn on both sides, turning into fabric ribbons with holes for a lace. The latter connects the ends of the sling and serves to regulate its length in accordance with the size of the patient's head (Fig. 52). Sling Pomerantseva - Urbanskaya is simple, convenient, and can be reused after washing. It is not used for fractures of edentulous jaws and the simultaneous absence of dentures.

Standard bandage for transport immobilization(hard chin sling) for fractures of the lower and upper jaws). This bandage for transport immobilization (Fig. 53) consists of a standard dimensionless cap (bandage) and a rigid chin sling with slots and tongue-like protrusions used to fix the rubber rings and the tongue of the victim, as well as to drain the wound contents. The cap has loops for fixing long rubber rings made from rubber tubes. To prevent squeezing of the soft tissues of the face, cotton rolls are inserted into the pockets under the loops. The cap is put on the head and by tightening the ribbons, the length of its circumference is adjusted to the size of the head, followed by tying them in a knot on the forehead of the victim. If the cap is large in depth, then cotton wool is placed in a special pocket located in the parietal part of the cap. A hard sling is filled with a cotton-gauze insert made of hygroscopic material, protruding beyond the sling, and placed on a broken lower jaw. Rubber rings are put on the tongue-like protrusions of the sling and slightly press the teeth of the lower jaw to the teeth of the upper jaw, fixing the fragments.

In order to avoid displacement of fragments of the lower jaw and create a threat of asphyxia, soft and hard slings should only keep fragments of the jaw from further displacement.

Rice. 52. Standard soft chin sling Pomerantseva-Urbanskaya.

Rice. 53. The standard bandage for transport immobilization is a rigid chin sling.

scheniya during transportation. In case of fractures of the upper jaw, the traction of the elastic elements should be increased in order to move the jaw upward.

Chin sling from adhesive tape strips. This method of temporary immobilization is rarely used for mandibular fractures. A wide band of adhesive tape is glued to the skin of the temporal region and carried out in the parotid-masticatory, buccal, chin, and further - in symmetrical areas. The second adhesive tape is passed through the same areas, but with the capture of the submental area. The patch should not be applied to the scalp and may cause skin irritation.

11.2.2. Intraoral methods of temporary (transport) immobilization.

Standard transport splint for immobilization of the upper jaw. It consists of a standard cap and a standard metal splint-spoon with extraoral rods ("whiskers") firmly fixed to the splint-spoon. The cap is fixed on the patient's head (described above). The splint-spoon is filled with iodoform gauze, inserted into the mouth of the victim and applied to the teeth of the upper jaw. Extraoral rods are located outside along the cheeks. For them, with the help of rubber rings, the upper jaw is fixed to the cranial vault. The rods significantly limit the movements of the patient's head, the splint moves and often shifts from the teeth, which leads to displacement of the jaw fragments, therefore, at present, the method is used extremely rarely.

Instead of a standard transport splint-spoon, some authors suggested using a standard wooden board or stick, which was fixed on the teeth of the upper jaw and fixed to the cap (A.A. Limberg et al.). The disadvantages of this method are the same.

Intermaxillary ligature fastening most often used in clinical practice as a temporary immobilization of jaw fragments. This method must be performed by any dentist. For intermaxillary ligature fastening, soft and durable wire ligatures are used, which should be easy to bend and not break with repeated bending, not oxidize and be relatively inexpensive. This requirement is most fully met by aluminum-bronze wire with a diameter of 0.5 - 0.6 mm or stainless steel wire with a cross section of 0.4 - 0.5 mm. If the latter is not soft enough, it is calcined before use.

To apply intermaxillary ligature bonding, you need:

- Materials: pieces of bronze-aluminum wire 7-10 cm long.

- Tools: crampon forceps, hemostatic clamps such as Billroth, Pean, Kocher, scissors for cutting metal wire, anatomical tweezers.

Indications for imposition intermaxillary ligature fastening:

Prevention of displacement of reduced fragments and elimination of intrawound injury during the transportation of the victim, as well as during his examination, until the moment of therapeutic (permanent) immobilization.

General rules, which must be observed when applying intermaxillary ligature fastening:

To carry out local anesthesia, better conduction,

Remove tartar before applying wire ligatures,

Movable teeth and teeth located in the fracture gap are not used for intermaxillary ligature fastening,

As far as possible, use pairs of stable antagonist teeth for intermaxillary ligature fastening,

After wire ligatures are passed through the interdental spaces, their ends are twisted only clockwise (as agreed by all doctors).

There are a large number of different ways of intermaxillary ligature fastening of fragments of the jaws. Some of them are currently only historical or cognitive interest. For example, the intermaxillary ligature fastening according to Silverman (the simplest) is easy to manufacture: a bronze-aluminum ligature is held around each of the two adjacent teeth and twisted, then the ends of these two ligatures are also twisted. The same is done in the area of ​​antagonist teeth. Next, the upper wire flagellum is twisted with the lower flagellum, and the end is cut off. This method has a number of disadvantages: after twisting the ligatures in the vestibule of the mouth, large wire balls are formed that injure the mucous membrane of the gums, cheeks and lips. In addition, in case of urgent need to open the patient's mouth (in the event of vomiting, coughing with copious sputum, etc.), it can be quite difficult to cut the wire flagella, consisting of 8 wire ends. After examining the oral cavity, the entire structure has to be redone.

Intermaxillary ligature fastening according to Geikin inconvenient because it requires the use of lead shots with holes, which, on the one hand, are not available in medical institutions, and on the other hand, are not environmentally friendly for humans.

We present the most commonly used methods of intermaxillary ligature fastening that doctors can use in their work.

Intermaxillary ligature fastening according to the Ivy method(1922) in comparison with other methods of intermaxillary ligature fastening is the best way, as it is easy to manufacture and easy to use (Fig. 54).

Manufacturing method: two pairs of antagonistic teeth are used on both sides of the fracture gap. They take a piece of bronze-aluminum wire 10 cm long, fold it in the form of a lady's "hairpin" so that one end is 1 - 1.5 cm longer than the other. The ends of the wire are twisted in such a way that a loop with a diameter of about 2 mm is formed at the end of the "hairpin". Both ends of the wire are inserted from the vestibule into the oral cavity through the interdental space and pulled up so that the loop is in the interdental space. The long end of the wire is brought back from the oral cavity to the vestibule through the distal interdental space, and the short end through the medial one, bending around the necks of adjacent teeth. The distal (long) end of the wire is passed through the loop and twisted with the short end. Next, the end of the wire is cut off, leaving a tip measuring 0.5 cm, which is bent to the teeth. A similar bandage is applied to the antagonist teeth. The same design is made for the teeth of the second fragment. Next, the fragments are repositioned and immobilized by passing the wire through the upper and lower loops, the ends of which are then twisted. If it is necessary to open the patient's mouth, it is enough to cut 2 vertical wire ligatures passed through the loops. In this case, the tooth wire loops are not cut. To restore the intermaxillary fastening, it is enough to reinsert the wire ligatures into the loops and twist their ends. The method is used in all cases of jaw fractures described above. In case of a fracture of the upper jaw, the intermaxillary ligature fastening is supplemented with the imposition of a chin sling to prevent its downward displacement during involuntary lowering of the lower jaw.

Intermaxillary ligature fastening according to Kazanyan less convenient compared to the Ivy method. Manufacturing technique: around two adjacent teeth of one fragment, a figure-eight ligature is carried out and its two ends are twisted in the vestibule of the mouth. The same manipulation is carried out on the antagonist teeth and on the teeth of another fragment. The free ends are twisted and cut off. Thus, the common end of the wire (flagellum) consists of 4 ends (Fig. 55).

The disadvantages of the method are the presence of a thick wire tourniquet in the vestibule of the mouth, which can injure the mucous membrane of the cheeks and lips, as well as the need to re-apply ligatures if they break during unwinding for examination and examination.

Rice. 54. Intermaxillary ligature fastening according to the Ivy method.

Rice. 55. Intermaxillary ligature fastening according to the Kazanyan method.

oral cavity work, or after emergency cutting of ligatures in case of vomiting or coughing with copious sputum.

