Maxillofacial injury - causes, symptoms, treatment. Injuries of the forehead Functional disorders in maxillofacial injuries

Maxillofacial orthopedics is one of the sections orthopedic dentistry and includes the clinic, diagnosis and treatment of injuries to the maxillofacial area resulting from trauma, wounds, surgical interventions for inflammatory processes, and neoplasms. Orthopedic treatment can be independent or used in combination with surgical methods.

Maxillofacial orthopedics consists of two parts: maxillofacial traumatology and maxillofacial prosthetics. IN last years Maxillofacial traumatology has become a predominantly surgical discipline. Surgical methods for fixing jaw fragments: osteosynthesis for jaw fractures, extraoral methods of fixing fragments of the lower jaw, suspended craniofacial fixation for fractures of the upper jaw, fixation using alloy devices with “shape memory” - have replaced many orthopedic devices.

Advances in facial reconstructive surgery have also influenced the field of maxillofacial prosthetics. Emergence of new methods and improvement existing methods skin grafts, bone grafting of the lower jaw, and plastic surgery for congenital cleft lip and palate have significantly changed the indications for orthopedic treatment methods.

Modern ideas about the indications for the use of orthopedic methods for treating injuries of the maxillofacial area are due to the following circumstances.

The history of maxillofacial orthopedics goes back thousands of years. Artificial ears, noses and eyes have been discovered in Egyptian mummies. The ancient Chinese restored lost parts of the nose and ears using wax and various alloys. However, before the 16th century there is no scientific information about maxillofacial orthopedics.

For the first time, facial prostheses and an obturator for closing a palate defect were described by Ambroise Pare (1575).

Pierre Fauchard in 1728 recommended drilling the palate to strengthen dentures. Kingsley (1880) described prosthetic structures for replacing congenital and acquired defects of the palate, nose, and orbit. Claude Martin (1889), in his book on dentures, describes structures for replacing lost parts of the upper and lower jaws. He is the founder of direct prosthetics after resection of the upper jaw.

Modern maxillofacial orthopedics, based on the rehabilitation principles of general traumatology and orthopedics, based on the achievements of clinical dentistry, plays a huge role in the system of providing dental care to the population.

• Tooth dislocations

Tooth luxation is the displacement of a tooth as a result acute injury. Tooth dislocation is accompanied by rupture of the periodontium, circular ligament, and gum. There are complete, incomplete and impacted dislocations. The history always contains indications of the specific cause that caused the tooth dislocation: transport, household, sports, work injury, dental interventions.

What causes damage to the maxillofacial area

• Tooth fractures

• False joints

The causes leading to the formation of false joints are divided into general and local. Common ones include: malnutrition, vitamin deficiencies, severe, long-term diseases (tuberculosis, systemic diseases blood, endocrine disorders, etc.). In these conditions, the body’s compensatory-adaptive reactions are reduced and reparative regeneration is inhibited bone tissue.

Among the local causes, the most likely are violations of the treatment technique, soft tissue interposition, bone defect, and complications of the fracture due to chronic bone inflammation.

• Contracture of the lower jaw

Contracture of the lower jaw can occur not only as a result of mechanical traumatic damage to the jaw bones, soft tissues of the mouth and face, but also other reasons (ulcerative-necrotic processes in the oral cavity, chronic specific diseases, thermal and chemical burns, frostbite, myositis ossificans, tumors and etc.). Here we consider contracture in connection with trauma to the maxillofacial area, when contractures of the lower jaw arise as a result of improper primary treatment of wounds, prolonged intermaxillary fixation of jaw fragments, untimely application physical therapy.

Pathogenesis (what happens?) during Injuries to the maxillofacial region

• Tooth fractures

• Contracture of the lower jaw

The pathogenesis of mandibular contractures can be presented in the form of diagrams. In scheme I, the main pathogenetic link is the reflex-muscular mechanism, and in scheme II, the formation of scar tissue and its negative actions on the function of the lower jaw.

Symptoms of Injuries to the Maxillofacial Area

The presence or absence of teeth on jaw fragments, the condition of the hard tissues of the teeth, the shape, size, position of the teeth, the condition of the periodontium, the oral mucosa and soft tissues that interact with prosthetic devices are important.

Depending on these characteristics, the design of the orthopedic apparatus and prosthesis changes significantly. The reliability of fixation of fragments and the stability of maxillofacial prostheses, which are the main factors for the favorable outcome of orthopedic treatment, depend on them.

It is advisable to divide the signs of damage to the maxillofacial area into two groups: signs indicating favorable and unfavorable conditions for orthopedic treatment.

The first group includes the following signs: the presence on jaw fragments of teeth with full-fledged periodontium during fractures; the presence of teeth with full periodontium on both sides of the jaw defect; absence of cicatricial changes in the soft tissues of the mouth and perioral area; integrity of the TMJ.

