Treatment of fractures of the lower jaw with the use of fixation devices. Maxillofacial prosthetics. The word "orthopedics" comes from the Greek orthos straight and paidevo to form, train, so under, orthopedics. Manufacture and overlay to the individual

dental wire
splinting,
proposed by S.S. Tigerstedt during the First World War (1916). IN
1967 V.S. Vasiliev developed a standard stainless steel band tire with ready-made toe hooks (Fig. 12
-2).
Rice. 12
-2.
Tires for tooth splinting for jaw fractures: a
- bent wire bus
S.S. Tigerstedt; b
- standard band splint for intermaxillary fixation according to V.S. Vasiliev

Distinguish
bent tires
from wire:

smooth tire
- bracket;

a smooth tire with a spacer;

a tire with hook loops;

a tire with hook loops and an inclined plane;

splint with toe loops and intermaxillary traction. For
splinting the following tools are required:

crampon tongs;

pliers;

anatomical and dental tweezers;

needle holder;

clip;

dental mirror;

file for metal;

crown scissors.
From
materials
needed:

aluminum wire 1.5 thick
-
2 mm in segments of 25 cm;

bronze-aluminum or copper wire, length 5
-
6cm thick 0.40.6cm;

rubber drain tube with 4 holes
-
6 mm for rubber rings;

dressing.
Before splinting, the patient's mouth must be freed from the remnants of food masses, plaque, broken teeth, bone fragments, blood clots with gauze balls soaked in a 3% hydrogen peroxide solution, followed by irrigation with potassium permanganate 1 ÷ 1000. If necessary, conduct anesthesia.
When fitting and applying
aluminum tires
(Fig. 12
-
3) it is necessary to adhere to certain requirements.

The tire should be curved along the vestibular surface of the dentition in such a way that it is adjacent to each tooth at least at one point. It is not necessary to bend it along the contours of the crowns of the teeth.

The tire should not be adjacent to the mucous membrane of the gums in order to avoid the formation of bedsores.

The ends of the splint are bent in the form of a hook around the distally located tooth in the form of an equator or in the form of a spike and inserted into the interdental space of the distal teeth from the vestibular side.
Rice. 12
-3.
Types of wire busbars: a
-
smooth tire
-
bracket; b
-
tire according to Schelhorn; in
-
wire splint with sliding hinge according to Pomerantseva
-
Urbanskaya; G
-
smooth
wire splint for impacted fracture

The arc is bent with fingers along the dentition with frequent correction in the oral cavity, avoiding repeated bending.

Forcible pressing of the tire to the teeth is unacceptable in order to avoid pain and displacement of fragments.

If there is a defect in the dentition, a U-shaped loop is bent on the splint, the upper crossbar of which corresponds to the width of the defect and faces the oral cavity.

The loops are bent with kampon tongs. The distance between the loops is not more than 15 mm, according to
2-
3 loops on each side. The toe loop should be no more than 3 mm long and bent at an angle of 45° to the gum. Loops should not injure the oral mucosa.

The splint is fixed with ligatures to as many teeth as possible. Ligatures are twisted clockwise, the excess is cut off and folded towards the center so that they do not injure the mucous membrane.
smooth tire
-
brace
shown:

with fractures of the alveolar process, if one-stage reduction of fragments is possible;

with median fractures of the lower jaw without vertical displacement of fragments;

with fractures within the dentition, if it is not accompanied by a vertical displacement of fragments;

with bilateral and multiple fractures of the lower jaw within the dentition, when a sufficient number of teeth are preserved on each fragment.
With the same indications, standard tires V.S. can be used. Vasiliev.
A smooth splint with a spacer is used for fractures with a defect in the dentition.
With vertical displacement of fragments in the event of a fracture within the dentition, tires with hook loops are used.
Tires with intermaxillary traction are used to treat fractures behind the dentition. In the treatment of fractures with vertical displacement of fragments, direct intermaxillary rubber traction is used. For the treatment of fractures with displacement of fragments in two planes, oblique intermaxillary traction is indicated.
In case of fractures of the lower jaw with a small number of teeth on fragments or in their complete absence, extra-osseous extra-oral devices V.F. Rud
- ko, Ya.M. Zbarzha.
In order to simplify the technique of manufacturing tooth splints and improve the fixation of fragments of the lower jaw, it is proposed to use a quick-hardening plastic, the main indication for the use of which is the fixation of bone fragments after they have been established in the correct position.
For fractures in the lateral sections, with osteomyelitis of the lateral section, to prevent displacement of fragments in the event of a pathological fracture, a stable inclined plane is used during surgery, which is 2
-
3 crowns made on the lateral teeth of the intact side, or a brazed tire, on the vestibular side of which a stainless steel plate is soldered. The plate rests on the vestibular surface of the teeth
- antagonists of the upper jaw. Its edge should not be higher than the necks of the teeth of the upper jaw with closed teeth, so as not to injure the mucous membrane. The plate is soldered to the crowns of the lower teeth just below the equator so that it does not interfere with the closing of the teeth.
In case of bilateral fractures of the lower jaw with a displacement of the median fragment downwards, the lateral fragments are parted and fixed in the correct position with a steel wire arch, and the short fragment is pulled up with the help of an intermaxillary traction. Treatment ends with a smooth splint
- with a bracket after all fragments are established in the correct closure of the teeth.
In case of a fracture of the lower jaw with one toothless fragment, it is fixed with a bent splint with a loop and a thermoplastic lining. Fragment with teeth is strengthened with wire ligatures to the teeth of the upper jaw.

For the treatment of single fractures of the lower jaw with complete mobility of fragments in the case of a small number of teeth on the fragments or the mobility of all teeth, a removable dentogingival Weber splint is used (Fig. 12
-
4). Such a tire covers the entire remaining dentition and gum on both fragments,
leaving open the chewing and cutting surfaces of the teeth. It can be used for post-treatment of mandibular fractures.
Rice. 12
-4.
Weber bus: a
-
the stage of manufacturing the wire carcass of the tire; b
-
finished tire
In case of fractures of the edentulous lower jaw and the absence of teeth on the upper jaw, devices are used
gunninga
-
Port, Limberg in combination with a chin sling (Fig. 12
-5).
Among fractures of the upper jaw, fractures of the alveolar process are more often noted. They can be without offset and with offset. The direction of displacement of the fragment is determined by the direction of the acting force. Basically, the fragments are displaced backwards or towards the midline.
First aid for treatment
fractures of the alveolar process comes down to setting the fragment in the correct position and applying a sling or outer bandage so that the teeth
- antagonists tightly closed. You can successfully apply an elastic sling bandage.
Simple specialized treatment of fractures of the alveolar process is carried out with a smooth aluminum or steel splint
- bracket. Fragment is repositioned first
Rice. 12
-5.
Devices used to treat fractures of the jaws in the complete absence
teeth: a
-
gunning apparatus
-
Port; b
-
Limberg apparatus

hands and with closed teeth bend the tire with hands
- bracket on the upper dentition. Then, between all the teeth, wire ligatures in the form of hairpins are threaded and their ends are brought out in the vestibule of the mouth. The splint is fixed to the teeth of the intact side, the patient is asked to close his teeth in the correct position, a sling is applied, and then the fragment is tied to the splint
- bracket. The sling is removed after the bracket is fully fixed. If there are contraindications to the tire
- bracket, a full splint is made with the location of the supporting crowns on the teeth of the intact area and the fragment.
At
fractures of the body of the upper jaw
(suborbital and subbasal) with free mobility of fragments, first aid is reduced to establishing the fragments in the correct position and fixing them to the head cap. For this purpose, standard devices are used: tires
- Spoons of Entin, Limberg, hard chin sling. Sling dressings are effective if the lower jaw is not damaged and both jaws have at least 6
-
8 pairs of teeth
- antagonists. Standard tires
- spoons impose on 1
-
2 days Their main disadvantages include: bulkiness, weak fixation of fragments, unhygienic, inability to follow the correct setting of the damaged upper jaw, since the splint
- the spoon covers the entire dentition.
Simple specialized treatment
is reduced to the simultaneous reduction and fixation of fragments in the correct position. For this, individual wire tires are used: solid-bent and composite. Inside
- and extraoral processes
- the levers connected to the tires are fixed in a plaster cap. For the treatment of fractures of the anterior jaw, Ya.M. Zbarzh proposed a solid-bent tire made of aluminum wire (Fig. 12
-6).
For the treatment of fractures of the upper jaw according to the Le Fort type I and II, Ya.M. Zbarzh has developed a standard kit consisting of a tire
- arc, support bandage and connecting rods, which can simultaneously fix and reduce fragments. Complex specialized treatment of a fracture of the upper
Rice. 12
-6.
Apparatus for the treatment of fractures of the upper jaw according to Ya.M. Zbarzhu: a
-
head
plaster cap; b
-
bent wire splint with extraoral processes,
fixed to the head cap

jaws with downward displacement with free mobility of the fragment (suborbital fracture) and the integrity of the lower jaw are carried out using the method inside
- oral fixation with a Weber splint with extraoral levers attached by means of elastic traction to the headband. It covers the teeth and the mucous membrane of the gums around the dentition from the palatine and vestibular sides.
Tubes are welded into the lateral sections on both sides, into which rods are inserted to connect with the head bandage. TO
deficiencies of the dentogingival
tires should include bulkiness, overlap of the mucous membrane of the alveolar process and hard palate, the need to obtain a complete impression from the upper jaw, weak fixation of the fragment. In order to eliminate shortcomings
Z.Ya. Schur proposed to replace the Weber splint with a single brazed splint with tetrahedral tubes in the lateral sections to strengthen the extraoral rods in them. The outer ends of the rods are rigidly connected to the gypsum cap with counter rods extending vertically down from the gypsum cap.
In the treatment of a simultaneous fracture of the upper and lower jaws, a periodontal splint with extraoral rods is indicated.
- with a mustache and toe hooks for intermaxillary fixation of fragments of the lower jaw, fixed to a soft head cap, proposed by A.A. Limberg.
With timely immobilization of jaw fragments with non-gunshot fractures, they grow together after 4
-
5 weeks Usually after 12
-
15 days after the injury, primary callus can be detected along the fracture line in the form of a dense formation. The mobility of bone fragments is markedly reduced. By the end of 4
-5th week, and sometimes even earlier, the mobility of fragments disappears with a decrease in compaction in the fracture area
- secondary callus is formed.
In X-ray examination, the gap between the bone fragments can be determined up to 2 months after the clinical healing of the fracture.
Therapeutic splints can be removed after the disappearance of the clinical mobility of fragments. The healing time for gunshot fractures is significantly increased.
Comprehensive restorative treatment of fractures is carried out under the control of radiography, myography and laboratory research methods.
12.2. CLASSIFICATION OF COMPLEX jaws
-
FACIAL DEVICES
Fastening of fragments of the jaws is carried out using various orthopedic devices. All orthopedic devices are divided into groups depending on the function, area of ​​fixation, therapeutic value, design, manufacturing method and material.