Intermaxillary ligature fastening according to Gotsko. A polyamide thread is used as a ligature. It is carried out around the neck of the tooth and tied in a knot on its vestibular surface. Further, both ends of the floss are passed through the interdental space of the antagonist teeth from the vestibule to the oral cavity, then each end is removed from the cavity to the vestibule of the mouth (distal and medial), pulled up and tied together with a knot, immobilizing. The method is less traumatic and quite effective (Fig. 56).

3. Methods of therapeutic (permanent) immobilization of jaw fragments using non-laboratory tooth splints.

3.1. Tooth individual wire splints.

Tigerstedt tires.

Tooth wire splints S.S. Tigerstedt were developed by the author in 1915. Several designs were proposed.

This method of therapeutic immobilization is characterized by low trauma, simplicity, high efficiency and low cost of the materials used.

The following Tigerstedt splints are currently in use: a smooth brace splint, a spacer bent splint, a toe loop splint, and very rarely an inclined plane splint.

materials, necessary for the manufacture of tooth splints:

Aluminum wire with a diameter of 1.8 - 2.0 mm and a length of 12 - 15 cm (in case of high rigidity it must be annealed),

Bronze-aluminum wire with a diameter of 0.5 - 0.6 mm or stainless steel wire with a cross section of 0.4 - 0.5 mm.

Tools for splinting:

Rice. 56. Intermaxillary ligature fastening according to the Gotsko method.

crampon tongs,

anatomical tweezers,

Billroth, Pean or Kocher hemostatic forceps,

Dental scissors for metal cutting,

File.

General rules dental splints:

Inject 0.5 ml of a 0.1% solution of atropine subcutaneously to reduce salivation (convenient for the doctor and patient during the manufacture of the splint),

Conduct local anesthesia, better conduction,

Remove tartar for free passage of the wire ligature in the interdental spaces;

Start bending the tire from the left side of the patient's jaw (for left-handers - from the right), some authors recommend starting the bending of the tire from the side of the fracture,

The tire is bent with the fingers of the left hand, holding the wire in the right hand with kampon tongs (for left-handers - vice versa),

Try on the splint to the teeth in the mouth, and bend it only outside the oral cavity,

The manufactured splint must be adjacent to the neck of each tooth included in it, at least at one point,

The tire should be fixed to each tooth included in it with a ligature wire,

It is necessary to twist the ligature wire only clockwise (as all doctors agreed). This ensures continuity in the care of the tire and its safety when tightening and loosening the ligatures.

Splint making begins by bending a large toe hook that wraps around the first tooth, or a toe spike inserted into the interdental space. The aluminum wire is always fixed with crampon tongs, and bent by pressing the fingers of the hand against the cheeks of the tongs in order to prevent deformation of the section of the tire fitted to the teeth. To try on the curved section of the tire, it is applied to the teeth and fixed with the fingers of the left hand in the area of ​​the hook or spike, that is, in the section of the manufactured tire. It is not recommended to try on the splint by holding it by the piece of wire protruding from the mouth, as this may lead to incorrect placement of the splint on the teeth. Having made a splint for one half of the jaw, they proceed to bending it to the teeth of the other half. In this case, the long end of the wire will interfere with the manufacture of the splint on the opposite side, so it must be bent 180 degrees in order to be able to fit (bend) the wire to the teeth of the opposite side.

A.Smooth tire-bracket.

It is used to treat fractures of the lower jaw, provided that there are at least 4 stable teeth on the larger fragment, and at least 2 stable teeth on the smaller one. Teeth located in the fracture gap are not taken into account in the calculation of this rule.

Indications for imposition smooth busbar:

Linear fractures of the lower jaw, located within the dentition, without displacement or with easily reducible fragments,

Fractures of the alveolar part of the lower jaw and the alveolar process of the upper jaw,

Fractures and dislocations of teeth, when there are stable teeth on both sides of the intact areas of the jaw,

Acute odontogenic osteomyelitis of the jaw and periodontitis,

Fractures of the upper jaw (when using the methods of Adams, Dingman, etc.),

As a method of preventing a pathological fracture of the lower jaw prior to certain operations (sequestrectomy, cystectomy, cystotomy, resection of part of the jaw, etc.).

Method for bending a smooth bus-bracket.

If there is displacement of fragments, then before bending the splint, it is necessary to compare them with your hands and temporarily fix them with a wire ligature for the teeth of the fragments facing the fracture gap.

For splinting, a piece of aluminum wire is taken in the left hand and with crampon forceps in the right hand, the toe hook is bent to the wisdom tooth (or to any last tooth in the dentition). When making a hook, the wire is bent at a small angle, each time capturing new sections of the wire with tongs, successively retreating from the end by 1-2 mm. The hook should tightly cover the distal and buccal surface of the last tooth, reach the middle of the crown of its lingual surface and be located between the equator and the edge of the gum. The lingual end of the hook is sharpened with a file at an angle of 45 degrees for a smooth transition of the wire to the tooth surface, which eliminates injury to the tongue.

Sometimes, instead of a toe hook, the bending of the tire begins with the manufacture of a toe spike, which should enter the interdental space, but not protrude into the oral cavity and not injure the interdental papilla.

After manufacturing, the hook is placed on the last tooth and the wire is grasped with forceps at the level of the middle of its crown from the vestibular side. In this case, the long end of the hook (the main part of the wire) will be significantly lowered down and not correspond to the projection of the dental arch (Spee curve). The tongs, when applied to the wire, should be horizontal. With kampon tongs, remove the hook from the tooth and with the second finger of the left hand at the cheeks of the tongs, bend the wire up at a small angle. Try on the tire in the mouth, applying it to the teeth. If the bending angle was correct, then the wire after the last manipulation will be at the level of the necks of several teeth. If the wire is above or below their necks, it must be bent down or up to the appropriate angle so that it is in the projection of the necks of several teeth. Then it is captured with forceps at the last point of contact with the tooth, removed and carefully removed from the mouth. Slightly loosening the fixation of the forceps, turn them on the wire with their handles down by 90 degrees and bend the wire away from you with the first finger of your left hand to the next tooth at a small angle. A splint is inserted into the vestibule of the mouth and tried on to the teeth. If it turns out that after bending the wire to the tooth, the correctly curved section of the splint moved away from the teeth, then this means that the wire was bent excessively. To correct it, you need to put forceps on the wire at the place of the last bend and bend it slightly away from the tooth, i.e. on itself, and again try on the tire to the teeth in the mouth, hooking it to the last tooth. If the position of the splint is correct, then again with the cheeks of crampon forceps they grab the splint at the place of the last touch to the tooth, remove the splint from the vestibule of the mouth and continue to bend in the direction of the occlusal plane until contact with the next tooth.

In a similar way, repeating the manipulations, the entire tire is sequentially bent to the required length and its bending is completed on the second fragment with a hook or spike, which is inserted into the interdental space (Fig. 57). To bend the spike, the wire is grasped with forceps exactly at the level of the back surface of the selected tooth, the splint is removed from the teeth and removed from the mouth. Slightly loosening the fixation of the tongs, turn them on the wire with their handles down by 90 degrees and bend the wire away from you with the first finger of your left hand by 90 degrees. Cut off the excess wire, leaving an end for a 3-6 mm spike. With the help of a file, the spike is processed, giving it the shape of a wedge so that it enters the interdental space. The size of the spike corresponds to the size of the interdental space, and the spike itself should be located just above the interdental papilla, not injure it and not protrude with a sharp end into the oral cavity. It should be noted that sometimes the teeth are so tight that the size of the spike does not exceed 1 - 1.5 mm.

Rice. 57. Smooth tire-bracket.

Try on the finished tire in your mouth. For the convenience of applying the splint, first a spike is inserted into the interdental space, and then the entire splint is put on the teeth, hooking the hook on the first tooth. A properly made splint should easily and effortlessly overlap the vestibular surface of the dental arch. It should touch all the teeth at least at one point and be located between the equator of the tooth and the edge of the gum.

