Already in Hippocrates and Celsus there are instructions for fixing fragments of the jaw when it is damaged. Hippocrates used a rather primitive apparatus consisting of two belts: one fixed the damaged lower jaw in the anteroposterior direction, the other from the chin to the head. Celsus used a cord of hair to strengthen the fragments lower jaw for 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 rigid chin sling with a plaster cast 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 suggested a sippy cup for feeding the wounded with maxillofacial injuries.

During the Franco-Prussian War (1870-1871), plate splints 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, became widespread ( Gunning-Port devices). The latter was used to secure fragments of the toothless lower jaw. In addition to these devices, patients were given a rigid chin sling to support jaw fragments, securing it to the head. These devices, quite complex in design, could be made individually based on impressions of the upper and lower jaw of the wounded in special dental prosthetic laboratories and therefore were used mainly in the rear medical institutions. Thus, to end of the 19th century There had not yet been a century of military field splinting, and assistance for maxillofacial wounds was provided very late.

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

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

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

Wire splints found widespread use during the First World War and took a strong place, later replacing plate splints in the treatment of gunshot wounds of the jaws. In Russia, aluminum wire tires were introduced into practice during the First World War by S. S. Tigerstedt (1916). Thanks to the softness of aluminum, the wire arch can easily be bent into a dental arch in the form of a single- and double-jaw splint with intermaxillary fixation of jaw fragments using rubber rings. These tires turned out to be rational in a military field situation. They do not require special dental equipment or support personnel, therefore they have gained universal recognition and are currently used with minor modifications.

During the First World War, the sanitary service in the Russian army was poorly organized, and service to those wounded in the maxillofacial area suffered especially. Thus, the wounded arrived late at the maxillofacial hospital in Moscow organized by G.I. Vilga in 1915, sometimes 2-6 months after injury, without proper fastening of jaw fragments. As a result, the treatment period was extended and persistent deformities occurred with impaired function of the masticatory apparatus.

After the Great October Socialist Revolution, all shortcomings in the organization of the sanitary service were gradually eliminated. Currently, good maxillofacial hospitals and clinics have been created in the Soviet Union. A coherent doctrine for organizing the sanitary service in Soviet army at the stages of medical evacuation of the wounded, including in the maxillofacial area.

During the Great Patriotic War, Soviet dentists significantly improved the quality of treatment for those wounded in the maxillofacial area. Medical assistance was provided to them at all stages of evacuation, starting from the military area. Specialized hospitals or maxillofacial departments were established in army and front-line areas. The same specialized hospitals were deployed in rear areas for the wounded in need of more long-term treatment. Simultaneously with the improvement of the organization of sanitary services, methods of orthopedic treatment of jaw fractures were significantly improved. All this played a big role in the outcome of treatment of maxillofacial wounds. Thus, 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%, whereas in the First World War (1914-1918) 41% of those wounded in the maxillofacial area were discharged from the army due to disability.

Classification of jaw fractures

Some authors base the classification of jaw fractures on the localization of the fracture along the lines corresponding to the places of weakest bone resistance, and the relationship 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) an orbital, or subbasal, fracture at the level of the nasal bones, orbit and main bone of the skull.

By localization, this classification corresponds to those zones where fractures of the upper jaw most often occur. The most severe cases 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 sealed with 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 neohyestrel fractures of the lower jaw according to their location into median, mental (lateral), angular (angular) and cervical (cervical). An isolated fracture of the coronoid process is relatively rare. (Fig. 226).

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

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

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

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

4) by type of wounding 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

By type of damaged tissue

1.Soft tissue injuries.

2.Wounds with bone damage:

A. Lower jaw

B. Upper jaw.

B. Both jaws.

G. Zygomatic bone.

D. Damage to several bones of the facial skeleton

II.Non-gunshot 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 facial organs (tongue, salivary glands and etc.);

b) with damage to facial organs

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

B. Singles.

G. Multiple.

D. Penetrating into the oral and nasal cavity

E. Non-penetrating

By type of wounding weapon

1.Bullet.

2. Fragmentation.

3.Radiation.

Classification of orthopedic devices used to treat jaw fractures

Fixing jaw fragments is done using various devices. It is advisable to divide all orthopedic devices into groups in accordance with function, area of ​​fixation, therapeutic value, and design.

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

Regulating (reducing) devices are called, facilitating the reposition of bone fragments: tightening or stretching them until they are installed in the correct position. These include aluminum wire splints with elastic traction, elastic wire brackets, devices with extraoral control levers, devices for jaw retraction for contractures, etc.

The 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 fixators. These include a smooth wire bracket, extraoral devices for fixing fragments of the upper jaw, extraoral and intraoral devices for fixing fragments of the lower jaw during bone grafting, etc.

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

Replacement devices include, replacing defects in the dentition formed after tooth extraction, filling defects in the jaws and parts of the face that arose after injury or surgery. They are also called dentures.

Combined devices include, having several purposes, for example, fixing jaw fragments and forming a prosthetic bed or replacing a jaw bone defect and simultaneously forming a skin flap.

Division of devices according to the place of fixation. Some authors divide devices for the treatment of jaw injuries into intraoral, extraoral and intra-extraoral. Intraoral include devices attached to the teeth or adjacent to the surface of the oral mucosa, 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 securing jaw fragments), 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-jaw and double-jaw splints. The former, regardless of their function, are located only within one jaw and do not interfere with the movements of the lower jaw. Double-jaw appliances are applied simultaneously to the upper and lower jaws. Their use is designed to fix both jaws with closed teeth.

Division of devices according to therapeutic purpose. Based on their therapeutic purpose, orthopedic devices are divided into primary and auxiliary.

The main ones are fixing and correcting splints, used for injuries and deformations of the jaws and having an 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 organ function (chewing, speech, etc.).

Auxiliary devices are devices 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 transportation of the patient. Individual tires can be of simple or complex design. The first (wire) ones are bent directly in front of the patient and secured to the teeth.

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

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

Orthopedic devices consist of two parts - supporting and acting.

The supporting parts are crowns, mouthguards, rings, wire arches, removable plates, head caps, etc.

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

FIRST SPECIALIZED AID FOR JAW FRACTURES (IMMOBILIZATION OF FRAGMENTS)

In wartime, when treating patients wounded in the maxillofacial area, transport splints and sometimes ligature bandages are widely used. Of the transport tires, the most comfortable is the rigid chin sling. It consists of a headband with side bolsters, a plastic chin sling and rubber rods (2-3 on each side).

A 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 in 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 facilitates the reduction of the fragment.

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

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

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

Rice. 227. Standard Zbarzh splints for immobilization of fragments of the upper jaw.

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

the wire arch is regulated by extension and shortening of its palatal part. The splint 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 securing fragments of the upper jaw, but only using a palatal plane made of plastic. The latter is corrected using quick-hardening plastic.

Ligature binding of teeth

Rice. 228. Intermaxillary bonding of teeth.