By function:
- immobilizing (fixing);
- reponing (correcting);
- corrective (guides);
- forming;
- resection (replacing);

Combined;
- prostheses for defects of the jaws and face.

Place of fixation:
- intraoral (single jaw, double jaw, intermaxillary);
- extraoral;
- inside
- and extraoral (maxillary, mandibular).

For medical purposes:
- basic (having independent medical value: fixing, correcting, etc.);
- auxiliary (serving for the successful implementation of skin
- plastic or bone
- plastic surgery).

By design:
- standard;
- individual (simple and complex).

According to the manufacturing method:
- laboratory production;
- non-laboratory production.

According to materials:
- plastic;
- metal;
- combined.

Immobilizing devices are used in the treatment of severe fractures of the jaws, insufficient number or absence of teeth on fragments. These include:
- wire tires (Tigerstedt, Vasiliev, Stepanov);
- tires on rings, crowns (with hooks for pulling fragments);
- tires
- kappas:

V metal
- cast, stamped, soldered;
V
plastic;

Removable tires Port, Limberg, Weber, Vankevich, etc.

Repositioning devices that promote the reposition of bone fragments are also used for chronic fractures with stiff jaw fragments. These include:
- repositioning devices made of wire with elastic intermaxillary traction, etc.;
- devices with inside
- and extraoral levers (Kurlyandsky, Oks
- mana);
- repositioning devices with a screw and a repulsive platform (Kur
- Landsky, Grozovsky);
- repositioning apparatus with a pelot on a toothless fragment (Kurlyandsko
- go, etc.);
- repositioning devices for edentulous jaws (Guning splints
-
port).

Fixing devices are called devices that help hold fragments of the jaw in a certain position. They are subdivided:
- for extraoral:

V standard chin sling with head cap;
V standard tire according to Zbarzh and others.
- intraoral:
■V
tooth splints:

wire aluminum (Tigerstedt, Vasiliev, etc.);

brazed tires on rings, crowns;

plastic tires;

fixing dental devices;
■
tooth-gingival tires (Weber and others);
■
gum tires (Port, Limberg);
- combined.

Guides (corrective) are called devices that provide a certain direction to the bone fragment of the jaw with the help of an inclined plane, pilot, sliding hinge, etc.
-
For wire aluminum tires, the guide planes are bent simultaneously with the tire from the same piece of wire in the form of a series of loops.
-
For stamped crowns and mouth guards, inclined planes are made of a dense metal plate and soldered.

-
For cast tires, the planes are modeled from wax and cast along with the tire.
-
On plastic tires, the guide plane can be modeled simultaneously with the tire as a whole.
-
In case of insufficient number or absence of teeth in the lower jaw, splints are used according to
Vankevich.

Forming devices are called devices that are the support of plastic material (skin, mucous membrane), create a bed for the prosthesis in the postoperative period and prevent the formation of cicatricial changes in soft tissues and their consequences (displacement of fragments due to constricting forces, deformations of the prosthetic bed, etc.). By design, the devices can be very diverse, depending on the area of ​​damage and its anatomy.
- physiological features. In the design of the forming apparatus, a forming part and fixing devices are distinguished.

Resection (replacement) devices are called devices that replace defects in the dentition formed after the extraction of teeth, filling defects in the jaws, parts of the face that arose after trauma, operations. The purpose of these devices
- restore the function of the organ, and sometimes keep fragments of the jaw from displacement or soft tissues of the face from retraction.

Combined devices are called devices that have several purposes and perform various functions, for example: fixing fragments of the jaw and forming a prosthetic bed or replacing a defect in the jawbone and simultaneously forming a skin flap.
A typical representative of this group is kappovo
- rod apparatus of combined sequential action according to Oxman for fractures of the lower jaw with a bone defect and the presence of a sufficient number of stable teeth on fragments.

Prostheses used in the maxillary
- facial orthopedics, divided into:
- on dentoalveolar;
- jaw;
- facial;
- combined;
- during resection of the jaws, prostheses are used, which are called post-resection prostheses.
Distinguish between immediate, immediate and distant prosthetics. In this regard, the prostheses are divided into operational and postoperative. Replacement devices also include orthopedic devices used for palatal defects: protective plates, obturators, etc.
Prostheses for defects of the face and jaws are made in case of contraindications to surgical interventions or in case of persistent unwillingness of patients to undergo plastic surgery.

If the defect captures a number of organs at the same time: nose, cheeks, lips, eyes, etc., a facial prosthesis is made in such a way as to restore all the lost tissues. Facial prostheses can be fixed with spectacle frames, dentures, steel springs, implants, and other devices.
12.3. TREATMENT TECHNIQUE FOR RIGID FRAGMENTS
A simple specialized treatment of mandibular fractures with limited mobility and stiffness of fragments is carried out by various devices that are well fixed on the jaw and have sufficient resistance to muscle traction. Limited mobility of fragments is observed when first aid is not provided in time or is carried out incorrectly. If the patient asked for help after 2
-
3 weeks after the fracture, the position of the fragments is almost always incorrect.
With single fractures with horizontal displacement of fragments to the midline, the most common, as well as for the treatment of fractures with freely movable fragments, are S.S. tires. Tigerstedt with hook loops.
In case of fractures within the dentition with stiff fragments, splints are made with hook loops on the upper jaw and a large fragment of the lower jaw, rubber traction is installed, and on a small fragment between the teeth
- antagonists place a gasket to squeeze it out. After a stable comparison of the fragments, the splint is removed and the treatment is completed with a single smooth splint. In some cases, it is advisable to leave the free end of the wire in the area of ​​a small fragment, and after correcting the position of the fragments, it is bent to the teeth of a small fragment and fixed with a ligature.
With bilateral and multiple fractures, along with Tiger splints
- stadt shows tires with vertical P
- and G
- figurative bends, to which fragments are pulled with ligatures. In case of fractures of the lower jaw with a shortened dentition or in the presence of an edentulous fragment, Tigerstedt splints with hook loops are applied to the large fragment and the upper jaw, and a pelot is made on the edentulous fragment. In case of fractures behind the dentition, Tigerstedt tires with intermaxillary traction are applied, which are retained even after correcting the position of the fragments.
In this case, the appointment of myogymnastics is mandatory.
For the treatment of single fractures and fractures with a bone defect in the anterior section, the A.Ya. Katz with intraoral springy levers. It consists of supporting elements
- kappa or crowns, to which a flat or quadrangular tube is soldered from the vestibular side, and two rods. The advantage of the Katz apparatus is that it is possible to move fragments in any direction: parallel expansion or convergence of fragments, movement of fragments in the sagittal and vertical directions, expansion or displacement only in the region of ascending branches and angles of the jaw, rotation of fragments around sagittal (longitudinal) axes.
With a complete detachment of the upper jaw with stiff fragments (subba
- hall fracture) with posterior displacement and rotation around the transverse axis for simple specialized treatment, traction is applied to the rod, reinforced to the plaster cast. The rod is made of steel

wire, its free end ends with a loop. A wire splint with hook loops is placed on the teeth of the upper jaw. By means of rubber traction, the displaced jaw is pulled to the lever fixed on the headband.
With a unilateral complete separation of the upper jaw, when a sufficient number of teeth have been preserved on both jaws, the reposition of the stiff fragment is achieved by intermaxillary traction. A splint with hook loops is placed on the lower jaw, and the upper splint is attached only on the healthy side, where the hook loops are made. On the affected side, the end of the tire is smooth and remains free. Rubber traction is applied between the toe loops, and between the teeth on the side of the fracture
- elastic lining. After the reposition of the fragment, the splint is fixed to the teeth of the diseased side.
12.4. ORTHOPEDIC TREATMENTS FOR FALSE JOINTS
To the consequences of the maxillofacial
- facial injuries also include ununited fractures of the jaws or a false joint (pseudoarthrosis). The most characteristic sign of an ununited fracture is the mobility of the jaw fragments. During the Great Patriotic War, about 10% of mandibular fractures ended in the formation of a false joint. These were fractures predominantly with a bone defect.

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 chosen method, one or two splints with hook loops can be used. Indications for use:
. mandibular fractures outside the dentition;
. fractures of the lower jaw within the dentition in the absence of four on a larger fragment, and two stable teeth on a smaller one;
. mandibular fractures 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 (complemented with a chin sling).
Tire bending technique with toe loops. A piece of aluminum wire 15 cm long is taken in the left hand and with the help of kampon forceps in the right hand, the hook hook is bent onto the wisdom tooth (or onto 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 splint should touch the second and third molars at least at one point and be located between the equator and the edge of the gum, 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, remove it from the mouth without changing position tires in tongs. Next, proceed to bending the toe loop.