The finished tire is tied to each tooth with a bronze-aluminum wire. To do this, before applying the aluminum tire, the wire is grasped with tweezers or a clamp, departing from its end by 2-3 cm, and it is led from the vestibule into the oral cavity through the interdental space. Next, the oral end of the wire is grasped with a clamp and it is brought out through another interdental space in the vestibule of the mouth, surrounding the tooth from the distal, lingual and medial sides. The wire should be below the equator of the tooth. The distal end of the wire is bent up, and the medial end is down. Between these ends (they should be approximately equal in size) a space is formed where the curved tire will subsequently be placed. When passing the wire into the oral cavity, it is necessary to protect the tongue from injury with the wire. To do this, with the second finger of the left, wire ligatures are applied in a similar way to all the teeth included in the splint. All distal ends are bent up, and medial down. After the ligatures are applied, the tire is fixed. It is applied to the teeth by inserting wire ligatures between the ends. The upper and lower ends of the wire ligature of each tooth are twisted clockwise, capturing them with a clamp at a distance of 2.0 - 2.5 cm from the vestibular surface of the crown. In order not to confuse the upper end of one ligature with the lower end of the other, they must be shaken before twisting. At the same time, the movement of one end in the oral-vestibular direction simultaneously moves the paired end of the same ligature.

After twisting the ligatures, each of them is cut to a length not exceeding 5 mm, and the ends are bent to the tire or to the teeth towards middle line. It is necessary to ensure that the ends of the ligatures do not injure the surrounding tissues.

You can fix the tire to the teeth in another way. To do this, the splint is fixed on the teeth with a spike and a hook. The wire ligature is bent in the form of a hairpin and its ends are introduced from the oral cavity: one - into the medial, the other - into the distal interdental spaces of the same tooth. In this case, one end of the wire (for example, medial) is carried out under the tire, and the other (distal) - above the tire. The wire is not twisted to the end, leaving the tire movable to facilitate subsequent ligatures. Similarly, ligatures are applied to all teeth. Twist all ligatures tightly, cut and bend the ends to the teeth, as indicated above. This method often causes difficulties when conducting, as a rule, the upper end of the ligature, which abuts against the inner surface of the tire.

After treatment, before removing the splint, loosen the ligatures and check the lack of mobility of the fragments by shaking them.

Remove the splint after 4 to 5 weeks. To do this, the ends of the wire ligatures are slightly untwisted with crampon tongs counterclockwise, one or both of them are cut with scissors for metal and the wire is removed from the interdental space. If the ligature jams, it must be slightly shifted towards the gums, pushed into the oral cavity and then removed. The tire is removed from the teeth, the gum is treated with a 3% hydrogen peroxide solution or 1% iodine solution.

After applying a smooth splint-bracket, the patient is recommended to wear a standard Pomerantseva-Urbanskaya chin sling to limit mouth opening. The patient needs to take liquid or pureed food. The doctor should regularly examine the patient 2 - 3 times a week. At the same time, it is necessary to control the state of bite, the strength of fixation of bone fragments with a splint, the state of tissues in the area of ​​the fracture (the presence or absence of inflammation), the state of the teeth in the fracture gap. When loosening the fixation of the splint on the teeth, it is necessary to tighten the ligatures by twisting them clockwise. If at the same time the ligature bursts, it is replaced with a new one.

Of particular importance is the condition of the oral cavity. The patient must be taught hygiene measures to prevent the development of gingivitis. To this end, the patient should brush his teeth and the splint twice a day (morning and evening) with toothpaste and a brush, after each meal, remove food debris with a toothpick and rinse the cavity and vestibule with antiseptic solutions 3-5 times a day: pink solution of potassium permanganate, decoctions of sage or chamomile and other means.

B.Bus-bracket with spacer bend.

This splint can be used if there are at least 2 stable teeth on the smaller fragment, and 4 stable teeth on the larger one. The spacer bend prevents lateral displacement of fragments.

Indications for use:

Fracture of the lower jaw within the dentition and the presence of a bone defect of no more than 2-4 cm,

Fracture of the lower jaw without displacement or with easily reducible fragments, if the fracture gap passes through the alveolar part, devoid of teeth.

The same materials and tools are needed for bending a cleat bar with a spacer bend as for making a smooth cleat bar.

Bending technique a bar with a spacer bend differs from the manufacture of a smooth bar-bracket only at the stage of forming the spacer. The length of the spacer bend should correspond to the length of the defect in the bone or dentition. Otherwise, there will be an increase or decrease in the length of the lower jaw. The shoulders of the spacer bend, abutting against the teeth, must be equal to the supporting surface. It's necessary

take into account the spacers when bending and make an allowance for the thickness of the wire, since it takes part in the formation of the shoulder.

To bend the spacer bend, the cheeks of the forceps are placed on the busbar parallel to the surface of the tooth facing the defect and, having removed the splint from the teeth, the wire is bent away from itself at an angle of 90 degrees. The long end of the wire is smoothly bent “toward itself” in the form of a semicircle until it is oriented towards the exit from the oral cavity, the splint is tried on and the wire is grasped with forceps at the level of the lingual surface of the tooth. You can do it differently: make a mark-scratch at this level. The splint is removed, the cheeks of the forceps are displaced from the place of capture (or mark-scratch) in the vestibular direction by the thickness of the wire and it is bent 90 degrees towards the defect. The wire is straightened in a section slightly longer than the existing defect. The tire is again tried on and, having removed it from the mouth, the wire is bent over the middle of the defect. It is necessary to ensure that this segment is not displaced orally, which will exclude injury to the tongue, or vestibularly, to prevent damage to the buccal or lip mucosa. This section of the wire must be raised to the upper edge of the crown of the tooth, which is on the other side of the defect, and placed on its oral surface. With a sharp instrument, you can make a scratch mark at the level of the surface of the tooth crown facing the defect, or put the cheeks of the forceps here and remove the splint from the mouth. Stepping back from the scratch or from the place where the cheeks of the forceps are applied towards the defect by the thickness of the wire, bend its free end towards itself by 90 degrees. Try on the splint, grab the wire at the site of the shoulder of the spacer bend that has been brought out at the border of the mesial and vestibular surfaces of the tooth crown and remove it from the mouth. Turning the forceps on the tire 90 degrees with the handles down, bend the wire away from you until it comes into contact with the vestibular surface of the abutment tooth crown. Further bending and fixation of the splint to the teeth is similar to that described for the brace splint (Fig. 58).

Rice. 58. Smooth busbar with spacer bend.

V.Tire with toe loops.

This tire is most often used to treat patients with fractures of the jaws. In case of fractures of the lower jaw, two splints are made with hook loops for the teeth of the upper and lower jaws. For fractures of the upper jaw, depending on the method chosen, either one (when fixing the upper jaw to the bones of the upper face) or two splints with hook loops (in the case of using a chin sling) can be used.

Indications for use:

Fractures of the lower jaw outside the dentition;

Fractures of the lower jaw within the dentition in the absence of 4 on a larger fragment, and 2 stable teeth on a smaller one (otherwise, the periodontium used for splinting teeth may not withstand the load and the teeth will become mobile);

Fractures of the lower jaw with fragments that are difficult to reduce and require traction;

Bilateral, double and multiple fractures of the lower jaw, fracture of the upper jaw (with the obligatory use of a chin sling);

Simultaneous fractures of the upper and lower jaws (complemented with a chin sling).

Tire bending technique with toe loops.

They take a piece of aluminum wire 15 cm long in the left hand and with the help of crampon forceps in the right hand, bend the hook on the wisdom tooth (or on the other last tooth in the dentition). The hook is bent and sharpened as in the manufacture of a smooth brace.

They bend the tire to the next tooth (let's say it will be the second molar). The tire should touch the second and third molars at least at one point and be located between the equator and the edge of the gum. They grab the splint with forceps in the interdental space of the first and second molars, a little closer to the first molar, remove the splint from the teeth and remove it from the mouth without changing the position of the splint in the forceps.

