The upper jaw is one of the largest paired bones of the facial part of the skull, occupying a central position and participating in the formation of the nasal and oral cavities, as well as the walls of the orbit. Injuries to the maxillary bone make up an insignificant part of all fractures of the facial bones - about 5%.

In medical practice, as a rule, the division of injuries into types according to the Lefort classification, developed by a prominent French figure in 1901, is used. The author singled out the upper, lower and middle types of fractures (grades 1, 2 and 3, respectively).

Introduction

Mechanical damage to the jaw can be quite severe, and entail negative consequences and complications. They arise as a result of an accident, a person falling from a height face down, damage to the face by a heavy and massive object (rebar, construction tools, etc.), kicking or other parts of the body in the face during a conflict with opponents. Such injuries are often accompanied by a concussion (traumatic brain injury) and other negative consequences for the victim.

When injured, the upper jaw is sometimes displaced in the direction of the impact force or downward. The downward displacement is often uneven - the posterior segments are deformed much more than the anterior ones.

Fractures are diagnosed using clinical examinations, plain radiography, orthopantomography, and computed tomography. Maxillary pathology is easily detected by a traumatologist during questioning and visual examination of the patient.

First aid measures are extremely important. After placing the patient in a hospital, depending on the clinical picture and the results of the examination, doctors decide whether to use a conservative or surgical method of treatment. The rehabilitation time directly depends on the timeliness of the surgical intervention, the selected type of surgical manipulation.

The age of the patient is also important. The leading role is played by maintaining the general condition of the victim at an optimal level, compensating for his acute and chronic pathologies. Timely appointment of antibacterial and anti-inflammatory drugs contributes to rapid recovery.

Injury to the upper jaw can lead to serious complications in cases of untimely first aid and an incorrectly selected or poorly performed therapeutic method:

Features of the structure of the upper jaw

The upper jaw is located in the upper front part of the facial region of the skull. The maxillary sinus is found in it, so it is classified as an air bone. The bone has 5 elements: the body and four processes.

The body is represented by several types of surfaces:

• infratemporal (participates in the formation of the tubercle of the upper jaw, contains 2-3 alveolar openings leading to channels with nerves of the posterior upper molars) (see also: the structure of the human upper jaw and its differences from the lower one);
• orbital (has smooth walls in the shape of a triangle, forms an eye socket);
• nasal (the most complex part of the body of the upper jaw, it is a combination of many elements and openings: the maxillary cleft and sinus, the suture with the palatine bone, the palatine and lacrimal grooves, the frontal and lacrimal processes, the nasolacrimal canal, the conch crest and the inferior nasal concha);
• anterior (contains infraorbital foramen and canine fossa).

Processes of the upper jaw:

• alveolar (participates in the formation of teeth);
• frontal (has two walls - nasal and facial);
• zygomatic (starts from the upper outer corner of the body);
• palatine (horizontal plate, which is the partition between the nasal and oral cavity).

Features of the upper jaw:

1. it is very durable, therefore it perfectly resists physical influences from the outside;
2. in most cases, fractures on it are open;
3. fracture occurs due to mechanical shear.

Types of fractures of the upper jaw, classification according to Lefort

A fracture of the upper jaw can be classified according to several criteria. Varieties due to occurrence:

According to the severity of the lesion, injuries of the upper jaw are divided into:

• complete: as a result of injury, the bone is divided into 2 or more parts;
• incomplete: a crack or break in the bone, in which it remains attached on one side.

Bone stability classification:

• with displacement of fragments (for example, due to improper first aid);
• no offset.

The shape and direction of the fracture is:

• splintered;
• wedge-shaped;
• compression;
• hammered;
• transverse;
• longitudinal;
• oblique.

Classification according to the integrity of the skin:

1. open (fracture, accompanied by the appearance of an open wound);
2. closed (damage to the bones of the jaw without tearing the skin).

Damage can be divided by complications:

• complicated (sepsis, bleeding, osteomyelitis, shock, etc.);
• uncomplicated.

Lefort classification:

Fracture symptoms

A fracture of the upper jaw is accompanied by a number of characteristic symptoms. In most cases, individual signs resemble the symptoms of other pathologies, so careful observation of the manifestations of trauma will help establish the truth.

For a fracture of the upper jaw, the following classification of symptoms is characteristic:

There are situations when internal injuries of the upper jaw do not immediately make themselves felt. Sometimes patients with such injuries are able to move normally and respond adequately to the surrounding circumstances. The anamnesis indicates the presence of a fracture, and the symptoms are treacherously silent. This injury can be life threatening. Often, jaw fractures are accompanied by a serious complication - a concussion.

A fracture of the jaw is also characterized by specific signs characteristic of a varying degree of pathology according to Lefort, which we presented above. Consider the symptoms of “impacted” jaw injuries:

• flattening of the middle third of the face;
• problems with bite and dentition;
• the appearance of a “step”, which is palpable on palpation of the cheekbones and the orbital area.

Injury diagnosis

Before starting treatment, the doctor must establish a diagnosis and determine the nature of the damage. First of all, the patient is sent for x-rays. The picture is not always able to give a sufficient amount of information, since the structure of the bones of the facial skull is quite specific. The picture does not show small areas of fractures and it is impossible to determine exactly whether there is a layering of the bones, which makes it difficult to see during the study.

In most cases, a survey radiograph in the sagittal projection is prescribed. The picture visually defines zigzags and cracks around the zygomatic-alveolar crest and at the borders of the maxillary sinuses.

X-ray in axial projection allows diagnosing a Lefort fracture II degree. In recent years, panoramic x-rays, computed tomography and MRI are gaining more and more popularity.

Timely and competent diagnosis allows to return the bone fragments to their original place in a few days, as a result of which the patient stays in the hospital for a short time. The risk of complications is reduced.

First aid for a fracture

A jaw injury is a serious incident, so it is important to correctly provide first aid. The injured person must be given rest.

General rules on how to provide first aid for a fracture:

1. By all means stop the bleeding. You can use improvised means.
2. Lay the patient on their side to avoid blocking the airways.
3. Carefully bring and secure the upper jaw to the lower, using a bandage.
4. In the hematoma area, you can put something cold (ice, frozen meat).
5. Transfer the patient to qualified emergency physicians who will place him in a hospital and begin treatment in a conservative or operative way.

In order to avoid complications, the attending physician immediately prescribes antibiotics and non-steroidal anti-inflammatory drugs. They must be taken in a complex, which is due to pain and swelling before and after surgery. Medications against edema, diuretics are prescribed. It is most effective to use them in the form of droppers.

Regardless of whether the fracture is open or closed, antibacterial agents are indicated. Next to the jaw are the brain and the maxillary sinus. Microorganisms in it are able to penetrate into the cranial cavity through the external injured area. At the initial stage of treatment, broad-spectrum antibiotics are prescribed.

Additionally, drugs are used to restore damaged tissues and blood supply to the brain. Medications and calcium supplements are shown, prescribed in strictly defined dosages. When the splint is removed, the process of rehabilitation and development of the upper jaw begins. Scars from a wound can be eliminated with the help of pharmacy gels and ointments. It is also mandatory to visit an ENT and a neurologist.

Treatment

Treatment of injuries of the upper jaw can be conservative or operative. The first (orthopedic) method consists in the use of special aluminum splints, which have hook loops with rubber traction to secure the jaws in a state of absolute immobility.

This method is used in the following cases:

• fracture according to Lefort of the first and second degree;
• the patient's condition is satisfactory, therefore, medical manipulations or physiotherapeutic procedures in the oral cavity are not prohibited;
• slight displacement of fragments of the bones of the upper jaw.

A rubber tube is placed between the opposing molars in order to correctly match the damaged elements. Along with the splint, a sling-like bandage is applied to the patient for reliable and durable fixation.

The conservative method involves the use of certain devices. The Zbarzh apparatus is most often used. It has a pair of wire arches that overlap the dentition. A special cap with attached rods coming from the indicated arcs is put on the head of an injured person.

The operational method is divided into the following varieties:

Three types of fractures should be distinguished:

Le Fort I - Inferior transverse fracture, in which the fracture line runs horizontally above the alveolar process from the base of the pyriform foramen to the pterygoid. This type of fracture was first described by Guerin. Le Fort also mentions him. Therefore, some authors call it the Guerin-Le Fort fracture.

Le Fort II - middle line; passes in the transverse direction through the nasal bones, the bottom of the orbit, the infraorbital margin down the zygomatic-maxillary floor and the pterygoid process of the sphenoid bone.

Le Fort III - Complete avulsion of the maxilla with nasal and zygomatic bones - the fracture line passes through the nasal bones, the lacrimal bone, the bottom of the orbit and ends in the pterygoid process of the sphenoid bone.

This type of fracture is called a complete craniofacial separation.

Gunshot fractures of the lower jaw.

With gunshot wounds of low-frequency splinters and bullets with great force often damage the lower jaw simultaneously in several places, causing small and large comminuted fractures.

Gunshot fractures n / h can be:

linear type fractures;

splintered (small and large splintered with a violation of the continuity of the jaw;

marginal fractures of various nature with preservation of the continuity of the jaw;

perforated fractures;

fractures with segmental defect of the jaw;

separation of significant sections of the jaw;

combined fractures.

When examining a wounded person in the first place, the general condition of the victim is assessed with a mandatory preliminary conclusion on the degree of blood loss. Pay attention to the magnitude of blood pressure, pallor of the skin, shallow breathing, etc. With increasing signs of asphyxia, indications arise - suction of mucus from the trachea and, possibly, blood.

External examination of the wound or wounds, examination of the oral cavity with the help of two spatulas or Buyalsky's shoulder blades, definition of the concept of occlusion, a careful test for the mobility of fragments and the possibility of their establishment in the occlusion during displacement, comparison of inlets and outlets in case of a penetrating wound - all this must be paid attention to when examining the wounded in n / h.

Gunshot fractures of the upper jaw.

In case of gunshot fractures in / h, one significant feature should be remembered, it lies in the fact that due to the fixed connection of the v / h with the bones of the brain skull, the proximity of the brain, eyeball, organs of hearing and smell, the symptomatology of gunshot injuries of this bone is compared, for example, with gunshot fractures, n / h seems, in some cases, more diverse.

When evaluating the victims of this group, in addition to the usual clinical examination, it is necessary to clarify whether there was a loss of consciousness, nausea, vomiting, whether there were any complaints of headache, what the speech of the wounded was, etc. Local manifestations of gunshot fractures in / h entirely depend on the location and degree of destruction of bone tissue. Mild, moderate, and severe lesions may be observed. In severe injuries - massive destruction of soft tissues and maxillary bone with simultaneous damage to the orbit, nose and other formations. Usually, on examination, one or more soft tissue wounds are found, bruising around the wounds and especially in the area of ​​eyelid tissue (a symptom of “glasses”), swelling of the tissues of the upper face, bleeding from wounds and the nasal cavity and traces of former bleeding. Opening the mouth is painful. With fractures in / h, swelling of the soft palate and arches is almost always detected, sometimes, there is a hanging of the soft tissues of the hard and soft palate, which can interfere with breathing. The study of the mobility of fragments should be done by grasping intact teeth with fingers while simultaneously feeling the outer integument of the jaw. X-ray examination (tomography, face, profile and axial image) allows in some cases to clarify the topical diagnosis of a fracture and the localization of foreign bodies in blind wounds.

All iLive content is reviewed by medical experts to ensure it is as accurate and factual as possible.

We have strict sourcing guidelines and only cite reputable websites, academic research institutes and, where possible, proven medical research. Note that the numbers in brackets (, etc.) are clickable links to such studies.

If you believe any of our content is inaccurate, outdated, or otherwise questionable, please select it and press Ctrl + Enter.

A maxillary fracture usually follows one of the three typical lines of least resistance described by Le Fort: upper, middle, and lower. They are called Le Fort lines (Le Fort, 1901).

• Le Fort I - the bottom line, has a direction from the base of the pyriform aperture horizontally and back to the pterygoid process of the sphenoid bone. This type of fracture was first described by Guerin, and Le Fort mentions it in his work, so a fracture along the lower line should be called a Guerin-Le Fort fracture.
• Le Fort II - the middle line, passes in the transverse direction through the nasal bones, the bottom of the orbit, the infraorbital margin, and then down the zygomatic-maxillary suture and the pterygoid process of the sphenoid bone.
• Le Fort III - the upper line of the least strength, passing in the transverse direction through the base of the nasal bones, the bottom of the orbit, its outer edge, the zygomatic arch and the pterygoid process of the sphenoid bone.

With a fracture along the Le Fort I line, only the dental arch of the upper jaw is mobile along with the palatine process; with a Le Fort II fracture, the entire upper jaw and nose, and in the case of a Le Fort III fracture, the entire upper jaw along with the nose and zygomatic bones. This mobility can be unilateral or bilateral. With unilateral fractures of the upper jaw, the mobility of the fragment is less pronounced than with bilateral fractures.

