6. Table of contents of lecture material.
Growth of quantity of a domestic, transport traumatism, different sort of battle and home-made shooting-iron related to application is everywhere marked in the last decade . Thus the percent of damages of maxillufacial area was increased from 10-15 to 30-40%. All of it stipulates actuality of lecture and the study of questions of clinic, diagnostics and treatment of victims is explained students with a maxillufacial trauma.
A damage of teeth is the most frequent type of damages of maxillufacial area in relation to other types of damages of maxillufacial area.
The frontal teeth of overhead and rarer lower jaw are in a greater degree added a trauma.
Dog-teeth and molares at забиттях, falling, shots added a trauma extraordinarily rarely. Usually these teeth are damaged at the violent opening of mouth in the moment of anesthesia or at support on these teeth during the delete of nearby teeth.
Classification of damages of teeth, offered the clinic of stomatology of child's age of MMSI
I of Hammering in a tooth (without a damage or with the damage of vascular bunch).
II Dislocation of tooth:
1. Incomplete (without a damage or with the damage of vascular-nervous bunch).
2. Inculcated (killed).
3. Complete.
III Break of tooth:
1. Crowns.
2. Necks of tooth.
3. Root of tooth.
IV. Trauma of dental rudiment.
V. Dentoal'veolyarni of damage.
Hammering in a tooth – most easy type of trauma – often accompanied a hemorrhage in paradontitis and mash due to the break of separate blood vessels or vascular-nervous bunch.
At first o'clock after hammering there are symptoms of sharp traumatic paradontitis, although position of tooth does not change in a small hole. Sometimes there is painting of crown of the tooth in a rose color as a result of hemorrhage in a pulp chamber. If viability of mash is stored, painting of tooth gradually disappears and recommences normal electro-excitability of mash.
The trauma of tooth with the unformed root can halt subsequent development of root of tooth. Necrosis of mash of, which arose up as a result of trauma, in future can result in chronic paradontitis.
Treatment of the hammered tooth at the stored mash consists in creation of rest of paradontitis. For this purpose a hard meal is temporally eliminated from a ration.
At darkening of crown as a result of necrosis of mash it costs to trepan a tooth. After stopping of channel done wight crowns of hydroperid.
Dislocation of tooth – accompanied the break of fibres of paradontium on a greater or more small draught. The changes of tooth are thus marked in a small hole and him considerable mobility, sometimes driving in.
The complete distinguish dislocation and incomplete; depending on the sizes of damage of paradontium. In connection with it the root of tooth can partly remain in a small hole or fully displaced for its limits.
Complete dislocation an odontectomy can exemplify.
At dislocations of teeth complaints are marked about changing of position of tooth, aching pain, at a touch to the tooth. A reception of meal is laboured or impossible. An endodontium at dislocations perishes not always.
Roentgenologic at dislocations the change of width of paradontal crack is determined in some cases projection shortening of length of tooth. The root of the killed tooth on sciagrams looks longer nearby teeth, if this change took a place for vertical lines. A paradontal crack disappears at the killed dislocation.
Killed a baby tooth can injure a follicle permanent.
Reaction of vascular-nervous bunch on traumatic influence not always with the sufficient degree of authenticity it is possible to define odontodiagnostic in the first 2 - 3 days.
In default of the expressed clinical symptoms of dislocation of tooth it is necessary medical supervision during 3 - 4 weeks. This period of time is needed for reparative processes in mash and in damaged paradontitis.
In the cases of change of teeth in relation to a small hole it is necessary above all things to add a tooth former position, that to do a replicon. This interference requires the local anaesthetizing and conducted or fingers, or tongs for an exodontia.
Reponovaniy tooth it is necessary well to fix in a small hole in correct position.
Another tactical reception in treatment of dislocations of teeth is replantaion. It is done in a different term after a trauma, but not later than 72 hours. Before the operation of raplantation it is necessary to enter contratetanus whey a patient.
One of important terms of replanting tooth is him beautiful fixing.
Methods of fixing of reponing and replanting teeth.
1) Ligature 8-like bandages.
2) bow-tire, fixed a ligature wire.
They can be made from plastics in a surgical separation or after all of rules in an orthopaedic separation.