Next, proceed to bending the toe loop. Holding the forceps with the handles up, put the cheeks on the tire at an angle of 30-40 degrees with respect to the vertical axis of the tooth. The splint is removed from the mouth, the forceps with the splint clamped are given a vertical position with the handles down and the first finger of the left hand is bent the wire 90 degrees away from you

firmly pressed to the cheeks of the forceps. Holding the bent (long) end of the wire with the left hand, move the cheeks of the tongs onto it, placing it close to the formed corner. With the second finger of the left hand, located near the left cheek of the forceps, turn the long end towards itself (by 180 degrees), pressing it tightly against the left cheek. The cheeks of the tongs are moved to the base of the loop, its shoulders are brought together and at the same time the long end of the wire is bent away from itself by 90 degrees, making it a continuation of the already bent part of the tire. The tire is tried on the teeth. The top of the loop on the lower jaw should be turned down, its length is not more than 5 mm, it should be located at an angle of 30 - 40 degrees to the tooth (Fig. 59). If the angle of inclination of the loop in relation to the mucous membrane of the gums is less than 30 degrees, then the toe rubber ring subsequently put on the loop will lead to the formation of a bedsore on the gums. If the angle is more than 45 degrees, then a bedsore can form on the mucous membrane of the cheek.

The criterion for the correct angle of inclination of the loop can be a piece of the wire from which the tire is bent: it must pass between the tooth and the loop, slightly touching them. If the wire does not pass, the loop should be bent; if two wires pass, the loop should be bent to the tooth. If the angle between the loop and the tooth does not correspond to the required one, then it is no longer possible to continue to bend the tire. It is necessary to immediately correct the angle of the hinge. To do this, immediately in front of the loop (in the area of ​​\u200b\u200bthe already bent tire), the wire is grasped with the cheeks of crampon tongs, and the loop

Rice. 59. Scheme of the stages of bending (1-4) of the toe loop.

fixed with a hemostatic clamp. Tightly holding the wire with kampon tongs, the hook loop is rotated with a clamp at a small angle, achieving a slope of 30-40 degrees. Using the experience of bending a smooth brace splint, bend the splint to the second premolar. Toe loops are bent on even teeth, i.e. on the second incisors, first premolars and first molars, if the anatomical conditions and localization of the fracture allow this. Having bent the toe loop to the first premolar, the splint is adjusted to the canine, after which the loop is bent to the second incisor and the splint is bent to the first incisor. After crossing the midline of the lower jaw, continue to bend the tire using the same technology. However, on the opposite side of the jaw, it is necessary to grab the wire to bend the toe loop in front of the tooth on which it should be located. They finish bending the tire by making a hook or spike, using the techniques described when bending the tire bracket (Fig. 60).

In a similar way, a splint with hook loops for the teeth of the upper jaw is made, but the hook loops on it should be turned with their top up. At the same time, the wire should be grasped with forceps in such a way that the handles of the forceps are facing downwards, and the angle of inclination is also 30-40 degrees to the buccal surface of the tooth crown. The first movement when bending the loop should be 90 degrees towards you.

Toe loops are usually bent on the tire so that they are located in the area of ​​the 6th, 4th and 2nd teeth. If the patient does not have these teeth, then toe loops are made in the area of ​​other teeth, but this must be done in teeth that have antagonists. Usually, 3-4 toe loops are bent on the splint adjacent to the teeth of the larger fragment, and 2-3 toe loops of the smaller one. The base of the loop must be within the crown of the tooth.

Manufactured tires are placed on the teeth of the jaws and their quality is checked: the tires must be adjacent to each tooth at least at one point, the toe loops must form an inclination angle of 30-40 degrees to the axis of the tooth, the toe loops of both tires should be approximately at the same level, the tire should located between the gingival margin and the equator.

A splint is attached to each tooth using aluminum-bronze wire as described above.

After fixing the splints on the teeth of the upper and lower jaws, the elastic and smooth movement of the fragments to the correct (normal) position is started. To do this, wear rubber rings on the hook loops. Repositioning rubber traction

Rice. 60. Tire with toe loops.

(oblique, vertical or mixed) should be directed in the direction opposite to the displacement of the fragments, taking into account the traction of the muscles and the severity of the fragments. In such cases, the rubber traction separates fragments of the jaw overlapping each other or wedged in their ends in a vicious position in different directions.

You should not create a small thrust for a long time (for several days), as this prolongs the suffering of the patient, gives a smaller effect and leads to tooth mobility. It is better to make anesthesia, apply a powerful rubber traction and reposition the fragments within a short time. The correct reposition of the fragments to which the splint is attached can be judged by the restoration of the correct bite. Then, the traction should be reduced and the fragments should be fixed for the entire period of treatment with the help of rubber rings or wire ligatures. The latter will relieve the periodontium of the teeth included in the splint from non-physiological load.

Sometimes, in case of fractures in the area of ​​the body of the lower jaw, it is more advantageous to tie a curved splint rigidly only to the teeth of the fragment being moved. To the teeth of a correctly standing fragment, the splint is only slightly fixed with ligatures. Reposition in any case will be faster and more successful when the pellet is temporarily placed on the teeth of an undisplaced (or slightly displaced) fragment. After the fragments are repositioned, the wire ligatures are twisted to a rigid attachment.

When the displacement of the fragments is large and it is not possible to bend one splint on both fragments, it is possible to make and firmly fix the splints on each of the fragments. After their reposition, rubber rings are put on the toe loops at an angle so that they create compression of the fragments, which significantly prevents their movement. Some authors, after reposition, recommend that such fragments be united with a smooth splint-bracket superimposed over a splint with hook loops. However, this is a complex and not entirely justified procedure. It is best to restore the continuity of the tire with a fast curing plastic placed on the two adjacent ends of the tire.

The correctness of the location of the fragments is finally judged by the occlusion and x-ray data, made in at least two projections.

After splinting for a fracture of the upper jaw, it is necessary to put on the patient an elastic chin sling. Otherwise, when opening the mouth, the lower jaw will shift (pull) down the upper one.

Periodically (2-3 times a week), the patient is examined, the fixation strength of the splints is corrected by twisting the ligatures, the rubber rings are changed, as they stretch and fragments can be displaced, and the vestibule of the mouth is treated with antiseptic solutions. They monitor the state of bite, the position of fragments and tissues in the area of ​​the fracture. 10-25 days after the fracture, a dynamic X-ray examination is performed to control the position of the fragments. It is necessary to educate the patient on oral hygiene measures, as described above. Particular attention should be paid to the proper nutrition of the patient.

After the fusion of fragments (determined clinically), before removing the splints, it is necessary to remove the rubber rings and let the patient walk for 1-2 days without fixation (with open jaws), taking soft food. If during this time there is no displacement of fragments, as indicated by a violation of the bite, the tires are removed. If there is a slight change in bite, then the rubber traction is retained for another 10-15 days.

A splint with hook loops can be used as one of the main bearing elements of the surgical method of immobilization of the upper jaw. In this case, the tops of the hook loops of the maxillary splint should be facing down. Usually bend no more than two loops on each side.

G.Splinting according to the method of A.P. Vikhrova and M.A. Slepchenko.

The authors proposed to use a polyamide thread to reinforce the fastening of the splint on the teeth (smooth - staples or with toe loops). To do this, take a bronze-aluminum wire ligature, fold it in the form of a hairpin and insert both ends of it into one interdental space from the mouth towards the vestibule of the mouth. The ligature is tightened so that a small loop is formed on the lingual surface of the interdental spaces. Do a similar procedure in the area of ​​all interdental spaces. They take a polyamide thread with a diameter of 1 mm and pass it through all the loops on the lingual side, the ends of the thread are brought out in the vestibule of the mouth behind the last teeth on both sides. Next, a previously made tire is placed on the teeth so that it is located between the two ends of the same previously made bronze-aluminum ligatures, which are then twisted. According to the authors, the advantages of their method are as follows: a stronger bonding of fragments, a reduction in the time of fixing the splint, and the absence of trauma to the gingival mucosa (Fig. 61).

D.Tooth bars made of bronze-aluminum wire.

They are variants of ligature knitting according to the type of machine seam.

Obwegeser method: take a piece of bronze-aluminum or other ligature wire 20-25 cm long. One of its ends is placed along the vestibular surface of the dental arch. The other end of the same wire is passed and removed through the same interdental space from the lingual side towards the vestibule of the mouth, while on the way on the vestibular surface a long ligature wire is captured like a machine seam. The protruding wire ligatures are twisted, thereby obtaining hook loops, which are later used to implement rubber traction (Fig. 62).

Stout method differs from the Obwegeser method in that the wire ligatures protruding into the vestibule of the mouth are twisted in the form of a loop using a device (Fig. 63).