Holding the forceps with their handles up, put the cheeks on the tire at an angle of 30-40 ° relative to the tooth. The splint is removed from the mouth, the tongs with the pinched splint are placed in a vertical position with the handles down, and the first finger of the left hand is bent the wire away from itself by 90°, pressing firmly against the cheeks of the tongs. Holding the bent (long) end of the wire with your 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 °), 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 °, making it a continuation of the already bent part of the tire. The tire is tried on on the teeth. The top of the loop should be turned down on the lower jaw and up - on the upper jaw, its length should be equal to 5 mm, it is located at an angle of 30-40 ° to the tooth (Fig. 5.9).

The criterion for the correct angle of inclination of the loop can be a piece of the wire from which the tire is bent: if this wire passes between the tooth and the loop, slightly touching them, the loop is bent correctly; if the wire does not pass, the loop should be bent; if two wires pass, the loop should be pressed against the tooth. If the angle between the loop and the tooth does not correspond to the required, further bending of the tire cannot be continued. The angle of the hinge should be corrected immediately. To do this, immediately in front of the loop (in the section of the already bent splint), the wire is grasped with the cheeks of crampon forceps, and the loop is fixed with a hemostatic clamp. Tightly holding the wire with kampon tongs, turn the hook loop with a clamp at a small angle, achieving a slope of 30-40 °. As with 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 over the second incisor and the splint is bent to the first incisor. After crossing the midline of the jaw, they 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. For example, if the toe loop is bent onto the second incisor, the wire is grasped with tongs between the first and second incisors, and so on. Finish bending the tire by making a hook or spike, using the techniques described for bending the brace. The spike should easily enter the interdental space, not injure the tongue and gums (Fig. 5.10).

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 in the mouth with forceps in such a way that the handles of the forceps are facing downwards, and the angle of inclination is also 30-40 ° to the buccal surface of the tooth crown. The first movement when bending the loop should be 90° towards you.

Toe loops are usually bent on the bar so that they are located in the area of ​​the sixth, fourth and second teeth. If these teeth are missing, then toe loops are made in the area of ​​other teeth, but this should be done, if possible, in teeth that have antagonists. Usually on the tire adjacent to the teeth of a larger fragment, 3-4 hook loops are bent, and to the teeth of a smaller fragment - 2-3 hook loops. The base of the loop must be within the crown of the tooth. If the angle of inclination of the loop with respect to the mucous membrane of the gums is less than 30°, then the toe rubber ring put on the loop causes the formation of a bedsore (decubital ulcer) on the gum. If this angle is greater than 45 °, a bedsore is formed on the mucous membrane of the cheek or lip.

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

Attach the tire to each tooth with a bronze-aluminum wire according to the described method.
After fixing both splints, depending on the location of the fracture and the nature of the displacement of the fragments, elastic and smooth movement of the jaw fragments into the correct (normal) position is started. To do this, rubber rings are put on the hook loops. The replicating rubber traction (oblique, vertical) 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 increases the suffering of the patient, gives a smaller effect and leads to tooth mobility. It is better to perform 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 is reduced and the fragments are fixed for the entire period of treatment with the help of rubber rings or (better) 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. In any case, reposition will be faster and more successful if the pellot 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, as if hammering them into each other, which significantly prevents the fragments from moving. 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 possible to finally judge the correctness of the location of the fragments using a radiograph made in at least two projections.

After splinting for a fracture of the upper jaw, the patient must wear an elastic chin sling. Otherwise, when opening the mouth, the lower jaw will move 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 are stretched and fragments can be displaced, the vestibule of the mouth is treated with antiseptic solutions: 3% hydrogen peroxide solution, potassium solution permanganate (pink), chlorhexidine solution, etc. They monitor the state of bite, the position of fragments and tissues in the fracture area. To control the quality of the reposition of fragments, an X-ray examination is performed immediately after immobilization. In order to control the fusion of fragments, x-rays are taken 10-25 days after the fracture.

Particular attention should be paid to the proper nutrition of the patient. See Chapter 7 for more on this.
Before removing the tires, rubber rings are removed and the patient is allowed to walk with open jaws for 1-2 days, taking soft food. If during this time there is no displacement of the fragments (the displacement will be indicated by a violation of the bite), the tires are removed. If there is a slight change in bite, 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 2 loops on each side. However, a smooth brace should be preferred.

Splinting according to the Vihrov-Slepchenko method. A.P. Vikhrov and M.A. Slepchenko (1981) suggested using a polyamide thread to reinforce the fastening of a splint (smooth staple or with hook loops) on the teeth. To do this, a bronze-aluminum wire ligature is folded in the form of a hairpin and both ends are inserted into the 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. A similar procedure is performed in the area of ​​all interdental spaces. A polyamide thread with a diameter of 1 mm is passed through all the loops from 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 applied to the teeth so that it is located between the two ends of the same previously made bronze-aluminum ligatures, which are then twisted. The authors pointed out the advantages of their method: the presence of a stronger attachment, a reduction in the time of fixing the splint, and the absence of trauma to the gingival mucosa (Fig. 5.11).

Ring tires.

The large contact surface of the annular tires with the teeth ensures good tire stability. In addition, the chewing surface of the teeth not covered with a splint makes it possible to control the ratio of the dentition in the occlusion. Due to the fact that the manufacture of high-quality ring splints is very laborious, recently, in medical institutions, they are used to fix the jaws in the complex surgical and orthopedic treatment of severe forms of malocclusion (progeny, open bite). For the treatment of patients with traumatic injuries of the jaws, ring splints are used less frequently. Distinguish standard And individual ring tires. The standard devices include Schroeder and Angle devices or arcs. Custom made tires consist of rings and arches soldered to the rings. If necessary, branches or hooks for intermaxillary fastening are soldered to the arcs. Rings are soldered or stamped. The ring splint is a temporary construction, therefore grinding of teeth, even in the area of ​​contact points, is unacceptable. With close interdental contacts, the separation of teeth is carried out by conservative methods (rubber strips or ligature wire).

Soldered tires.

Soldered rod (beam) tire of Limberg.

Indications for use: treatment of jaw fractures with low clinical crowns of teeth, their insufficient number, and with tooth mobility. If necessary, the crowns in this tire are replaced with rings or crowns are turned into rings by sawing off their chewing surface. When intermaxillary traction is necessary, then wire processes-hooks are soldered to the rods - rods 3-4 mm long, and the splint on the lower jaw is made of two parts, respectively, to the fragments. After the fragments are repositioned, an impression is taken from the lower jaw, both parts of the splint are soldered on the resulting model, making it single-jawed. Sometimes, a rectangular or oval-shaped sleeve-tube for extraoral levers is additionally soldered to the buccal surface of the crowns (rings).

Solid tyres.

Indications for use: used for fractures of the lower jaw without displacement of fragments or their slight reposition within the dentition, when the teeth on the fragments are placed parallel (without inclination). In the presence of inclination of the teeth, collapsible solid tires are used. These tires are removable, so they can be additionally fixed with cement, special glue.

Multi-link solid tire with front arches. It is fixed to the orthopedic cap with bandages (rubber bands).

Indications for use: treatment of fractures of the upper jaw with a sufficient number of stable teeth on fragments.

Kappa tyres.

Distinguish plastic and metal kappa tires , the latter are divided into stamped and cast.

Plastic kappa splints laboratory production.

Manufactured from hot hardened plastic. They have high aesthetic qualities. However, due to the elasticity and fragility of the plastic, they are not used to fix the jaws with complete fractures.

Indications for use: dislocations of teeth, fractures of the alveolar process, treatment of fractures of the lower jaw in children under 3 years of age. In the event that there is a need for depulpation of the tooth, a hole is created in the kappa before fixation, taking into account better access to the pulp chamber. Fixation of the mouth guard on the teeth with cement or fast-hardening plastic. Kappa is put on the victim for 4-6 weeks along with a chin sling.

Metal kappa splints.

Indications for use: fixation of jaw fragments during bone grafting operations, fractures of the lower jaw within the dentition for single-jaw fixation. Splinting with metal mouthguards is possible only in patients who do not suffer from periodontal disease, with complete dentition or with small defects. It is advisable to use them for fractures of the jaws in patients with common diseases (tuberculosis), when enhanced nutrition is needed.

Tires of Kurlyandsky V.Yu. for intraoral immobilization in case of mandibular fractures(fixation: a) square, b) round tubes).

Each apparatus consists of mouth guards, to which, from the vestibular side, levers with a lock are soldered: each lever is soldered in such a way that the middle of the lock coincides with the middle of the lower jaw. When the lock is opened, it will turn out that a metal plate of different lengths will be soldered to each mouthguard applied to the teeth of each fragment, equalizing the length of the arms of both fragments. Thus, the apparatus can both reposition and immobilize fragments.

Metal stamped mouthguards.

Indications for use: used if necessary, rigid fixation of fragments for a long period (with multiple fractures, fractures of the lower jaw with the formation of a defect). The kappa can be stamped from separate links for 3-5 teeth, followed by soldering the links into one kappa. To increase rigidity, a wire arc is soldered to the kappa on one side, more often on the oral one.

Dental splints.

Dental splint Weber.

The author made a splint from rubber, currently it is made from acrylic plastics, hot cured in the laboratory, and cold cured in the clinic. In the latter case, the mucous membrane of the alveolar process is lubricated with petroleum jelly to avoid chemical burns with the monomer. Use with a full dentition or partial loss of teeth. If there is a defect in the dentition, artificial teeth can be welded onto the splint, thereby restoring its continuity. Then the Weber splint not only fixes the fragments, but also plays the role of a replacement prosthesis, and also prevents loosening of the teeth. Its disadvantages include the fact that it does not keep fragments from vertical displacement, time-consuming imposition and mobility that occurs over time. Therefore, it has recently been abandoned.

Indications for use:

1) fracture (crack) without displacement of jaw fragments;

2) in fractures with a slight displacement of fragments, if after reposition they do not return to their previous position;

3) in the aftertreatment of fractures, after the removal of the double-maxillary apparatus, when there was a consolidation of fragments, but the callus is not yet reliable;

4) with insufficient number of teeth to fix the tooth splints;

5) with the mobility of the teeth remaining on the fragments.