Splintage plastics worse, because they:
1) rough is an additional trauma of mucous shells;
2) much monomer - undertakes the toxic operating on mucous shells and on the organism of patient;
3) surpluses are plastics, not cleaned in time during forming of tire, a tongue mix, to sky, lips are bedsores.
Breaks of teeth - can be observed in the area of crown (without a damage or with the damage of mash), neck or root. Breaks in the area of neck and especially in the area of root for certain can be diagnosed only roentgenologic.
Breaks of teeth are transversal, longitudinal and slanting.
The breaks of crown of the second teeth within the limits of enamel require cosmetic renewal it by insets or crowns.
At fractures of part of crown with the near location of mash it is desirable on the surface of fractures to impose the hydroxide of calcium, cavity-тимолову paste, calcine or calcemin, that instrumental in formation of the second dentine. For the best fixing of remedies and on a tooth it is put on the limit of trauma of mash plastic crown - disperser.
In 8 - 12 months the defect of crown can be removed restoration or permanent crown.
At the trauma of tooth which is accompanied baring of mash apply two methods of treatment:
1) biological method of maintainance of mash;
2) extirpation mashes are with the next stopping of channel of root. Crowns in such case recommence an inset with штифтом. At it is desirable to save the відломі crowns of the second teeth root, that after treatment is utillized under a shtift tooth.
At the breaks of root of tooth depending on a level it is possible to apply an odontectomy (middle third), operation of resection of apex of root (overhead third), detulpation tooth (a break is close to the neck), or do no manipulations (a break of apex of root is without the damage of vascular-nervous bunch).
Which pass the longitudinal breaks of tooth of, through an ax, are an absolute testimony to the delete of him.
It costs to remember, that approximately 75% damages of frontal teeth unite with the partial breaks of alveolar sprout. Before all breaks of bones of facial skeleton breaks of alveolar sprout are 50%.
The breaks of alveolar sprout more frequent meet on a supramaxilla. His considerable damages quite often are accompanied dislocation at once a few teeth or by their breaks.
For children in a greater degree, what for adults, there are breaks of слизуватої shell, bleeding, edemata.
Sometimes an alveolar sprout unstucks together with soft fabrics, and quite often vice versa, contained by them.
In all of cases of breaks of alveolar sprouts of jaws there is mobility of wreckages and different degree by violation of bite.
Treatment at the breaks of alveolar sprouts consists in fixing обломків tires from an aluminium or steel wire (smooth; with a ramp; bymaxillar with зачіпними hooks) or tires-капами.
Classification of breaks. Distinguish the one-sided, bilateral, single, double, plural breaks of lower jaw. Among single breaks select the breaks of branch of lower jaw (arthral, coronal sprouts, actually branches) and its body (within the limits of dental row).
Depending on direction crack breaks can be transversal, longitudinal, slanting, arcform, Z-form .
The break of lower jaw can be full, passing through all layer of bone fabric, and incomplete (crack), when integrity of compact plate of some department of bone is not broken.
The body of lower jaw de bene esse is divided by a department (between small holes 33, 43) by a chin, lateral department (from 33, 43 to 37, 47), area of corner (between 37, 38, 47, 48, and by small holes 38, 48).
Breaks of lower jaw within the limits of dental row, as a rule, opened, as at the change of wreckages there is a break of not only periosteum but also mucus shell of alveolar sprout related to it. In addition, in the case when the root of tooth is located in the crack of break, then it combines through a trauma periodontal crack with the cavity of mouth. Breaks after a dental row more frequent all closed, but can be opened in the case of damage of surrounding soft fabrics or mucus shell.
Mechanism of break of lower jaw. The break of lower jaw arises up as a result of bend, rarer is a compression and change, very much rarely - to tearing away. A lower jaw has the arched form, operating on it force causes the expressed tension of bone fabric in its most arcuated areas (department of chin, corner of jaw, area of the mental opening of chin, small hole of dog-tooth) and in thin places, that its most reliable bend (neck of lower jaw). Exactly in these most «weak» areas a lower jaw breaks a secret as a result of bend. There can be different clinical variants of breaks of lower jaw from a bend:
direct break of lateral department of body of lower jaw, if force is added on the small area of this area. This direct break can be combined sometimes with непрямим in an area arthral a sprout from an opposite side;
a non-direct break is from an opposite side in the area of neck of lower jaw or its corner, if force is added on the large area of lateral department of body of lower jaw;
direct break on a middle line, if force is added symmetric on the wide area of lateral department of body of lower jaw on either side;
non-direct break in the lateral department of part of chin of body of lower jaw and in the area of neck of it (from other side), if force is added from two sides asymmetrically on the wide area of lateral department of body of lower jaw. At the change of force from one side to the corner of body of lower jaw a direct break will take a place in the area of corner and непрямий - in the lateral area of department of chin of body of lower jaw;
a non-direct break is in the area of necks of lower jaw from two sides, if force is added on a wide area in the area of department of chin of body of lower jaw.