Fractures of the upper jaw, especially along the Le Fort III line, are often accompanied by damage to the base of the skull, concussions, bruises, or compression of the brain. Simultaneous damage to the jaw and brain is more often the result of a gross and severe injury: a blow to the face with a heavy object, compression, a fall of the victim from a great height. The condition of patients with a fracture of the upper jaw is significantly aggravated by damage to the walls of the paranasal sinuses, the nasal part of the pharynx, the middle ear, the meninges, the anterior cranial fossa with the nasal bones driven into it, the walls of the frontal sinus. As a result of a fracture of the walls of this sinus or the ethmoid labyrinth, emphysema of the subcutaneous tissue in the orbit, forehead, and cheeks may occur, which is manifested by a characteristic symptom of crepitus. Often there is crushing or rupture of the soft tissues of the face.

, , ,

ICD-10 code

S02 Fracture of skull and facial bones

Symptoms of a fracture of the upper jaw

Fractures of the base of the skull accompanied by a symptom of "bloody glasses", subconjunctival suffusion (blood soaking), retroauricular hematoma (with a fracture of the middle cranial fossa), bleeding and especially liquorrhea from the ear and nose, dysfunction of the cranial nerves and general neurological disorders. Most often, the branches of the trigeminal, facial and oculomotor nerves are damaged (loss of sensitivity, impaired facial expressions, pain when the eyeballs move up or to the sides, etc.).

It is of great diagnostic value the rate of development of hematomas: fast - indicates its local origin, and slow - within 1-2 days - is typical for indirect, deep bleeding, i.e., a fracture of the base of the skull.

Diagnosis of fractures of the upper jaw compared to injuries of the lower jaw is a more difficult task, since they are often accompanied by rapidly increasing swelling of the soft tissues (eyelids, cheeks) and interstitial hemorrhages.

Assistance to victims with trauma to the maxillofacial region

Treatment of patients with fractures of the jaws provides for the restoration of their lost form and function in the shortest possible time. The solution to this problem includes the following main stages:

1. comparison of displaced fragments,
2. securing them in the correct position;
3. stimulation of bone tissue regeneration in the fracture area;
4. prevention of various kinds of complications (osteomyelitis, false joint, traumatic sinusitis, maxillary phlegmon or abscess, etc.).

Specialized care for jaw fractures should be provided as early as possible (in the first hours after injury), since timely reposition and fixation of fragments provide more favorable conditions for bone regeneration and healing of damaged oral soft tissues, as well as help stop primary bleeding and prevent the development of inflammatory complications.

The organization of assistance to victims with trauma to the maxillofacial region should provide for the continuity of therapeutic measures along the entire route of the victim from the scene of the incident to the medical institution with mandatory evacuation to the destination. The volume and nature of the assistance provided may vary depending on the situation at the scene, the location of medical centers and institutions.

Distinguish:

1. first aid, which is directly at the scene, sanitary posts and is carried out by the victims (in the order of self- or mutual assistance), an orderly, a medical instructor;
2. first aid, provided by a paramedic or nurse and intended to supplement first aid measures;
3. first aid, which should be provided, if possible, within 4 hours from the moment of damage; it is carried out by non-specialist doctors (in rural district hospitals, at medical health centers, ambulance stations);
4. skilled surgical care which should be provided in medical institutions no later than 12-18 hours after the injury;
5. specialized help which should be provided in a specialized institution within one day after the injury. The given terms for the provision of various types of assistance are optimal.

, , , , , , , ,

First aid at the scene

Favorable outcomes in the treatment of injuries of the maxillofacial region largely depend on the quality and timeliness of first aid. Not only health, but sometimes the life of the victim depends on its proper organization, especially when bleeding or asphyxia occurs. Often one of the main features of injuries of the maxillofacial region is discrepancy between the type of the victim and the severity of the injury. It is necessary to draw the attention of the population to this feature when conducting sanitary and educational work (in the Red Cross system, during civil defense classes).

The medical service should pay great attention to training in first aid, especially workers in those industries where the injury rate is quite high (mining, agriculture, etc.).

When providing first aid to an injured person at the scene of an accident Firstly it is necessary to give a position that prevents asphyxiation, i.e., lay on its side, turning its head towards the wound or face down. Then an aseptic bandage should be applied to the wound. In case of chemical burns of the face (acids or alkalis), it is necessary to immediately wash the burnt surface with cold water to remove the remnants of the substances that caused the burn.

After providing first aid at the scene (sanitary post), the victim is evacuated to a medical aid station, where first aid is provided by paramedical personnel.

Many patients with injuries of the maxillofacial region can independently get to medical centers located near the scene of the incident (health centers of factories, plants). Those victims who cannot move independently are transported to medical institutions in compliance with the rules for preventing asphyxia and bleeding.

First aid for injuries of the maxillofacial region can be provided by paramedical workers called to the scene.

First aid

As well as emergency, assistance for vital indications is provided at the scene of the incident, at sanitary posts, in health centers, feldsher and feldsher-obstetric stations. At the same time, efforts should be directed primarily to stopping bleeding, preventing asphyxia and shock.

Paramedical workers (dental technician, paramedic, midwife, nurse) must know the basics of diagnosing facial injuries, the elements of first aid and the peculiarities of transporting patients.

The volume of first aid depends on the nature of the injury, the condition of the patient, the environment in which this assistance is provided, and the qualifications of these medical workers.

Medical personnel must ascertain the time, place and circumstances of the injury; after examining the victim, make a preliminary diagnosis and perform a number of therapeutic and preventive measures.

Fighting bleeding

An abundant network of blood vessels in the maxillofacial region creates favorable conditions for the occurrence of bleeding in case of facial injuries. Bleeding can occur not only outside or into the oral cavity, but also into the depths of the tissues (hidden).

When bleeding from small vessels, you can pack the wound and apply a pressure bandage (if this does not cause a threat of asphyxia or displacement of fragments of the jaws). By using pressure bandage can stop bleeding in most injuries of the maxillofacial region. In cases of injury major branches of the external carotid artery (lingual, facial, maxillary, superficial temporal), temporary arrest of bleeding in emergency can be carried out finger pressure.

Asphyxia prevention and methods of dealing with it

First of all, it is necessary to correctly assess the patient's condition, paying attention to the nature of his breathing and position. In this case, the phenomena of asphyxia may be detected, the mechanism of which may be different:

1. backward displacement of the tongue (dislocation);
2. blockage of the trachea with blood clots (obstructive);
3. compression of the trachea by hematoma or edematous tissues (stenotic);
4. closure of the entrance to the larynx with a hanging flap of soft tissues of the palate or tongue (valve);
5. aspiration of blood, vomit, earth, water, etc. (aspiration).

For asphyxiation warnings the patient should be seated, slightly tilting him forward and lowering his head down; in case of severe multiple injuries and loss of consciousness - lay on your back, turning your head in the direction of the wound or to one side. If injury allows, the patient can be laid face down.

The most common cause of asphyxia is tongue retraction, which occurs in case of fragmentation of the body of the lower jaw, especially the chin, with double mental fractures. One of the effective methods of dealing with this (dislocation) asphyxia is fixing the tongue with a silk ligature or piercing it with a safety pin or hairpin. To prevent obstructive asphyxia, it is necessary to carefully examine the oral cavity and remove blood clots, foreign bodies, mucus, food debris or vomit.

Anti-shock measures

These measures, first of all, should provide for timely stopping of bleeding, elimination of asphyxia and implementation of transport immobilization.

The fight against shock in injuries of the maxillofacial region includes the whole range of measures taken in cases of shock in case of injuries to other areas of the body.

To prevent further infection of the wound, it is necessary to apply an aseptic (protective) gauze bandage (for example, an individual bag). At the same time, it must be remembered that in case of fractures of the bones of the face, it is impossible to tighten the bandage tightly in order to avoid mixing fragments, especially in case of fractures of the lower jaw.

Paramedics are prohibited from suturing soft tissue wounds for any facial injuries. With open wounds of the maxillofacial region, including all fractures of the jaws within the dentition, the introduction of 3000 AU antitetanus serum according to Bezredko is mandatory at this stage of care.

For transport immobilization, fixing bandages are applied - an ordinary gauze, sling-shaped, circular, hard chin sling or a standard transport bandage consisting of a chin sling and a soft head cap.

If the doctor does not have these standard means, he can apply the usual gauze (bandage) Hippocrates cap in combination with a sling-like gauze bandage; however, in cases where the patient is transported over a long distance in a specialized institution, it is more expedient to apply a plaster sling bandage.

It is necessary to clearly fill out a referral to a medical institution, indicating everything what is done to the patient, and to ensure the correct method of transportation.

With indications in the patient's history of loss of consciousness, examination, assistance and transportation should be carried out only in the supine position.

The equipment of the medical assistant's station should provide everything necessary to provide first aid in case of a facial injury, including feeding and quenching the patient's thirst (drinking bowl, etc.).

In the event of a mass arrival of victims (as a result of accidents, catastrophes, etc.), it is very important that they are properly sorted by evacuation and transport (by a paramedic or nurse), i.e., establishing the order of evacuation and determining the position of the victims during transportation.

First aid

First medical aid is provided by doctors of regional, district, rural district hospitals, central; district and city medical health centers, etc.

The main task at the same time is to help according to vital indications: control of bleeding, asphyxia and shock, checking and, if necessary, correcting or replacing previously applied dressings.

Bleeding is controlled by ligation of vessels in a wound or tight tamponade. With massive bleeding from the “mouth cavity”, which cannot be stopped by conventional means, the doctor must perform an urgent tracheotomy and tightly pack the oral cavity and pharynx.

In the event of signs of suffocation, therapeutic measures are determined by the cause that caused it. With dislocation asphyxia, the tongue is stitched. A thorough examination of the oral cavity and the removal of blood clots and foreign bodies eliminate the threat of obstructive asphyxia. If, despite these measures, asphyxia nevertheless developed, it is shown emergency tracheotomy.

Anti-shock measures carried out according to the general rules of emergency surgery.

Then, in case of jaw fractures, be sure to apply a fixing bandage for the implementation of transport (temporary) immobilization and drink the patient in the usual way or with the help of a drinker with a rubber tube put on the spout.

Methods for temporary fixation of jaw fragments

Currently, there are the following methods of temporary (transport) immobilization of jaw fragments:

1. chin sling bandages;
2. sling plaster or adhesive bandage;
3. intermaxillary tying with wire or plastic thread;
4. standard set and others. for example, a continuous connection with a figure eight, a lingual-labial connection, a ligature by Y. Galmosh, a continuous wire ligature according to Stout, Reedson, Obwegeser, Elenk, quite well described by Y. Galmosh (1975).

The choice of the method of temporary immobilization of fragments is determined by the location of fractures, their number, the general condition of the victim and the presence of sufficiently stable teeth to fix the splint or bandage.

At a fracture alveolar process of the upper or lower jaw, after comparing the fragments, an external gauze sling-like bandage is usually used, pressing the lower jaw to the upper.

For all fractures body of the upper jaw after the fragments are repositioned, a metal splint-spoon of A. A. Limberg is put on the upper jaw or a sling-like bandage is applied to the lower jaw.

In the absence of teeth in the upper jaw, a stencil or wax pad is placed on the gums.

If there are dentures in the patient's mouth, they are used as splints between the dental arches and an additional sling-like bandage is applied. In the anterior part of the plastic dentition, you need to make a hole with a cutter for the spout of a drinking bowl, a drainage tube or a teaspoon to enable the patient to be fed.

If both jaws have teeth, then with fractures of the body of the lower jaw fragments are strengthened with an intermaxillary ligature bandage, a rigid standard sling or a plaster splint. which is applied to the lower jaw and attached to the vault of the skull.

At fractures in the region of the condylar processes of the mandible apply an intraoral ligature or rigid bandage with elastic traction to the head cap of the victim. In cases of fractures of the condylar processes with malocclusion (open), the lower jaw is fixed with a spacer between the last antagonizing large molars. If there are no teeth on the damaged lower jaw, dentures can be used in combination with a hard sling; if there are no prostheses, a hard sling or a gauze circular bandage is used.

With combined fractures of the upper and lower jaws the above-described methods of separate fixation of fragments are used, for example, the Rauer-Urbanskaya splint-spoon in combination with the ligature binding of the teeth to each other at the ends of the fragments of the lower jaw. The ligature should cover in the form of a figure eight two teeth on each fragment. If there is no threat of intraoral bleeding, retraction of the tongue, vomiting, etc., a hard sling can be used.

During the first aid phase, correctly decide the issue of the timing and method of transportation of the victim, determine, if possible, an evacuation destination. In the presence of complicated and multiple fractures of the bones of the face, it is advisable to minimize the number of "stages of evacuation" by referring such patients directly in stationary maxillofacial departments of republican, regional and regional (city) hospitals, hospitals.

With associated trauma(especially trauma to the skull), the issue of transporting the patient should be decided carefully, thoughtfully and in conjunction with the relevant specialists. In these cases, it is more expedient to call specialists from regional or city institutions for a consultation to a rural district hospital than to transport patients there with a concussion or brain injury.