The second group of signs consists of: the absence of teeth on jaw fragments or the presence of teeth with diseased periodontal disease; pronounced cicatricial changes in the soft tissues of the mouth and perioral area (microstomy), lack of a bone base for the prosthetic bed in case of extensive defects of the jaw; pronounced disturbances in the structure and function of the TMJ.

The predominance of signs of the second group narrows the indications for orthopedic treatment and indicates the need for complex interventions: surgical and orthopedic.

When assessing clinical picture damage, it is important to pay attention to the signs that help establish the type of bite before the damage. This need arises due to the fact that displacement of fragments during jaw fractures can create relationships of dentition similar to prognathic, open, crossbite. For example, with a bilateral fracture of the lower jaw, the fragments shift along the length and cause shortening of the branches; the lower jaw moves back and upward with a simultaneous lowering of the chin. In this case, the closure of the dentition will be similar to prognathia and open bite.

Knowing that each type of bite is characterized by its own signs of physiological tooth wear, it is possible to determine the type of bite the victim had before the injury. For example, with an orthognathic bite, wear facets will be on the incisal and vestibular surfaces of the lower incisors, as well as on the palatal surface of the upper incisors. With progeny, on the contrary, there is abrasion of the lingual surface of the lower incisors and the vestibular surface of the upper incisors. A direct bite is characterized by flat wear facets only on the cutting surface of the upper and lower incisors, and with an open bite there will be no wear facets. In addition, anamnestic data can also help to correctly determine the type of bite before damage to the jaws.

• Tooth dislocations

The clinical picture of a dislocation is characterized by swelling of the soft tissues, sometimes rupture around the tooth, displacement, mobility of the tooth, and disruption of occlusal relationships.

• Tooth fractures

• Fractures of the lower jaw

Of all the bones of the facial skull, the lower jaw is most often damaged (up to 75-78%). Among the causes, traffic accidents come first, followed by domestic, industrial and sports injuries.

Clinical picture of mandibular fractures, except common symptoms(dysfunction, pain, facial deformation, occlusion disorder, jaw mobility in an unusual place, etc.), has a number of features depending on the type of fracture, the mechanism of displacement of fragments and the condition of the teeth. When diagnosing fractures of the lower jaw, it is important to identify signs indicating the possibility of choosing one or another method of immobilization: conservative, surgical, combined.

The presence of stable teeth on jaw fragments; their slight displacement; localization of the fracture in the area of ​​the angle, ramus, condylar process without displacement of fragments indicates the possibility of using conservative method immobilization. In other cases, there are indications for the use of surgical and combined methods of fixation of fragments.

• Contracture of the lower jaw

Clinically, unstable and persistent contractures of the jaws are distinguished. According to the degree of mouth opening, contractures are divided into mild (2-3 cm), medium (1-2 cm) and severe (up to 1 cm).

Unstable contractures most often they are reflex-muscular. They occur when jaws are fractured at the attachment points of the muscles that lift the mandible. As a result of irritation of the muscle receptor apparatus by the edges of fragments or decay products of damaged tissue, a sharp increase in muscle tone occurs, which leads to contracture of the lower jaw

Scar contractures, depending on which tissues are affected: skin, mucous membrane or muscle, are called dermatogenic, myogenic or mixed. In addition, contractures are distinguished between temporo-coronal, zygomatic-coronal, zygomatic-maxillary and intermaxillary.

Although the division of contractures into reflex-muscular and cicatricial is justified, in some cases these processes do not exclude each other. Sometimes, with damage to soft tissues and muscles, muscle hypertension turns into persistent scar contracture. Preventing the development of contractures is a very real and concrete measure. It includes:

• preventing the development of rough scars by correct and timely treatment of the wound (maximum approximation of the edges with sutures; for large tissue defects, suturing the edge of the mucous membrane with the edges of the skin is indicated);
• timely immobilization of fragments, if possible, using a single-jaw splint;
• timely intermaxillary fixation of fragments in case of fractures at the sites of muscle attachment in order to prevent muscle hypertension;
• the use of early therapeutic exercises.

Diagnosis of Injuries to the maxillofacial area

• Tooth dislocations

Diagnosis of tooth dislocation is carried out on the basis of examination, tooth displacement, palpation and x-ray examination.

• Tooth fractures

The most common fractures of the alveolar process of the upper jaw are predominantly localized in the area of ​​the anterior teeth. They are caused by road accidents, impacts, falls.

Diagnosing fractures is not very difficult. Recognition of dentoalveolar damage is carried out on the basis of anamnesis, examination, palpation, and x-ray examination.

During a clinical examination of the patient, it should be remembered that fractures of the alveolar process can be combined with damage to the lips, cheeks, dislocation and fracture of teeth located in the broken area.