Thus, as a result of bend the direct break of lower jaw arises up in the case of addition of force on the small area of certain area of jaw, a break will be non-direct (from an opposite side), if force is added on the considerable area of bone fabric.
Mechanism of displacement. This mechanism can trace then, when area of bone, that added the action of force, displaced in relation to nearby, that has a foothold. More frequent all, as a result of change there is a longitudinal break of branch of lower jaw, when force is added in the area of lower моляра and corner of jaw in the projection of coronal sprout on a narrow area and directed upwards. The area of branch of lower jaw which does not have support for counteraction the enclosed force (a front department is industry with a coronal sprout) is displaced upwards in relation to a back department which has support in an arthral fossula. Such break is more reliable in default of large and small root teeth on a lower jaw or their antagonists in the area of damage, at complete absence of teeth on lower and overhead jaws or if in the moment of causing of trauma for a victim a mouth was half-open.
Mechanism of compression. If two forces operate in meetings directions and enclosed on a wide area, bone fabric is added a compression. At the action of force from a top to the bottom on the wide area of lower edge of corner of lower jaw, fixed in arthral западині the branch of lower jaw is added a compression. Thus there is a break of bone beams, violation of structure of bone. Hereupon a bone becomes separated from on both sides from the compressed area. The crack of break more frequent passes in the middle department of branch in its transversal direction.
Mechanism of tearing away. The break of corone can be explained by force, enclosed to the chin from above downward or from one side, and the teeth of both jaws are densely compressed and a temporal muscle is tense. Isolated his damage meets rarely.
Displacement of wreckages. Displacement of wreckages takes a place as a result of action of the enclosed force under act of their own weight and through reduction (traction), muscles fastened on a fragment. The last factor is basic at the break of lower jaw, as operates constantly and different direction.
A lower jaw moves under act of two groups of muscles – those, which lift (back group) and those which drop (front group) a lower jaw. All of muscles парні and register in symmetric points. They operate on all of lower jaw and strengthen an action each other.
Muscles which drop a lower jaw are more weak of masseters which lift it. It is related not only to the less transversal crossing them but also with operating of these muscles on a chin under an acute enough angle. When safety of нижньощелепної arc is broken and the crack of break passes not on a middle line, appears, at least, two different in size of fragment.
The masseters of every side influence on нерівні on a size wreckages independently. Muscles which drop a lower jaw are not disconnected and fastened, mainly, in the area of internal surface of chin on a large fragment. They overcome resistance of masseters, fastened on him, and pull the end of large fragment downward. Thus, force of masseters which lift a lower jaw from one side, less force of all of muscles which drop a lower jaw. Displacement of wreckages the more considerable, than anymore area of attachment of muscles to the separate wreckages.
Masseter (m. masseter ). Back group: muscles which lift a lower jaw.) begins from a lower edge and internal surface of zygomatic arc. He registers to the masticatory hilly external surface of corner of lower jaw (tuberositas masseterica), lifts a lower jaw. At one-sided reduction he displaces a jaw toward reduction.
A temporal muscle (m. temporalis) consists of 3th layers: superficial, middle and deep. Begins from the internal sheet of temporal фасції in the area of temporal line, temporal bone, temporal surface of large wing and підскроневого comb of wedge-shaped bone, parietal bone, temporal surface of виличної bone. Registers to the coronal sprout of branch of lower jaw, lifts a lower jaw, back pinches displace it back. Knowing the function of muscles and direction of traction of their fibres, it is possible to define character of displacement of wreckages. The front group of muscles displaces the ends of long fragment донизу. Lateral and, in a less measure, медіальна крилоподібні muscles displace him toward a break. The back group of muscles lifts a less fragment up.