If there is a dentist in the local hospital, first medical aid for such conditions as non-penetrating injuries of the soft tissues of the face that do not require primary plasty, tooth fractures, fractures of the alveolar processes of the upper and lower jaws, uncomplicated single fractures of the lower jaw without mixing, fractures of the bones of the nose that do not require reduction, dislocations of the lower jaw that have been successfully reduced, burns of the face of I-II degrees, can be supplemented with elements of specialized care.

Patients with a combined facial injury, especially in the presence of a concussion, should be hospitalized in district hospitals. When deciding on their transportation in the first hours after the injury to specialized departments, one should take into account the general condition of the patient, the type of transport, the state of the road, the distance to the medical institution. The most suitable means of transport for these patients can be considered a helicopter and, if the roads are in good condition, specialized ambulances.

After providing first medical aid in the local hospital, patients with fractures of the upper and lower jaws, multiple trauma to the bones of the face, complicated by trauma of any localization, penetrating and extensive soft tissue injuries requiring primary plasty, are referred to specialized departments of the district, city or regional hospital. The question of where the patient should be sent - to the district hospital (if there are dentists there) or to the maxillofacial department of the nearest hospital, is decided depending on local conditions.

Qualified surgical care

Qualified surgical care is provided by surgeons and traumatologists in polyclinics, trauma centers, surgical or trauma departments of city or district hospitals. It should be provided primarily to those victims who need it according to vital testimony. These include patients with signs of shock, bleeding, acute blood loss and asphyxia. For example, if bleeding from large vessels of the maxillofacial region that has not been stopped at the previous stages or has arisen, it is not possible to reliably tie off the bleeding vessel, then the external carotid artery is ligated on the corresponding side. At this stage of care, all victims with injuries of the maxillofacial region are divided into three groups.

The first group - those who need only surgical assistance (soft tissue injuries without true defects, burns of I-II degrees, frostbite of the face); for them, this stage of treatment is final.

specialized treatment (soft tissue injuries requiring surgical treatment of plastic elements; damage to the bones of the face; burns of the III-IV degree and frostbite of the face, requiring surgical treatment); after providing emergency surgical care, they are transported to the maxillofacial hospitals.

The third group - non-transportable victims, as well as persons with combined injuries of other areas of the body (especially traumatic brain injury), which are leading in their severity.

One of the reasons for re-surgical treatment of the wound is intervention without prior X-ray examination. If fractures of the facial bones are suspected, it is mandatory. The increased regenerative capacity of facial tissues allows for surgical intervention, sparing the tissues as much as possible.

When providing qualified surgical care to the victims of group II, who will be sent to specialized medical institutions (if they have no contraindications for transportation), the surgeon must:

1. produce prolonged anesthesia fracture sites; and even better - prolonged anesthesia of the entire half of the face or according to the method of P. Yu. Stolyarenko (1987): through a needle injection under the bone ledge on the lower edge of the zygomatic arch at the junction of the temporal process of the zygomatic bone with the zygomatic process of the temporal bone;
2. treat the wound with antibiotics inject antibiotics inside;
3. implement the simplest transport immobilization, for example, apply a standard transport bandage;
4. make sure there is no bleeding from a wound, asphyxia or its threat during transportation;
5. control the introduction tetanus toxoid serum;
6. provide correct transportation to a specialized medical institution, accompanied by medical personnel (determine the type of transport, the position of the patient);
7. clearly indicate in accompanying documents everything that is done to the patient.

In cases where there are contraindications to sending the victim to another medical institution (group III), he is provided with qualified assistance in the surgical department with the involvement of dentists of hospitals or clinics who obliged

General surgeons and traumatologists, in turn, must be familiar with basics assistance in case of trauma to the maxillofacial region, observe principles surgical treatment of facial wounds, know main methods of transport immobilization of fractures.

Treatment of victims with combined injuries of the face and other areas in a surgical (traumatological) hospital should occur with the participation of a maxillofacial surgeon.

If there is a maxillofacial department or a dental office in a district hospital, the head of the department (dentist) should be responsible for the state and organization of trauma dental care in the area. For the correct accounting of maxillofacial traumatism, contact between the dentist and feldsher points and district hospitals should be established. In addition, it is necessary to analyze the results of treatment of patients with facial trauma who were in district and regional institutions.

Patients with complex and complicated facial injuries when it is necessary to perform primary soft tissue plasty and use the latest methods of treatment of facial fractures, including primary bone grafting.

Specialized emergency care and follow-up treatment of a maxillary fracture

This type of care is provided in stationary maxillofacial departments of republican, regional, regional, city hospitals, in surgical dentistry clinics of medical universities, research institutes of dentistry, in maxillofacial departments of research institutes of traumatology and orthopedics.

Upon admission of the victims to the admission department of the hospital, it is advisable to distinguish three sorting groups (according to V. I. Lukyanenko):

The first group - those in need of urgent measures, in qualified or specialized care in the dressing room or operating room: wounded in the face with ongoing bleeding from under the bandages or the oral cavity; in a state of asphyxia or with unstable external respiration, after tracheotomy with tight tamponade of the oral cavity and pharynx, in an unconscious state. They are sent to the operating room or dressing room on a stretcher in the first place.

The second group is those who need clarifying the diagnosis and determining the leading severity of damage. These include the wounded with combined injuries of the jaws and face, ENT organs, skull, organs of vision, etc.

The third group - to be sent to the department in the second turn. This group includes all victims not included in the first two groups.

Before starting surgical treatment, the victim should be examined clinically and radiographically. Based on the data obtained, the scope of intervention is determined.

Surgical debridement, whether early, delayed or late, should be simultaneous and, if possible, complete, include local plastic surgery on soft tissues and even bone grafting of the lower jaw.

As A. A. Skager and T. M. Lurie (1982) point out, the nature of the regenerative blastema (osteogenic, chondrogenic, fibrous, mixed) is determined by the oxybiotic activity of tissues in the fracture zone, and therefore all traumatic and therapeutic factors affect the speed and quality of reparative osteogenesis mainly through local blood supply. As a result of damage, circulatory disorders always occur. local(area of ​​wound and fracture), regional(maxillofacial area) or general(traumatic shock) character. Local and regional circulatory disorders are usually longer, especially in the absence of immobilization of fragments and the occurrence of inflammatory complications. As a result, the reparative reaction of tissues is perverted.

At adequate blood supply to the area of ​​damage in conditions of stability of fragments occurs primary, the so-called angiogenic bone formation. IN less favorable vascular-regeneration conditions, which are created mainly in the absence of stability in the area of ​​​​the junction of fragments, connective tissue is formed, or cartilaginous, regenerate, i.e., “reparative osteosynthesis” occurs, especially in the absence of timely and correct comparison of fragments. Such a course of reparative regeneration requires more tissue resources and time. It can end with a secondary bone union of the fracture, but at the same time, scar connective tissue sometimes remains in the fracture zone for a long time or remains forever. with foci of chronic inflammation, which can be clinically manifested in the form of exacerbation of traumatic osteomyelitis.

From the point of view of optimization of the vascular-regeneration complex, closed reposition and fixation of facial bone fragments have an advantage over open osteosynthesis with a wide exposure of the ends of the fragments.

Therefore, the basis contemporary treatment of bone fractures based on the following principles:

1. perfect exact comparison of fragments;
2. bringing fragments over the entire surface of the fracture into position close contact(clumps);
3. strong fixation fragments reduced and in contact with the fracture surfaces, excluding or almost excluding any mobility visible to the eye between them for the entire period necessary for the complete union of the fracture;
4. preservation of mobility of the temporomandibular joints, if the surgeon has an apparatus for extraoral reposition and fixation of mandibular fragments.

This more rapid fusion of bone fragments is provided. Compliance with these principles ensures primary union of the fracture and allows cut terms of treatment of patients.

Additional general and local therapeutic measures for fresh fractures complicated by an inflammatory process

Specialized care for maxillofacial injuries provides for a set of measures aimed at preventing complications and accelerating bone tissue regeneration (physiotherapy, physiotherapy, vitamin therapy, etc.). It should also provide all patients with the necessary nutrition and proper oral care. In large departments, it is recommended to allocate special wards for trauma patients.

For all types of assistance, it is necessary to clearly and correctly fill out medical documentation.

Measures that prevent the development of complications include the introduction of tetanus toxoid, local administration of antibiotics in the preoperative period, sanitation of the oral cavity, temporary immobilization of bone fragments (within the limits of possibility). It must be remembered that infection during fractures within the dentition can occur not only when the mucous membrane is ruptured or the skin is damaged, but also in the presence of periapical inflammatory foci of the teeth located in the fracture area or in close proximity to it.

If necessary, in addition to applying a standard transport bandage, intermaxillary fixation is performed using ligature tying of teeth.

The method of anesthesia is chosen depending on the situation and the number of patients admitted. At the same time, in addition to the general condition of the patient, it is necessary to take into account the location and nature of the fracture, as well as the time that is supposed to be spent on the implementation of orthopedic fixation or osteosynthesis. In most cases of fractures of the body and jaw branch (with the exception of high fractures of the condylar process, accompanied by dislocation of the head of the lower jaw), local conduction and infiltration anesthesia can be limited. It is better to carry out conduction anesthesia in the region of the foramen ovale (if necessary, on both sides) in order to turn off not only the sensitive, but also the motor branches of the mandibular nerve. Potentiated local anesthesia is more effective. Prolonged conduction blockade and its combination with the use of calypsol in subnarcotic doses are also used.

To resolve the issue of how to deal with a tooth located directly in the fracture gap, it is necessary to determine the ratio of its roots to the fracture plane. There are three possible positions:

1. the fracture gap runs along the entire lateral surface of the tooth root - from its neck to the opening of the apex;
2. the apex of the tooth is in the fracture gap;
3. the fracture gap runs obliquely with respect to the vertical axis of the tooth, but outside its alveoli, without damage to the periodontium and the walls of the alveolus of the tooth.

most favorable in terms of prognosis of consolidation (without the development of a clinically noticeable inflammatory complication) is the third position of the tooth, and least- the first, since in this case there is a rupture of the mucous membrane of the gums at the neck of the tooth and gaping of the fracture gap, causing the inevitable infection of the jaw fragments with pathogenic microflora of the oral cavity. Therefore, even before immobilization, it is necessary to remove the teeth that are in the first position, as well as broken, dislocated, crushed, destroyed by caries, complicated by pulpitis or chronic periodontitis. After tooth extraction, it is recommended to isolate the fracture zone by plugging the hole with iodoform gauze. N. M. Gordiyuk et al. (1990) recommend plugging the wells with canned (in 2% chloramine solution) amnion.

It is very important to determine the nature of the microflora in the area of ​​the fracture and to investigate its sensitivity to antibiotics. Intact teeth in the second and third positions can be conditionally left in the fracture gap, however, in this case, complex treatment should include antibiotic and physiotherapy. If, in the process of such treatment, the first clinical signs of inflammation appear in the fracture zone, the left tooth is treated conservatively, its root canals are sealed, and if they are obstructed, they are removed.

Tooth germs, teeth with unformed roots and teeth that have not yet erupted (in particular, the third large molars), in the absence of inflammation around them, can also be conditionally leave in the fracture area, because, as our experience and observations of other authors show, well-being in the zone of teeth left in the fracture gap, clinically determined on the day the patient is discharged from the hospital, is often deceptive unstable, especially in the first 3-9 months after injury. This is due to the fact that sometimes the pulp of two-rooted teeth located in the fracture zone, accompanied by damage to the mandibular neurovascular bundle, undergoes deep inflammatory-dystrophic changes, ending in necrosis. When the neurovascular bundle of a single-rooted tooth is damaged, necrotic changes in the pulp are observed in most cases.

According to different authors, the preservation of teeth in the fracture gap is possible only in 46.3% of patients, since the rest develop periodontitis, bone resorption, osteomyelitis. At the same time, tooth germs and teeth with incompletely formed roots, preserved in the absence of signs of inflammation, have high viability: after reliable immobilization of fragments, the teeth continue to develop normally (in 97%) and erupt in a timely manner, and the electrical excitability of their pulp normalizes in the long term. Teeth replanted into the fracture gap die on average in half of the patients.

In the presence, in addition to damage to the maxillofacial region, concussion or contusion of the brain, dysfunction of the circulatory organs, respiratory and digestive systems, etc., take the necessary measures and prescribe appropriate treatment. Often you have to resort to the advice of various specialists.

Due to the anatomical relationship between the bones of the brain skull and the face, all structures of the brain part of the skull suffer in case of trauma to the maxillofacial region. The strength of the acting factor in its intensity usually exceeds the limit of elasticity and strength of individual bones of the face. In such cases, adjacent and more deeply located sections of the facial and even brain part of the skull are damaged.

A feature of the combined trauma of the face and brain is that brain damage can also occur in the absence of a blow to the cerebral region of the skull. The traumatic force that caused the fracture of the facial bone is transmitted directly to the nearby brain, causing neurodynamic, pathophysiological and structural changes of varying degrees in it. Therefore, combined injuries of the maxillofacial region and the brain can be caused by the impact of a traumatic agent only on the facial part of the skull or on the facial and cerebral parts of the skull simultaneously.