6) when using the method of the surrounding suture for fractures of the lower jaw, fragments are fixed to the Weber splint with nylon or wire ligatures.

Weber tooth-gingival splint with an inclined plane.

Indications for use:

1) used for immobilization and prevention of lateral displacement of fragments in case of fractures of the lower jaw outside the dentition, fracture of a branch or articular process due to the emphasis of the inclined plane on the vestibular surface of the teeth-antagonists of the upper jaw;

2) in addition, the Weber splint is used for significant defects in the lower jaw as a result of traumatic osteomyelitis, a gunshot wound, or after resection of the lower jaw for a tumor.

The tire is superimposed for a period of 2-3 months. The imposition of a splint can lead to the elimination of a pronounced lateral displacement of the mandible after removal of the splint.

Weber dental splint with extraoral rods.

Indications: treatment of fractures of the upper jaw with displacement of fragments from top to bottom with an intact lower jaw.

Dental splint M.M. Vankevich.

Indications for use: 1) in the treatment of fractures of the lower jaw with significant defects in the anterior region, to prevent the displacement of fragments forward, upward and inward, due to the emphasis of the inclined planes in the anterior edges of the branches or in the alveolar part of the lateral parts of the body; 2) in the treatment of fractures of the lower jaw with edentulous alveolar processes or with the absence of a large number of teeth. 3) with bone grafting of the lower jaw to hold bone grafts.

Tire M.M.Vankevich can also be used in orthopedic treatment of fractures of the edentulous lower jaw for repositioning of fragments that have shifted in the transversal direction. For this purpose, the vertical processes of the apparatus are corrected with the help of cold-curing plastic or with the help of a sten, followed by its replacement with plastic. The rollers formed in this way put pressure on the fragments and gradually spread them outwards. To the disadvantages of the tire M.M. Vankevich refers to its bulkiness and the impossibility of using it with limited mouth opening.

Sheena M.M.Vankevich modified by A.I.Stepanov

In this device, the maxillary base is replaced by a metal arch, like in a clasp prosthesis, which makes the device lighter and more convenient, accelerates adaptation, improves hygiene, and does not change the taste sensation.

Indications for use: the same as for the tire M.M. Vankevich. Both devices are used in combination with a chin sling.

Gingival tyres.

Port bus.

Indications for use: it is used for fractures of the edentulous lower jaw without displacement of fragments, the patient does not have removable dentures and teeth in the upper jaw. A necessary condition is unhindered opening of the mouth.

Gunning bus (split)

Indications for use: it is used for fractures of the jaws in case of complete adentia or in the presence of 1-2 teeth, when there is limited mouth opening (post-traumatic contracture, TMJ disease, with sutures in the lips or cheeks).

Both tires are used as an immobilizing device only in combination with wearing a chin sling bandage. The tires have a front section with a hole for feeding.

Tire Limberg.

Indications for use: treatment of mandibular fractures with complete adentia and difficulty opening the mouth.

Sheena Limberga in the modification of the circle members of the Department of Orthopedic Dentistry of KhSMU: blanks (sleeves) for metal stamped crowns are used as locks.

Apparatus of A.M. Rarog.

Indications for use: for the treatment of fractures of the edentulous jaws. It is made of wire by bending horizontal loops located across the edentulous alveolar processes. These loops, worn on both sides of the jaw, are connected by an arc and placed on both sides. The device is held by the elasticity of the wire. It does not allow the fragments to move and does not deprive the patient of the opportunity to freely open his mouth. The disadvantage of such tires is their indentation into the mucous membrane of the alveolar process and the formation of bedsores. To protect the mucous membrane from injury N.I. Mikhelson recommends placing black gutta-percha under the wire, which allows the patient to use the devices without harm to him for 12-14 days.

At the Department of Orthopedic Dentistry of KhSMU, it was proposed to use alginate impression material Stomalgin-04 with improved clinical and technological properties for the manufacture of removable gingival splints at the stage of obtaining impressions.

The splint is used for fixing fragments of the lower jaw after they have been compared and for post-treatment of fractures of the jaws. It covers the remaining dentition and gums on both fragments, leaving open occlusal surfaces and cutting edges of the teeth.

Manufacturing. Impressions are taken from the damaged and opposite jaws, models are obtained, they are made in the position of central occlusion and plastered into the occluder. A frame is made of stainless wire with a diameter of 0.8 mm in the form of a closed arc. The wire should be separated from the teeth and the alveolar part (process) by 0.7-0.8 mm and held in this position by transverse wires passed in the area of ​​interdental contacts. The places of their section with longitudinal wires are soldered. When using a tire for the treatment of fractures of the upper jaw in the lateral sections, oval-shaped tubes are soldered for the introduction of extraoral rods. Then a tire is modeled from wax, plastered into a ditch in a direct way and the wax is replaced with plastic, after which it is processed.

2.3 Apparatus a. I. Betelman

It consists of several crowns (rings) soldered together, covering the teeth on fragments of the jaw and antagonist teeth. On the vestibular surface of the crowns of both jaws, tetrahedral tubes were soldered for the insertion of a steel bracket. The device is used in the presence of a defect in the lower jaw in the chin area with 2-3 teeth on each fragment.

Manufacturing. Casts are taken from the jaw fragments for the manufacture of crowns. They fit crowns on the teeth, take casts from the fragments of the jaw and from the upper jaw. Models are cast, compared in the position of central occlusion, and plastered into the occluder. The crowns are soldered together and horizontal quadrangular or oval tubes are soldered from the vestibular surface of the crowns of the upper and lower jaws. Two U-shaped brackets are made, 2-3 mm thick, according to the shape of the bushings. The apparatus is applied to the jaw, the fragments are placed in the correct position and fixed by inserting a staple.

2.4 Lamellar tire a. A. Limberg

The tire is used to treat fractures of edentulous jaws.

Manufacturing. Impressions are taken from each edentulous fragment of the lower jaw and intact edentulous upper jaw. Individual spoons are made for each fragment of the lower jaw and the upper jaw. Individual spoons are fitted, solid occlusal stencils are fixed on them, the central ratio is determined and fixed with the help of a chin “sling”. In this state, individual spoons of the lower jaw are fastened with quick-hardening plastic, removed from the oral cavity. Gypsum is put into the occluder, the wall rollers are removed and replaced with columns of quick-hardening plastic. Impose on the jaw tires and chin "sling".

2.5 Soldered tire on rings according to A. A. Limberg.

The tire is used to treat single linear fractures of the jaws in the presence of at least three supporting teeth on each fragment. Manufacturing. According to the casts, crowns (rings) are made for the abutment teeth, checked in the oral cavity, casts are taken from the fragments on the teeth of which there are crowns, and a cast from the opposite jaw. Models are cast in the laboratory, fragments with crowns are set in the correct ratio with the antagonist teeth and plastered into the occluder. Wires are soldered to the crowns vestibularly and orally; if the tire is used for intermaxillary traction, then hook hooks are soldered to the wire, curved towards the gum. The soldered splint on the lower jaw can be supplemented with an inclined plane in the form of a stainless steel plate on the vestibular side of the intact half of the jaw. After finishing, grinding and polishing, the splint is fixed on the abutment teeth with cement.

Already in Hippocrates and Celsus there are indications of the fixation of fragments of the jaw when it is damaged. Hippocrates used a rather primitive apparatus, consisting of two straps: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus, using a cord of hair, strengthened the fragments of the lower jaw by the teeth standing on both sides of the fracture line. At the end of the 18th century, Ryutenik and in 1806 E. O. Mukhin proposed a “submandibular splint” for fixing fragments of the lower jaw. A hard chin sling with a plaster bandage for the treatment of fractures of the lower jaw was first used by the founder of military field surgery, the great Russian surgeon N. I. Pirogov. He also offered a drinker for feeding the wounded with maxillofacial injuries.

During the Franco-Prussian War (1870-1871), lamellar splints became widespread in the form of a base attached to the teeth of the upper and lower jaws, with bite rollers made of rubber and metal (tin), in which there was a hole in the anterior region for eating ( Guning-Port apparatus). The latter was used to fix fragments of the edentulous lower jaw. In addition to these devices, a hard chin sling was applied to the patients to support the fragments of the jaw, fixing it on the head. These devices, quite complex in design, could be made individually according to the impressions of the upper and lower jaws of the wounded in special dental laboratories and therefore were used mainly in the rear medical institutions. Thus, by the end of the 19th century, there was still no military field splinting, and assistance for maxillofacial wounds was provided with a great delay.

In the first half of the 19th century, a method was proposed for fixing fragments of the lower jaw with a bone suture (Rogers). A bone suture for fractures of the lower jaw was also used during the Russo-Japanese War. However, at that time, the bone suture did not justify itself due to the complexity of its use, and most importantly, the subsequent complications associated with the lack of antibiotics (development of osteomyelitis of the jaw, repeated displacement of fragments and malocclusion). Currently, the bone suture has been improved and is widely used.

Prominent surgeon Yu. K. Shimanovsky (1857), rejecting a bone suture, combined a plaster cast in the chin area with an intraoral "stick splint" for immobilizing jaw fragments. Further improvement of the chin sling was carried out by Russian surgeons: A. A. Balzamanov proposed a metal sling, and I. G. Karpinsky - a rubber one.

The next stage in the development of methods for fixing jaw fragments are dental splints. They contributed to the development of methods for early immobilization of jaw fragments in front-line military sanitary institutions. Since the 90s of the last century, Russian surgeons and dentists (M. I. Rostovtsev, B. I. Kuzmin, etc.) have used dental splints to fix jaw fragments.

Wire splints were widely used during the First World War and took a firm place, later replacing plate splints in the treatment of gunshot wounds of the jaws. In Russia, aluminum wire tires were put into practice during the First World War by S. S. Tigerstedt (1916). Due to the softness of aluminum, the wire arc can be easily bent into the dental arch in the form of a single and double jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires proved to be rational in a military field situation. They do not require special prosthetic equipment and support staff, therefore they have won universal recognition and are currently used with minor changes.