Clinical picture and diagnostics of breaks of lower jaw. At the breaks of lower jaw complaints sick can be various depending on localization of break and his character. Patients are always disturbed by pains in the certain area of lower jaw, which increase at its motion. Nibble and chewing of meal, especially hard, sharply sickly, sometimes impossible. Some patients mark numbness of skin of chin and lower lip (more frequent at the break of alveolar nerve), wrong closing of teeth. There can be dizziness, head pain, nausea. Collecting anamnesis, it follows to find out, where, when, a trauma, its character, is under what circumstances got (production, unproductive and others like that). It is necessary to set time and place of trauma, information, characteristic for the traumatic damages of cerebrum or basis of skull (loss of consciousness, retrograde amnesia, nausea, vomit, bleeding from ears, etc.). These information fix illnesses in history, as they not only have a substantial value for diagnostics of damage and tactic of conduct sick but also determine character of document about an uncapacity, can be of interest for law enforcement authorities and to state insurance.
At objective research estimate the general state of patient on a clinical sign (consciousness, character of breathing, pulse, level of arteriotony, muscular defence or pain, is at palpation of stomach, internalss). It is necessary to eliminate the traumatic damages of other areas. At the external review of maxillufacial area it is possible to define violation of configuration of person due to the посттравматичного edema of soft fabrics, haematoma, displacement of chin aside. On a skin persons can be scratch, bruises, wounds.
It follows to conduct пальпацію of lower jaw in symmetric points. A doctor gradually moves the fingers of hands on a body гільці jaws in direction from a middle line to the arthral sprout or vice versa. It is thus possible to define bone appearance, or defect of bone, or sickly point, more frequent in the area of the most certain slight swelling or haematoma of soft fabrics.
It follows to define amplitude of motion of head of arthral sprout in arthral западині. For this purpose a doctor enters a finger-point in the external acoustic duct of patient. At displacement of jaw downward and toward пальпаторно it is possible to judge displacement of head of arthral sprout about sufficientness. Information is got it is possible to confirm, пальпуючи a head ahead of козелка of ear.
After it a doctor must utillize the symptom of loading, by which it is possible to find out the most sickly area, proper the site of the supposed fracture. Determine this symptom thus: 1. a doctor fixes the index and large fingers of right arm on the department of chin of body of lower jaw of patient and renders moderate pressure at the front back; 2-пальці hands a doctor disposes in the area of external surface of corner of lower jaw on the left and business and puts pressure towards a middle line (to meet to each other); a doctor places 3-large fingers in the area of lower edge of corner of lower jaw on the left and on the right and easily presses to direction from a top to the bottom (to the head of condylar sprout).
At the break of lower jaw moderate displacement of wreckages under act of effort which is added a doctor is accompanied appearance of pain in the area of break. Projection of the most pain area on a skin, a patient shows one finger. It, as a rule, coincides with objectively certain before bone appearance and edema or haematoma of soft fabrics. A chin often is displaced toward a break. By a sharp needle it is possible to define the algesthesia of skin of lower lip and chin on the left and on the right. If the break of lower alveolar nerve took a place, it fully absents on the side of break. It is possible to set also violation of, haptic and temperature algesthesia of mucus shell of cavity of mouth, gums, teeth on the area of jaw, located medial from the crack of break.
Then examine the cavity of mouth. Suggest to open a patient and close a mouth. Diminishing of amplitude of motion of lower jaw can be the sign of its break. At opening of mouth a chin is sometimes displaced aside from a middle line (toward a break). In the area of fabrics a vestibular company is determined haematoma (a mucus shell is saturated with blood). In case of occurring as a result of break of body of lower jaw it will be disposed from the vestibular and language side of alveolar sprout. Localization of haematoma answers the area of break and coincides with such in near mandibular soft fabrics. It is possible to find out the breaks of mucus shell of alveolar sprout. Perkusiya of teeth, which the crack of break, sickly, bite, is located between, more frequent all broken. The change of bite will depend on character of displacement of wreckages, that, in same queue, related to localization of break. On a large fragment register most muscular fibres which drop a lower jaw. On the force they prevail above muscles which lift a lower jaw. Therefore a large fragment is displaced донизу, and more small – up. The most frequent variants of displacement of wreckages which meet in a clinic are considered below.