Palpation and percussion of each tooth, determining its position and stability make it possible to recognize damage. Electroodontodiagnosis is used to determine damage to the neurovascular bundle of teeth. The final conclusion about the nature of the fracture can be made on the basis of radiological data. It is important to establish the direction of displacement of the fragment. Fragments can be displaced vertically, in the palatine-lingual, vestibular direction, which depends on the direction of the blow.

Treatment of alveolar process fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.

• Fractures of the lower jaw

Clinical diagnosis of mandibular fractures is supplemented by radiography. Based on radiographs obtained in anterior and lateral projections, the degree of displacement of fragments, the presence of fragments, and the location of the tooth in the fracture gap are determined.

For fractures of the condylar process, TMJ tomography provides valuable information. The most informative is CT scan, which allows you to reproduce the detailed structure of the bones of the articular area and accurately identify the relative location of fragments.

Treatment of Injuries to the Maxillofacial Area

Development surgical methods treatment, especially neoplasms of the maxillofacial area, required widespread use of orthopedic interventions in the surgical and postoperative period. Radical treatment malignant neoplasms maxillofacial area improves survival rates. After surgical interventions, serious consequences remain in the form of extensive defects of the jaws and face. Severe anatomical and functional disorders that disfigure the face cause painful psychological suffering to patients.

Very often, reconstructive surgery alone is ineffective. The tasks of restoring the patient's face, chewing, swallowing functions and returning him to work, as well as to perform other important social functions, as a rule, require the use of orthopedic treatment methods. Therefore, the joint work of dentists - a surgeon and an orthopedist - comes to the fore in the complex of rehabilitation measures.

There are certain contraindications to the use of surgical methods for treating jaw fractures and performing operations on the face. Usually this is the presence in patients of severe blood diseases, the cardiovascular system, an open form of pulmonary tuberculosis, severe psycho-emotional disorders and other factors. In addition, there are injuries for which surgical treatment is impossible or ineffective. For example, in case of defects of the alveolar process or part of the palate, prosthetics are more effective than surgical restoration. In these cases, the use of orthopedic measures as the main and permanent method treatment.

The timing of restoration operations varies. Despite the tendency of surgeons to perform the operation as early as possible, it is necessary to allow a certain amount of time when the patient is left with an unrepaired defect or deformity awaiting surgical treatment, plastic surgery. The duration of this period can be from several months to 1 year or more. For example, reconstructive operations for facial defects after tuberculous lupus are recommended to be carried out after permanent elimination of the process, which is approximately 1 year. In such a situation, orthopedic methods are indicated as the main treatment for this period. At surgical treatment Patients with injuries to the maxillofacial area often face auxiliary tasks: creating support for soft tissues, closing the postoperative wound surface, feeding patients, etc. In these cases, the use of the orthopedic method is indicated as one of the auxiliary measures in complex treatment.

Modern biomechanical studies of methods for fixing fragments of the lower jaw have made it possible to establish that dental splints, in comparison with known on-bone and intraosseous devices, are the fixators that most fully meet the conditions of functional stability of bone fragments. Dental splints should be considered as a complex retainer, consisting of an artificial (splint) and natural (tooth) retainer. Their high fixing abilities are explained by the maximum area of ​​contact of the fixator with the bone due to the surface of the roots of the teeth to which the splint is attached. These data are consistent with successful results wide application dentists use dental splints in the treatment of jaw fractures. All this is another justification for the indications for the use of orthopedic devices for the treatment of injuries to the maxillofacial area.

Orthopedic devices, their classification, mechanism of action

Treatment of injuries to the maxillofacial area is carried out using conservative, surgical and combined methods.

Main method conservative treatment are orthopedic devices. With their help, they solve problems of fixation, reposition of fragments, formation of soft tissues and replacement of defects in the maxillofacial area. In accordance with these tasks (functions), devices are divided into fixing, reducing, forming, replacing and combined. In cases where one device performs several functions, they are called combined.

Based on the place of attachment, the devices are divided into intraoral (unimaxillary, bimaxillary and intermaxillary), extraoral, intra-extraoral (maxillary, mandibular).

According to the design and manufacturing method, orthopedic devices can be divided into standard and individual (non-laboratory and laboratory manufacturing).

Fixing devices

There are many designs of fixing devices. They are the main means of conservative treatment of injuries to the maxillofacial area. Most of them are used in the treatment of jaw fractures and only a few - in bone grafting.

For primary healing of bone fractures, it is necessary to ensure the functional stability of the fragments. The strength of fixation depends on the design of the device and its fixing ability. Considering the orthopedic device as a biotechnical system, it can be divided into two main parts: splinting and actually fixing. The latter ensures the connection of the entire structure of the device with the bone. For example, the splinting part of a dental wire splint consists of a wire bent to the shape of a dental arch and a ligature wire for attaching the wire arch to the teeth. The actual fixing part of the structure is the teeth, which provide connection between the splinting part and the bone. Obviously, the fixing ability of this design will depend on the stability of the connections between the tooth and the bone, the distance of the teeth in relation to the fracture line, the density of the connection of the wire arch to the teeth, the location of the arch on the teeth (at the cutting edge or chewing surface of the teeth, at the equator, at the neck of the teeth) .