During the First World War, the medical service in the Russian army was poorly organized, and the care of the wounded in the maxillofacial region suffered especially. So, in the maxillofacial hospital organized by G. I. Vilga in 1915 in Moscow, the wounded arrived late, sometimes 2-6 months after the injury, without proper fixation of jaw fragments. As a result, the duration of treatment was prolonged and persistent deformities occurred with a violation of the function of the masticatory apparatus.

After the Great October Socialist Revolution, all the shortcomings in the organization of the sanitary service were gradually eliminated. Good maxillofacial hospitals and clinics have now been set up in the Soviet Union. A coherent doctrine of the organization of the sanitary service in the Soviet Army at the stages of medical evacuation of the wounded, including to the maxillofacial area, has been developed.

During the Great Patriotic War, Soviet dentists significantly improved the quality of treatment of the wounded in the maxillofacial region. Medical assistance was provided to them at all stages of the evacuation, starting from the military district. Specialized hospitals or maxillofacial departments were deployed in the army and front-line areas. The same specialized hospitals were deployed in the rear areas for the wounded in need of longer treatment. Simultaneously with the improvement of the organization of the sanitary service, the methods of orthopedic treatment of fractures of the jaws were significantly improved. All this played a big role in the outcomes of treatment of maxillofacial wounds. So, according to D. A. Entin and V. D. Kabakov, the number of completely healed wounded with damage to the face and jaw was 85.1%, and with isolated damage to the soft tissues of the face - 95.5%, while in the First World War (1914-1918) 41% of those wounded in the maxillofacial region were dismissed from the army due to disability.

Classification of fractures of the jaws

Some authors base the classification of jaw fractures on the localization of the fracture along the lines corresponding to the places of the weakest bone resistance, and the ratio of the fracture lines to the facial skeleton and skull.

I. G. Lukomsky divides fractures of the upper jaw into three groups depending on the location and severity of clinical treatment:

1) fracture of the alveolar process;

2) suborbital fracture at the level of the nose and maxillary sinuses;

3) orbital fracture, or subbasal, at the level of the nasal bones, the orbit and the main bone of the skull.

By localization, this classification corresponds to those areas where fractures of the upper jaw most often occur. The most severe are fractures of the upper jaw, accompanied by a fracture, separation of the nasal bones and the base of the skull. These fractures are sometimes pumped up by death. It should be pointed out that fractures of the upper jaw occur not only in typical places. Very often one type of fracture is combined with another.

D. A. Entin divides non-gunshot fractures of the lower jaw according to their localization into median, mental (lateral), angular (angular) and cervical (cervical). An isolated fracture of the coronoid process is relatively rare. (fig. 226).

D. A. Entin and B. D. Kabakov recommend a more detailed classification of jaw fractures, consisting of two main groups: gunshot and non-gunshot injuries. In turn, gunshot injuries are divided into four groups:

1) by the nature of the damage (through, blind, tangential, single, multiple, penetrating and not penetrating the mouth and nose, isolated with and without damage to the palatine process and combined);

2) by the nature of the fracture (linear, comminuted, perforated, with displacement, without displacement of fragments, with and without defect of the bone, unilateral, bilateral and combined;

3) by localization (within and outside the dentition);

4) according to the type of injuring weapon (bullet, fragmentation).

Rice. 226 Localization of typical fractures in the lower jaw.

Currently, this classification includes all facial injuries and has the following form.

I . gunshot wounds

Type of damaged tissue

1. Wounds of soft tissues.

2. Wounds with bone damage:

A. Mandible

B. Upper jaw.

B. Both jaws.

G. Zygomatic bone.

D. Damage to several bones of the facial skeleton

II. Non-fire wounds and damage

III. Burns

IV. Frostbite

According to the nature of the damage

1. Through.

2. Blind.

3. Tangents.

A.Insulated:

a) without damage to the organs of the face (tongue, salivary glands and others);

b) with damage to the organs of the face

B. Combined (simultaneous injuries to other areas of the body).

B. Single.

D. Multiple.

D. Penetrating into the mouth and nose

E. Non-penetrating

By the type of weapon that hurts

1. Bullets.

2. Fragmentation.

3.Ray.

Classification of orthopedic devices used for the treatment of jaw fractures

Fixation of fragments of the jaws is carried out using various devices. It is advisable to divide all orthopedic devices into groups in accordance with the function, area of ​​fixation, therapeutic value, design.

Division of devices according to function. Apparatuses are divided into corrective (reponing), fixing, guiding, shaping, replacing and combined.

Regulatory (reponing) devices are called, contributing to the reposition of bone fragments: tightening or stretching them until they are placed in the correct position. These include wire aluminum splints with elastic traction, wire elastic braces, devices with extraoral control levers, devices for spreading the jaw with contractures, etc.

Guides are mainly devices with an inclined plane, a sliding hinge, which provide a certain direction to the bone fragment of the jaw.

Devices (spikes) that hold parts of an organ (for example, the jaw) in a certain position are called fixing devices. These include a smooth wire clamp, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw during bone grafting, etc.

Forming devices are called, which are the support of the plastic material (skin, mucous membrane) or create a bed for the prosthesis in the postoperative period.

Substitutes include devices, replacing the defects of the dentition, formed after the extraction of teeth, filling the defects of the jaws, parts of the face that arose after an injury, operations. They are also called prostheses.

Combined devices include that have several purposes, for example, fixation of fragments of the jaw and the formation of a prosthetic bed or replacement of a defect in the jawbone and at the same time the formation of a skin flap.

Division of devices according to the place of fixation. Some authors divide devices for the treatment of jaw injuries into intraoral, extraoral and intra-extraoral. To intraoral devices are attached to the teeth or adjacent to the surface of the oral mucosa, to extraoral - adjacent to the surface of the integumentary tissues outside the oral cavity (chin sling with a headband or extraoral bone and intraosseous spikes for fixing jaw fragments), to intra-extraoral - devices, one part of which is fixed inside, and the other outside the oral cavity.

In turn, intraoral splints are divided into single-jawed and double-jawed. The former, regardless of their function, are located only within one jaw and do not interfere with the movements of the lower jaw. Two-jaw devices are applied simultaneously to the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.

Division of devices for medical purposes. According to the therapeutic purpose, orthopedic devices are divided into basic and auxiliary.

The main ones are fixing and correcting splints, used for injuries and deformities of the jaws and having independent therapeutic value. These include replacement devices that compensate for defects in the dentition, jaw and parts of the face, since most of them help restore the function of the organ (chewing, speech, etc.).

Auxiliary devices are those that serve to successfully perform skin-plastic or osteoplastic operations. In these cases, the main type of medical care will be surgical intervention, and the auxiliary one will be orthopedic (fixing devices for bone grafting, shaping devices for facial plastic surgery, protective palatal plastic surgery for palate plastic surgery, etc.).

Division of devices by design.

By design, orthopedic devices and splints are divided into standard and individual.

The first include the chin sling, which is used as a temporary measure to facilitate the transportation of the patient. Individual tires can be of simple or complex design. The first (wire) ones are bent directly at the patient and fixed on the teeth.

The second, more complex ones (plate, cap, etc.) can be made in a dental laboratory.

In some cases, from the very beginning of treatment, permanent devices are used - removable and non-removable splints (prostheses), which at first serve to fix the jaw fragments and remain in the mouth as a prosthesis after the fragments have fused.

Orthopedic devices consist of two parts - supporting and acting.

The supporting part is crowns, mouthguards, rings, wire arches, removable plates, head caps, etc.

The active part of the device is rubber rings, ligatures, an elastic bracket, etc. The active part of the device can be continuously operating (rubber rod) and intermittent, acting after activation (screw, inclined plane). Traction and fixation of bone fragments can also be carried out by applying traction directly to the jawbone (the so-called skeletal traction), with a head plaster bandage with a metal rod serving as the supporting part. The traction of the bone fragment is performed using an elastic traction attached at one end to the jaw fragment by means of a wire ligature, and at the other end to the metal rod of the head plaster bandage.

FIRST SPECIALIZED AID FOR JAW FRACTURES (IMMOBILIZATION OF FRAGMENTS)

In wartime, in the treatment of wounded in the maxillofacial region, transport tires, and sometimes ligature bandages, are widely used. Of the transport tires, the most convenient is a hard chin sling. It consists of a headband with side rollers, a plastic chin sling and rubber bands (2-3 on each side).

Rigid chin sling is used for fractures of the lower and upper jaws. In case of fractures of the body of the upper jaw and intact lower jaw, and in the presence of teeth on both jaws, the use of a chin sling is indicated. The sling is attached to the headband with rubber bands with significant traction, which is transmitted to the upper dentition and contributes to the reduction of the fragment.

In case of multi-comminuted fractures of the lower jaw, rubber bands connecting the chin sling with the head bandage should not be tightly applied, in order to avoid significant displacement of the fragments.

3. N. Pomerantseva-Urbanskaya, instead of the standard hard chin sling, proposed a sling that looked like a wide strip of dense material, into which pieces of rubber were sewn on both sides. The use of a soft sling is easier than a hard one, and in some cases more comfortable for the patient.

Ya. M. Zbarzh recommended a standard splint for fixing fragments of the upper jaw. Its splint consists of an intraoral part in the vnds of a double stainless steel wire arc, covering the dentition of the upper jaw on both sides, and outwardly extending extraoral levers directed posteriorly to the auricles. The extraoral levers of the tire are connected to the head bandage using connecting metal rods (Fig. 227). The diameter of the wire of the inner arc is 1-2 mm, the diameter of the extraoral rods is 3.2 mm. Dimensions

Rice. 227. Standard tires Zbarzha for immobilization of fragments of the upper jaw.

a - bus-arc; b - headband; c - connecting rods; e - connecting clamps.

wire arch are regulated by extension and shortening of its palatal part. The tire is used only in cases where manual reduction of fragments of the upper jaw is possible. M. 3. Mirgazizov proposed a similar device for a standard splint for fixing fragments of the upper jaw, but only using a plastic palatal plane. The latter is corrected with a quick-hardening plastic.