By a reliable clinical sign, that allows not only to set a break but also define his localization, there is a symptom of mobility of wreckages of jaw. Determine him thus: the index finger of right arm is disposed on the teeth of one of the supposed wreckages, index finger of left arm - on the teeth of the second fragment, engulf the body of lower jaw pollexs from below. Conducting insignificant motions in different directions (upwards - downward, forward - back, «on a fracture»), it is possible to set the change of height of the teeth, increase of міжзубного interval, increase of width of break of mucus shell of alveolar sprout, located alongside. It takes a place as a result of displacement of wreckages under act of efforts of doctor.
Clinical suppositions must be confirmed x-ray photography research. Sciagrams allow to specify character of break, degree of displacement of wreckages and presence of fragments, location of crack of break, relation of roots of teeth to it. It follows to do two radiographs (in a line and lateral projection), if there is possibility - ortjpantomogramma, on which it is possible to trace changes on a body and branch of lower jaw, that arose up as a result of traumatic action. At the breaks of arthral sprout valuable additional information is given by томограма of TMJ. On the basis of clinicoradiological information a doctor puts a топічний diagnosis and makes the plan of treatment sick.
At the break of lower jaw in the area of chin, when the crack of break begins between central chisels and goes almost apeak downward, wreckages under act of equivalent force which operates on either side displaced will be only to the bottom. However much a break on a middle line passes too rarely. It, as a rule, will deviate from the hump of chin and closed in the projection of apex of root of the second chisel, dog-tooth or small cheek-tooth. In such case there is an infraplacement of greater fragment, as more muscular fibres which drop a lower jaw register on him. At the slanting location of crack of break of displacement of wreckages takes a place at direction to each other (in a horizontal plane) due to the function of латеральних крилоподібних muscles. It results in narrowing of dental arc and violation of bite. As a result of traction of mylohyoideus muscle alveolar part of wreckages some bends over in a middle (to the middle line). At the single break of lateral department of body of lower jaw two appears different in size of fragment. A less fragment will be displaced upwards (under the action of muscles which lift a lower jaw) to the contact with teeth-antagonists, alveolar part him inclined inward, and basis of lower jaw will be displaced outwardly due to the function of masseter and as a result of traction of mylohyoideus muscle. A contact of teeth will be tubercular: cheek tubercles teeth of lower jaw will contact with palatal teeth-antagonists. A large fragment will be displaced downward (under the action of muscles which drop a lower jaw, and own weight) and toward a break (under the action of one-sided reduction of lateral muscle and partly medial, and also muscles of bottom of cavity of mouth). Thus, a dental arc is deformed, a middle line will be displaced in the side of break of this fragment, located near-by the crack of break, does not contact with the teeth of supramaxilla. Closing of teeth (tubercular contact) will be only in the area of large native, and sometimes small cheek-teeth. Wreckages can be displaced in a horizontal plane, if in the moment of trauma a break exceeded the thickness of body of lower jaw. When the line of break passes obliquely forward, wreckages can be not, as a large fragment is firmly contained on small. If a break passes through a нижньощелепний channel, the possible dug up vascular-nervous bunch which results in the loss of algesthesia in the area of chin and lower lip and accompanied the expressed bleeding. Stopping bleeding is possible after the leadthrough of replicon of bone fragments and fixing of them in correct position.
The single break of lower jaw in the area of corner often passes through the small hole of the third large cheek-tooth or between him and by the second large cheek-tooth. If the crack of break in the area of corner of jaw is located on the point of attachment actually masseter and medial pterigoideal muscles, wreckages are not displaced, as a mighty tendon-muscular case which engulfs the corner of jaw from external and internal his sides retains wreckages in correct position. If this case is torn or the crack of break passes ahead from the indicated muscles, a less fragment, if there is not a tooth on him, will be displaced up and inward, greater - downward and in the side of break. Violation of bite will be more considerable, in accordance with positions, resulted higher for a greater fragment.