With tooth mobility, severe atrophy alveolar bone It is not possible to ensure reliable stability of fragments using dental splints due to the imperfection of the actual fixing part of the device design.

In such cases, the use of periodontal splints is indicated, in which the fixing ability of the structure is enhanced by increasing the area of ​​contact of the splinting part in the form of coverage of the gums and alveolar process. In case of complete loss of teeth, the intra-alveolar part (retainer) of the device is absent; the splint is located on the alveolar processes in the form of a base plate. By connecting the base plates of the upper and lower jaws, a monoblock is obtained. However, the fixing ability of such devices is extremely low.

From a biomechanical point of view, the most optimal design is a soldered wire splint. It is attached to rings or full artificial metal crowns. The good fixing ability of this tire is explained by the reliable, almost motionless connection of all structural elements. The sinus arc is soldered to the ring or to metal crown, which is fixed to the supporting teeth using phosphate cement. When ligating teeth with an aluminum wire arch, such a reliable connection cannot be achieved. As the splint is used, the tension of the ligature weakens, and the strength of the connection of the splinting arch decreases. The ligature irritates the gingival papilla. In addition, food debris accumulates and rots, which disrupts oral hygiene and leads to periodontal disease. These changes may be one of the causes of complications that arise during orthopedic treatment of jaw fractures. Soldered busbars do not have these disadvantages.

With the introduction of fast-hardening plastics, many various designs dental splints. However, in terms of their fixing abilities, they are inferior to soldered splints in a very important parameter - the quality of the connection between the splinting part of the device and the supporting teeth. A gap remains between the surface of the tooth and the plastic, which is a receptacle for food debris and microbes. Long-term use of such tires is contraindicated.

The designs of dental splints are constantly being improved. By introducing actuator loops into a splinting aluminum wire arch, they try to create compression of fragments in the treatment of mandibular fractures.

The real possibility of immobilization with the creation of compression of fragments with a dental splint appeared with the introduction of alloys with a shape “memory” effect. A dental splint on rings or crowns made of wire with thermomechanical “memory” allows not only to strengthen fragments, but also to maintain constant pressure between the ends of the fragments.

Fixing devices used in osteoplastic operations are a dental structure consisting of a system of welded crowns, connecting locking bushings, and rods.

Extraoral apparatuses consist of a chin sling (plaster, plastic, standard or customized) and a head cap (gauze, plaster, standard strips of belt or ribbon). The chin sling is connected to the head cap using a bandage or elastic cord.

Intraoral apparatuses consist of an intraoral part with extraoral levers and a head cap, which are interconnected by elastic traction or rigid fixing devices.

AST. Rehearsal devices

There are one-stage and gradual reposition. One-time reposition is carried out manually, and gradual reposition is carried out using hardware.

In cases where it is not possible to compare the fragments manually, reduction devices are used. The mechanism of their action is based on the principles of traction, pressure on displaced fragments. Reduction devices can be mechanical or functional. Mechanically operating reduction devices consist of 2 parts - supporting and acting. The supporting parts are crowns, mouthguards, rings, base plates, and a head cap.

The active part of the apparatus are devices that develop certain forces: rubber rings, an elastic bracket, screws. In a functionally functioning reduction apparatus, the force of muscle contraction is used to reposition fragments, which is transmitted through guide planes to the fragments, displacing them in the desired direction. Classic example Such a device is the Vankevich bus. With the jaws closed, it also serves as a fixation device for fractures of the lower jaws with toothless fragments.

Forming apparatus

These devices are designed to temporarily maintain the shape of the face, create a rigid support, prevent cicatricial changes in soft tissues and their consequences (displacement of fragments due to tightening forces, deformation of the prosthetic bed, etc.). Forming devices are used before restorative surgical interventions and in the process of them.

The design of the devices can be very diverse depending on the area of ​​damage and its anatomical and physiological characteristics. In the design of the forming apparatus, one can distinguish the forming part and the fixing devices.

Replacement devices (prostheses)

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

Dental prosthetics is inextricably linked with maxillofacial prosthetics. Achievements in the clinic, materials science, and technology for manufacturing dentures have an impact positive influence on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid-cast clasp dentures have found application in the design of resection dentures and dentures restoring dentoalveolar defects.