These and other similar methods are laborious and do not always allow to achieve good long-term immobilization, therefore, they are currently used extremely rarely.

Rice. 61. Splinting according to Vikhrov - Slepchenko.

Rice. 62. Intermaxillary ligature fastening according to the Obwegeser method.

Rice. 63. Intermaxillary ligature fastening according to the Stout method.

3.2. Tooth standard splints.

Good manual skills are required to make custom wire or plastic splints. In addition, the process of their manufacture requires a lot of time and frequent step-by-step fitting to the dental arch. It is especially difficult to bend splints in case of bite anomalies, teeth dystopia, etc. Considering the above, standard splints were proposed, which are manufactured in the factory, do not need to bend the toe loops and, thereby, simplify splinting.

In Russia, V.S. Vasiliev. This bar is made from a thin, flat metal band 2.3 mm wide and 134 mm long, which has 14 hook loops. The tire flexes easily in the horizontal plane, but does not flex in the vertical plane. The Vasiliev tire is cut to the required size, bent along the dental arch so that it touches each tooth at least at one point, and is tied to the teeth with a ligature wire.

The advantages of the tire in the speed of its application, however, a significant disadvantage of the tire is the impossibility of bending it in the vertical plane, which does not allow to avoid injury to the mucous membrane in the lateral parts of the jaws due to the discrepancy between the Spee curve. For single-jaw splinting, this tire is not suitable due to its low strength.

Abroad, there are various designs of standard tires made of steel wire (Winter tires) and polyamide materials that can be bent in any plane. The tires roll easily into a roll and come with pre-made hooks. These splints are also not strong enough and can only be used for double jaw splinting.

3.3. Permanent (therapeutic) immobilization of jaw fragments using laboratory-made splints (Port splint, Weber splint, Vankevich splint, etc., kappa devices).

Laboratory-made splints are classified as orthopedic immobilization methods. They perform both an independent function of immobilization, and can be an additional device for various surgical methods of fastening fragments.

The most commonly used removable orthopedic structures, these include:

A. Dental splints:

Simple dentogingival or inclined plane Weber splint,

Sheena Vankiewicz,

Sheena Vankevich - Stepanova and others. B. Gingival Tires:

Bus Port,

b. Fixed orthopedic constructions:

Tooth kappa splints with fixing elements of various modifications.

Indications for use tires of laboratory production:

Severe damage to the jaws with significant bone defects, in which jaw bone grafting is not performed;

The presence of severe concomitant diseases in the victim (diabetes mellitus, myocardial infarction, stroke, etc.), in which the use of surgical methods of immobilization is contraindicated;

Refusal of the patient from the operational fixation of fragments;

The need for additional fixation of fragments simultaneously with the use of wire splints.

For the manufacture of laboratory splints, appropriate conditions are necessary: ​​a dental laboratory, special materials. Dental work is carried out by dental technicians.

A. Simple dentogingival splint Weber.

It can be used alone or as one of the main elements when using the surrounding suture method for mandibular fractures.

Manufacturing technique tires: take an impression from the dental arch of the lower jaw or separately from each fragment with a significant displacement. Next, a model is cast, according to which a tooth-gingival splint is modeled from wax in such a way that the cutting edges and tubercles of the teeth are free from wax, and from below the splint should be slightly higher (1-2 mm) than the lower arch of the vestibule of the mouth. The wax model is replaced with a plastic one, which is applied to the alveolar part of the lower jaw and the teeth of fragments, fixing the latter. If the casts were taken separately from each fragment, or if a significant displacement of the fragments is found on the cast plaster model, then this model is cut along the fracture line and parts of the model are set in the correct position using the previously cast model of the upper jaw. The models are fixed in an occluder, a tooth-gingival splint is modeled from wax, and a plastic splint is welded according to the resulting template.

It is possible to make a tooth-gingival splint directly in the patient's mouth from quick-hardening plastic. To do this, the mucous membrane of the alveolar part of the lower jaw and teeth are lubricated with petroleum jelly. Quick-hardening plastic is kneaded and, when it acquires a dough-like state, a long thick cylinder is modeled from it, given an arcuate shape, placed on the teeth and the alveolar part of the lower jaw, squeezed with fingers, pushing until the cutting edges and chewing surface of the teeth are exposed. Before the plastic hardens, the splint is removed from the mouth and placed in cold water to slow down polymerization. Before fitting the splint to the teeth, it is machined, ground and fitted

to fragments. During rapid polymerization in hot water, the tire deforms and becomes unusable. The disadvantage of this method is that the splint can deform when removed from the teeth, making it unusable.

Modification by M.B. Shvyrkova: An individual impression tray is prepared from three layers of a dental wax plate, the boundaries of which should be 2 mm higher than the lower arch of the vestibule of the mouth. One inner layer of wax is removed, the tire is filled with mixed fast-hardening plastic and an impression is taken. A wax spoon with a plastic impression is placed in cold water. After the plastic hardens, the wax spoon is removed, and the splint is ground and fitted to the teeth.

If the tire is used as the main element when using surrounding sutures, fragments of the lower jaw are fixed to it with nylon or wire ligatures.

B. Weber's tooth-gingival splint with an inclined plane.

It differs from a simple tooth-gingival Weber splint in that in the posterior section at the level of the molars it has an inclined plane in height slightly less than the vertical size of the crowns of the antagonist molars.

Manufacturing technique the same as the simple tooth-gingival Weber splint. Additionally, an inclined plane is made in the lateral section.

A Weber splint with an inclined plane is used to immobilize and prevent lateral displacement of fragments of the lower jaw by resting the inclined plane against the vestibular surface of the teeth-antagonists of the upper jaw.

In addition, the Weber splint is used for significant defects in the lower jaw as a result of the development of traumatic osteomyelitis, a gunshot wound, or after resection of the lower jaw for a tumor. In these cases, prolonged wearing of the splint (within 2-3 months) can lead to the elimination of a pronounced lateral displacement of the lower jaw after the removal of the splint.

V. Tire Vankevich and Tire Vankevich-Stepanova.

It is a tooth-gingival splint based on the alveolar process of the upper jaw and the hard palate. It has two downward-facing inclined planes in the lateral sections, which abut against the anterior edges of the branches or into the alveolar part of the lateral sections of the body of the lower jaw, mainly from the lingual side and do not allow the fragments of the lower jaw to move forward, up and inward.

The Vankevich splint is used to fix and prevent lateral and rotational displacement of fragments of the lower jaw, especially with significant defects, due to the emphasis of the inclined planes on the anterior edges of the jaw branches.

Tire Vankevich in Stepanov's modification differs in that instead of the maxillary base there is a metal arc, like a clasp prosthesis.

G. Bus Port.

The Port splint is used in case of a fracture of the edentulous lower jaw without displacement of fragments and the absence of removable dentures and teeth in the upper jaw in the patient.

The splint consists of two basic plates for each jaw, according to the type of full removable dentures rigidly interconnected in the position of central occlusion. In the front section of the tire, a hole is created for eating. The Porta splint is used as an immobilizing device only in combination with wearing a chin sling bandage.

D. Kappovye braces with fixing elements.

It is used for immobilization of fragments of the lower jaw in the presence of a defect in the bone tissue within the dentition, when there is a sufficient number of stable supporting teeth on the fragments. You can use these splints to immobilize fragments and in case of insufficient stability of the supporting teeth (for example, in periodontitis), when the use of a splint to immobilize fragments is undesirable or contraindicated.

These splints consist of metal caps fitted to the teeth of the lower jaw. The caps are soldered together and fixed on the teeth of each fragment. With the help of locks of various designs (pins, levers, etc.), after their reposition, the fragments are fixed for the period necessary for consolidation. The teeth used for splinting are not prepared.

It should be noted that kappa devices are laborious to manufacture, require experienced dental technicians and a dental laboratory, are expensive and therefore are rarely used to treat patients with mandibular fractures.