Ligature bonding of teeth

Rice. 228. Intermaxillary bonding of teeth.

1 - according to Ivy; 2 - according to Geikin; .3—but Wilga.

One of the simplest ways of immobilization of jaw fragments, which does not require much time, is ligature binding of teeth. A bronze-aluminum wire 0.5 mm thick is used as a ligature. There are several ways to apply wire ligatures (according to Ivy, Wilga, Geikin, Limberg, etc.) (Fig. 228). Ligature binding is only a temporary immobilization of fragments of the jaw (for 2-5 days) and is combined with the imposition of a chin sling.

Wire busbar overlay

More rational immobilization of fragments of the jaw with splints. Distinguish between simple special treatment and complex. The first is the use of wire tires. They are imposed, as a rule, in the army area, since the manufacture does not require a dental laboratory. Complex orthopedic treatment is possible in those institutions where there is an equipped prosthetic laboratory.

Before splinting, conduction anesthesia is performed, and then the oral cavity is treated with disinfectant solutions (hydrogen peroxide, potassium permanganate, furatsilin, chloramine, etc.). The wire splint should be curved along the vestibular side of the dentition so that it is adjacent to each tooth at least at one point, without imposing on the gingival mucosa.

Wire tires have a variety of shapes (Fig. 229). Distinguish between a smooth wire splint-bracket and a wire splint with a spacer corresponding to the size of the defect in the dentition. For intermaxillary traction, wire arcs with hook loops on both jaws are used for A.I. Stepanov and P.I. desired section of the tire.

The method of applying ligatures

To fix the tire, wire ligatures are used - pieces of bronze-aluminum wire 7 cm long and 0.4-0.6 mm thick. The most common is the following method of conducting ligatures through the interdental spaces. The ligature is bent in the form of a hairpin with ends of various lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and removed from the vestibule (one under the splint, the other over the splint). Here the ends of the ligatures are twisted, the excess spiral is cut off and bent between the teeth so that they do not damage the gum mucosa. In order to save time, you can first hold the ligature between the teeth, bending one end down and the other up, then lay the tire between them and secure it with ligatures.

Indications for the use of bent wire bars

A smooth arc of aluminum wire is indicated for fractures of the alveolar process of the upper and lower jaws, median fractures of the lower jaw, as well as fractures of other localization, but within the dentition without vertical displacement of fragments. In the absence of a part of the teeth, a smooth splint with a retention loop is used - an arc with a spacer.

The vertical displacement of fragments is eliminated with wire splints with hook loops and intermaxillary traction using rubber rings. If the jaw fragments are simultaneously reduced, then the wire slime is immediately attached to the teeth of both fragments. With stiff and displaced fragments and the impossibility of their simultaneous reduction, the wire splint is first attached with ligatures to only one fragment (long), and the second end of the splint is attached with ligatures to the teeth of another fragment only after the normal closure of the dentition is restored. Between the teeth of a short fragment and their antagonists, a rubber gasket is placed to speed up the bite correction.

In case of a fracture of the lower jaw behind the dentition, the method of choice is the use of a wire spike with intermaxillary traction. If the fragment of the lower jaw is displaced in two planes (vertical and horizontal), an intermaxillary traction is shown. In case of a fracture of the lower jaw in the area of ​​​​the angle with a horizontal displacement of a long fragment towards the fracture, it is advisable to use a splint with a sliding hinge (Fig. 229, e). It differs in that it fixes the fragments of the jaw, eliminates their horizontal displacement and allows free movement in the temporomandibular joints.

With a bilateral fracture of the lower jaw, the middle fragment, as a rule, is displaced downwards, and sometimes also backwards under the influence of muscle traction. In this case, often the lateral fragments are displaced towards each other. In such cases, it is convenient to immobilize the jaw fragments in two stages. At the first stage, the lateral fragments are bred and fixed with a wire arc with the correct closure of the dentition, at the second, the middle fragment is pulled up with the help of intermaxillary traction. Having set the middle fragment in the position of the correct bite, it is attached to a common tire.

In case of a fracture of the lower jaw with one toothless fragment, the latter is fixed with a bent spike made of aluminum wire with a loop and lining. The free end of the aluminum tire is fixed on the teeth of another fragment of the jaw with wire ligatures.

Rice. 229. Wire bus according to Tigerstedt.

a - smooth tire-arc; b - a smooth tire with a spacer; in - bus with. hooks; g - a spike with hooks and an inclined plane; e - splint with hooks and intermaxillary traction; e - rubber rings.

In case of fractures of the edentulous lower jaw, if the patient has dentures, they can be used as splints for temporary immobilization of jaw fragments with simultaneous application of a chin sling. To ensure the intake of food in the lower prosthesis, all 4 incisors are cut out and the patient is fed from a drinker through the hole formed.

Treatment of fractures of the alveolar process

Rice. 231. Treatment of fractures of the alveolar process.

a - with an inward displacement; b - with posterior displacement; c - with vertical displacement.

In case of fractures of the alveolar process of the upper or lower jaw, the fragment, as a rule, is fixed with a wire splint, most often smooth and single-jawed. In the treatment of a non-gunshot fracture of the alveolar process, the fragment is usually set at the same time under novocaine anesthesia. The fragment is fixed with a smooth aluminum wire arc 1.5–2 mm thick.

In case of a fracture of the anterior part of the alveolar process with a displacement of the fragment back, the wire arc is attached with ligatures to the lateral teeth on both sides, after which the fragment is pulled anteriorly with rubber rings (Fig. 231, b).

In case of a fracture of the lateral part of the alveolar process with its displacement to the lingual side, a springy steel wire 1.2-1.5 mm thick is used (Fig. 231, a). The arc is first attached with ligatures to the teeth of the healthy side, then the fragment is pulled with ligatures to the free end of the arc. When the fragment is vertically displaced, an aluminum wire arc with hook loops and rubber rings is used (Fig. 231, c).

In case of gunshot injuries of the alveolar process with crushing of the teeth, the latter are removed and the defect in the dentition is replaced with a prosthesis.

In case of fractures of the palatine process with damage to the mucous membrane, a fragment and a flap of the mucous membrane are fixed with an aluminum clip with support loops directed back to the site of damage. The mucosal flap can also be fixed with a celluloid or plastic palatal plate.

Orthopedic treatment of fractures of the upper jaw

Fixation splints, attached to the headband with elastic traction, often cause displacement of fragments of the upper jaw in and deformities of the bite, which is especially important to remember in case of comminuted fractures of the upper jaw with bone defects. For these reasons, wire fixing splints without rubber traction have been proposed.

Ya. M. Zbarzh recommends two options for bending splints made of aluminum wire for fixing fragments of the upper jaw. In the first option, a piece of aluminum wire 60 cm long is taken, its ends15 cm long, each is bent towards each other, then these ends are twisted in the form of spirals (Fig. 232). In order for the spirals to be uniform, the following conditions must be met:

1) during twisting, the angle formed by the long axes of the wire must be constant and not more than 45°;

2) one process must have the direction of the turns clockwise, the other, on the contrary, counterclockwise. The formation of twisted processes is considered complete when the middle part of the wire between the last turns is equal to the distance between the premolars. This part is further the front part of the tooth splint.

In the second option, they take a piece of aluminum wire of the same length as in the previous case, and bend it so that the intraoral part of the splint and the remains of the extraoral part are immediately determined (Fig. 232, b), after which they begin to twist the extraoral rods, which, as in the first variant, they are bent over the cheeks towards the auricles and are attached to the headband by means of connecting, vertically extending rods. The lower ends of the connecting rods are bent upwards in the form of a hook and connected with a ligature wire to the process of the tire, and the upper ends of the connecting rods are reinforced with plaster on the head bandage, which gives the lm greater stability.

Displacement of a fragment of the upper jaw posteriorly can cause asphyxia due to the closure of the lumen of the pharynx. In order to prevent this complication, it is necessary to pull the fragment anteriorly. Traction and fixation of the fragment is performed by an extraoral method. To do this, a head bandage is made and in its anterior part a plate of tin with a soldered lever made of steel wire 3-4 mm thick is plastered or 3-4 twisted

Fig, 232. The sequence of manufacturing wire tires from aluminum wire (according to Zbarzh).

a - the first option; b - the second option; e - fastening of solid-bent aluminum wiretires using connecting rods.

aluminum wires, which are hooked with a toe loop against the oral fissure. A brace made of aluminum wire with hook loops is applied to the teeth of the upper jaw or a supragingival lamellar spike with hook loops in the area of ​​the incisors is used. By means of an elastic traction (rubber ring), a fragment of the upper jaw is pulled up to the arm of the headband.

In case of lateral displacement of a fragment of the upper jaw, a metal rod is plastered on the opposite side of the displacement of the fragment to the lateral surface of the head plaster cast. Traction is carried out by elastic traction, as in the case of displacements of the upper jaw posteriorly. Fragment traction is performed under bite control. With vertical displacement, the apparatus is supplemented with traction in the vertical plane by means of horizontal extraoral levers, a supragingival plate splint and rubber bands (Fig. 233). The plate splint is made individually according to the impression of the upper jaw. From impression materials

Rice. 233. Lamellar gingival splint for fixing fragments of the upper jaw. a - view of the finished tire; b - the splint is fixed on the jaw and to the headband.

it is better to use alginate. According to the obtained plaster model, they start modeling the lamellar tire. It should cover the teeth and the mucous membrane of the gums both from the palatine side and from the vestibule of the oral cavity. The chewing and cutting surfaces of the teeth remain bare. Tetrahedral sleeves are welded to the side surface of the apparatus on both sides, which serve as bushings for extraoral levers. The levers can be made in advance. They have tetrahedral ends corresponding to the sleeves into which they are inserted in the anteroposterior direction. In the canine region, the levers form a bend around the corners of the mouth and, going outward, go towards the auricle. A loop-shaped curved wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. The levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband by means of rubber rings.