Clinically closed craniocerebral injury is manifested by cerebral and local symptoms. TO cerebral symptoms should include loss of consciousness, headache, dizziness, nausea, vomiting, amnesia, and local - dysfunction of the cranial nerves. All patients with a history of concussion require complex treatment together with a neurosurgeon or neuropathologist. Unfortunately, concussion associated with trauma to the bones of the face is usually diagnosed only in cases with pronounced neurological symptoms.

Complications of a jaw fracture, prevention and treatment

All complications arising from jaw fractures can be divided into general and local, inflammatory and non-inflammatory; by time they are divided into early and distant (late).

TO common early complications include violations of the psycho-emotional and neurological status, changes in the circulatory organs and other systems. Prevention and treatment of these complications are carried out by maxillofacial surgeons in conjunction with relevant specialists.

Among local early complications the most commonly observed dysfunction of the masticatory apparatus (including the temporomandibular joints), traumatic osteomyelitis (in 11.7% of victims), suppuration of hematomas, lymphadenitis, arthritis, abscesses, phlegmon, sinusitis, delayed consolidation of bone fragments, etc.

To prevent possible general and local complications, it is advisable to carry out novocaine trigemino-sympathetic and carotid sinus blockades, which make it possible to turn off extracerebral reflexogenic zones, due to which liquorodynamics, respiration, and cerebral circulation are normalized.

Trigemino-sympathetic blockade produced according to the well-known method of MP Zhakov. Sinocarotid blockade carried out as follows: under the back of the victim, lying on his back, at the level of the shoulder blades, a roller is placed so that the head is slightly thrown back and turned in the opposite direction. A needle is injected along the inner edge of the sternocleidomastoid muscle, 1 cm below the level of the upper edge of the thyroid cartilage (projection of the carotid sinus). As the needle moves forward, novocaine is injected. When the fascia of the neurovascular bundle is punctured, a certain resistance is overcome and a pulsation of the carotid sinuses is felt. Enter 15-20 ml of 0.5% solution of novocaine.

Given the increased risk of developing septic complications in patients with damage to the maxillofacial region, brain and other areas of the body, it is necessary to prescribe massive doses of antibiotics (after an intradermal test for individual tolerance) already on the first day after admission to the hospital.

With the appearance of complications from the respiratory organs (often causing the death of such patients), hormone therapy and dynamic X-ray observation (with the involvement of relevant specialists) are indicated. Specialized care for such patients should be provided by the maxillofacial surgeon immediately after removing the victims from shock, but no later than 24-36 hours after the injury.

Various local and general unfavorable factors (infection of the oral cavity and decayed teeth, crushing of soft tissues, hematoma, insufficiently rigid fixation, exhaustion of the patient due to a violation of normal nutrition, psycho-emotional stress, dysfunction of the nervous system, etc.) contribute to occurrence of inflammatory processes. Therefore, one of the main points of the treatment of the victim is to stimulate the healing process of a jaw fracture by increasing the regenerative abilities of the patient's body and preventing inflammatory layers in the area of ​​damage.

In recent years, due to the increased resistance of staphylococcal infections to antibiotics, the number of inflammatory complications in facial bone injuries has increased. The greatest number of complications in the form of inflammatory processes occurs with fractures localized in the region of the angle of the lower jaw. This is due to the fact that the chewing muscles, located on both sides of the fracture area, contract reflexively, penetrate into the gap and infringed upon between fragments. As a result of the fact that the mucous membrane of the gums in the region of the angle of the lower jaw is tightly soldered to the periosteum of the alveolar process and is torn at the slightest mixing of fragments, constantly gaping entry gates for infection, through which pathogenic microorganisms, saliva, exfoliating epithelial cells and food masses enter the bone gap. During swallowing movements, the muscle fibers restrained by fragments are reduced, as a result of which there is an active flow of saliva into the depth of the bone gap.

Evidence of increasing inflammation of the bone and soft tissues are usually rapidly occurring skin hyperemia, soreness, infiltration, etc.

The development of complications is facilitated by factors such as periodontitis (in 14.4% of victims), late hospitalization and untimely provision of specialized care, advanced age of patients, the presence of chronic concomitant diseases, bad habits (alcoholism), decreased body reactivity, incorrect diagnosis and choice of treatment, disorders functions of the peripheral nervous system resulting from a fracture (damage to the branches of the trigeminal nerve), etc.

A significant factor delaying the consolidation of jaw fragments is traumatic osteomyelitis, which, along with other inflammatory processes, especially often occurs in cases where reposition and immobilization of fragments was carried out at a later date.

It must be taken into account that as a result of any injury, an inflammatory reaction develops around the wound. Regardless of the type of damaging agent (physical, chemical, biological), the pathogenetic mechanisms of the developing inflammatory process are the same and are characterized by a violation of the state of microcirculation, redox processes and the action of microorganisms in damaged tissues. For injuries not fromrefugees is bacterial contamination of the wound. The severity of the purulent-inflammatory process depends on the characteristics of the causative agent of infection, the immunobiological state of the patient's body at the time of the introduction of the pathogen, on the degree of vascular and metabolic disorders of the tissues at the site of injury. The resistance of damaged tissues to purulent infection is sharply reduced, conditions are created for the reproduction of the pathogen and the manifestation of its pathogenic properties, causing an inflammatory reaction and having a destructive effect on tissues.

At the site of action of the damaging factor, optimal conditions are created for the activation of proteolytic enzymes released from microorganisms, affected tissues, leukocytes, and the formation of inflammation-stimulating mediators - histamine, serotonin, kinins, heparin, activated proteins, etc., which cause a violation of microcirculation, transcapillary metabolism, blood clotting. Tissue proteases, waste products of microbes contribute to the breakdown of redox processes, uncoupling of tissue respiration.

As a result, the accumulation of underoxidized products, the development of tissue acidosis leads to secondary disorders of microhemodynamics in the focus of damage, development local avitaminosis.

Particularly severe damage in the processes of tissue regeneration is noted when C-vitamin deficiency, leading to inhibition of connective tissue collagen synthesis and wound healing; while in the sluggish granulations of infected wounds, the content of vitamin C is significantly reduced.

With any injury, a significant place in limiting the inflammatory process is given to the hemostatic reaction, since the formation of the fibrin layer and the deposition of toxic substances and microorganisms on its surface prevents the further spread of the pathological process.

Thus, with purulent complications of injuries, a closed chain of pathological processes arises that contribute to the spread of infection and prevent wound healing. Therefore, the early use of various biologically active drugs with anti-inflammatory, antimicrobial, antihypoxic and reparative processes stimulating effects is pathogenetically substantiated in order to reduce purulent complications and increase the effectiveness of complex treatment.

In the Kiev Research Institute of Orthopedics of the Ministry of Health of Ukraine, studies have been carried out to study the mechanism of action of biologically active substances and are recommended for use in purulent-inflammatory diseases of amben, galascorbin, kalanchoe, propolis.

Unlike natural inhibitors of proteolysis (trasilol, contrical, iniprol, tsalol, Gordox, pantrypin) amben easily penetrates all cell membranes and can be applied topically as a 1% solution, intravenously or intramuscularly at 250-500 mg every 6-8 hours. Within 24 hours, the drug is excreted by the kidneys unchanged. When applied topically, it penetrates well into tissues and completely neutralizes tissue fibrinolysis of damaged tissues within 10-15 minutes.

With purulent-inflammatory complications of jaw fractures, it is successfully used amoxiclav - a combination of clavulanic acid with amoxicillin, which is administered intravenously at 1.2 g every 8 hours or orally at 375 mg 3 times a day for 5 days. Patients operated on in a planned manner, the drug is administered intravenously at 1.2 g 1 time per day or orally in the same doses.

Biological activity galascorbin far exceeds the activity of ascorbic acid due to the presence of ascorbic acid in the preparation in combination with substances with P-vitamin activity (polyphenols). Galascorbin promotes the accumulation of ascorbic acid in organs and tissues, thickens the vascular wall, stimulates wound healing processes, accelerates the regeneration of muscle and bone tissues, and normalizes redox processes. Galascorbin is applied orally 1 g 4 times a day; locally - in 1-5% freshly prepared solutions or in the form of a 5-10% ointment.

Propolis contains 50-55% vegetable resins, 30% wax and 10-18% essential oils; it contains various balms, it contains cinnamic acid and alcohol, tannins; rich in trace elements (copper, iron, manganese, zinc, cobalt, etc.), antibiotic substances and vitamins of groups B, E, C, PP, P and provitamin A; has an analgesic effect. Its antibacterial action is most pronounced. The antimicrobial properties of propolis in relation to a number of pathogenic gram-positive and gram-negative microorganisms were established, while its ability to increase the sensitivity of microorganisms to antibiotics, change the morphological, cultural and tinctorial properties of various strains was noted. Under the influence of propolis, wounds are quickly cleared of purulent and necrotic cover. It is used in the form of an ointment (33 g of propolis and 67 g of lanolin) or sublingually - in the form of tablets (0.01 g) 3 times a day.

Other measures are also recommended to prevent inflammatory complications and stimulate osteogenesis. Some of them are given below:

1. The introduction of antibiotics (taking into account the sensitivity of the microflora) into the soft tissues surrounding the open fracture area, starting from the first day of treatment. Local administration of antibiotics can reduce the number of complications by more than 5 times. With the introduction of antibiotics at a later date (on the 6th-9th day and later), the number of complications does not decrease, but the elimination of inflammation that has already developed is accelerated.
2. Intramuscular administration of antibiotics if indicated (increasing infiltrate, fever, etc.).
3. Local UHF therapy from the 2nd to the 12th day from the moment of injury (10-12 minutes daily), total quartz irradiation from the 2nd-3rd day (about 20 procedures), calcium chloride electrophoresis on the fracture area - from 13 -14th day before the end of treatment (up to 15-20 procedures).
4. Oral administration of multivitamins and 5% calcium chloride solution (one tablespoon three times a day with milk); especially useful are ascorbic acid and thiamine.
5. In order to accelerate the consolidation of fragments, O. D. Nemsadze (1991) recommends additional use of the following drugs: anabolic steroid (for example, nerobol per os, 1 tablet 3 times a day, for 1-2 months, or retabolil 50 mg intramuscularly once a week for 1 month); sodium fluoride 1% solution, 10 cap. 3 times a day for 2-3 months; protein hydrolyzate (hydrolysin, casein hydrolyzate) for 10-20 days.
6. In order to reduce spasm of blood vessels in the fracture zone (which, according to A. I. Elyashev (1939), lasts 1-1.5 months and inhibits bone formation), as well as to accelerate the consolidation of fragments, O. D. Nemsadze (1985) suggests after 3 days after an injury, intramuscularly administer antispasmodic drugs (gangleron, dibazol, papaverine, trental, etc.) for 10-30 days.
7. Intramuscular injection of lysozyme 100-150 mg twice a day for 5-7 days.
8. The use of a complex of antioxidants (tocopherol-acetate, flacumin, ascorbic acid, cysteine, eleutherococcus extract or acemin.
9. The use of local hypothermia according to the method described by A. S. Komok (1991), subject to the use of a special device for local hypothermia in the maxillofacial region; allows to ensure the temperature regime of injured tissues, including the bone of the lower jaw, in the mode of +30°С - +28°С; due to the balanced cooling of tissues with the help of external and intraoral chambers, the temperature of the refrigerant circulating in them can be lowered to +16°C, which makes the procedure well tolerated and allows it to be continued for a long time. A. S. Komok indicates that the decrease in local tissue temperature in the area of ​​the fracture of the lower jaw to the levels: on the skin +28°С, on the mucous membrane of the cheek +29°С and on the mucous membrane of the alveolar process of the lower jaw +29.5°С - contributes to the normalization of blood flow, elimination of venous stasis, swelling, prevents the development of hemorrhages and hematomas, eliminates pain reactions. Layer-by-layer, uniform, moderate hypothermia of tissues in the cooling mode +30°С - +28°С within the next 10-12 hours after double-maxillary immobilization in combination with medications allows normalizing blood flow in tissues by the third day, eliminating temperature reactions and inflammation produces a pronounced analgesic effect.

At the same time, A. S. Komok also emphasizes the complexity of this method, since, according to his data, only a complex of electrophysiological techniques, including electrothermometry, rheography, rheodermatometry and electroalgesimetry, allows a fairly objective assessment of blood flow, heat transfer and innervation in injured tissues and the dynamics of changes in these indicators under the influence of the treatment.