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

Combined devices

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

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

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

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

• use the preserved natural teeth as support as much as possible, connecting them into blocks, using well-known techniques for splinting teeth;
• make maximum use of the retention properties of alveolar processes, bone fragments, soft tissues, skin, cartilage that limit the defect (for example, the cutaneous-cartilaginous part of the lower nasal passage and part of the soft palate, preserved even after total resections of the upper jaw, serve as a good support for strengthening the prosthesis);
• apply surgical methods to strengthen prostheses and devices in the absence of conditions for their fixation in a conservative way;
• use the head and top part torso, if the possibilities of intraoral fixation have been exhausted;
• use external supports (for example, a system of traction of the upper jaw through blocks with the patient in a horizontal position on the bed).

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

Orthopedic treatment methods for injuries of the maxillofacial area

Dislocations and fractures of teeth

• Tooth dislocations

Treatment of complete dislocation is combined (tooth replantation followed by fixation), and treatment of incomplete dislocation is conservative. In fresh cases of incomplete dislocation, the tooth is set with the fingers and strengthened in the alveolus, fixing it with a dental splint. As a result of untimely reduction of a dislocation or subluxation, the tooth remains in an incorrect position (rotation around an axis, palatoglossal, vestibular position). In such cases, orthodontic intervention is required.

• Tooth fractures

The previously mentioned factors can also cause tooth fractures. In addition, enamel hypoplasia and dental caries often create conditions for tooth fracture. Root fractures can occur from corrosion of metal pins.

Clinical diagnosis includes: anamnesis, examination of the soft tissues of the lips and cheeks, teeth, manual examination of the teeth, alveolar processes. To clarify the diagnosis and draw up a treatment plan, it is necessary to conduct x-ray studies of the alveolar process and electroodontic diagnostics.

Fractures of teeth occur in the area of ​​the crown, root, crown and root; microfractures of cement are distinguished, when sections of cement with attached perforating (Sharpey) fibers peel off from the dentin of the root. The most common fractures of the tooth crown are within the enamel, enamel and dentin with exposure of the pulp. The fracture line can be transverse, oblique and longitudinal. If the fracture line is transverse or oblique, passing closer to the cutting or chewing surface, the fragment is usually lost. In these cases, tooth restoration is indicated by prosthetics with inlays and artificial crowns. When opening the pulp, orthopedic measures are carried out after appropriate therapeutic preparation of the tooth.

For fractures at the neck of the tooth, often resulting from cervical caries, often associated with an artificial crown that does not tightly cover the neck of the tooth, removal of the broken part and restoration using a stump pin insert and an artificial crown are indicated.

A root fracture is clinically manifested by tooth mobility and pain when biting. The fracture line is clearly visible on dental x-rays. Sometimes, in order to trace the fracture line along its entire length, it is necessary to have x-rays obtained in different projections.

The main method of treating root fractures is to strengthen the tooth using a dental splint. Healing of tooth fractures occurs after 1 1/2-2 months. There are 4 types of fracture healing.

Type A: the fragments are closely juxtaposed with each other, healing ends with the mineralization of the tooth root tissue.

Type B: healing occurs with the formation of pseudarthrosis. The gap along the fracture line is filled with connective tissue. The radiograph shows an uncalcified band between the fragments.

Type C: grow between fragments connective tissue and bone tissue. The x-ray shows the bone between the fragments.

Type D: the gap between the fragments is filled with granulation tissue: either from the inflamed pulp or from gum tissue. The type of healing depends on the position of the fragments, immobilization of the teeth, and pulp viability.

• Fractures of the alveolar ridge

Treatment of alveolar bone fractures is mainly conservative. It includes repositioning the fragment, fixing it and treating damage to soft tissues and teeth.

Reposition of the fragment in case of fresh fractures can be carried out manually, in case of old fractures - by the method of bloody reposition or with the help of orthopedic devices. When the fractured alveolar process with teeth is displaced to the palatal side, reposition can be performed using a palatal release plate with a screw. The mechanism of action of the device is to gradually move the fragment due to the pressing force of the screw. The same problem can be solved by using an orthodontic apparatus by pulling the fragment towards the wire arch. In a similar way, it is possible to reposition a vertically displaced fragment.

If the fragment is displaced to the vestibular side, reposition can be carried out using an orthodontic apparatus, in particular a vestibular sliding arch fixed on the molars.

Fixation of the fragment can be carried out with any dental splint: bent, wire, soldered wire on crowns or rings, made of quick-hardening plastic.

• Fractures of the body of the upper jaw

Non-gunshot fractures of the upper jaw are described in textbooks on surgical dentistry. Clinical features and the principles of treatment are given in accordance with Le Fort's classification, based on the location of fractures along lines corresponding to weak points. Orthopedic treatment of fractures of the upper jaw consists of repositioning the upper jaw and immobilizing it with intra-extraoral devices.