4. Doctor's tactics in relation to the teeth located in the fracture gap.

The roots of the teeth located in the fracture gap are the cause of the development of the inflammatory process, up to traumatic osteomyelitis. Until now, there is no consensus among specialists about medical tactics in relation to these teeth. Some of them believe that early extraction of teeth in the fracture gap is the main prevention of the development of various complications. So, N.M. Michelson (1956) pointed out that if immobilization is not carried out in the first hours or days after injury, then the only prevention of the development of traumatic osteomyelitis is the removal of a tooth from the fracture gap. Other authors believed that these teeth should be damaged.

Let's consider some aspects of this issue.

Proponents of early tooth extraction from the fracture gap mistakenly see only in it the main cause of traumatic osteomyelitis. Experimental studies on animals (MB Shvyrkov, 1987) showed that the cause of complications in jaw fractures, including traumatic osteomyelitis, is programmed at the genetic level.

The tooth located in the fracture gap is the conductor of microorganisms to the bone wound. However, not every wound, being infected, suppurates, therefore, it is believed that if adequate therapy is not carried out, the consolidation of fragments can be complicated by the development of traumatic osteomyelitis. There are observations that this complication does not occur in a number of patients, regardless of their behavior after the injury, but the reasons for this phenomenon have not yet been studied enough.

There may be one or two teeth in the fracture gap. In this case, various options can be detected: the fracture line can pass through the entire periodontium or part of it, it is possible to expose only the apical part of the tooth in the fracture gap, sometimes there is a root fracture in its various sections or in the area of ​​bifurcation. The tooth in the fracture gap may be on larger or smaller fragments. It is not possible to reliably speak about the viability of the pulp of such teeth in the early post-traumatic period, since the sensitivity determined by EDI always decreases significantly and recovers no earlier than 10-14 days from the moment of injury, and sometimes even later. Therefore, dynamic EDI is shown to address the issue of pulp viability.

Some authors believe that if, along with high EDI numbers, there is paresthesia of the lower lip and chin, then dynamic EDI is not necessary. It is enough to control the pain or tactile sensitivity of the lips.

Clinical practice shows that teeth with a bare root, even with a live pulp or filled, slow down the process of consolidation of bone fragments, since bone trabeculae grow only from one fragment to another and do not fuse with the root of the tooth. In this case, there is an absolute indication for the early removal of such teeth. The proof of the correctness of this statement is the mobility of fragments after the usual time required for consolidation, i.e. after 4-5 weeks.

Teeth in the fracture gap with periapical chronic foci are always potentially dangerous in terms of the development of inflammatory complications; therefore, early extraction of such teeth is indicated.

Particularly noteworthy are the teeth located in the fracture gap on the distal fragment, and especially the second and, especially, the third molars. These teeth, when using conservative immobilization techniques, are of great importance in preventing upward displacement of the loose distal fragment. It should be noted that an attempt to remove such a tooth on a small fragment in the first days after the fracture is always associated with significant technical difficulties due to the impossibility of firmly holding this fragment by hand when dislocating the tooth with forceps. In this case, the ends of the fragments rub against each other, which is completely unacceptable. Additional injury to the inferior alveolar nerve can sometimes lead to its crushing and (or) rupture. Possible damage to the ligamentous apparatus of the temporomandibular joint and even its dislocation. To prevent a purulent inflammatory process in the fracture area, in this case, antibiotic therapy is prescribed for 1-2 weeks. 12-14 days after the formation of primary callus and the subsidence of acute inflammation caused by trauma, such teeth can be removed with less difficulty due to the development of chronic periodontitis, accompanied by a decrease in the strength of edematous periodontal collagen fibers (collagen fibers swell and lose strength in an acidic environment) and resorption of the walls of the hole. But even in this case, a strong fixation of a small fragment is required, since there is a danger of damage not only to the lower alveolar nerve, but also the destruction of the fragile newly formed primary callus.

The presence of teeth in the fracture gap with various pathological changes and conditions (root fracture, tooth mobility, the presence of chronic foci of infection in the periapical tissues, wide exposure of the root cement, dislocation of the tooth from the hole);

The presence of a tooth fracture in the gap, which maintains inflammation despite ongoing drug therapy;

Teeth interfering with comparison of fragments.

When choosing a treatment strategy for a tooth located in the line of a mandibular fracture, A.V. Avdeev (1999) suggested using the following formula for the probability of tooth “survival” in the fracture gap: Y = 0.23 X1 + 0.21 X2 + 0.30 X3 + 0.26 X4

In this case, the values ​​of X will be equal to:

X1 = 1, when the fracture gap passes through the root of the tooth;

X1 = 0, when the fracture gap passes along the proximal surface of the tooth;

Х2 = 1, if the injury was older than 3 days;

X2 = 0, if the injury was more than 3 days old;

X3 = 1, with the degree of displacement of bone fragments of the lower jaw up to 0.5 cm; X3 = 0, with the degree of displacement of bone fragments of the lower jaw over 0.5 cm; X4 = 1, with tooth electrodontometry up to 30 μA; X4 = 0, with tooth electrodontometry over 30 µA.

Values ​​Y = from 0 to 0.5 are considered unfavorable for the preservation of the tooth in the fracture gap, values ​​Y = from 0.5 to 1 - favorable for the preservation of the tooth.

In doubtful cases, it is advisable to resolve the issue in favor of removing the tooth from the fracture gap immediately or at the first signs of the development of an inflammatory process in the area of ​​jaw fragments. Leaving the tooth not removed, the doctor takes responsibility for the possible consequences (development of certain complications). Such a patient requires particularly careful monitoring during the treatment period.

jaw fracture is a severe pathological situation in which the linear integrity of the bones that form the lower jaw is disturbed. This happens under the influence of some traumatic factor, the intensity of which exceeds the strength of the bone. Mandibular fracture is a fairly common pathology that occurs among all age categories, but young men aged 21 to 40 most often suffer from it. This is due to several factors that are determined by both socio-economic status and lifestyle, as well as anatomical and physiological characteristics. Tooth fracture- this is a tooth injury received under the influence of mechanical force. With a fracture, the anatomical integrity of the tooth root or its crown is violated. The causes of a tooth fracture are mechanical injuries resulting from a blow, a fall, or during chewing, when solid foreign bodies are present in the food. The anterior teeth of the upper jaw are more prone to fractures than the teeth of the lower jaw, often fractures of the teeth are combined with their incomplete dislocations.

Causes

Fractures of the lower jaw occur as a result of exposure to some traumatic factor, the force of which exceeds the margin of safety of the bone. In most cases, this occurs as a result of falls, bumps, traffic accidents, sports and professional accidents. Nevertheless, the consequences of a traumatic impact are far from being the same in all cases and depend not only on the intensity, but also on a number of other factors, among which the physiological and structural state of the bone before the injury is of particular importance.
In medical practice, it is customary to distinguish two main types of fractures, in which the integrity of bone structures is violated, but which are the result of several different cause-and-effect relationships. Depending on the type of fracture corresponding to the classification based on the initial cause of the fracture, the most appropriate treatment and prophylactic tactics are selected. There are the following types of fractures:
Basically, in clinical practice, there are traumatic fractures, which, due to the peculiarities of the shape and anatomy of the jaw, differ from fractures of other bones of the skeleton. First, due to the arcuate shape of the bone, when pressure is applied anteriorly in the chin area, the resultant force acts on the lateral portions of the arc. This is due to the rigid fastening of the jaw in the temporomandibular joint, which does not allow it to move and thereby dampen the impact energy. Thus, under the influence of one traumatic factor, a multiple fracture of the jaw quite often develops ( usually in the area of ​​the mandibular symphysis and angle of the jaw). Secondly, the jaw is a fairly strong bone that requires a lot of force to break. From a physical point of view, for a jaw fracture in the region of the corner, it is necessary to apply energy corresponding to 70 accelerations of free fall ( 70g), and for a fracture in the symphysis region, this indicator must be increased to 100. However, it should be understood that under pathological conditions and with violations of bone development, the force of the necessary blow is significantly reduced. According to statistical data, the cause of mandibular traumatism largely determines the location of the fracture. This is most likely due to the fact that with certain types of injuries, the mechanism of impact and the place of maximum absorption of energy are similar. In car accidents, fractures usually occur in the region of the mandibular symphysis and condylar process ( on both sides), in motorcycle accidents - in the area of ​​the symphysis and dental alveoli ( i.e. at the level of the body of the jaw), and in case of injuries resulting from an act of physical violence - in the area of ​​the condylar process, body and angle of the jaw. Typical places for the formation of a jaw fracture line are:
Fractures of the lower jaw, as well as fractures of other bones of the body, are divided into open and closed, depending on the contact of bone fragments with the external environment. However, unlike other bones, jaw fractures have their own characteristics, which are associated with the proximity of the oral cavity. Fractures of the lower jaw are of the following types: Depending on the displacement of bone fragments, the following types of jaw fractures are distinguished:

• Displaced fracture. A fracture with displacement of fragments occurs when bone fragments lose their normal relationship and are displaced under the influence of any internal ( bone heaviness, muscle pull) or external ( direction and force of impact, displacement during movement) factors.
• Fracture without displacement of fragments. In a fracture without displacement, there is a pathological defect between the bone fragments ( fissure or fracture line), but the fragments correlate correctly. This situation is typical for incomplete fractures, in which part of the bone tissue retains its integrity, as well as for fractures that have developed under the influence of a traumatic factor of low intensity.
• Comminuted fracture. A comminuted fracture of the lower jaw is quite rare, but it is characterized by the presence of many bone fragments, which are displaced to one degree or another. A feature of this fracture is that, firstly, for its occurrence, it is necessary to apply a large force to a small area of ​​​​the bone ( e.g. hit with a hammer), and secondly, comminuted fractures require surgical treatment, as they significantly destabilize the bone.

Knowledge of the degree of displacement of bone fragments is necessary for planning a therapeutic approach, since significantly displaced fragments require much more labor-intensive treatment, which involves surgical comparison and fixation of the bone. In addition, the displacement of bone fragments, which after a fracture have rather sharp edges, can cause damage to the nerves and blood vessels, which is an extremely unfavorable situation and requires immediate medical attention. Odontogenic osteomyelitis Odontogenic osteomyelitis is an infectious and inflammatory lesion of the bone tissue of the lower jaw, which arose against the background of a dental infection. In other words, this pathology is an infection that has penetrated into the lower jaw from the primary focus, localized in the tooth or teeth. It is relatively rare, but it is quite dangerous and difficult to treat.
With osteomyelitis of the lower jaw, the developed infectious process stimulates an inflammatory reaction, under the influence of which the environment and local metabolism change. In addition, thrombus formation increases, local blockage of blood vessels occurs, necrosis occurs ( dying off) bone tissue. In the cavity under the tooth, pus forms, the dental ligaments weaken, the causative tooth and adjacent teeth acquire pathological mobility, begin to stagger. Due to malnutrition of the bone, it becomes more fragile, loses its original strength. This is especially pronounced in total osteomyelitis, that is, in cases where the pathological infectious-inflammatory process covers the entire lower jaw. Odontogenic osteomyelitis is one of the most common causes of pathological mandibular fractures. This ailment is accompanied by severe pain in the affected area, aggravated by chewing, putrid breath, bleeding from the mouth, redness and swelling of the skin over the focus.

Symptoms

The symptoms of a jaw fracture are quite varied. In most cases, this pathology is combined with a number of external manifestations, as well as with a number of subjective sensations. However, since quite often a jaw fracture is combined with craniocerebral injuries, in which the victim may be unconscious, highest value have exactly those clinical manifestations that the doctor can see during the examination. A fracture of the lower jaw is accompanied by the following symptoms:
Among other symptoms of a broken jaw, bleeding from the nose or ears deserves special attention, since cerebrospinal fluid can leak along with the blood through the damaged base of the skull. You can distinguish such bleeding by laying a clean napkin. With normal bleeding, one reddish spot remains on the napkin, while with bleeding combined with loss of cerebrospinal fluid, a yellowish spot appears on the napkin, diverging to the periphery.

Tooth fracture

Tooth fracture- traumatic damage to the tooth, accompanied by a violation of the integrity of its root or crown. There are various types of tooth fractures: enamel, dentin and root fractures. Manifested by sharp mobility and displacement of the injured tooth, intense pain. In case of crown fractures, the tooth can be saved with subsequent cosmetic restoration, in case of a root fracture, its removal is required. With a root injury, there is a high risk of developing periostitis, osteomyelitis, and other complications.

Tooth fracture

Tooth fracture- this is a tooth injury received under the influence of mechanical force. With a fracture, the anatomical integrity of the tooth root or its crown is violated. The causes of a tooth fracture are mechanical injuries resulting from a blow, a fall, or during chewing, when solid foreign bodies are present in the food. The anterior teeth of the upper jaw are more prone to fractures than the teeth of the lower jaw, often fractures of the teeth are combined with their incomplete dislocations.

Clinical manifestations of a fractured tooth

When a tooth is fractured, severe unbearable pain occurs, the victim has difficulty opening his mouth and closing his teeth. In addition, a fracture of the tooth is preceded by some kind of trauma, bleeding of the gums and pathological loosening of the tooth. Painful sensations during mechanical and thermal irritation depend on the type and location of the fracture, as well as on the mobility of the tooth. During the examination, swelling of the soft tissues of the oral cavity and petechial hemorrhages in the skin and mucous membranes are detected. Fracture of the crown of the tooth is clinically manifested in the form of its defect, often such a fracture is accompanied by the opening of the pulp chamber. When the root of the tooth is fractured, the tooth becomes mobile, its percussion is sharply painful, and the crown sometimes acquires a pink tint. Tooth fracture can be minor in the form of a chipping of the tooth enamel, or significant when there is a fracture of the dentin with or without exposure of the pulp and a fracture of the tooth root. Complete fractures are called fractures with opening of the pulp, incomplete - without opening the pulp.

Diagnostics

A fracture of the jaw can be suspected on the basis of a patient interview, examination data and clinical examination. However, in most cases, for the final diagnosis, additional instrumental studies are required to diagnose both the fracture itself and a number of existing and potential complications of this phenomenon. It should be noted that in pathological fractures, the diagnostic process is not limited to identifying the site and type of fracture, but also involves a number of additional radiographic and laboratory studies aimed at identifying the initial bone pathology. However, since the vast majority of people entering trauma departments hospitals with a fractured jaw, suffered during various traumatic circumstances, their examination is considered routine and includes an examination and a number of additional procedures. A jaw fracture is detected using the following methods: During a clinical examination, the doctor identifies the main objective ( visible or felt by an outside observer) and subjective ( perceived exclusively by the patient) symptoms, and also finds out the circumstances of the incident. Objective symptoms of a jaw fracture include:

• unilateral displacement of the jaw due to shortening of the body on one side;
• pathological jaw mobility;
• visualization of bone fragments in the depth of the wound;
• violation of the relief of the bone;
• asymmetry when opening the mouth;
• spasm of masticatory muscles;
• crepitus ( crunch) bone fragments during movement.