According to V.P. Korobov et al. (1989), correction of metabolic changes in the blood in mandibular fractures can be achieved either with ferramide or (even more effectively) with coamide, which accelerate the healing of bone fragments. In case of acute traumatic osteomyelitis an abscess is opened, the fracture gap is washed; fractional autohemotherapy is also desirable - reinfusion of blood irradiated with ultraviolet rays 3-5 times along with active anti-inflammatory antiseptic therapy according to a generally recognized scheme; in the stage of chronic inflammation, it is recommended to activate bone regeneration according to the scheme: levamisole (150 mg orally 1 time per day for 3 days; a break between cycles - 3-4 days; such cycles - 3), or T-activin subcutaneously (0.01% for 1 ml for 5 days), or exposure to a helium-neon laser on biologically active points of the face and neck (10-15 s per point with a light flux of no more than 4 mW for 10 days). After the onset of stiffness in the fracture zone, dosed mechanotherapy and other general biological effects were prescribed. According to the authors, the duration of treatment in a hospital is reduced by 10-12 days, and temporary disability - by 7-8 days.

For the prevention or treatment of traumatic osteomyelitis of the jaws, many other means and methods have been proposed, for example, a suspension of demineralized bone, Nitazol aerosol, staphylococcal toxoid with autologous blood, vacuum aspiration of the contents of the fracture gap and washing the bone wound under pressure with a jet of 1% dioxidine solution; immunocorrective therapy. E. A. Karasyunok (1992) reports that he and his colleagues in the experiment studied and clinically proved the feasibility of using a 25% solution of acemin inside 20 ml 2 times a day for 10-14 days against the background of rational antibiotic therapy, as well as sounding the area fracture with the UPSK-7N apparatus in a continuous labile mode, the introduction of a 10% solution of lincomycin hydrochloride by electrophoresis. The use of this technique led to a decrease in complications from 28% to 3.85% and a reduction in temporary disability by 10.4 days.

R. 3. Ogonovsky, I. M. Got, O. M. Syria, I. Ya. Lomnitsky (1997) recommend using cell xenobrefotransplantation in the treatment of long-term non-healing jaw fractures. To do this, a suspension of devitalized bone marrow cells of 14-day-old embryos is introduced into the fracture gap. On days 12-14, the authors observed a thickening of the periosteal callus, and on days 20-22, the onset of stable consolidation of the fracture, which had not healed during 60 days of immobilization before. The method allows you to get rid of repeated surgical interventions.

Domestic and foreign literature is replete with other proposals, which, unfortunately, are still available only to doctors working in clinics well equipped with the necessary equipment and medicines. But every doctor should be aware of the availability of other, more affordable means of preventing complications in the treatment of facial fractures. For example, one should not forget that such a simple procedure as calcium chloride electrophoresis (the introduction of 40% solution from the anode at a current strength of 3 to 4 mA) contributes to the rapid compaction of the resulting callus. When the fracture is complicated by inflammation, in addition to antibiotic therapy, it is advisable to use an alcohol-novocaine blockade (0.5% solution of novocaine in 5% alcohol). Complex treatment according to the described scheme allows to reduce the time of immobilization of fragments by 8-10 days, and in case of fractures complicated by the inflammatory process - by 6-8 days.

We observed a significant reduction in the duration of hospitalization when osteogenic cytotoxic serum (stymoblast) was injected into the fracture area in a dose of 0.2 ml in isotonic sodium chloride solution (1:3 dilution). Serum was injected on the 3rd, 7th, 11th day after injury.

To accelerate the consolidation of jaw fragments, some authors recommend including microwave and UHF therapy in combination with general ultraviolet irradiation and calcium chloride electrophoresis in the complex treatment, and V.P. 1 mm 3 cells per 1 cm 2 of the bone fracture surface).

Based on the mechanism of development of inflammatory complications of fractures in the area of ​​the angles of the lower jaw, for their prevention it is necessary possibly earlier immobilization of bone fragments in combination with targeted anti-inflammatory drug therapy. In particular, after treating the oral cavity with a solution of furacilin (1: 5000), infiltration anesthesia should be performed in the fracture area with 1% solution of novocaine (from the side of the skin) and, making sure that the needle is in the fracture gap (blood enters the syringe, and anesthetic - into the mouth), to produce repeated leaching (with a solution of furacilin) ​​of the contents from the gap into the oral cavity through the damaged mucous membrane (L. M. Vartanyan).

Before proceeding with the immobilization of jaw fragments using rigid intermaxillary fastening (traction) or the method of the least traumatic (percutaneous) osteosynthesis with a Kirschner wire, it is recommended to infiltrate the soft tissues in the area of ​​the mandibular angle fracture with a broad-spectrum antibiotic solution. The application of a more significant injury (for example, exposing the angle of the jaw and applying a bone suture) is undesirable, as it contributes to the intensification of the inflammatory process that has begun.

In the presence of developed traumatic osteomyelitis after sequestrectomy, it is possible to fix a fracture with a metal needle inserted transfocally (through the fracture gap), however, fixation of fragments of the lower jaw with external extrafocal compressive devices that, in fractures complicated by traumatic osteomyelitis (in the acute stage of the course), provide consolidation in the usual time (not exceeding the healing of fresh fractures) and contribute to the relief of the inflammatory process due to the fact that compression is carried out without prior intervention in the lesion. Extrafocal fixation of fragments allows further necessary surgical intervention (opening an abscess, phlegmon, removing sequesters, etc.) without violating immobilization.

Traumatic osteomyelitis is almost always sluggish course, does not significantly violate the general condition of the patient. Long-lasting swelling of soft tissues in the fracture zone is associated with congestion, periosteal reaction, infiltration of lymph nodes. Rejection of bone sequesters from the fracture gap occurs slowly; their size is usually insignificant (several millimeters). Periodically, exacerbations of osteomyelitis, periostitis and lymphadenitis are possible with the formation of perimandibular abscesses, phlegmon and adenophlegmon. In these cases, it is necessary to dissect the tissues to evacuate the pus, drain the wound, and prescribe antibiotics.

IN chronic stage osteomyelitis, it is advisable to use compression approaching of jaw fragments, or to prescribe pentoxyl 0.2-0.3 g 3 times a day for 10-14 days (both after tooth splinting and after percutaneous osteosynthesis), or to inject (through a Dufo needle) into the fracture gap 2 -3 ml suspension of lyophilized fruit allograft powder. It is recommended to administer the suspension once, under local anesthesia, 2-3 days after the reposition and fixation of the fragments, i.e. when the healed wound on the gum prevents the outflow of the suspension into the oral cavity. Thanks to this tactic, intermaxillary traction can be removed, both with single and double fractures, 6-7 days earlier than usual, reducing the overall duration of disability by an average of 7-8 days. Extraoral injection of 5-10 ml of 10% alcohol solution in 0.5% novocaine solution into the fracture area also accelerates the clinical consolidation of fragments by 5-6 days and reduces the duration of disability by an average of 6 days. The use of allokost and pentoxyl can significantly reduce the number of inflammatory complications.

There are data on the effectiveness of the use for the purpose stimulation of osteogenesis(in the area of ​​traumatic osteomyelitis) various other methods and means: focal dosed vacuum, ultrasonic exposure, magnetic therapy according to N. A. Berezovskaya (1985), electrical stimulation; low-intensity radiation of a helium-neon laser, taking into account the stage of the post-traumatic process; local oxygen therapy and three-, four-fold X-ray irradiation in doses of 0.3-0.4 fairy (with pronounced signs of acute inflammation, when it is necessary to remove edema and infiltration or accelerate abscess formation, stop the pain symptom complex and create favorable conditions for wound healing); thyrocalcitonin, ectericide in combination with ascorbic acid, nerobol in combination with protein hydrolyzate, phosphrene, hemostimulin, fluorine preparations, osteogenic cytotoxic serum, carbostimulin, retabolil, eleutherococcus; inclusion in the patient's diet of paste "Ocean" from krill, etc. In the stage of chronic traumatic osteomyelitis after necrectomy, some authors use X-ray therapy at a dose of 0.5-0.7 gray (5-7 exposures) to eliminate local signs of exacerbation of the inflammatory process, to accelerate the cleansing of the wound from necrotic masses, improve sleep, appetite and general well-being of patients. Good results in traumatic osteomyelitis of the lower jaw are obtained in the case of a combination of sequestrectomy with radical treatment of the bone wound, filling the bone defect with brefokos and rigid immobilization of the jaw fragments.

When a fracture is combined with periodontitis inflammatory phenomena in the soft tissues of the fracture area are especially pronounced. In such patients, arriving on the 3rd-4th day, there are pronounced phenomena of gingivitis, bleeding gums, fetid breath, pus discharge from pathological pockets. Fracture consolidation in periodontitis is longer. In such cases, it is recommended to carry out complex treatment of periodontitis along with fracture treatment.

Of great importance in the treatment of fractures of the lower jaw is physiotherapy. 1-2 days after immobilization with a single-jaw dental splint or a bone extraoral apparatus, active exercises for masticatory (with a minimum range of motion), facial muscles and tongue can be started. With intermaxillary traction from the 2-3rd day after the fracture (splinting) and until the rubber traction is removed, general tonic exercises, exercises for facial muscles and tongue, exercises for volitional tension for masticatory muscles can be used. After the initial consolidation of the fracture and the removal of the intermaxillary rubber traction, active exercises for the lower jaw are prescribed.

Violation of blood flow in the region of masticatory muscles leads to a decrease in the intensity of mineralization of the regenerate in the gap of the angular fracture (V. I. Vlasova, I. A. Lukyanchikova), which is also the cause of frequent inflammatory complications. A timely prescribed mode of motor activity (physiotherapy exercises) significantly improves electromyographic, gnatodynamometric and dynamometric indicators of masticatory muscle function. Early functional load on the alveolar processes with the help of dentogingival splints used for fractures within the dentition (in the presence of one edentulous fragment that can be manually reduced and held by the base of the prosthesis splint, as well as in cases of rigidly stable immobilization using osteosynthesis ), also helps to reduce the period of disability by an average of 4-5 days. When functional masticatory loads are included in the complex of therapeutic measures, the regenerate undergoes restructuring faster, restores its histological structure and function, while maintaining its anatomical shape.

To reduce the degree of hypodynamic disorders in the masticatory muscles and in the area of ​​the fracture of the lower jaw, the method can be used. bioelectric stimulation(common in general traumatology, sports and space medicine) of the temporal-parietal and masticatory muscles proper using the Myoton-2 apparatus. The procedures are carried out daily for 5-7 minutes for 15-20 days, starting from the 1st-3rd day after immobilization. Electrical stimulation leads to the reduction of these muscles without the occurrence of movements in the temporomandibular joints; thanks to this, blood circulation and neuroreflex connections are restored faster in the maxillofacial region, muscle tone is maintained. All this also helps to reduce the period of fracture consolidation.

According to V. I. Chirkin (1991), the inclusion of procedures for multichannel biocontrolled proportional electrical stimulation of the temporal, masticatory muscles and muscles that lower the lower jaw into the usual complex of rehabilitation measures in the subthreshold and therapeutic regimen in patients with unilateral trauma made it possible by the 28th day to completely restore tissue blood supply, increase the volume of mouth opening up to 84%, and the amplitude of the M-response up to 74% in comparison with the norm. It was possible to normalize the function of chewing, and patients spent as much time chewing food samples and used the same number of chewing movements as healthy individuals.

In patients with bilateral surgical trauma of the masticatory muscles, the procedures of multichannel biocontrolled proportional electrical stimulation in the subthreshold, therapeutic and training modes can be started from an early date (7-9 days after surgery), which provides positive changes in the blood filling of the injury zone, as evidenced by the indicators of rheographic studies, which by the time the tires were removed had reached the norm.

It was possible to achieve an increase in the volume of mouth opening up to 74%, the amplitude of the M-response also increased to 68%. According to functional electromyography, chewing function almost returned to normal, the indicators of which reached the level of the average indicators of healthy individuals. The author believes that the method of multichannel rheovasofaciography, stimulation electromyography of masticatory muscles, registration of the periodontal muscle reflex and the method of multichannel functional electromyography with standard food samples are the most objective in the study of the masticatory system and can be the methods of choice when examining patients with both fractures of the jaws and with surgical (operative) trauma of the masticatory muscles.

The procedures of multichannel biocontrolled proportional electrical stimulation of masticatory muscles in three modes according to the method recommended by the author make it possible to start functional rehabilitation treatment from an early date. This type of treatment most closely matches the natural function of the masticatory system, is well dosed and controlled, which provides by far the highest results in the restoration of function and allows to reduce the total time of disability of patients by 5-10 days.

The problem of treatment and rehabilitation of patients with mandibular fractures accompanied by damage to the inferior alveolar nerve deserves special consideration. According to S. N. Fedotov (1993), injuries of the inferior alveolar nerve were diagnosed in 82.2% of patients with mandibular fractures, of which 28.3% were mild, 22% moderate and 31.2% severe. The light category of injuries includes those in which the reaction of all teeth on the side of the fracture was in the range of 40-50 μA, and slight hypoesthesia was observed in the skin of the chin and oral mucosa; to the middle category - the reaction of the teeth is up to 100 μA. With a reaction above 100 μA and partial or complete loss of soft tissue sensitivity, damage is considered severe. At the same time, neurological disorders in fractures of the facial bones and their treatment in practical medicine have not received enough attention so far. The depth of nerve damage, according to S. N. Fedorov, increases even more with surgical methods of joining fragments. As a result of this, long-term sensory disorders develop, neurotrophic destructive processes in bone tissue, slowing down of fragment fusion, decreased chewing function and excruciating pain.