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

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

Wire splint application

Immobilization of jaw fragments using splints is more rational. There are simple special treatments and complex ones. The first is to use wire tires. They are applied, as a rule, in the military area, since production does not require a denture laboratory. Complex orthopedic treatment is possible in those institutions where there is an equipped dental 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 adheres to each tooth at least at one point, without imposing on the gum mucosa.

Wire bars have a variety of shapes (Fig. 229). There are a smooth wire splint and a wire splint with a spacer corresponding to the size of the dentition defect. For intermaxillary traction, wire arches with hooking loops are used on both jaws for A.I. Stepanov and P.I. For the manufacture of a wire splint with hooking loops, it is recommended to use a smooth wire splint and pre-prepared movable hooking hooks made of brass for intermaxillary traction, which are installed on required section of the tire.

Method of applying ligatures

To secure the splint, wire ligatures are used - pieces of bronze-aluminum wire 7 cm long and 0.4-0.6 mm thick. The most common method is to pass ligatures through interdental spaces. The ligature is bent into a hairpin shape with ends of different lengths. Its ends are inserted with tweezers from the lingual side into two adjacent interdental spaces and brought out from the vestibule (one under the splint, the other above the splint). Here the ends of the ligatures are twisted, the excess spiral is cut off and folded between the teeth so that they do not damage the mucous membrane of the gums. To save time, you can first place a ligature between the teeth, bending one end down and the other up, then place a splint between them and secure it with ligatures.

Indications for the use of bent wire tires

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

Vertical displacement of fragments is eliminated with wire splints with hooked loops and intermaxillary traction using rubber rings. If simultaneous reduction of jaw fragments is performed, then the wire mud is immediately attached to the teeth of both fragments. In case of stiff and displaced fragments and the impossibility of their immediate 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 the other fragment only after restoration of normal closure of the dentition. A rubber gasket is placed between the teeth of the short fragment and their antagonists to speed up bite correction.

For a fracture of the lower jaw behind the dentition, the method of choice is the use of wire spikes with intermaxillary traction. If the fragment of the lower jaw is displaced in two planes (vertical and horizontal), intermaxillary traction is indicated. In case of a fracture of the lower jaw in the area of ​​the corner with horizontal displacement of a long fragment towards the fracture, it is advisable to use a splint with a sliding hinge (Fig. 229, e). It is distinguished by the fact that it secures jaw fragments, eliminates their horizontal displacement and allows free movement in the temporomandibular joints.

With a bilateral fracture of the lower jaw, the middle fragment, as a rule, moves downward, and sometimes also posteriorly under the influence of muscle traction. In this case, the lateral fragments often shift towards each other. In such cases, it is convenient to immobilize jaw fragments in two stages. At the first stage, the lateral fragments are separated and secured using a wire arch with the correct closure of the dentition; at the second stage, the middle fragment is pulled upward using intermaxillary traction. Having placed the middle fragment in the correct bite position, it is attached to a common splint.

In case of a fracture of the lower jaw with one toothless fragment, the latter is secured using a bent spike made of aluminum wire with a loop and a lining. The free end of the aluminum splint is secured to the teeth of the other jaw fragment with wire ligatures.

Rice. 229. Wire tire according to Tigerstedt.

a — smooth splint-arc; b - smooth tire with spacer; c— tire c. hooks; g - a tenon with hooks and an inclined plane; d — splint with hooks and intermaxillary traction; e - rubber rings.

For fractures of the edentulous lower jaw, if the patient has dentures, they can be used as splints for temporary immobilization of jaw fragments while simultaneously applying a chin sling. To ensure food intake, all 4 incisors are cut out in the lower denture and the patient is fed from a sippy cup through the hole formed.

Treatment of alveolar bone fractures

Rice. 231. Treatment of alveolar process fractures.

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

In case of fractures of the alveolar process of the upper or lower jaw, the fragment is usually secured with a wire splint, most often smooth and single-jawed. When treating a non-gunshot fracture of the alveolar process, the fragment is usually reduced simultaneously under novocaine anesthesia. The fragment is secured using a smooth aluminum wire arch with a thickness of 1.5-2 mm.

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

In case of a fracture of the lateral part of the alveolar process with its displacement to the lingual side, a springy steel wire with a thickness of 1.2-1.5 mm is used (Fig. 231, a). The arch 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 arch. When the fragment is vertically displaced, an aluminum wire arch with hooking loops and rubber rings is used (Fig. 231, c).

In case of gunshot damage to the alveolar process with fragmentation of teeth, the latter are removed and the dentition defect is replaced with a prosthesis.

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

Orthopedic treatment of fractures of the upper jaw

Fixing splints attached to the headband with elastic traction often cause displacement of fragments of the upper jaw and bite deformation, 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, take a piece of aluminum wire 60 cm long, its endseach 15 cm long 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 no more than 45°;

2) one process should have the direction of 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 then becomes the front part of the dental 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 visible (Fig. 232, b), after which they begin to twist the extraoral rods, which, as in the first option, they are bent over the cheeks towards the ears and attached to the headband by means of connecting, vertically extending rods. The lower ends of the connecting rods are bent upward in the form of a hook and connected with a ligature wire to the extension of the splint, and the upper ends of the connecting rods are strengthened with plaster on the head bandage, which gives the lm greater stability.

Posterior displacement of a fragment of the upper jaw 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 carried out using an extraoral method. To do this, a headband is made and in its anterior section a plate of tin with a soldered lever made of steel wire 3-4 mm thick is plastered or 3-4 twisted ones are plastered along the midline

Fig. 232. Sequence of manufacturing wire tires from aluminum wire (according to Zbarzh).

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

aluminum wires, embedded with a hook loop against the oral slit. A bracket made of aluminum wire with hooking loops is applied to the teeth of the upper jaw, or a supragingival plate spike with hooking loops is used in the area of ​​the incisors. Using an elastic rod (rubber ring), the fragment of the upper jaw is pulled to the lever 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 with posterior displacement of the upper jaw. The fragment is pulled out under bite control. With vertical displacement, the apparatus is supplemented with traction in the vertical plane through 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 supragingival splint for securing fragments of the upper jaw. a - type of finished tire; b - the splint is fixed to the jaw and to the headband.

It is better to use alginate. Based on the resulting plaster model, they begin to model the lamellar splint. It should cover the teeth and mucous membrane of the gums both from the palatal side and from the vestibule of the oral cavity. The chewing and cutting surfaces of the teeth remain exposed. Tetrahedral sleeves are welded to the side surface of the apparatus on both sides, which serve as bushings for extraoral levers. Levers can be made in advance. They have tetrahedral ends corresponding to the bushings into which they slide in the anteroposterior direction. In the area of ​​the fangs, the levers form a curve around the corners of the mouth and, coming out, go towards the auricle. A loop-shaped wire is soldered to the outer and lower surfaces of the levers to fix the rubber rings. Levers should be made of steel wire 3-4 mm thick. Their outer ends are fixed to the headband using rubber rings.