At the bilateral break of lower jaw 3 wreckages are formed in its lateral department. To middle, more frequent all, muscles which drop a lower jaw register only, that determines character of his displacement. He is displaced downward and back, and frontal teeth lean forward. Sometimes it results in falling back of language which causes a labouring breath. Lateral wreckages are displaced up (action actually of masseters, temporal, medial pterigoideal) and inward (action of lateral pterigoideal muscle). In the case of fixing of middle fragment two lateral, falling back of language does not take a place and breathing remains free. Now and then a middle fragment is displaced beforehand. It is possible when lateral fragments which are displaced to direction to each other in the moment of trauma can chuck out a middle fragment forward.
Single breaks of branch of lower jaw can be longitudinal and transversal. They are not accompanied substantial displacement of wreckages and violation of bite. At lowering of lower jaw there can be displacement of middle line toward a break and violation of bite, as in the case of break of alveolar sprout.
The break of coronal sprout can take a place at the break of виличної arc. Isolated break him meets rarely (blow by a narrow object from one side at the opened mouth of patient, blow to the chin from above downward at the densely closed mouth and tension of masseters). If the line of break passes through basis of coronal sprout, the broken off fragment will be displaced upwards towards a temporal area. A similar break meets rarely. The function of lower jaw here does not change substantially. At palpation the branch of lower jaw from the side of cavity of mouth is determined pain in the area of basis of coronal sprout.
The break of arthral sprout can take a place in his bases, in the area of neck and arthral head. If injuring force is added to the lateral department of body of lower jaw or chin, there is a break of basis of arthral sprout as a result of bend. Thickness of bone here in медіально-латеральному direction considerably less than, than in front-back. The crack of break passes obliquely downward and back through basis of undercut of lower jaw. Displacement of less fragment can be different and depends on the level of damage of external and internal compact plates:
1. If the line of break on an external plate passes below such on internal (the slant of break is directed outwardly upwards and to the middle), a small fragment is displaced on outwardly and something back. In this direction he is pushed by a large fragment, displaced under act of masseters upwards and back. The head of sprout, remaining in an arthral cavity, is opened out so, that contacts with an arthral surface it by a lateral grasser. In this clinical situation it is possible to make an attempt improve position of small fragment the conservative methods of treatment (intradental gasket on the side of damage and intermaxillary elastic extraction).
2. If the line of break on an external surface passes higher that inwardly (the slant of break is directed outwardly downward and inward), a small fragment is displaced beforehand under the action of lateral pterigoideal muscle. A large fragment, getting up, increases displacement of small fragment. A break in the area of neck of arthral sprout of lower jaw arises up, if a power action spreads from a chin back. Exactly in front-back direction a bone in the area of neck is most thin. These breaks quite often are accompanied dislocation of head of lower jaw. Displacement of small fragment takes a place due to the action of lateral pterigoideal muscle. At breaks in the area of basis of arthral sprout and neck, when a small fragment is displaced inward from the branch of jaw, not possibly by the conservative methods of treatment to put wreckages in correct position. At the breaks of head of lower jaw quite often there is parts of medial grasser. In the case of break of arthral capsule the small fragment of head is displaced inward and forward. At the one-sided break of arthral sprout middle line something displaced toward a break. On the side of break teeth contact densely, and on the healthy side of contact between them is. The important sign of break of alveolar sprout with dislocation of head is falling back of fabrics ahead of ear, and also absence of active motion of arthral head in an arthral fossula. If dislocation of head is not, saved motion of it, but amplitude them far fewer, than on a healthy side, that absents synchronousness in motions of heads of both sides. At the bilateral break of arthral sprouts both branches of lower jaw are displaced upwards. Contact only large коренні teeth, that a bite will be opened. Breaks of other localizations, at the twoextraneous break of body of lower jaw in the area of corners a middle fragment is displaced downward (hangs down). The change of him does not take a place back. At a double break, located from one side, a middle fragment is displaced downward and inward under an action fastened on him m.melohiodeus. A back (more small) fragment moves upwards and a few inward, large — downward and toward a middle fragment. A dental arc is considerably deformed, a bite is violated. At the plural breaks of lower jaw wreckages are displaced in different directions under the action of those muscular bunches which register to them. Thus they quite often call the ends for each other, displaced in the direction of muscles which are abbreviated. Displacement the more than anymore area of attachment of muscles, and muscular fibres to the separate fragments and than less than this motion is braked nearby wreckages.