Based on his clinical observations (336 patients), the author developed a rational complex for the rehabilitation treatment of mandibular fractures, accompanied by damage to the third branch of the trigeminal nerve, using physical methods and drug stimulant drugs (neurotropic and vasodilating). To prevent secondary damage to the inferior alveolar nerve and its branches during the surgical treatment of fractures, a new variant of osteosynthesis of fragments with metal wires is proposed, based on sparing relation to the teeth, as well as to the branches of the inferior alveolar nerve.

For one patient with neurological disorders, as early as 2-3 days after immobilization of fragments, the author prescribed exposure to an UHF electric field or a sollux lamp; in the presence of pain along the course of the lower alveolar nerve, electrophoresis of a 0.5% solution of novocaine with adrenaline according to A.P. Parfenov (1973) was used. Other patients, according to indications, were prescribed only ultrasound. After 12 days, at the stage of formation of primary bone callus, electrophoresis was prescribed with a 5% solution of calcium chloride.

Simultaneously with physical treatment from 2-3 days, stimulant medications were also used: vitamins B 6 B 12; dibazole 0.005; with deep disorders - 1 ml of a 0.05% solution of prozerin according to the scheme. At the same time, drugs that stimulate blood circulation were prescribed (papaverine hydrochloride 2 ml of a 2% solution; nicotinic acid 1% 1 ml; complamin 2 ml of a 15% solution, for a course of 25-30 injections).

After a 7-10 day break, if nerve damage persisted, electrophoresis with a 10% solution of potassium iodide or electrophoresis with enzymes was prescribed, for a course of 10-12 procedures; Galanthamine 1% 1 ml was used for a course of 10-20 injections, applications of paraffin, ozokerite. After 3-6 months, while maintaining neurological disorders, the courses of treatment were repeated until a complete cure. An obligatory component of the treatment recommended by S. N. Fedotov is the constant monitoring of its effectiveness according to neurological research methods. The use of the described complex of rehabilitation treatment contributed to a more rapid restoration of the conduction of the lower alveolar nerve: with mild functional disorders - within 1.5-3 months, moderate and severe - within 6 months. In the group of patients who were treated by traditional methods, the conduction of the lower alveolar nerve with mild disorders was restored within 1.5-3-6 months, with moderate and severe disorders - within 6-12 months. According to S. N. Fedorov, approximately 20% of patients had persistent and deep disorders of pain sensitivity over a year. Injuries of the lower alveolar nerve of moderate severity and severe, in all likelihood, are accompanied by overstretching of the nerve trunk at the time of displacement of fragments, bruises with interruption of nerve fibers, partial or complete ruptures. All this slows down reinnervation. Earlier restoration of the trophic function of the nervous system had a beneficial effect on the quality and timing of fragment consolidation. In the first (main) group of patients, the consolidation of fragments occurred on average after 27±0.58 days, the period of disability was 25±4.11 days. The chewing function and muscle contractility reached normal values ​​by 1.5-3 months. In the second (control) group, these indicators were 37.7+0.97 and 34+5.6 days, respectively, and the chewing function and muscle contractility were restored later - by 3-6 months. It is advisable to carry out these measures for the aftercare of patients with trauma in rehabilitation rooms.

In addition to traumatic osteomyelitis, abscesses and phlegmon, with a fracture of the jaws, against the background of sluggish inflammation of the bone, submandibular lymphadenitis, unresponsive to conventional treatments. Only with a detailed comprehensive examination of such patients using radiography, indirect radionuclide scan-lymphography using a colloidal solution of 198 Au, immunodiagnostic tests, it is possible to confidently diagnose secondary (post-traumatic) actinomycosis submandibular lymph nodes.

Possibility of complication of mandibular fractures cannot be ruled out actinomycosis and tuberculosis at the same time(more often in patients with tuberculosis). More rare, but no less severe complications of injuries of the maxillofacial region are possible: Zhansul-Ludwig's angina; late bleeding after osteosynthesis, complicated by inflammation; asphyxia after intermaxillary traction, sometimes leading to the death of the patient due to aspiration of blood during bleeding from the lingual or carotid artery; false aneurysm of the facial artery; thrombosis of the internal carotid artery; secondary paralysis of the facial nerve (with a fracture of the lower jaw); emphysema of the face (with a fracture of the upper jaw); pneumothorax and mediastinitis (with a fracture of the zygomatic bone and upper jaw), etc.

Length of stay of patients in hospital depend on the localization of the trauma of the maxillofacial region, the course of the period of consolidation, the presence of complications.

The specified terms are not optimal, in the future, as the economic crisis is overcome and the number of beds is expanded, it will be possible to extend the stay of patients in the hospital until the treatment of facial injuries of various localization is completed. Patients with injuries of the maxillofacial region from rural areas should be in the hospital longer, as they, as a rule, cannot come to the city for outpatient observation and treatment due to the distance. The availability of well-established trauma care, rooms for the rehabilitation of patients with similar injuries in the city's dental institutions can somewhat reduce the length of their stay in the hospital.

Outpatient treatment (rehabilitation) of victims with injuries of the maxillofacial region

The organization of the outpatient stage of treatment of victims with injuries of the maxillofacial region is not always clear enough, since patients in many cases are under the supervision of doctors from various institutions who do not have sufficient training in the field of traumatology of the maxillofacial region.

In this regard, it can be recommended to use the experience of the rehabilitation room at the maxillofacial clinic of the Zaporozhye GIDUV and the regional dental clinic, which has introduced into its practice exchange cards containing all the information about the treatment of the victim in the hospital, in the clinic at the place of residence and in the rehabilitation room.

When rehabilitating patients with injuries of the maxillofacial region, it should be taken into account that such injuries are often combined with closed craniocerebral injuries, and are also accompanied by impaired function and structure of the temporomandibular joints (TMJ). The severity of these disorders depends on the location of the fracture: in fractures of the condylar process, degenerative changes in both joints are observed more often than in extra-articular fractures. Initially, these disorders have the character of functional insufficiency, which after 2-7 years can develop into degenerative changes. Unilateral arthrosis develops on the side of injury after single fractures, and bilateral arthrosis after double and multiple fractures. In addition, in all patients with mandibular fractures, according to electromyography data, pronounced changes in the masticatory muscles are noted. Therefore, to ensure continuity in the aftercare of trauma patients in dental clinics, they should be taken by a dentist-traumatologist, who provides comprehensive treatment for patients with facial injuries of any localization.

Particular attention should be paid to the prevention of inflammatory complications and neuropsychiatric disorders - cephalgia, meningoencephalitis, arachnoiditis, vegetative disorders, hearing and vision impairment, etc. For this purpose, it is necessary to use physiotherapeutic methods of treatment and physiotherapy exercises more widely. It is necessary to carefully monitor the condition of the fixing bandages in the oral cavity, the condition of the teeth and mucous membranes, as well as to carry out timely and rational prosthetics. When determining the timing of immobilization, the duration of temporary disability and treatment, it is necessary to individually approach each patient, taking into account the nature of the injury, the course of the disease, the age and profession of the patient.

In the rehabilitation dental office, the patient must complete the treatment. Therefore, by special order of the relevant health department, the doctor of this office is given the right to issue and extend sheets of temporary disability, regardless of the place of work and residence of the patient. It is desirable to organize one dental rehabilitation room for 200-300 thousand people. In the event of a decrease in the frequency of injuries, the tasks of the office can be expanded by providing assistance to surgical patients of other profiles discharged from the hospital for outpatient treatment.

In rural areas, post-treatment of victims with injuries to the maxillofacial region should be carried out in district clinics (hospitals) under the supervision of a district dental surgeon.

The system of treatment of patients with facial trauma should include a systematic examination of long-term results of treatment.

Stationary dental departments of regional hospitals and regional (regional) dental clinics should provide organizational and methodological guidance for the provision of dental care in the region, including patients with facial trauma.

Centers for specialized dental care are often the clinical bases of the departments of maxillofacial surgery of medical universities and institutes (academies, faculties) for the improvement of doctors. The presence of highly qualified personnel makes it possible to widely apply here the latest methods of diagnosis and treatment of various injuries of the maxillofacial region and, moreover, allows significant savings.

The chief dentist and maxillofacial surgeon of the region, region, city, head of the maxillofacial department have the following tasks to improve the state of care for victims with facial trauma:

1. Prevention of injuries, including the clarification and analysis of the causes of industrial injuries, especially in agricultural production; participation in the implementation of general preventive measures to prevent industrial, transport, street, sports injuries; prevention of traumatism of children; carrying out extensive explanatory work among the population, especially young working age, in order to prevent domestic injuries.
2. Development of the necessary recommendations for the provision of first and first medical aid to patients with facial trauma at health centers, feldsher stations, trauma centers, ambulance stations; familiarization of paramedical personnel and doctors of other specialties with the elements of first aid and first aid for facial injuries.
3. Organization and conduct of permanent cycles of specialization and improvement of dentists, surgeons, traumatologists, general practitioners on issues of providing assistance to patients with facial injuries.
4. Application and further development of the most advanced methods for the treatment of jaw fractures; prevention of complications, especially of an inflammatory nature; wider use of complex methods of treatment of traumatic injuries of the face.
5. Training of nursing staff with basic first aid skills for patients with injuries to the face and jaws.

When analyzing the quality indicators of the work of dental institutions, the state of care for patients with facial injuries should also be taken into account. Particular attention should be paid to the analysis of errors made in the provision of assistance. It is necessary to distinguish between diagnostic, therapeutic and organizational errors, for which it is recommended to keep a special log (for each city and district).

The choice of the method of reposition and fixation of jaw fragments in chronic fractures

Depending on the prescription of the fracture of the upper or lower jaw and the degree of stiffness of the fragments, orthopedic or surgical methods are used. So, in case of fractures of the alveolar process of the upper jaw with difficult to eliminate displacement of fragments, steel wire tires are used for skeletal traction. The reposition of the fragment horizontally and vertically is facilitated by the elasticity of the steel wire. In particular, if a fragment of the frontal alveolar process shifted backwards, impose a smooth bus-bracket, fixing it in the usual way to the teeth on both sides of the fracture line; the teeth of the fragment are fixed on the wire with the so-called "suspended" ligatures with a slight tension. Gradually (simultaneously or within a few days - depending on the prescription of the fracture), pulling the ligature wire by twisting, slowly adjust the fragment of the alveolar process. For the same purpose, thin rubber rings can be used, covering the neck of the tooth and fixed anteriorly on the wire, which in this embodiment does not have to be steel.

If the lateral portion of the alveolar process moves inward upper jaw, the steel wire splint is bent in the shape of a normal dental arch. Gradually, the fragment returns to the correct position in relation to the lower dental arch. In case of mixing of the lateral part of the alveolar process outside set it inward with the help of elastic traction, installed across the hard palate.

With stiffness downshifted fragment of the alveolar process of the upper jaw for traction, you can use rubber rings or a bandage according to Schelhorn, applied through the surface of the closure of the teeth.

With stiffness of fragments of the lower jaw, intermaxillary traction is used with the help of tooth splints. If there are no teeth on stiff jaw fragments, devices for repositioning and fixing fragments can be used, or reposition and fixation of fragments can be performed through extraoral or intraoral access.

, , [

Disability after an injury is stated in case of impossibility to perform socially useful work without damage to health and production efficiency.

With fractures of the jaws, temporary and permanent disability is possible, the latter is divided into full and partial.

If the dysfunctions of the jaws that impede professional work are reversible and disappear with treatment, the disability is temporary. At full temporary disability, the victim cannot perform any work and needs treatment in accordance with the regimen prescribed by the doctor. For example, patients with fractures of the jaws in the acute period of trauma with severe pain and impaired function are completely temporarily disabled.

Partial temporary disability is stated in cases where the victim is not able to work in his specialty, but can perform other work without harm to health, which ensures peace or an acceptable load on the damaged organ. For example, a drifter in a mine who has received a fracture of the lower jaw, with a slow consolidation of fragments, is usually unable to work in his specialty for 1.5-2 months. However, after the elimination of acute phenomena, 1.5 months after the injury, by the decision of the VKK, the worker can be transferred to lighter work (for a period of not more than 2 months): as a lifting engineer, a loader in a lamp, etc. When transferring to another job due to the consequences of a jaw fracture disability certificates are not issued.

An expert examination of the victim should begin with the establishment of the correct diagnosis, which helps to determine the labor prognosis. Sometimes the doctor, having made the correct diagnosis, does not take into account the labor prognosis. As a result, the victim is either prematurely discharged for work, or when his ability to work is restored, he is unreasonably long extended sick leave. The first leads to all sorts of complications that adversely affect health and delay treatment; the second - to the unreasonable expenditure of funds to pay for disability certificates.