A similar splint can also be used to treat combined fractures of the upper and lower jaws. In such cases, hook loops are welded to the plate spike of the upper jaw, bent at a right angle upwards. Fixation of fragments of the jaws is carried out in two stages. At the first stage, fragments of the upper jaw are fixed to the head with the help of a splint with extraoral levers connected to the plaster cast with rubber bands (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled up to the splint of the upper jaw by means of an aluminum wire splint with hook loops fixed on the lower jaw.

Orthopedic treatment of mandibular fractures

Orthopedic treatment of fractures of the lower jaw, median or close to the midline, in the presence of teeth on both fragments, is carried out using a smooth aluminum wire arc. As a rule, wire ligatures going around the teeth should be fixed on the splint with closed jaws under bite control. Prolonged treatment of mandibular fractures with wire splints with intermaxillary traction can lead to the formation of scar bands and the occurrence of extra-articular contractures of the jaws due to prolonged inactivity of the temporomandibular joints. In this regard, there was a need for a functional treatment of injuries of the maxillofacial region, providing physiological rather than mechanical rest. This problem can be solved by returning to the undeservedly forgotten single jaw splint, to fixing jaw fragments with devices that preserve movement in the temporomandibular joints. Single-jaw fixation of fragments ensures early use of maxillofacial gymnastics as a therapeutic factor. This complex formed the basis for the treatment of gunshot injuries of the lower jaw and was called the functional method. Of course, the treatment of some patients without more or less significant damage to the oral mucosa and oral region, patients with linear fractures, with closed fractures of the lower jaw branch can be completed by intermaxillary fixation of bone fragments without any harmful consequences.

In case of fractures of the lower jaw in the area of ​​the angle, at the place of attachment of the masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. With multi-comminuted fractures, damage to the mucous membrane, oral cavity and facial integument, fractures accompanied by a bone defect, etc., the wounded need single-maxillary fixation of fragments, which allow them to maintain movement in the temporomandibular joints.

A. Ya. Katz proposed a regulating apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin area. The apparatus consists of rings reinforced with cement on the teeth of a jaw fragment, oval-shaped sleeves soldered to the buccal surface of the rings, and levers originating in the sleeves and protruding from the oral cavity. By means of the protruding parts of the lever, it is possible to quite successfully adjust the fragments of the jaw in any plane and set them in the correct position (see Fig. 234).

Rice. 234. Replicating apparatus forreduction of fragments of the lower jaw.

l - Katz; 6 - Pomerantseva-Urbanskaya; a - Shelhorn; Mr. Porno and Psom; e - kappa-rod apparatus.

Of the other single-jaw devices for the treatment of fractures of the lower jaw, it should be noted the spring-loaded bracket made of stainless steel "Pomerantseva-Urbaiska. This author recommends the method of applying ligatures according to Schelgorn (Fig. 234) to regulate the movement of fragments of the jaw in the vertical direction. With a significant defect in the body of the lower jaw and a small number of teeth on fragments of the jaw, A. L. Grozovsky suggests using a kappa-rod repositioning apparatus (Fig. 234, e). The preserved teeth are covered with crowns, to which rods in the form of semi-arches are soldered. At the free ends of the rods there are holes where screws and nuts are inserted, which regulate and fix the position of the jaw fragments.

We proposed a spring-loaded apparatus, which is a modification of the Katz apparatus for repositioning mandibular fragments in case of a defect in the chin region. This is an apparatus of combined and sequential action: at first repositioning, then fixing, shaping and replacing. The op consists of metal trays with double tubes soldered to the buccal surface, and springy levers made of stainless steel 1.5–2 mm thick. One end of the lever ends with two rods and is inserted into the tubes, the other protrudes from the oral cavity and serves to regulate the movement of jaw fragments. Having set the jaw fragments in the correct position, they replace the extraoral levers fixed in the kappa tubes with a vestibular clip or a forming apparatus (Fig. 235).

The kappa apparatus undoubtedly has some advantages over wire splints. Its advantages lie in the fact that, being single-jawed, it does not restrict movements in the temporomandibular joints. With the help of this device, it is possible to achieve stable immobilization of jaw fragments and, at the same time, stabilization of the teeth of the damaged jaw (the latter is especially important with a small number of teeth and their mobility). Kappa apparatus without wire ligatures is used; the gum is not damaged. Its disadvantages include the need for constant monitoring, since cement resorption in kappas and displacement of jaw fragments are possible. To monitor the state of cement on the chewing surface kappas make holes (“windows”). For this reason, these patients should not be transported, since the decementation of the mouthguards along the way will lead to a violation of the immobilization of jaw fragments. Kappa devices have found wider use in pediatric practice for fractures of the jaws.

Rice. 235. Repositioning apparatus (according to Oksman).

a - replicating; 6 - fixing; c - forming and replacing.

M. M. Vankevich proposed a plate splint covering the palatine and vestibular surface of the mucous membrane of the upper jaw. From the palatal surface of the tire depart downward, to the lingual surface of the lower molars, two inclined planes. When the jaws close, these planes push apart the fragments of the lower jaw, displaced in the lingual direction, and fix them in the correct position (Fig. 236). Tire Vankevich modified by A. I. Stepanov. Instead of a palatal plate, he introduced an arc, thus freeing part of the hard palate.

Rice. 236. Plastic splint for fixing fragments of the lower jaw.

a - according to Vankevich; b - according to Stepanov.

In case of a fracture of the lower jaw in the region of the angle, as well as in other fractures with displacement of fragments to the lingual side, tires with an inclined plane are often used, and among them a plate supragingival splint with an inclined plane (Fig. 237, a, b). However, it should be noted that a supragingival splint with an inclined plane can be useful only with a slight horizontal displacement of the jaw fragment, when the plane deviates from the buccal surface of the teeth of the upper jaw by 10-15°. With a large deviation of the plane of the tire from the teeth of the upper jaw, the inclined plane, and with it the fragment of the lower jaw (will be pushed downward. Thus, the horizontal displacement will be complicated by the vertical one. In order to eliminate the possibility of this position, 3. Ya. Shur recommends providing an orthopedic apparatus springy inclined plane.

Rice. 237. Dental splint for the lower jaw.

a - general view; b - tire with an inclined plane; c - orthopedic devices with sliding hinges (according to Schroeder); g - steel wire tire with a sliding hinge (according to Pomerantseva-Urbanskaya).

All of the described fixing and regulating devices retain the mobility of the lower jaw in the temporomandibular joints.

Treatment of mandibular body fractures with edentulous fragments

Fixation of fragments of the edentulous lower jaw is possible by surgical methods: bone suture, intraosseous pins, extraoral bone splints.

In case of a fracture of the lower jaw behind the dentition in the area of ​​​​the angle or branch with a vertical displacement of a long fragment or a shift forward and towards the fracture, intermaxillary fixation with oblique traction should be used in the first period. In the future, to eliminate the horizontal displacement (shift towards the fracture), satisfactory results are achieved by using the Pomerantseva-Urbanskaya articulated splint.

Some authors (Schroeder, Brun, Gofrat, etc.) recommend standard tires with a sliding hinge, fixed on the teeth with the help of caps (Fig. 237, c). 3. N. Pomerantseva-Urbanskaya proposed a simplified design of a sliding hinge made of stainless wire 1.5-2 mm thick (Fig. 237, d).

The use of splints with a sliding hinge for fractures of the lower jaw in the area of ​​the angle and branch prevents the displacement of fragments, the occurrence of deformations of facial asymmetry and is also the prevention of jaw contractures, because this splinting method preserves the vertical movements of the jaw and is easily combined with therapeutic exercises. A short fragment of a branch in case of a fracture of the lower jaw in the angle area is strengthened by skeletal traction with the help of elastic traction to a head plaster cast with a rod behind the ear, as well as a wire ligature around the angle of the jaw.

In case of a fracture of the lower jaw with one edentulous fragment, the extension of the long fragment and the fixation of the short one are carried out using a wire clamp with hook loops, fastened to the teeth of the long fragment with a flight to the alveolar process of the edentulous fragment (Fig. 238). Intermaxillary fixation eliminates the displacement of the long fragment, and the pelot keeps the edentulous fragment from displacement upward and to the side. There is no downward displacement of the short fragment, since it is held by the muscles that lift the lower jaw. The tire can be made of elastic wire, and the pilot can be made of plastic.

Rice. 238. Skeletal traction of the lower jaw in the absence of teeth.

In case of fractures of the body of the edentulous lower jaw, the simplest method of temporary fixation is the use of the patient's prostheses and fixation of the lower jaw with a rigid chin sling. In their absence, temporary immobilization can be carried out with a block of bite rollers made of thermoplastic mass with bases made of the same material. Further treatment is carried out by surgical methods.

plastic tires

In case of fractures of the jaws, combined with radiation injuries, the use of metal splints is contraindicated, since metals, as some believe, can become a source of secondary radiation, causing necrosis of the gingival mucosa. It is more expedient to make tires from plastic. M.R. Marey recommends that instead of a ligature wire, nylon threads be used to fix the splint, and a splint for fractures of the lower jaw is made of quick-hardening plastic along a pre-made aluminum groove of an arcuate shape, which is filled with freshly prepared plastic, applying it to the vestibular surface of the dental arch. After the plastic has hardened, the aluminum chute can be easily removed, and the plastic is firmly connected to the nylon threads and fixes the jaw fragments.