A similar splint can also be used to treat combined fractures of the upper and lower jaw. In such cases, hooking loops bent upward at a right angle are welded to the plate tenon of the upper jaw. Fixation of jaw fragments is carried out in two stages. At the first stage, fragments of the upper jaw are secured to the head using a splint with extraoral levers connected to the plaster cast with rubber rods (the fixation must be stable). At the second stage, fragments of the lower jaw are pulled to the upper jaw splint using an aluminum wire splint with hooking loops, fixed to the lower jaw.

Orthopedic treatment of mandibular fractures

Orthopedic treatment of fractures of the lower jaw, midline or close to the midline, in the presence of teeth on both fragments, is carried out using a smooth aluminum arch wire. As a rule, wire ligatures that go around the teeth should be secured to the splint with the jaws closed under control of the bite. Long-term treatment of mandibular fractures with wire splints with intermaxillary traction can lead to the formation of scar cords 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 functional treatment damage to the maxillofacial area, 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 the early use of maxillofacial gymnastics techniques as a therapeutic factor. This complex formed the basis for the treatment of gunshot injuries to the lower jaw and was called the functional method. Of course, treatment of some patients without more or less significant damage to the mucous membrane of the oral cavity and perioral area, patients with linear fractures, with closed fractures The ramus of the mandible can be completed by intermaxillary fixation of fragments without any harmful consequences.

For fractures of the lower jaw in the area of ​​the angle, at the place of attachment masticatory muscles, intermaxillary fixation of fragments is also necessary due to the possibility of reflex muscle contracture. In case of 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 allows maintaining movement in the temporomandibular joints.

A. Ya. Katz proposed a regulatory apparatus of an original design with extraoral levers for the treatment of fractures with a defect in the chin region. The device consists of rings reinforced with cement on the teeth of the 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 jaw fragments in any plane and install them in the correct position (see Fig. 234).

Rice. 234. Reduction devices forreduction of fragments of the lower jaw.

l - Katz; 6 - Pomerantseva-Urbanskaya; a - Shelgorn; g—Pornoia and Dogma; d — kappa-rod apparatus.

Among other single-jaw devices for the treatment of fractures of the lower jaw, the spring bracket made of stainless steel by Pomerantseva-Urbaiskaya should be noted. This author recommends the Shelhorn method of applying ligatures (Fig. 234) to regulate the movement of jaw fragments in the vertical direction. In case of a significant defect in the body of the lower jaw and a small number of teeth on the jaw fragments, A. L. Grozovsky suggests using a kappa-rod reduction apparatus (Fig. 234, e). The preserved teeth are covered with crowns, to which rods in the form of half-arches are soldered. At the free ends of the rods there are holes into which screws and nuts are inserted, with which the position of the jaw fragments is adjusted and secured.

We proposed a spring apparatus, which is a modification of the Katz apparatus for the reposition of fragments of the lower jaw with a defect in the chin area. This is a device of combined and sequential action: first reducing, then fixing, forming and replacing. It consists of metal mouth guards, with double tubes soldered to the buccal surface, and springy stainless steel levers 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 placed the jaw fragments in the correct position, replace the extraoral levers secured in the mouthguard tubes with a vestibular clamp or a shaping apparatus (Fig. 235).

The mouth guard undoubtedly has some advantages over wire splints. Its advantages are that, being single-jawed, it does not limit 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 when there are a small number of teeth and their mobility). A mouthguard apparatus without wire ligatures is used; the gums are not damaged. Its disadvantages include the need for constant monitoring, since the cement in the aligners may be reabsorbed and jaw fragments may be displaced. To monitor the condition of cement on the chewing surface The mouth guards make holes (“windows”). For this reason, these patients should not be transported, since decementing of the mouthguards along the way will lead to disruption of the immobilization of jaw fragments. Mouth guards have found wider use in pediatric practice for jaw fractures.

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

a—reducing; 6 - fixing; c - formative and replacing.

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

Rice. 236. Plate splint made of plastic for securing fragments of the lower jaw.

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

For a fracture of the lower jaw in the area of ​​the angle, as well as for other fractures with displacement of fragments to the lingual side, splints 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 maxillary teeth by 10-15°. If there is a large deviation of the plane of the splint from the teeth of the upper jaw, the inclined plane, and with it the fragment of the lower jaw (will be pushed downwards. Thus, the horizontal displacement will be complicated by the vertical one. In order to eliminate the possibility of this position, 3. Ya. Shur recommends equipping 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 described fixing and regulating devices maintain mobility of the lower jaw in the temporomandibular joints.

Treatment of fractures of the body of the lower jaw with toothless fragments

Fixation of fragments of the toothless lower jaw is possible surgical methods: application of a bone suture, intraosseous pins, extraoral bone splints.

In case of a fracture of the lower jaw behind the dentition in the area of ​​an 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 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 splints with a sliding hinge, secured to the teeth using mouthguards (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 ramus prevents the displacement of fragments, the occurrence of facial asymmetry deformities and is also the prevention of jaw contractures, because this method of splinting preserves the vertical movements of the jaw and is easily combined with techniques therapeutic exercises. A short fragment of a branch in a fracture of the lower jaw in the area of ​​the angle is strengthened by skeletal traction using elastic traction to the head plaster cast with a rod behind the ear, as well as a wire ligature around the angle of the jaw.

In case of a fracture of the lower jaw with one toothless fragment, traction of the long fragment and fastening of the short one is carried out using a wire bracket with hooking loops, secured to the teeth of the long fragment with a flight to the alveolar process of the toothless fragment (Fig. 238). Intermaxillary fixation eliminates displacement of the long fragment, and the pelot keeps the toothless fragment from moving upward and to the side. There is no downward displacement of the short fragment, since it is held by the muscles that elevate the mandible. 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.

For fractures of the body of the edentulous lower jaw, the simplest method of temporary fixation is the use of the patient's dentures and fixation of the lower jaw using a rigid chin sling. In their absence, temporary immobilization can be carried out using a block of bite ridges made of thermoplastic mass with bases made of the same material. IN further treatment carried out surgically.

Plastic tires

For jaw fractures 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 gum mucosa. It is more expedient to make tires from plastic. M.R. Marey recommends using nylon threads instead of ligature wire to secure the splint, and a splint for fractures of the lower jaw - made of fast-hardening plastic along a pre-made aluminum channel of an arcuate shape, which is filled with freshly prepared plastic, placing it on the vestibular surface of the dental arch. After the plastic hardens, the aluminum gutter is easily removed, and the plastic is firmly connected to the nylon threads and fixes the jaw fragments.

Method of applying plastic by G. A. Vasiliev and co-workers. A nylon thread with a plastic bead on the vestibular surface of the tooth is applied to each tooth. This creates a more reliable fixation of the ligatures in the splint. Then a splint is applied according to the method described by M. R. Marey. If intermaxillary fixation of jaw fragments is necessary, holes are drilled in the appropriate areas with a spherical bur 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. Sequence of manufacturing jaw splints from quick-hardening plastic.

a — fixation of beads; b - bending of the groove; c - groove; d - 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 dental splint (Fig. 240) with mushroom-shaped rods for intermaxillary traction. The tire is reinforced 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

Dental trauma. Bruises of the facial area may be accompanied by injury to one tooth or a group of teeth. Dental trauma is detected in 1.8-2.5% of examined schoolchildren. Injury to the maxillary incisors is more common.