In the first type (Le Fort I), when it is possible to manually set the upper jaw into the correct position, intra-extraoral devices supported on the head can be used to immobilize fragments: a solid-bent wire splint (according to Ya. M. Zbarzh), a dentogingival splint with extraoral levers, soldered splint with extraoral levers. The choice of design for the intraoral part of the apparatus depends on the presence of teeth and the condition of the periodontium. In the presence of large quantity stable teeth, the intraoral part of the apparatus can be made in the form of a wire dental splint, and in case of multiple absence of teeth or mobility of existing teeth - in the form of a dentogingival splint. In toothless areas of the dentition, the dentogingival splint will consist entirely of a plastic base with imprints of antagonist teeth. In case of multiple or complete absence surgical methods of treatment are indicated.

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Facial injuries can be open or closed. Open injuries are accompanied by protrusion of bone fragments of the maxillofacial region (MFA) of the skull into the wound surface.

Injuries to the maxillofacial area occur due to the mechanical impact of a blunt object. In percentage terms, injuries to the maxillofacial area are divided: domestic - 62%; transport - 17%; production - 12%; street - 5%; sports - 4%.

The maxillofacial region has a powerful vascular network and a large array of loose subcutaneous tissue, therefore, injuries to the maxillofacial area are accompanied by significant swelling, hemorrhage, and a seeming discrepancy between the size of the wound and the amount of bleeding. Facial injuries are often combined with wounds facial nerve and parotid salivary gland, injuries to the lower jaw - with damage to the nerves of the larynx, pharynx and large vessels.

Urgent Care for injuries of the maxillofacial area:

• relief (if necessary) of signs of acute respiratory and cardiovascular failure;
• to prevent asphyxia, the victim is placed face down, turning his head to the side;
• carry out sanitation of the oral cavity;
• in case of threat of obstructive asphyxia, an S-shaped air duct is installed for the victim;
• bleeding is stopped with a pressure bandage, tight wound tamponade, or application of a hemostatic clamp;
• in place soft bruises apply a pressure bandage;
• the victim is hospitalized in medical institution.

Damage to teeth

In case of maxillofacial injuries, the following dental injuries occur: crown fracture, tooth dislocation, tooth root fracture.

A fracture of the tooth crown is accompanied by pain, the presence of sharp edges of the remaining teeth, exposed tooth pulp or root canal, and bleeding is possible. When a tooth dislocates, it comes out of its socket and becomes pathologically mobile. With an impacted dislocation, the crown moves inside the alveolar process.

Emergency care for dental damage consists of anesthesia with a 2% solution of novocaine; a cotton ball soaked in 1 g of carboxylic acid, 3 g of camphor and 2 ml of ethyl alcohol is placed on the exposed pulp stump.

A completely dislocated tooth is removed from the socket and then replanted into the same socket. A partially dislocated tooth is reduced and secured to adjacent teeth with a metal ligature.

Fracture of the alveolar process of the mandible

When a fracture occurs, the alveolar process of the lower jaw is mobile, bleeding from the gums, buccal mucosa, lips, and nosebleeds is observed. In case of damage to the maxillary sinus, foamy blood is released from the wound.

Emergency care consists of removing blood clots, fragments of mucous membrane, and loose fragments of the alveolar process from the mouth to prevent possible aspiration and asphyxia. Local anesthesia is performed with a 2% novocaine solution, the victim is hospitalized in a hospital, where the fracture site is permanently fixed and measures are taken to preserve the teeth.

Fracture of the body of the lower jaw

Such fractures are considered open, primarily infected, since the fracture occurs within the dentition with damage to the mucosa. Most often, the fracture line lies at the level of the fangs and mental foramina, in the area of ​​the lower 8th tooth and the angle of the jaw.

With fractures of the lower jaw, the mobility of mouth opening is limited, the bite is disturbed, there is profuse salivation, bleeding, fragments of the lower jaw are pathologically mobile, multiple fractures can be accompanied by asphyxia due to the retraction of the tongue.

Emergency care involves removing foreign bodies from the mouth; if necessary, an S-shaped air duct is inserted into the mouth to prevent tongue retraction and the development of acute respiratory failure. Pain relief is performed with a 50% analgin solution intramuscularly in a volume of 2-4 ml; if it is ineffective, narcotic analgesics are indicated. The victim is hospitalized in the department maxillofacial surgery. During transportation, a sling bandage is used to temporarily immobilize the damaged jaw.

Dislocation of the lower jaw

Dislocation of the lower jaw can occur with maximum mouth opening, trauma, insertion of an endotracheal tube, gastric tube, or mouth dilator.

When the lower jaw is dislocated, the head of the articular process of the lower jaw is displaced beyond the limits of the articular cavity, while the victim cannot close his mouth, he is drooling, and he feels pain in the area of ​​the temporomandibular joint. With a bilateral dislocation, the chin moves downwards, with a unilateral dislocation - to the healthy side.