The method of overlaying plastic G. A. Vasiliev and co-workers. A nylon thread with a plastic bead is applied to each tooth on the vestibular surface of the tooth. This creates a more secure fixation of the ligatures in the tire. Then a splint is applied according to the method described by M, R. Marey. If necessary, intermaxillary fixation of fragments of the jaw in the appropriate areas, holes are drilled with a spherical burr and pre-prepared plastic spikes are inserted into them, which are fixed with freshly prepared quick-hardening plastic (Fig. 239). The spikes serve as a place for applying rubber rings for intermaxillary traction and fixation of jaw fragments.

Rice. 239. The sequence of manufacturing jaw splints from fast-hardening plastic.

a - fixation of beads; b - bending of the groove; in - groove; g - a smooth splint is applied to the jaw; d - tire with hook loops; e—fixation of the jaw.

F. L. Gardashnikov proposed a universal elastic plastic tooth splint (Fig. 240) with mushroom-shaped rods for intermaxillary traction. The tire is strengthened with a bronze-aluminum ligature.

Rice. 240. Standard tire made of elastic plastic (according to Gardashnikov)

a - side view; b - front view; c - mushroom-shaped process.

Orthopedic treatment of jaw fractures in children

Tooth trauma. Bruises of the facial area may be accompanied by trauma to one tooth or group of teeth. Tooth trauma is found in 1.8-2.5% of the examined schoolchildren. More often there is an injury to the incisors of the upper jaw.

When the enamel of a milk or permanent tooth is broken off, the sharp edges are ground with a carborundum head to avoid injury to the mucous membrane of the lips, cheeks, and tongue. In case of violation of the integrity of the dentin, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed on artificial dentin without its preparation. During this timethe formation of replacement dentin is expected. In the future, the crown is replaced with a filling or inlay to match the color of the tooth. In case of a fracture of the tooth crown with damage to the pulp, the latter is removed. After filling the root canal, the treatment is completed by applying an inlay with a pin or a plastic crown. When the crown of a tooth is broken off at its neck, the crown is removed, and the root is tried to be preserved in order to use it to strengthen the pin tooth.

When a tooth is fractured in the middle part of the root, when there is no significant displacement of the tooth along the vertical axis, they try to save it. To do this, put a wire splint on a group of teeth with a ligature bandage on the damaged tooth. In young children (up to 5 years old), it is better to fix broken teeth with a mouthguard made ofplastics. The experience of domestic dentists has shown that a fracture of the tooth root sometimes grows together in l "/g-2 months after splinting. The tooth becomes stable, and its functional value is completely restored. If the color of the tooth changes, electrical excitability sharply decreases, pain occurs during percussion or palpation in near the apical region, then the crown of the tooth is trepanned and the pulp is removed.

With bruises with root wedging into a broken alveolus, it is better to adhere to expectant tactics, bearing in mind that in some cases the tooth root is somewhat pushed out due to the developed traumatic inflammation. In the absence of inflammation after healing of the injury, the holes resort to orthopedic treatment.

If a permanent tooth has to be removed from a child due to an injury, then the resulting defect in the dentition will be mixed with a fixed prosthesis with unilateral fixation or a sliding removable prosthesis with bilateral fixation in order to avoid deformation of the bite. Crowns, pin teeth can serve as supports. A defect in the dentition can also be replaced with a removable prosthesis.

With the loss of 2 or 3 front teeth, the defect is replaced using a hinged and removable denture according to Ilyina-Markosyan or a removable denture. When individual front teeth fall out due to a bruise, but with the integrity of their sockets, they can be replanted, provided that assistance is provided soon after the injury. After replantation, the tooth is fixed for 4-6 weeks with a plastic kappa. It is not recommended to replant milk teeth, as they can interfere with the normal eruption of permanent teeth or cause the development of a follicular cyst.

Treatment of dislocation of teeth and fracture of the holes .

In children under the age of 27, with bruises, dislocation of the teeth or fracture of the holes and the region of the incisors and displacement of the teeth to the labial or lingual side are observed. At this age, fixing the teeth with a wire arch and wire ligatures is contraindicated due to the instability of milk teeth and the small size of their crowns. In these cases, the method of choice should be to manually set the teeth (if possible) and secure them with a celluloid or plastic tray. The psychology of a child at this age has its own characteristics: he is afraid of the doctor's manipulations. The unusual environment of the office affects the child negatively. Preparation of the child and some caution in the behavior of the doctor are necessary. First, the doctor teaches the child to look at the instruments (spatula and mirror and the orthopedic apparatus) as if they were toys, and then carefully proceeds to orthopedic treatment. Techniques for applying a wire arc and wire ligatures are rough and painful, so preference should be given to mouth guards, the imposition of which the child tolerates much more easily.

How to make a kappa Pomerantseva-Urbanskaya .

After a preparatory conversation between the doctor and the child, the teeth are smeared with a thin layer of petroleum jelly and an impression is carefully taken from the damaged jaw. On the resulting plaster model, the displaced teeth are broken at the base, set in the correct position and glued with cement. On the model prepared in this way, a mouthguard is formed from wax, which should cover the displaced and adjacent stable teeth on both sides. The wax is then replaced with plastic. When the mouthguard is ready, the teeth are manually set under appropriate anesthesia and the mouthguard is fixed on them. In extreme cases, you can carefully not completely apply a mouth guard and invite the child to gradually close the jaws, which will help set the teeth in their sockets. A kappa for fixing dislocated teeth is strengthened with artificial dentin and left in the mouth for 2-4 weeks, depending on the nature of the damage.

Fractures of the jaws in children. Jaw fractures in children occur as a result of trauma due to the fact that children are mobile and careless. Fractures of the alveolar process or dislocation of teeth are more often observed, less often fractures of the jaws. When choosing a treatment method, it is necessary to take into account some age-related anatomical and physiological features of the dental system associated with the growth and development of the child's body. In addition, it is necessary to take into account the psychology of the child in order to develop the correct methods of approaching him.

Orthopedic treatment of mandibular fractures in children.

In the treatment of fractures of the alveolar process or the body of the lower jaw, the nature of the displacement of bone fragments and the direction of the fracture line in relation to the dental follicles are of great importance. Fracture healing proceeds faster if its line runs at some distance from the dental follicle. If the latter is on the fracture line, it may become infected and complication of a jaw fracture with osteomyelitis. In the future, the formation of a follicular cyst is also possible. Similar complications can develop when the fragment is displaced and its sharp edges are introduced into the tissues of the follicle. In order to determine the ratio of the fracture line to the dental follicle, it is necessary to produce x-rays in two directions - in profile and face. In order to avoid layering of milk teeth on permanent images, it should be taken with a half-open mouth. In case of a fracture of the lower jaw at the age of up to 3 years, a plastic palatine plate with imprints of the chewing surfaces of the dentition of the upper and lower jaws (tire-kappa) in combination with a chin sling can be used.

Technique for the manufacture of a plate splint-kappa.

After some psychological preparation of a small patient, an impression is taken from the jaws (first from the top, then from the bottom). The resulting model of the lower jaw is sawn into two parts at the fracture site, then they are made up with a plaster model of the upper jaw in the correct ratio, glued with wax and plastered into the occluder. After that, a well-heated semi-circular wax roller is taken and placed between the teeth of plaster models in order to obtain an imprint of the dentition. The latter should be at a distance of 6-8 mm from each other. The wax roller with the plate is checked in the mouth and, if necessary, it is corrected. Then the plate is made of plastic according to the usual rules. This apparatus is used together with a chin sling. The child uses it for 4-6 weeks until the fusion of the jaw fragments occurs. When feeding a child, the device can be temporarily removed, then immediately put it back on. Food should only be given in liquid form.

In children with chronic osteomyelitis, pathological fractures of the lower jaw are observed. To prevent them, as well as the displacement of fragments of the jaw, especially after sequestrotomy, splinting is shown. From a wide variety of tires, preference should be given to the Vankevich tire in Stepanov's modification (see Fig. 293, a) as more hygienic and easily portable.

Impressions from both jaws are taken before sequestrotomy. Plaster models are plastered into the occluder in the position of central occlusion. The palatal plate of the tire is modeled with an inclined plane downward (one or two depending on the topography of a possible fracture), to the lingual surface of the chewing teeth of the lower jaw. It is recommended to fix the device with arrow-shaped clasps.

With fractures of the jaw at the age of 21/2 to 6 years, the roots of milk teeth are already formed to one degree or another and the teeth are more stable. The child at this time is easier to persuade. Orthopedic treatment can often be carried out using stainless steel wire splints 1-1.3 mm thick. Tires are strengthened with ligatures to each tooth along the entire length of the dentition. For low crowns or tooth decay by caries, plastic mouthguards are used, as already described above.

When applying wire ligatures, it is necessary to take into account some anatomical features of the teeth of the milk bite. Milk teeth, as you know, are low, have convex crowns, especially in chewing teeth. Their large circle is located closer to the neck of the tooth. As a result, wire ligatures applied in the usual way slip off. In such cases, special techniques for applying ligatures are recommended: a ligature covers the tooth around the neck and twists it, forming 1-2 turns. Then the ends of the ligature are pulled over and under the wire arc and twisted in the usual way.

In case of jaw fractures at the age of 6 to 12 years, it is necessary to take into account the peculiarities of the dentition of this period (resorption of the roots of milk teeth, eruption of crowns of permanent teeth with immature roots). Medical tactics in this case depends on the degree of resorption of milk teeth. With complete resorption of their roots, the dislocated teeth are removed, with incomplete resorption, they are splinted, keeping them until the eruption of permanent teeth. When the roots of milk teeth are broken, the latter are removed, and the defect in the dentition is replaced with a temporary removable prosthesis to avoid bite deformation. For immobilization of fragments of the lower jaw, it is advisable to use a soldered splint, and as supporting teeth it is better to use the 6th teeth as more stable and milk canines, on which crowns or rings are applied and connected with a wire arc. In some cases, the manufacture of a mouthguard for a group of chewing teeth with hook loops for intermaxillary fixation of jaw fragments is shown. At the age of 13 years and older, splinting is usually not difficult, since the permanent teeth are already well-formed.