When the enamel of a baby or permanent tooth is broken, the sharp edges are ground with a carborundum head to avoid injury to the mucous membrane of the lip, cheek, and tongue. If the integrity of the dentin is damaged, but without damage to the pulp, the tooth is covered for 2-3 months with a crown fixed to artificial dentin without preparing it. During this timeThe formation of replacement dentin is assumed. Subsequently, the crown is replaced with a tooth-colored filling or inlay. If the crown of a tooth is fractured and the pulp is damaged, the pulp is removed. After filling the root canal, 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 an attempt is made to preserve the root 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, apply a wire splint to a group of teeth with a ligature bandage on the damaged tooth. In young children (under 5 years old), it is better to fix broken teeth using a mouth guard made ofplastics. The experience of domestic dentists has shown that a fracture of the tooth root sometimes heals within 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, the corpus canal is filled with cement and thus the tooth is preserved.

In case of bruises with root wedging into a fractured alveolus, it is better to adhere to a wait-and-see approach, remembering that in some cases the tooth root is somewhat pushed out due to the development of traumatic inflammation. In the absence of inflammation, after healing of the socket injury, orthopedic treatment is resorted to.

If a child’s permanent tooth has to be removed due to an injury, the resulting defect in the dentition will be replaced with a fixed denture with unilateral fixation or a sliding removable denture with bilateral fixation to avoid bite deformation. Crowns and pin teeth can serve as supports. A dental defect can also be replaced with a removable denture.

If 2 or 3 front teeth are lost, the defect is replaced using a hinged and removable prosthesis according to Ilina-Markosyan. If individual front teeth fall out due to a bruise, but their sockets are intact, 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 tray. It is not recommended to replant baby teeth, as they may interfere with the normal eruption of permanent teeth or cause the development of follicular cyst.

Treatment of dislocated teeth and fractured sockets .

In children under the age of 27 years, with bruises, dislocation of teeth or fracture of the sockets and incisor areas and displacement of teeth to the labial or lingual side are observed. At this age, securing teeth using a wire arch and wire ligatures is contraindicated due to the instability of baby teeth and the small size of their crowns. In these cases, the method of choice should be to manually adjust the teeth (if possible) and secure them with a celluloid or plastic mouth guard. The psychology of a child at this age has its own characteristics: he is afraid of the doctor’s manipulations. The unusual furnishings of the office have a negative effect on the child. The child's preparation and some caution in the doctor's behavior are necessary. First, the doctor teaches the child to look at the instruments (spatula and mirror and orthopedic apparatus) as if they were toys, and then carefully begins orthopedic treatment. The methods of applying a wire arch and wire ligatures are rough and painful, so preference should be given to mouth guards, the application of which is much easier for the child to tolerate.

Method for making a mouth guard Pomerantseva-Urbanskaya .

After a preparatory conversation between the doctor and the child, the teeth are smeared with a thin layer of Vaseline 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 mouth guard is ready, the teeth are manually adjusted under appropriate anesthesia and the mouth guard is secured to them. In extreme cases, you can carefully not completely apply the mouthguard and invite the child to gradually close his jaws, which will help install the teeth in their sockets. A mouthguard for fixing dislocated teeth is strengthened with artificial dentin and left in the mouth for 2-4 weeks, depending on the nature of the damage.

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

Orthopedic treatment of mandibular fractures in children.

When treating 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. Healing of a fracture proceeds faster if its line passes at some distance from the dental follicle. If the latter is located on the fracture line, it may become infected and complicate the jaw fracture with osteomyelitis. In the future, the formation of a follicular cyst is also possible. Similar complications can develop when a fragment is displaced and its sharp edges become embedded in the tissues of the follicle. In order to determine the relationship of the fracture line to the dental follicle, it is necessary to take x-rays in two directions - in profile and frontal. To avoid overlap of primary teeth with permanent images, photographs should be taken with the mouth half-open. For a fracture of the lower jaw under the age of 3 years, you can use a palatal plate made of plastic with imprints of the chewing surfaces of the dentition of the upper and lower jaws (splint-guard) in combination with a chin sling.

Technique for making a plate-shaped splint.

After some psychological preparation of the little patient, an impression is taken from the jaws (first from the upper, then from the lower). The resulting model of the lower jaw is sawed into two parts at the fracture site, then they are combined with a plaster model of the upper jaw in the correct ratio, glued with wax and plastered in an occluder. After this, take a well-heated semicircular wax roller and place it between the teeth of the plaster models to get an impression 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 device is used in conjunction with a chin sling. The child uses it for 4-6 weeks until the jaw fragments heal. When feeding the baby, the device can be temporarily removed, then immediately reapplied. Food should be given only in liquid form.

In children with chronic osteomyelitis, pathological fractures of the lower jaw are observed. To prevent them, as well as displacement of jaw fragments, especially after sequestrotomy, splinting is indicated. Of the wide variety of tires, preference should be given to the Vankevich tire as modified by Stepanov (see Fig. 293, a) as it is 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 splint is modeled with an inclined plane downwards (one or two depending on the topography of the possible fracture), towards the lingual surface of the chewing teeth of the lower jaw. It is recommended to fix the device using arrow-shaped clasps.

In case of jaw fractures between the ages of 21/2 and 6 years, the roots of the baby teeth are already formed to one degree or another and the teeth are more stable. At this time, the child is more easily persuaded. Orthopedic treatment can often be carried out using stainless steel wire splints 1-1.3 mm thick. The splints are strengthened with ligatures to each tooth along the entire length of the dentition. In case of low crowns or tooth decay due to caries, plastic mouthguards are used, as already described above.

When applying wire ligatures, it is necessary to take into account some anatomical features primary teeth. Baby teeth are known to be short and have convex crowns, especially in the posterior teeth. Their larger circumference 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: the ligature is wrapped around the tooth around the neck and twisted, forming 1-2 turns. The ends of the ligature are then pulled over and under the wire and twisted in the usual way.

For jaw fractures between the ages of 6 and 12 years, it is necessary to take into account the characteristics of the dentition of this period (resorption of the roots of baby teeth, eruption of the crowns of permanent teeth with unformed roots). Medical tactics depend on the degree of resorption of baby teeth. When their roots are completely absorbed, the dislocated teeth are removed; if they are incomplete, they are splinted, preserving them until the permanent teeth erupt. If the roots of baby teeth are broken, the latter are removed, and the defect in the dentition is replaced with a temporary removable denture to avoid bite deformation. To immobilize 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 primary fangs, on which crowns or rings are applied and connected with a wire arch. In some cases, it is indicated to make a mouthguard for a group of chewing teeth with hooking loops for intermaxillary fixation of jaw fragments. At the age of 13 years and older, splinting is usually not difficult, since the roots of the permanent teeth are already sufficiently formed.