Dislocation of the lower jaw is treated by reduction. The patient is given anesthesia and seated on a low chair so that his head rests against the headrest and is level elbow joint doctor

The doctor places his thumbs in the retromolar region of both sides of the lower jaw, and with the remaining fingers covers the outer surface of the jaw from the angle to the chin. After this, the jaw is pressed down with the thumbs, after which the chin is sent upward with the remaining fingers.

After reduction of the dislocation, the patient is given a fixing sling-shaped bandage for 10-12 days.

Maxillary fracture

There are three types of maxillary fractures:

1. Fracture of the body of the upper jaw above the alveolar process from the base of the pyriform to the pterygoid processes - bleeding from the mucous membrane of the mouth and nose, lengthening of the middle zone of the face, hemorrhage in the conjunctiva, eyelids, impaired closure of teeth.
2. Complete separation of the upper jaw - the symptoms are the same, but the symptom of “glasses” is more pronounced, when the entire upper jaw with the root of the nose is pathologically mobile without movement of the zygomatic bones. A combined fracture of the upper jaw with a fracture of the base of the skull may occur with symptoms of irritation of the meninges.
3. Complete separation of the bones of the facial skull - is characterized by a serious condition of the patient with pronounced signs of damage to the base of the skull.

Emergency care consists of eliminating signs of acute respiratory and cardiovascular failure, cold in the area. Anesthesia is carried out with a 2% solution of promedol in a volume of 2 ml. The damaged jaw is immobilized using a parietal-mental or sling-shaped bandage, and the victim is transported in a lateral position to a medical facility.

Fracture of the zygomatic bone

The victim feels pain and numbness in the area of ​​the nose and upper lip on the injured side, and a feeling of pressure in the eyes. Examination reveals the symptom of “spectacles”, limitation of movement of the lower jaw, and nosebleeds often develop. The irregularity along the lower orbital edge is determined by palpation.

Emergency care consists of adequate pain relief and cold in place. The victim is hospitalized in a hospital.

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Injuries of the maxillofacial area (face). Clinic (signs) of trauma to the maxillofacial area (face). Emergency (first) aid for trauma to the maxillofacial area (face). There are open and closed facial injuries. Open wounds are characterized by protrusion of bone fragments of the maxillofacial region (mandibular region) of the skull into the wound surface. Closed injuries include bruises, hemorrhages, ruptures of muscles, tendons and nerves, bone fractures and dislocation of the lower jaw. Etiology of injuries to the maxillofacial area (face). Injuries to the maxillofacial area (face), as a rule, are the result of the mechanical impact of a blunt or flat wounding object. Most common types injuries: household (62%), transport (17%), industrial 12% (industrial and agricultural), street (5%) and sports (4%). Pathogenesis of injuries to the maxillofacial region (face). Anatomical feature The maxillofacial region is characterized by a powerful vascular network along with the presence of a large array of loose subcutaneous tissue. This causes significant swelling and hemorrhage in the facial area during trauma and a seeming discrepancy between the size of the wound and the amount of bleeding. Wounds to the face are often combined with damage to the branches of the facial nerve and the parotid salivary gland, and wounds to the lower jaw with damage to large vessels and nerves of the larynx and pharynx. Clinic (signs) of trauma to the maxillofacial area (mandibular area) Diagnosis of trauma to the maxillofacial area (mandibular area) is not difficult. Characterized by the presence of a gaping wound and bleeding, pain, dysfunction of opening the mouth, eating, and breathing. Possible complications: shock, asphyxia, bleeding, closed or open brain injury. Emergency (first) aid for trauma to the maxillofacial area (face) If indicated - relief of signs of ARF and OSHF. To prevent asphyxia, the wounded person is placed face down and his head is turned to the side. The oral cavity is sanitized. If there is a threat of obstructive asphyxia, an S-shaped air duct is installed in the oral cavity. For soft tissue bruises, apply a pressure bandage and apply cold locally. Stopping bleeding is achieved with the help of a pressure bandage, tight wound tamponade, application of a hemostatic clamp, or in extreme situations - digital pressure of the arteries. An aseptic bandage is applied to the wound. Hospitalization in a specialized institution. jaw facial fracture injury

Fracture of the alveolar process of the lower jaw. Clinic (signs) of a fracture of the process of the lower jaw. Emergency (first) aid for a fracture of the alveolar process of the lower jaw. Clinic of fracture of the process of the lower jaw. The bone fragment of the alveolar process of the lower jaw is mobile during examination, but with an impacted fracture the mobility is insignificant. Bleeding from the gums, mucous membrane of the cheek, lips. Nosebleeds are observed. If the maxillary sinus is damaged, foamy blood is released from the wound. Emergency (first) aid for a fracture of the alveolar process of the lower jaw Blood clots, pieces of mucous membrane, loose fragments of the alveolar process are removed from the oral cavity to prevent possible aspiration and asphyxia. Local anesthesia is performed with 1-2% novocaine solution. Hospitalization in a specialized institution. Patients with injuries to the maxillary sinus are hospitalized in ENT departments. Specialized assistance with a fracture of the alveolar process of the lower jaw. In the Department of Maxillofacial Surgery, the fracture site is permanently fixed and measures are taken to preserve the teeth.