Subjective signs of a jaw fracture usually include pain in the area of ​​the fracture and primary injury, as well as a change in sensation on the fragment located behind the fracture line. This is due to the fact that during a fracture, a structural or functional ( due to swelling and inflammation) damage to the nerve, which reduces the sensitivity of the corresponding zone or causes specific sensations of numbness in it. Since this ailment is often combined with craniocerebral injuries, it can be accompanied by nausea, vomiting, headaches, lethargy, loss of orientation. Such sensations should be reported to the doctor, as they may indicate rather severe complications that must be taken into account when planning treatment. In addition to identifying signs of a fracture, the doctor, especially at the stage of providing primary care, checks the patency of the victim's airway, detects the presence of respiratory movements and heart contractions ( pulse). If there are any abnormalities, the doctor provides the necessary medical care by restoring the airway and performing cardiopulmonary resuscitation. Plain radiography Plain radiography is a fast, effective and non-invasive method that allows you to accurately determine both the presence of a jaw fracture and its location. This study is indicated in all cases with suspected jaw fracture, as well as in most cases with craniocerebral injuries. The method is based on the ability of X-rays to pass through the tissues of the body and form a negative image on a special film. At its core, this method is similar to photography, with the difference that X-rays are used to form an image, not the visible spectrum of light. Since solid formations, such as bones, are capable of absorbing and retaining rays, a shadow image is formed on the film placed under the tissue, which will correspond to the bone formation. The degree of absorption of x-rays bone tissue very large, so you can get a fairly clear image of the jaw and adjacent bone formations.
If a fracture of the lower jaw is suspected, X-rays of both the upper and lower jaws are performed in the direct and lateral projection, which also covers the area of ​​the facial skeleton, the vault and base of the skull, and several cervical vertebrae. As a result, diagnostics is not limited to only one bone, but covers the whole anatomical formation. With a fracture of the lower jaw, radiography allows you to determine the location of the fracture gap, the number of fractures, the presence or absence of fragments, the degree of their displacement. In case of a fracture of the upper jaw, the involvement of adjacent bone structures is assessed on the x-ray, as well as darkening of the maxillary sinuses ( as a result of hemorrhage in them). It should be noted that, despite its advantages, radiography has a number of significant drawbacks, among which the most significant is the need to irradiate the patient. In terms of hygiene environment, one of the tasks of which is to assess the radiological background and its effects on the body, performing several radiographic procedures increases the dose of radiation to a person, but the overall health impact is relatively small. However, since the effects of ionizing radiation can "cumulate", it is highly discouraged to be exposed to radiation unnecessarily. Orthopantomography Orthopantomography is an x-ray method of research that allows you to get a panoramic picture of the dentoalveolar system. It is performed using a special device - an orthopantomograph, in which the image is obtained by rotating the x-ray source and the film around the fixed head of the patient being examined. As a result of this, a panoramic image of the dentition, as well as the upper and lower jaws and nearby bone formations, is obtained on the film. This research method allows you to determine the presence and number of fractures of the jaw bones, damage to the temporomandibular joint and teeth. The whole procedure takes no more than five minutes and is relatively harmless. CT scan (CT ) Today, computed tomography is the preferred method for diagnosing jaw fractures, as it provides more accurate and detailed information. The method is also based on X-ray radiation - the patient is placed in a special CT scanner, and the X-ray machine rotating around it takes many pictures. After computer processing, a clear layer-by-layer image of the area under study is obtained, and if necessary, it is even possible to create a three-dimensional image of the facial skeleton. CT provides clear information about the presence and number of fractures, localization of the fracture gap, allows you to identify small fractures of the upper and lower jaws, fractures and cracks in nearby bone structures, visualize small fragments that may not be visible on a simple radiograph. Computed tomography is indicated in the following situations:

• in the presence of two or more fractures, determined radiographically;
• jaw fractures involving the dentition;
• suspicion of fractures of adjacent bone formations;
• before surgical treatment of jaw fractures.

It should be noted that the advantage of computed tomography is the clarity of the resulting image and the detail of the image. In addition, this method is extremely informative for traumatic brain injuries, and due to the speed of execution, it allows you to quickly diagnose cerebral hemorrhages. A significant disadvantage of computed tomography is the slightly higher dose of radiation to which the patient is exposed during the procedure. This is due to the fact that the device produces many consecutive shots, each of which irradiates the patient. However, due to the high degree of image detail and the absence of the need to take images in additional projections, this method is comparable in terms of safety to other radiological procedures. Magnetic resonance imaging (MRI ) Magnetic resonance imaging is a modern and highly informative method used in the diagnosis of jaw fractures. It is based on obtaining an image of soft tissues by fixing the properties of water molecules changed in a magnetic field. This method is more sensitive in the study of periarticular tissues, provides information about the state of the jaw vessels and nerves, allows you to assess the degree of damage to muscles, ligaments, intraarticular discs, determine hemorrhage into the cavity of the joint capsule and rupture of the joint capsule. All these pathologies can be detected only by this method, since other radiological procedures based on x-rays are relatively poor at imaging soft tissues. If damage to the vessels of the lower jaw, face and base of the skull is suspected, magnetic resonance can be performed using contrast. This method involves the intravenous administration of a special substance, which, under conditions magnetic field will be clearly visible in the picture. As a result, due to the presence of this substance in the vascular bed, damage to even the smallest vessels can be detected. The great advantage of MRI is the absolute safety of the method, which allows it to be used many times in the process of diagnosing and treating jaw fractures. The only contraindication for MRI is the presence of implants or metal elements in the patient's body, as they, moving under the influence of a magnetic field, can damage human tissues and organs during the procedure.

Treatment

Surgical treatment of jaw fractures

Surgical treatment of a jaw fracture, which is indicated for most patients, and which is called osteosynthesis in medicine, is the main effective method restoration of bone integrity. The following types of osteosynthesis are used to treat fractures:
In addition to the above methods used to fix fracture fragments, other methods are used in traumatology practice, the choice of which depends on the severity of the patient's condition, the type and complexity of the fracture, as well as the skills of the surgeon. Indications for osteosynthesis are:

• the presence of large and small bone fragments;
• a strong displacement of fragments and, as a result, the impossibility of comparing them without surgical intervention;
• fractures behind the dentition;
• pathological inflammatory or neoplastic process in the fracture area;
• reconstructive operations;
• a small number of healthy stable teeth on bone fragments.

Bone suture

To apply a bone suture, the fracture area is exposed from the soft tissues from the lateral and inner sides. Holes are made in the fragments, through which, after comparison, a wire is passed, with which the fragments are fixed. The wire can be made of stainless steel or titanium. In some cases, synthetic threads are used instead of wire, however, due to their lower strength, this method is of limited use. This method of osteosynthesis is indicated in all cases of fresh fractures of the lower and upper jaws, in which there is no significant displacement of bone fragments. Contraindications to this method are:

• inflammatory process in the fracture zone;
• the presence of many small bone fragments;
• osteomyelitis;
• gunshot wounds in the area;
• the presence of bone defects.

advantage this method is to maintain the ability to independently eat and perform oral hygiene, as well as the exclusion of complications in the temporomandibular joint.

Bone metal plates

Extra-osseous metal plates are widely used in maxillofacial surgery, since, firstly, they can reduce soft tissue injuries during surgery ( it is necessary to cut the skin and muscles from only one, lateral side), which positively affects the recovery period and the time of bone fusion, and secondly, it allows better fixation of fragments in areas subject to strong dynamic loads. To fix bone fragments, small narrow plates of titanium or stainless steel are used, which are screwed into the fracture area so that the fracture line is rigidly fixed.
Also, fast-hardening plastics, special glue ( resorcinol epoxy resins), memory metal staples, Kirchner spokes. For closed osteosynthesis, various extraoral wires and staples can be used. These include S-shaped and unified hooks, Kirschner wires, static and dynamic extraoral devices for immobilization, etc. The choice of fixation method is individual and is largely determined by the characteristics of the fracture.

Closed comparison of fragments

In addition to the above methods surgical treatment in some cases, it is possible to achieve comparison of bone fragments and non-surgical way. This approach has a number of advantages, since, firstly, it does not require surgery, and therefore it is devoid of a number of risks, and secondly, it is not associated with soft tissue injuries in the fracture area, which disrupts blood microcirculation and slightly increases the bone fusion time. However, the need for external bone fixation and limited jaw function are disadvantages of this method. Closed matching of fragments of the lower jaw involves the imposition of a special fixing splint, which is attached to the teeth and stabilizes the bone fragments. Today, closed comparison of bone fragments is used in cases where the fracture line of the bone allows it, when surgical intervention is associated with high risks, as well as in fractures with a large number of small bone fragments, which cannot be surgically compared.

Recovery period

The effectiveness and recovery time in the postoperative period depends, first of all, on the time of the operation relative to the moment of injury and on the type of osteosynthesis chosen. Also important is the general condition of the patient and the degree of compensation of his chronic and acute diseases. Timely prescription of antibiotics and restorative agents reduces the risk of complications, thereby reducing the recovery period. The use of physiotherapy, physiotherapy exercises and regular oral hygiene according to medical prescriptions are the basis for a quick recovery with full restoration of jaw function. Physiotherapy exercises can be carried out as early as 4-5 weeks after the fracture, of course, after removing the tires. It is aimed at restoring chewing and swallowing functions, as well as speech and facial expressions. The food regimen should be mechanically and chemically gentle, but at the same time cover daily requirement in nutrients. The food is crushed, diluted to a liquid state with broths, heated to 45 - 50 degrees.