Transcript

1 Federal Agency for Railway Transport FSBEI HPE “Irkutsk State Transport University” Medical College of Railway Transport WORK PROGRAM FOR PROFESSIONAL MODULE PM. 05 Manufacturing of maxillofacial devices Specialty Orthopedic Dentistry Irkutsk 015

2 Developer: Sidorova E. P., teacher of the first qualification category of the Federal State Budgetary Educational Institution of Higher Professional Education MK ZhT

3 CONTENTS 1. PASSPORT OF THE PROFESSIONAL MODULE WORK PROGRAM. RESULTS OF MASTERING THE PROFESSIONAL MODULE 6 pages STRUCTURE AND CONTENT OF THE PROFESSIONAL MODULE 8 4 CONDITIONS FOR IMPLEMENTING THE PROFESSIONAL MODULE 1 5. CONTROL AND EVALUATION OF THE RESULTS OF MASTERING THE PROFESSIONAL MODULE (TYPE OF PROFESSIONAL ACTIVITIES) 14 3

4 1. PASSPORT OF THE WORKING PROGRAM OF THE PROFESSIONAL MODULE PM.05 Manufacturing of maxillofacial devices 1.1. Scope of application of the work program Working programm The professional module is part of the training program for mid-level specialists in accordance with the Federal State Educational Standard in the specialty Orthopedic Dentistry, in terms of mastering the main type (VPD): PM 05 Manufacturing maxillofacial devices and corresponding professional competencies (PC): PC 5.1 Manufacture the main types of maxillofacial devices for defects of the maxillofacial area. PC 5. Manufacture therapeutic and prophylactic maxillofacial devices (splints). The work program of the professional module can be used in the program of advanced training and retraining in the specialty of Orthopedic Dentistry. 1.. Goals and objectives of the professional module requirements for the results of mastering the professional module In order to master the specified type and the corresponding professional competencies, the student during the development of the professional module must: be able to: manufacture the main types of maxillofacial apparatus; manufacture therapeutic and prophylactic maxillofacial devices (splints); zt: goals and objectives of maxillofacial orthopedics; history of the development of maxillofacial orthopedics; connection of maxillofacial orthopedics with other sciences and disciplines; classification of maxillofacial apparatus; definition of injury, damage, their classification; gunshot injuries to the maxillofacial area, their features; orthopedic assistance during medical evacuation; non-gunshot fractures of the jaws, their classifications and the mechanism of displacement of fragments; features of care and nutrition of maxillofacial patients; methods of dealing with complications at the stages of medical evacuation; principles of treatment of jaw fractures; features of splint (mouthguard) manufacturing. 4

5 1.3. Number of hours mastered sample program professional module: a total of 16 hours, including: maximum student workload 16 hours, including: mandatory classroom student workload 108 hours; independent work of the student 84 hours; 5

6. RESULTS OF MASTERING THE PROFESSIONAL MODULE The result of mastering the professional module is that students master the following type: Manufacturing of maxillofacial apparatus, including professional (PC) and general (GC) competencies: PC code 1. PC. OK 1 OK OK 3 OK 4 Name of learning outcome To manufacture the main types of maxillofacial devices for defects of the maxillofacial area. To produce therapeutic and prophylactic maxillofacial devices (splints). Understand the essence and social significance of your future profession, show a steady interest in her. Organize your own activities, choose standard methods and ways of performing professional tasks, evaluate their effectiveness and quality. Make decisions in standard and non-standard situations and take responsibility for them. Search and use information necessary for the effective performance of professional tasks, professional and personal development. OK 5 Use information and communication technologies c. OK 6 Work in a team and team, communicate effectively with colleagues, management, and consumers. OK 7 Take responsibility for the work of team members (subordinates) and for the results of completing tasks. OK 8 Independently determine the tasks of professional and personal development, engage in self-education, and consciously plan professional development. 6

7 OK 9 Navigate in the face of frequent changes in technology c. OK 10 Be careful about the historical heritage and cultural traditions of the family, respect social, cultural and religious differences. OK 11 Be ready to take on moral obligations towards nature, society and people. OK 1 Provide first (pre-hospital) medical aid in case of emergency conditions. OK 13 OK 14 OK 15 Organize workplace in compliance with the requirements of labor protection, industrial sanitation, infection and fire safety. Lead a healthy lifestyle, exercise physical culture and sports to improve health, achieve life and professional goals. Perform military duties, including using acquired professional knowledge (for young men). 7

8 1. STRUCTURE AND CONTENT OF PROFESSIONAL MODULE PM.05. MANUFACTURE OF MAXILLOFACIAL APPLIANCES 3.1. Thematic plan of the professional module Codes of professional competencies Names of sections of the professional module 1 Total hours (max. study load and practice) Amount of time allocated for mastering an interdisciplinary course (courses) Obligations of the auditor study load of the student Total, hours incl. laboratory works and practical classes, hours incl. coursework a (project), hours Independent work of the student Total, hours including, course work (project), hours Study, hours Production practice (according to specialty profile), hours (if dispersed practice is provided) PC 5.1., PC 5.. Section 1. Manufacturing of main types of maxillofacial apparatuses week (36 hours) Production practice (according to specialty profile), hours (if final (concentrating) practice is provided) Total: week (36 hours) 8

9 3.. Contents of training in the professional module PM.05 Manufacturing of maxillofacial apparatus Name of sections of the professional module (PM), interdisciplinary courses (IDC) and topics Content of educational material, laboratory work and practical exercises, independent work of students, coursework (project ) (if provided) Volume of hours Level of mastery Section PM Manufacturing of the main types of maxillofacial apparatuses MDK Manufacturing technology of maxillofacial apparatuses 108 Topic 1.1. Contents of educational material 4 Gunshot fractures of the maxillofacial region 1 The concept of maxillofacial orthopedics. Types of injuries to the maxillofacial area. Gunshot fractures. Classification of gunshot fractures Topic 1. Non-gunshot fractures of the maxillofacial area Organization medical care maxillofacial wounded stages of evacuation Methods of dealing with complications stages of medical evacuation Contents of educational material 1 Non-gunshot fractures of the maxillofacial region. Classification of non-gunshot jaw fractures Topic 1.3. Orthopedic methods of treating jaw fractures with fixing devices Contents of educational material 1. Classification of maxillofacial devices. Devices for fixation of jaw fragments Practical exercises 18 9