Therefore, the main differential criterion for temporary disability is a favorable clinical and labor prognosis, characterized by a complete or significant restoration of jaw dysfunctions as a result of injury and disability in a relatively short period of time. Restoration of working capacity for fractures of the jaws is characterized by the degree of restoration of the function of the damaged jaw, namely: good consolidation of fragments in the correct position, maintaining a normal occlusion of the teeth, sufficient mobility in the temporomandibular joints, the absence of severe blood and lymph circulation disorders, pain and any other disorders associated with damage to peripheral nerves in the maxillofacial region.

Temporary disability in case of jaw fractures may be due to work injury and household injury. Determining the cause of temporary disability in case of jaw fracture is one of the important tasks of a dentist, since in this case it is necessary to resolve issues that require not only medical, but also legal competence.

The disease is considered to be associated with a “labor injury” in the following cases: when performing work duties (including on a business trip during office hours), when performing an action in the interests of an enterprise, firm, although not ordered by their administration; in the performance of public or state duties, as well as in connection with the performance of special tasks of state, trade union or other public organizations, even if these tasks were not associated with this enterprise or institution; on the territory of an enterprise or institution or in another place of work during working hours, including established breaks, as well as during the time necessary to put in order the tools of production, clothing, etc. before and after work; near the enterprise or institution during working hours, including the established breaks, if being there did not contradict the rules of the established routine; on the way to work or home from work; when fulfilling the duty of a citizen to protect law and order, save human life and protect state property.

To establish the cause of temporary disability, an accident report is required, which is drawn up in a timely manner and in the form by the administration of the enterprise where the accident occurred. The act should contain an indication that the accident occurred during work, a description of its nature, etc. In case of group accidents, acts should be drawn up for each victim.

The act cannot be drawn up if the accident occurred on the way to or from work. In these cases, it is necessary to have information from the transport administration, protocol drawn up by the authorities militia, certificates of the enterprise or institution in which the victim works, indicating the start and end time of his work on a given date, as well as certificates of residence.

The greatest difficulties arise in determining the nature of disability (temporary or permanent), as well as in establishing the end date for temporary disability, which is individual for each patient.

It should be borne in mind that in some cases the terms of temporary disability do not correspond to the period for which the patient is issued a certificate of incapacity for work (for example, in case of domestic injury, etc.). Therefore, to characterize the average period of disability, it is necessary to accurately indicate the period between the moment of injury and the moment the victim returns to work.

Patients with fractures of the jaws at the end of the inpatient period of treatment continue to be treated on an outpatient basis, while until the disability group is established, the loss of ability to work is documented by a certificate of incapacity for work. However, the period of stay on the sick leave for patients later recognized as disabled cannot be equated with the indicator of the average duration of temporary disability. This period, preceding the transfer of the patient to disability, is correctly called the pre-disability period.

When deciding on the timing of temporary disability, it is necessary to take into account not only the nature of the injury, but also the profession of the patient, his working and living conditions, the type of injury (work or domestic injury, etc.). So, the fastest way to work is restored with relatively mild sports injuries; in the case of industrial and transport injuries, the period of temporary disability is longer.

To exclude possible aggravation, such objective research methods as palpation, masticography, radiography, and osteometry should be widely used.

The terms of disability for fractures of the jaws also depend on the characteristics of the profession of the victim: for mental workers, temporary disability is less long than for people engaged in physical labor; they can be discharged to work 20-25 days after the injury, continuing treatment on an outpatient basis. At the same time, patients whose profession is associated with constant tension and movement of the muscles of the maxillofacial region (artists, lecturers, musicians, teachers, etc.) are allowed to return to work only when the function of the jaws is fully restored.

Particularly long is the period of temporary disability in patients involved in heavy physical labor. For this contingent of patients, the disability certificate is extended after the removal of the fixing splints and devices for another 2-3 days to fully adapt the chewing process. Complications (osteomyelitis, jaw refractories, etc.) may develop if they are discharged prematurely. In addition, such patients are often unable to perform the full scope of basic labor processes. So, for example, workers in the coal industry have a longer period of temporary disability than workers in other professions, which is due to the special specifics of work in underground conditions and the nature of injuries, which are often accompanied by damage to the soft tissues of the face.

Persons over 50 years old the duration of the period of temporary disability increases due to the slowdown in consolidation.

Consolidation of a mandibular fracture patients with periodontitis lasts 1.5-2 months longer. In patients without periodontitis, it occurs on average 3-4 months after the injury. Factors of environmental ill-being must also be taken into account when determining both the duration of fixation and the period of temporary disability.

The use of extrafocal compression methods for the treatment of jaw fractures in combination with the general effect on the body and the treatment of periodontitis, as well as timely and rational local orthopedic and surgical measures aimed at repositioning and fixing jaw fragments, help to reduce the period of temporary disability.

If in the acute period of injury it is relatively easy to solve the issues of disability examination, then in the future, when the patient develops certain complications (delayed consolidation of fragments, contracture, ankylosis, etc.), it becomes difficult to determine the duration and type of disability of the victim. Based on the nature of the fracture, its clinical course and the onset of complications, the dental surgeon must determine, at least roughly, the duration of temporary disability for the victims and make a correct labor prognosis, which is a criterion for establishing temporary or permanent disability.

Labor forecast can be favorable, unfavorable and doubtful. At favorable In the labor forecast, it is possible to restore working capacity and return the victim to the previous or equivalent work. Labor forecast is unfavorable in cases where, as a result of an injury or its complications, the victim cannot work in his specialty and it becomes necessary to transfer him to another job corresponding to the state of health, or when the victim is unable to perform any work. Doubtful labor prognosis means that at the time of the examination there is no data necessary to resolve the issue of the outcome of a jaw fracture and the possibility of restoring working capacity. Certain difficulties are presented by the prognosis in case of delayed consolidation of jaw fractures complicated by traumatic osteomyelitis. In some cases, with the use of surgical, physiotherapeutic and other methods of treatment, the fusion of fragments in the correct position still occurs and the ability to work is restored, in others, despite the treatment, bone defects are formed that lead to permanent disability.

It should be noted that the labor forecast is closely related to the clinical one, depends on it, but does not always coincide with it. So, even with an unfavorable clinical outcome of jaw fractures (improper union without malocclusion or with edentulous jaws), the labor prognosis may turn out to be favorable, since it is determined not only by anatomical changes, but also, mainly, by the degree of restoration of function, the development of compensatory devices, the profession victim, and other factors.

Examination of temporary disability in case of fractures of the lower jaw

The average duration of temporary disability for mandibular fractures is 43.4 days. The recovery time depends on the location of the fractures. In cases of fractures in the area condylar process and ramus of the jaw with a good comparison of bone fragments, the duration of the period of temporary disability is minimal (36.6 days). Fractures of this localization are usually closed, uninfected.

The main factors contributing to rapid consolidation are good blood supply to the bone in the area of ​​the fracture and the presence of a muscle case, which makes it possible to remove the intermaxillary rubber traction on the 12-14th day. Early functional treatment accelerates the consolidation of jaw fragments.

The treatment of patients with fracture-dislocations of the condylar processes of the lower jaw, as a result of which the period of temporary disability of persons engaged in physical labor is on average 60 days.

To assess the degree of consolidation of fragments of the jaw, it is useful to use an echo osteometer EOM-01-c with an oscillation frequency of 120 ± 36 kHz. The indicator of echoosteometry when using, for example, an extrafocal device by V. A. Petrenko et al. (1987) for the treatment of fractures of the condylar process almost normalizes only on the 90th day. Therefore, obviously, the mentioned 60-day period, previously established in the Methodological Recommendations, is subject to either scientific justification or change, especially in areas of radioisotope, industrial and chemical contamination of soil, water, and food.

In cases of mandibular fractures in the presence of tooth in fracture gap the duration of the period of temporary disability is much longer than with fractures outside the dentition.

At central fractures of the lower jaw, the recovery time is almost the same as in the localization of fractures in its lateral sections (44.2 days).

Recovery time for solitary fractures of the lower jaw are on average 41.2 days, in patients with double fractures - 44.8 days. Multiple mandibular fractures are the most severe, since they almost always involve a significant displacement of fragments that can protrude into the oral cavity. These fractures are open and susceptible to infection. The average period of temporary disability with them is 59.6 days.

At comminuted fractures of the lower jaw, the recovery period is somewhat longer than with linear fractures, and is equal to an average of 45.5 days.

In patients with mandibular fractures, associated with concussion, the average period of incapacity for work increases to 47.4 days. The issue of the possibility of discharge of such patients from the hospital should be decided together with a neurologist.

The timing of disability also depends on what methods used to treat fractures of the lower jaw. Recovery period in patients with mandibular fractures treated non-surgical methods, on average is 43.7 days, surgical- 41.3 days. The minimum terms of loss of temporary ability to work are observed in the treatment of fractures of the lower jaw without displacement of fragments with mouth guards made of self-hardening plastics (26.3 days) and a sling-like bandage by 3. I. Urbanskaya (36.7 days). The working capacity of the victims, in whom toothbrushes were used for the treatment of fractures of the lower jaw double-jawed aluminum tires, was restored later (after 44.6 days).

The main reasons for the increase in the recovery period are prolonged intermaxillary fixation without the use of early functional treatment, the relative mobility of fragments, trauma to the interdental papillae of the gums with wire splints, loosening of the teeth, etc.

The duration of disability in case of injury to a certain extent is determined by the severity of the injury. Recovery from a fracture alveolar process of the upper jaw occurs on average within 43.6 days, and in case of a fracture body in the upper jaw, the average period of disability is 69.9 days; 56.0 days for the Le Fort I type, 65.4 days for the Le Fort II type, and 74.7 days for the Le Fort III type.

At uncomplicated fractures of the upper jaw, the period of disability is an average of 60.1 days, and with complicated - 120-130 days.

One of the features of fractures of the upper jaw is their combined character due to anatomical proximity of the facial and cerebral parts of the skull. Traumatic injuries of the bones of the skull and brain are not always diagnosed by dentists, which negatively affects the treatment of patients.

Terms of temporary disability with isolated and combined fractures of the upper jaw, they are different. So, with a fracture of the upper jaw, matching with a concussion of the brain, they are 70.8 days; with a combination with a fracture of the lower jaw, the average period of disability is 73.3 days; with a fracture of the base of the skull - 81.0 days; days.

Multiple fractures of the bones of the face, skull and torso give temporary disability within 87.5 days.

The timing of temporary disability also depends from methods of treatment of fractures of the upper jaw. When used in patients with fractures of the upper jaw orthopedic methods of treatment, the average period of temporary disability is 59.2 days (55.4 for uncomplicated and 116.0 for complicated fractures), and surgical methods - 76.0 days (69.3 - for uncomplicated and I53.5 - for complicated fractures).

A longer period of temporary disability in surgical methods of treating fractures is due to the fact that they are used for the most severe injuries, when orthopedic methods are not indicated or are ineffective.

In case of disability due to production injury, the doctor issues a certificate of incapacity for work, which is a document confirming temporary incapacity for work and giving the right to receive social insurance benefits to the injured.

In case of disability due to domestic In case of injury, the medical institution issues a certificate of incapacity for work for five days, and starting from the sixth - a certificate of incapacity for work. In the case when the victim goes to the doctor on the day that he has already worked at work, the doctor, if necessary, issues a certificate of incapacity for work, dating it from the day of the appeal, but releases the injured from work only from the next day.

Patients with jaw fractures treated in the hospital a sick leave certificate is issued upon discharge, but in cases of a long stay in it, a certificate of incapacity for work can be issued before discharge to receive wages.

If, as a result of inpatient treatment, the patient's ability to work recovering, certificate of incapacity for work close. In the event that the patient, upon discharge from the hospital due to the consequences of a fracture, continues to be disabled, the disability certificate in the hospital is not closed, but an appropriate note is made on it about the need for outpatient treatment. In the future, the disability certificate is extended by the dentist of the medical institution in which the patient continues treatment. It should be noted that persons who have been injured due to intoxication or during actions due to intoxication and who need outpatient and inpatient treatment are not issued sick leave certificates.

The issue of discharge to work or referral of a patient with a simple or complicated fracture of the upper jaw to VTEC is decided depending on the clinical and labor prognosis. In cases where, despite the implementation of all therapeutic measures, the clinical and labor prognosis remains unfavorable and disability becomes persistent, patients should be referred to VTEK to determine the disability group, for example, in the case of a mandibular fracture complicated by osteomyelitis with subsequent formation a large defect in bone tissue and, if necessary, reconstructive osteoplastic surgery. In such cases, the timely establishment of a disability group and the release of the patient from work allow for the full range of therapeutic measures to restore the health of the victim, after which he can perform work in his or any other specialty. The disability certificate is closed on the day the VTEK conclusion is issued on the establishment of disability, regardless of its causes and group.

Rational employment of disabled people is of great importance, since feasible work contributes to a more rapid recovery or compensation of impaired functions, improves the general condition of the disabled and increases their material security.

Sometimes related diseases that in themselves do not cause significant disability, aggravate the patient's condition and combined with the main disease cause more pronounced functional impairment. Therefore, when conducting an examination of working capacity in such cases, extreme caution and a critical approach are necessary in order to correctly assess the proportion of these changes in the reduction or loss of working capacity.