10 Topic 1.4. Orthopedic methods of treating jaw fractures with reduction devices Topic 1.5. Orthopedic treatment methods for non-healed and improperly healed jaw fractures Topic 1.6. Orthopedic methods of treatment for contractures and microstomia 1. Manufacturing technology of the Weber splint. Manufacturing of a metal frame. 3. Modeling the wax composition of the splint. Replacing wax with plastic Contents of educational material 1. Devices for repositioning jaw fragments Design features of manufacturing splints for the treatment of fractures in childhood Contents of educational material 1. Prosthetics for patients with non-union of jaw fractures. Prosthetics for patients with improperly healed fractures Contents of educational material 1. Etiology, clinical picture and treatment of jaw contractures Etiology, clinical picture and treatment of microstomia 3 1 Topic 1.7. Orthopedic methods of treatment of patients with congenital defects of the hard and (or) soft palate Topic 1.8. Replacement, resection devices Contents of educational material 1. Providing orthopedic care to children with congenital defects of the hard and (or) soft palate. Types of obturators. Contents of educational material 1. Orthopedic methods of treating patients with defects of the hard and soft palate. Practical exercises 1. Technology of manufacturing a replacement prosthesis for a median defect of the hard and soft palate. Making models, determining the central relationship of the jaws. 3. Placement of artificial teeth. Modeling the wax composition of the prosthesis

11 Topic 1.9. Shaping devices Topic: Facial ectoprosthetics Topic: Orthopedic protective equipment for athletes 4. Replacement of wax with plastic. Processing, grinding, polishing of the prosthesis. Contents of educational material 1. Immediate and subsequent prosthetics after resection of the jaws. Forming devices. Indications for use. Requirements and manufacturing principles Contents of educational material 1. Orthopedic treatment with ectoprostheses. Modern materials for the manufacture of ectoprostheses Practical exercises 4 1. Manufacturing of an ectoprosthesis of the ear from hard plastics. Manufacturing of an ectoprosthesis of the ear from elastic materials. 3. Manufacturing of an ectoprosthetic nose. 4. Manufacturing of an ectoprosthetic nose from elastic materials. Contents of educational material 1. Manufacturing technology of boxing splints from various materials. Practical lessons Manufacturing technology of a boxing splint. Making casts, models.. Making a boxing splint from elastic materials. 3. Making a boxing splint from silicone masses. Independent work when studying section PM 5 1. Work with textbooks, atlases, notes on questions teaching aids compiled by the teacher. Independent study of algorithms for practical manipulations in section 3. Independent practice of practical manipulations (manufacturing the main types of maxillofacial devices)

12 Examples of topics for extracurricular independent work 1. Work with educational and additional literature. Filling out tables for the topics “Gunshot and non-gunshot fractures of the maxillofacial region” 3. Abstract message for the topics of the section: “Manufacturing the main types of maxillofacial devices” 4. Filling out the table “Clinical and laboratory stages of manufacturing a Weber splint” 5. Write comparative characteristics hinged prostheses according to Gavrilov, Oksman, Weinstein 6. Drawing up test tasks 7. Drawing up a terminological dictation 8. Drawing up graphic diagrams using multimedia technologies 9. Working with Internet resources Industrial practice in the specialty profile Types of work: Manufacturing the main types of maxillofacial devices for defects of the maxillofacial area. Manufacturing of therapeutic and prophylactic maxillofacial devices (splints). 1 week (36 hours) Total 16 1

13 4.1. Minimum logistics requirements. The implementation of the professional module presupposes the presence of laboratories for the manufacture of maxillofacial apparatus. Equipment of the laboratory and workplaces of the laboratory “Technology for the manufacture of maxillofacial apparatuses”: 1. Furniture set. A set of equipment, instruments and consumables: dental tables, portable drills, grinding motors, a pneumatic polymerizer, electric spatulas, occluders, electric plates, a cuvette press, a fume hood, a dental compressor, dummies, phantom models of jaws, tools for the manufacture of maxillofacial devices, Consumables for the manufacture of maxillofacial devices; Technical teaching aids: computers, modem (satellite system), projector, interactive board, TV, DVD player, general and professional software. Implementation of the module program does not require mandatory practical training. 4.. Information support for training Basic literature: 1. Dental prosthetic equipment. / solution Rasulova M.M. and others. M.: GEOTAR-Media", Smirnov B.A. Dental engineering in dentistry. - M.: GEOTAR-Media, 014 Additional literature: 1. Smirnov B. Dental engineering in dentistry - M.: ANMI, General requirements to the organization of the educational process 13

14 The main forms of student education are classroom training, including lectures, seminars, lessons, and practical exercises. The topics of lectures and practical classes must correspond to the content of the program of this professional module. Theoretical classes are conducted in classrooms equipped technical means training, visual aids, ready-made maxillofacial devices. Practical classes must be conducted in a dental training laboratory. Knowledge is consolidated and skills are acquired to work with specific designs, materials and equipment of the educational dental laboratory used in maxillofacial orthopedics. The level of independence in students’ work should be determined individually by the teacher and gradually increase as they master theoretical knowledge and manual skills. Outside the classroom, independent work should be accompanied by methodological support and consulting assistance to students in all sections of the professional module, the opportunity to practice practical skills on phantoms and treasuries, as well as the opportunity to practice those missed. Mastering this module should be preceded by the study of the following disciplines: “Human atomy and physiology with a course in biomechanics of the dentoalveolar system”, “Dental materials science with a course in occupational health and safety”, “First aid”, “Dental diseases”, “Life safety”, and also the study of professional modules: PM.01 Manufacturing of removable laminar dentures, PM.0 Manufacturing of fixed dentures, PM.03 Manufacturing of clasp dentures Personnel support for the educational process Qualification requirements for teaching (engineering and pedagogical) personnel providing training in the interdisciplinary course(s): The implementation of the main educational program in the specialty of secondary vocational education should be provided by teaching staff with higher education corresponding to the profile of the taught discipline (module). Experience in organizations in the relevant field is mandatory for teachers responsible for students’ mastery of the professional cycle; these teachers must undergo internships in specialized organizations at least once every 3 years 14

15 5. Monitoring and evaluation of the results of mastering a professional module (type) Results (mastered professional competencies) PC5.1 Manufacturing the main types of maxillofacial devices for defects of the maxillofacial area PC5. Manufacturing of therapeutic and prophylactic maxillofacial devices (splints) Main indicators for assessing the result Knowledge of the goals and objectives of maxillofacial orthopedics. Knowledge of the etiology, clinical picture and orthopedic treatment of defects of the maxillofacial region. Demonstration of skills in making a replacement prosthesis. Ability to identify maxillofacial trauma Knowledge of clinical and orthopedic treatment of gunshot and non-gunshot fractures of the maxillofacial region Demonstration of skills in making a Weber splint. Demonstration of skills in making a boxing splint. Forms and methods of control and assessment Current control in the form of: - conversations; - oral questioning; - test control; - problematic situational tasks. Expert assessment of the manufacture of a replacement prosthesis practical lesson Interim certification Current control in the form of: - conversations; - oral questioning; - test control; - problematic situational tasks Expert assessment of the production of a Weber splint in a practical lesson Expert assessment of the production of a boxing splint in a practical lesson Intermediate certification Forms and methods for monitoring and assessing learning outcomes should make it possible to check in students not only the formation of professional competencies, but also the development of general competencies and the skills that support them. 15

16 Results (mastered general competencies) GC1. Understand the essence and social significance of your future profession, show sustained interest in it. OK. Organize your own activities, choose standard methods and ways of performing professional tasks, evaluate their effectiveness and quality. OK3. Make decisions in standard and non-standard situations and take responsibility for them. OK4. Search and use information necessary for the effective implementation of professional tasks, professional and personal development. OK5. Use information and communication technologies c. OK6. Main indicators for assessing the result Presence of interest in the future profession Validity of the choice and application of methods and methods for solving professional problems in the manufacture of maxillofacial devices; Efficiency and quality of performing professional tasks. The ability to make decisions in standard and non-standard situations and bear responsibility for them. Searching and using information for the effective implementation of professional tasks, professional and personal development. Skills in using information and communication technologies in Effective interaction with students, Forms and methods of monitoring and evaluation Monitoring the student’s activities in the process of mastering the educational program Solving problem-situational problems Solving problem-situational problems Assessing independent work Assessing independent work 16

17 Work in a team and team, communicate effectively with colleagues, management, and consumers. OK7. Take responsibility for the work of team members (subordinates) and for the results of completing tasks. OK8. Independently determine the tasks of professional and personal development, engage in self-education, and consciously plan professional development. OK9. To navigate the conditions of frequent changes in technologies in OK10. Take care of the historical heritage and cultural traditions of the family, respect social, cultural and religious differences. teachers during training Responsibility for the work of team members, for the results of completing assignments Increasing personal and qualification levels Showing interest in innovations in the field Respect for the historical heritage and cultural traditions of the family, respect for social, cultural and religious differences Providing a portfolio of results in increasing personal and qualification levels . Assessment of independent work OK11. Be ready to take on moral obligations towards nature, society and people. OK1.Provide first (pre-hospital) medical aid in emergency conditions. OK13. Organize the workplace in compliance with the requirements Willingness to take on moral obligations in relation to nature, society and people Ability to provide first (pre-hospital) medical aid in emergency conditions Organize the workplace in compliance with the requirements 17

18 labor protection, industrial sanitation, infectious and fire safety. labor protection, industrial sanitation, infection and fire safety OK14. Lead a healthy lifestyle, engage in physical education and sports to improve health, achieve life and professional goals. OK15. Perform military duties, including using acquired professional knowledge (for young men). Maintaining a healthy lifestyle, engaging in physical education and sports to improve health, achieve life and professional goals Willingness to perform military duty, including using acquired professional knowledge (for boys) 18

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Classification of maxillofacial devices

n By function:

1). Fixing

2). Repairing

4). Formative

5). Substituting

n At the point of attachment:

1). Inside the oral

2). Extra oral

3). Combined

n According to medicinal value:

1). Basic

2). Auxiliary

n By location:

1). Single jawed

2). Bimaxillary

n By design

1). Removable

2). Fixed

3). Standard

4). Individual

Bent wire tires.

Currently, the following types of bent wire busbars are best known: 1) single-jaw smooth connecting busbar-bracket; 2) single-jaw connecting splint with a spacer bend; 3) a splint with hooking loops for intermaxillary fixation;

4) single-jaw splint with an inclined plane; 5) single-jaw splint with a supporting plane. Single-jaw smooth connecting splint-bracket. A single-jaw smooth connecting splint-clamp is used in cases where it is possible to firmly hold fragments in the correct position using single-jaw fixation.

To use this splint-brace, it is necessary to have a sufficient number of stable teeth on each fragment. To make a smooth connecting bus bar, aluminum wire 2 mm thick and 15-20 cm long is used.

The splint is bent so that it covers the molars located at the end of the dental arch from the distal and lingual sides with hooks. The hook should be curved so that it follows the shape of the equator of the tooth. If the outermost tooth cannot be covered with a hook (it is affected by caries or has a low crown), then a spike is bent, entering the spaces between the two outer teeth and sharpened with a file in the form of a triangular pyramid. The tenon should cover no more than half of the distal side of the penultimate tooth, and the edge should be curved toward the occlusal surface. Then the splint is bent along the dental arch in such a way that it is adjacent to each tooth at one point on its vestibular surface. The splint should be located on the gingival part of the tooth crown, i.e. between the equator and the gingival margin, located at a distance of 1-1.5 mm from the gingival margin. The technique for fitting the splint to the teeth is as follows: bending a hook or spike on one side, say the left side, insert the wire into the oral cavity, inserting the spike or hook into the space allocated for it, and mark the point on the wire that is adjacent to the teeth.

The wire is grabbed with crampon forceps at the marked point, removed from the oral cavity and the splint is bent with a finger towards the teeth that are not yet adjacent to it. Then they try on the splint in the mouth, again grab it with forceps and bend the splint with their fingers towards the teeth that are not yet adjacent to it.

This is done until the splint is adjacent to the teeth on the left side. It is more difficult to fit the splint to the other, i.e. right, side, since the other end of the wire enters the mouth with difficulty. In these cases proceed as follows. First, bend the splint so that it fits into the mouth and rests approximately on the teeth. right side. 0

In this case, the right end of the wire is cut off so that the splint is only 2-3 cm longer than the dentition. Then a splint is fitted to each tooth on the right side in the manner described, and a hook is bent from 2-3 cm of excess wire. One important rule to remember is that you need to bend the wire with your fingers and hold it with pliers.

When the tire is completely bent, tie it with a wire ligature. The splint must be tied to as many stable teeth as possible, preferably to all teeth. Before tying the splints, the mouth is cleared of food debris,

blood clots, wipe the teeth and mucous membrane with a cotton swab with a 3% solution of hydrogen peroxide, and then irrigate with a solution of potassium permanganate. Tartar, which interferes with the passage of ligatures through the interdental spaces, is also removed, and the splint is tied to the teeth.

To strengthen the splint, take a piece of wire ligature 140-160 cm long and wipe it with a swab with alcohol, this simultaneously removes curls and gives the ligature an even direction. Then they cut it into pieces 6-7 cm long for the front teeth and 14-15 cm for the side teeth.

Each segment is bent into the shape of a hairpin, having one end longer than the other, and the hairpin is given semicircular shape. The splint is tied to the teeth with a single knotted oblique ligature. For this purpose, both ends of the pin are passed from the side of the oral cavity through the gaps between the target tooth and two adjacent ones, so that the wire covers the tooth on both sides. One end should go into the vestibule of the mouth above the wire splint, the other - under the splint. Grasping both ends from the vestibular side with forceps, twist them clockwise, cut off the excess ligature so that the ends are no more than 3-4 mm in length, and bend them upward on the lower jaw above the splint, and on the upper jaw downwards - under the splint . For easy implementation ligatures through the interdental space, it is necessary that the position of the pin initially has a vertical direction.

When the ends have already entered the interdental spaces, you need to give the hairpin a horizontal position. You should not forcefully push the ligature; in these cases it bends and does not go in the right direction. Then they pull both ends from the vestibular side and twist them clockwise.