The fracture line passes through the junction of the frontal process of the upper jaw with the nasal part of the frontal bone along the inner wall of the orbit to the infraorbital fissure. Further, it spreads anteriorly along the lower wall of the orbit to the infraorbital margin, crossing it either along the zygomatic-maxillary suture, or near it. Then it goes down and back along the anterior surface of the upper jaw, spreading to the pterygoid process of the sphenoid bone (sometimes on the border of its upper and middle thirds) (Fig. 3.7).

The nasal septum breaks in the horizontal plane. The fracture line can pass directly through the infraorbital canal and through the infraorbital foramen with significant damage to the infraorbital nerve. If the fracture line crosses the zygomatic bone, the zygomatic nerve may be damaged.

In the case of a fracture according to Le Fort II, the upper jaw with the bones of the nose is broken off from the zygomatic bones. In this case, to a greater or lesser extent, a fracture of the frontal, ethmoid, body of the sphenoid, lacrimal and palatine bones of the orbital surface of the zygomatic bone occurs. Therefore, in this case, we can talk not only about a fracture of the upper jaw, but also about a fracture of other bones located next to it, including those involved in the formation of the base of the skull (see Fig. 3.2; 3.3; 3.8).

The terms "maxillofacial separation" and "suborbital fracture" that exist in the literature to a certain extent reflect the essence of a fracture of the upper jaw of this type.

It should be remembered that, in addition to the typical location of the fracture lines according to Le Fort II, a fracture in the sagittal plane is possible, i.e. the fracture gap passes through the hard palate. It is known that the upper jaws are fused in the embryonic period and only by the palatine processes. Such a fracture is not so much dangerous for the patient as it significantly complicates the fixation of the jaw fragments. Its clinical manifestation is described above. With a fracture according to Le Fort II, there is always a possibility of a skull base fracture and associated brain damage, which largely depends on the direction of the fracture line and its location in the area of ​​​​the bones that form the base of the skull. The frequency of damage to the ethmoid bone is due not only to the fact that it takes part in the formation of the medial wall of the orbit, but also because the ethmoid notch of the frontal bone, in the zone of which the fracture line passes, connects with its posterior edge to the perforated plate of this bone.

Patients may complain of pain in the region of the upper jaw, aggravated by closing the teeth and chewing food; sensation of a foreign body in the throat, urge to vomit; difficulty breathing through the nose; sometimes double vision; numbness of the skin in the infraorbital region and upper lip, lower eyelid, wing and skin part of the nasal septum; numbness of incisors, canines, premolars and mucous membrane of the alveolar process from the vestibular side within these teeth; sometimes a decrease or loss of smell in case of rupture or infringement of the olfactory filaments (fild olfactoria) passing through the holes of the perforated plate of the ethmoid bone.

If the nasolacrimal canal is damaged (flattened), complaints of lacrimation may appear, which is confirmed by an objective examination. The configuration of the face was changed due to pronounced post-traumatic edema, sometimes subcutaneous emphysema, and hemorrhage into the soft tissues of the infraorbital and zygomatic regions. Localization of hemorrhage in the orbital zone is characteristic. Impregnation of soft tissues with blood is more pronounced in the root of the nose, upper and lower eyelids, conjunctiva and sclera of the eyeball. Hemorrhage in the tissues of the eyelids and their edema are sometimes so pronounced that it is difficult to examine the eyeball. Hematoma can spread to the superciliary and infraorbital regions. Hemorrhage is less intense or may not be detected at all in the area corresponding to the upper outer quadrant of the orbit, if the hematoma is due only to bone damage.

However, bruising of the soft tissues of the near-orbital zone at the time of injury can cause the uniformity of the location of the hemorrhage zone around the orbit. Quite often the conjunctiva is soaked with blood so much that chemosis is expressed, and it bulges between closed eyelids.
With hemorrhage in the retrobulbar tissue, exophthalmos can be determined. In the horizontal position, the patient's face is flattened due to the posterior displacement of the fragment and pronounced contouring of the zygomatic bones. In the vertical position of the patient, the face is somewhat elongated due to the displacement of the upper jaw down. On palpation of the soft tissues of the infraorbital region and the root of the nose, crepitus is sometimes felt - a sign of subcutaneous emphysema, which, in our opinion, occurs as a result of exfoliation of the mucous membrane of the maxillary sinus when the fragment of the upper jaw is displaced, which is accompanied by the creation of a space with negative pressure. When the mucous membrane ruptures, atmospheric air rushes into the zone of low pressure and penetrates into the subcutaneous fatty tissue. Pain sensitivity is reduced or absent in the zone of innervation of the small crow's foot. A bone protrusion (step) is clearly palpated along the lower edge of the orbit. In the area of ​​the root of the nose, it is much more difficult to determine it due to the pronounced swelling of the tissues and their sharp pain. More often, the absence of a bone base under the finger is revealed here in case of displacement of the fragment, occasionally crepitus due to air emphysema.

If you place the index finger of the left hand on the lower edge of the orbit in the projection of the bony prominence, the big finger on the root of the nose, and with the right hand slightly shake the upper jaw in the anteroposterior direction, shifting it by no more than 2-3 mm, you can determine the synchronous "movement" bone fragment at the same time in both places. In this case, the skin above the root of the nose will fold or change in color due to its uneven tension when the fragment is displaced. Palpation with three fingers of the left hand (I, II and III) of the root of the nose, the infraorbital margin on the left and right makes it possible to verify the synchronous displacement of the fragment at three points. In case of damage to the nasolacrimal canal, in addition to lacrimation, blood may appear from the lacrimal openings.

It is known that in case of a fracture of the upper jaw, regardless of its type, the fracture gap can have a different length and be located at different levels depending on the shape of the injuring object, the strength of its impact and the structure of the bone of a given individual. Clinical experience shows that with a Le Fort II fracture, the fracture line in the region of the lower wall of the orbit can pass outward from the infraorbital canal and go not to the infraorbital margin, but go towards the lower-outer corner of the orbit, i.e. through the zygomatic bone and further along the tubercle of the upper jaw to the pterygoid process. In this situation, as a rule, the zygomatic-facial and zygomatic-temporal branches of the zygomatic nerve are injured, which is located on the outer wall of the orbit and enters the thickness of the zygomatic bone through the zygomatic-orbital foramen (foramen zygomatico-orbitale), dividing into two branches. On the temporal surface of the zygomatic bone, there is a zygomatic-temporal foramen (foramen zygomatico-temporale), through which the branch of the zygomatic nerve of the same name emerges, pierces the temporal muscle and its fascia, and innervates the skin of the anterior part of the temporal and posterior parts of the frontal region. Through the zygomatic-facial opening (f. zygomatico-facialis), located on the outer surface of the zygomatic bone, the nerve of the same name emerges, innervating a small area of ​​the face. It is in these areas that patients subjectively note numbness of the skin, which is confirmed by an objective determination of pain sensitivity using a sharp sterile needle. At the same time, there is no numbness of the skin in the zone of innervation of the small crow's foot. If the infraorbital nerve is injured in the infraorbital groove, then pain sensitivity may be disturbed according to the classical version and in the zone of innervation by the branches of the zygomatic nerve. With such an arrangement of the fracture gap, the bottom of the eye socket descends along with the eyeball, which is accompanied by diplopia and enophthalmos, as in a Le Fort I fracture. This may complicate the topical diagnosis of the fracture, however, paresthesia of the skin of the zygomatic and temporal regions will resolve temporary difficulties.

When examining the vestibule of the mouth, a malocclusion is determined - more often only molars are in contact. However, the bite can be direct, progenic, cross, which depends on the initial ratio of the jaws, the size and direction of the displacement of the broken fragment. In the vestibule of the mouth, as a rule, there is a hemorrhage in the region of the upper large and partially small molars, which extends not only along the transitional fold, but also to the buccal region. A bony protrusion is palpated along the zygomatic-alveolar crest and behind it. Pain sensitivity of the gingival mucosa is reduced or absent within the incisors, canines and premolars. The soft palate is displaced posteriorly, and a small tongue touches the posterior pharyngeal wall or the root of the tongue.

In the upper part of the pterygo-mandibular fold, anterior palatine arch and soft palate, there may be a hemorrhage due to soaking it with blood descending from the fracture site of the tubercle of the upper jaw and the pterygoid process of the sphenoid bone. Sometimes the side wall of the pharynx bulges, which indicates the presence of a hematoma in the peripharyngeal space. The pain symptom of the load is positive: when pressing on the hook of the pterygoid process of the sphenoid bone or the upper molars, pain occurs along the fracture line. When determining the pain symptom of the load in the vertical position of the patient, the bone fragments are simultaneously shifted upwards, respectively, to the frontal process of the upper jaw, the lower edge of the orbit and the zygomatic-alveolar crest, which is determined by palpation. In addition, a skin fold appears in the region of the root of the nose. With percussion of the teeth, the sound is low.

On the radiograph of the facial bones in the naso-mental and lateral projections, one can note a violation of the continuity of the bone in the region of the root of the nose, the lower edge and bottom of the orbit, the zygomatic-alveolar ridge, and a decrease in the transparency of the maxillary sinuses.

Clinically, there are mainly 3 types of fractures of the body of the upper jaw, which are described by Le Fort and are still designated by his name.

Le Fort type I fracture

The fracture line passes through the edge of the piriform opening, the nasal septum above the alveolar process, under the bottom of the maxillary sinus and goes to the tubercle of the upper jaw through the ends of the pterygoid processes of the sphenoid bone.

During an external examination, it is not always possible to immediately make a correct diagnosis, since the configuration of the face is mostly not changed. Facial lengthening due to lowering of the alveolar process in a Le Fort I fracture is extremely rare.

Usually there are hemorrhages, localized mainly on the skin of the upper lip, rarely cheeks. If the patient does not arrive immediately after the injury, then the swelling of the upper lip is quite pronounced, as a result of which the cartilaginous part of the nose seems to be displaced upward. Puffiness can spread to the middle zone of the face and the area of ​​​​the lower eyelids. Sometimes patients note a feeling of difficulty in nasal breathing, which is associated with reactive swelling of the nasal mucosa and hemorrhages in it.

When examining the oral cavity, hemorrhages are found in the mucous membrane of the alveolar process of the upper jaw, swelling in the region of the transitional fold.

The final diagnosis can be made by palpation examination. At the same time, the mobility of fragments is revealed, determined by careful swaying by the upper teeth or by the alveolar process.

Le Fort II fracture

The fracture line passes through the root of the nose along the suture connecting the frontal processes of the upper jaw and the nasal bones proper with the nasal processes of the frontal bone, continues along the inner wall of the orbit to the posterior border of the inferior orbital fissure, from where it goes forward through the infraorbital margin, descends down the anterior wall of the maxillary sinus , through the zygomatic-alveolar crest goes to the tubercle of the upper jaw and the pterygoid processes of the main bone.

Similarly, the fracture line runs along the opposite side. Posteriorly, the fracture line runs vertically through the bony septum of the nose.

The general condition of patients is usually moderate, and when combined with a craniocerebral injury - severe. In the skin, especially in the eyelids, there are hemorrhages, pronounced swelling of the tissues.

The face is elongated, elongated by lowering the upper jaw down. The mouth is open or half-open, which is associated either with difficulty in nasal breathing, or, conversely, with the patient's desire to close his mouth, when, as a result of muscle tension in the mouth, the height of the lips increases, and the face lengthens even more.

With fractures of the Le Fort II type, due to the tilting of the posterior sections of the body of the upper jaw, an open bite can be observed with a displacement of the dentition in one direction or another.

At the same time, blood is released from the external nasal passages, sometimes from the ears and oral cavity, which may be associated with damage to the maxillary or other accessory nasal cavities, the eardrum.

If cerebrospinal fluid joins the bloody discharge, then the diagnosis of an open penetrating craniocerebral injury is obvious.

Here there is a real threat of the development of purulent traumatic. Palpation examination determines the mobility of the entire upper jaw along with the hard palate and nasal bones.

Le Fort III fracture

The fracture line goes in the same way as in Le Fort II, but from the infraorbital fissure it goes to the outer wall of the orbit and through its outer edge goes to the zygomatic arch. The entire upper jaw becomes mobile along with the nasal and zygomatic bones, as well as with the walls of the orbit.

The condition of patients with fractures of the Le Fort III type is always severe, since these fractures are usually combined with a traumatic brain injury.

The upper jaw, as in Le Fort II fractures, can tilt backwards, closing the entrance to the larynx, which is clinically manifested by a sharp difficulty in breathing.

Le Fort II-III fractures are characterized by a symptom of doubling of objects - diplopia. This is due to the omission of the infraorbital margin, and sometimes the bottom of the orbit, as a result of which the function of the muscular apparatus, which provides coordinated eye movement, is disrupted.

With Le Fort III fractures, the movement of the entire bone fragment is followed by the movement of the eyeballs, which is not the case with Le Fort II fractures.

"Emergency Surgical Care for Trauma",
ed. B.D. Komarova