Jaw fragments are secured using various orthopedic devices. All orthopedic devices are divided into groups depending on their function, area of ​​fixation, therapeutic value, design, manufacturing method and material. By function:

– immobilizing (fixing);

– repositioning (correcting);

– corrective (guides);

– formative;

– resection (replacement);

– combined;

– dentures for defects of the jaws and face.

Chapter 12. Orthopedic treatment of patients with maxillofacial pathology 605

According to the place of fixation: – intraoral (single-maxillary, double-maxillary, intermaxillary); – extraoral; – intra- and extraoral (maxillary, mandibular).

By therapeutic purpose: – basic (having independent medicinal value: fixing, correcting, etc.);

– auxiliary (serving for the successful performance of skin-plastic or osteoplastic operations).

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

By manufacturing method: – laboratory manufacturing; – non-laboratory production.

By materials: – plastic; – metal; – combined.

Immobilizing devices are used in the treatment of severe jaw fractures, insufficient number or absence of teeth on the fragments. These include:

– wire tires (Tigerstedt, Vasiliev, Stepanov); – splints on rings, crowns (with hooks for traction of fragments); – splint guards:

✧ metal - cast, stamped, soldered; ✧ plastic; – removable tires Port, Limberg, Weber, Vankevich, etc.

Reduction devices that facilitate the reposition of bone fragments,
also used for old fractures with stiff fractures
kami jaws. These include:

– reduction devices made of wire with elastic intermaxillary rods, etc.;

– devices with intra- and extraoral levers (Kurlyandsky, Oksman);

– reduction devices with a screw and a repelling platform (Kurlyandsky, Grozovsky);

– reduction devices with a pelot for a toothless fragment (Kurlyandsky, etc.);

– reduction devices for toothless jaws (Gouning-Port splints).

Fixing devices are devices that help to retain a break.
kov jaws in a certain position. They are divided:
– to extraoral:

✧ standard chin sling with head cap; ✧ standard tire according to Zbarzh et al.

Course of orthopedic treatment of patients...

– intraoral: ✧ dental splints:

Aluminum wire (Tigerstedt, Vasiliev, etc.);

Soldered tires on rings, crowns;

Plastic tires;

Fixing dental appliances; ✧ dentogingival splints (Weber, etc.); ✧ supragingival splints (Porta, Limberga);

– combined.

Guides (corrective) are devices that provide
press the bone fragment of the jaw in a certain direction using
an inclined plane, a hinge, a sliding hinge, etc.
– For aluminum wire busbars, the guide planes are curved
beat simultaneously with a bus from the same piece of wire in the form of a row
loops

– Inclined planes for stamped crowns and aligners are made from a dense metal plate and soldered.

– For cast tires, the planes are modeled in wax and cast together with the tire.

– On plastic tires, the guide plane can be modeled simultaneously with the tire as a single unit.

– If there is an insufficient number or absence of teeth in the lower jaw, Vankevich splints are used.

Formative devices are devices that support plastic material (skin, mucous membrane), create a bed for the prosthesis in the postoperative period and prevent the formation of scar changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformations of the prosthetic bed, etc.). The design of the devices can be very diverse depending on the area of ​​damage and its anatomical and physiological characteristics. The design of the forming apparatus includes a forming part and fixing devices.

Resection (replacement) devices are devices that replace defects in the dentition formed after tooth extraction, filling defects in the jaws and parts of the face that arise after injury or surgery. The purpose of these devices is to restore the function of the organ, and sometimes to keep jaw fragments from moving or the soft tissues of the face from retraction.

Combined devices are devices that have several purposes and perform various functions, for example: securing jaw fragments and forming a prosthetic bed or replacing a jaw bone defect and simultaneously forming a skin flap. A typical representative of this group is the Kappa-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 the fragments.

Prostheses used in maxillofacial orthopedics are divided into: – dentoalveolar; – jaw;

Chapter 12. Orthopedic treatment of patients with maxillofacial pathology 607

– facial; – combined;

– for jaw resection, prostheses are used, which are called post-resection. There are immediate, immediate and remote prosthetics. In this regard, prostheses are divided into operational and postoperative. Replacement devices also include orthopedic devices used for palate defects: protective plates, obturators, etc.

Prosthetics for facial and jaw defects are made in case of contraindications to surgical interventions or in case of persistent reluctance of patients to undergo plastic surgery.

If the defect affects 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 lost tissue. Facial prostheses can be supported by eyeglass frames, dentures, steel springs, implants, and other devices.

Details

Replacement devices (prostheses)

Prostheses used in maxillofacial orthopedics can be divided into dentoalveolar, maxillary, facial, and combined. When resection of the jaws, prostheses are used, which are called post-resection. There are immediate, immediate and remote prosthetics. It is legitimate to divide prostheses into surgical and postoperative.

Dental prosthetics is inextricably linked with maxillofacial prosthetics. Advances in clinical practice, materials science, and technology for manufacturing dentures have a positive impact on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid-cast clasp dentures have found application in the designs of resection dentures and dentures restoring dentoalveolar defects (Fig. 248).

Replacement devices also include orthopedic devices used for palate defects. This is primarily a protective plate - used for palate plastic surgery; obturators - used for congenital and acquired palate defects.

Rice. 247. Forming apparatus (according to A.I. Betelman). The fixing part is fixed on the upper teeth, and the forming part is located between the fragments of the lower jaw.

Combined devices.

For reposition, fixation, shaping and replacement, a single design that can reliably solve all problems is advisable. An example of such a design is an apparatus consisting of soldered crowns with levers, fixing locking devices and a forming plate (Fig. 249).

Dental, dentoalveolar and jaw prostheses, in addition to their replacement function, often serve as a forming apparatus.

The results of orthopedic treatment of maxillofacial injuries largely depend on the reliability of fixation of the devices.

When solving this problem, you should adhere to the following rules:.

♦ use preserved natural teeth as support as much as possible, connecting them into blocks using known techniques for splinting teeth;

♦ make maximum use of the retention properties of the alveolar processes, bone fragments, soft tissues, skin, cartilage that limit the defect (for example, the cutaneous-cartilaginous part of the lower nasal passage and part of the soft palate, preserved even with total resections of the upper jaw, serve as a good support for strengthening the prosthesis);

Rice. 248. Prosthesis based on a solid cast frame with multi-link clasps. a - palate defect; b - solid cast frame; c - general view of the prosthesis.

♦ apply surgical methods to strengthen prostheses and devices in the absence of conditions for their fixation in a conservative way;.

♦ use the head and top part torso, if the possibilities of intraoral fixation have been exhausted;

♦ use external supports (for example, a system of traction of the upper jaw through blocks with the patient in a horizontal position on the bed).

Clasps, rings, crowns, telescopic crowns, mouth guards, ligature binding, springs, magnets can be used as fixing devices for maxillofacial devices. spectacle frame, sling bandage, corsets. The right choice and the use of these devices adequately to clinical situations allows us to achieve success in the orthopedic treatment of injuries to the maxillofacial area.