Fracture of the body of the lower jaw. Dislocation of the lower jaw. Clinic (signs) of a fracture, dislocation of the lower jaw. Emergency (first) aid for a fracture or dislocation of the lower jaw. A fracture of the body of the lower jaw most often occurs along the midline, at the level of the canines and mental foramina, in the area of ​​the lower 8th tooth and the angle of the jaw. Since fractures within the dentition are accompanied by damage to the mucous membrane, they are considered primarily infected and open. Clinic for fracture of the body of the lower jaw. Pain at the site of injury, aggravated by speech and opening the mouth. On examination, mouth opening is limited, malocclusion is observed, bleeding from the damaged mucosa and profuse salivation are noted. Fragments of the body of the lower jaw are mobile by palpation. With multiple fractures, asphyxia is possible due to retraction of the tongue. Emergency care for a fracture of the body of the lower jaw. A thorough examination of the oral cavity, removal of foreign bodies. If the tongue is retracted and there is a threat of developing ODA, an S-shaped air duct is inserted into the horny cavity or other air ducts and methods are used. Anesthesia is performed by intramuscular injection of 2-4 ml of 50% analgin solution, and with it low efficiency- narcotic analgesics (for example, promedol 1 ml 2% solution subcutaneously or intramuscularly). Temporary transport immobilization is carried out using a sling-like bandage. Hospitalization in the department of maxillofacial surgery. Dislocations of the lower jaw The basis of dislocation of the lower jaw is the displacement of the head of the articular process of the lower jaw outside the articular cavity. Etiology of dislocation of the lower jaw. Dislocation occurs due to injury, maximum opening of the mouth, insertion of an endotracheal tube, gastric tube, or mouth dilator. Clinic for dislocation of the lower jaw. The victim cannot close his mouth, he is bothered by drooling and pain in the temporomandibular joint. With a unilateral dislocation, the chin shifts to the healthy side, with a bilateral dislocation - downwards. Emergency care for dislocation of the lower jaw The patient sits on a low chair, his head rests against the headrest and is at the level of the doctor’s elbow joint. After local anesthesia, the doctor’s thumbs are placed in the retromolar region of both sides of the lower jaw, the rest cover its outer surface from the angle to the chin. Use your thumbs to push the jaw down, and then use the remaining fingers to push the chin up. After reduction of the dislocation, a fixing sling-shaped bandage is applied for 10-12 days. Dentist consultation.

Fractures of the upper jaw. Fractures of the zygomatic bone. Classification of fractures of the upper jaw. Clinic (signs) of a fracture of the upper jaw. Emergency (first) aid for a fracture of the upper jaw, zygomatic bone. Depending on the level of the gap, there are three types of fractures of the upper jaw. Type I - fracture of the body of the upper jaw above the alveolar process from the base of the pyriform to the pterygoid processes. Type II - complete separation of the upper jaw (the gap runs along the frontonasal suture, along the inner wall of the orbit, along the zygomaticomaxillary suture and pterygoid processes). Type III is characterized by a complete separation of the bones of the facial skull. Maxillary fracture clinic. The first type is characterized by bleeding from the mucous membranes of the mouth and nose; There is an elongation of the middle zone of the face, hemorrhage in the conjunctiva, eyelids, and impaired closure of the teeth. In the second type of fracture of the upper jaw, the same symptoms are observed, but the symptom of “glasses” is more pronounced; the entire upper jaw with the root of the nose is mobile without movement of the zygomatic bones. It is possible that this type of fracture of the upper jaw can be combined with a fracture of the base of the skull; in this case, symptoms of irritation of the dura mater will be determined. Exophthalmos occurs due to hemorrhage into the retrobulbar tissue. The third type of fracture of the upper jaw is characterized by a severe condition of the victim with pronounced signs of damage to the base of the skull. Emergency (first) aid for a fracture of the upper jaw Elimination of ARF and OSHF, local cold. Anesthesia 1-2 ml of 2% r-rapromedol or any other narcotic analgesic. Transport immobilization is achieved using a parietomental or sling-shaped bandage. In order to prevent asphyxia, at the evacuation stage the patient is transported in a lateral position to a specialized medical facility. Fractures of the zygomatic bone and its arch Clinic of a fracture of the zygomatic bone. Pain and numbness in the area of ​​the nose and upper lip of the affected side, a feeling of pressure in the eyes. On examination, a symptom of “spectacles”, limited movement of the lower jaw, and possible nosebleeds are noted. The irregularity along the lower orbital edge is determined by palpation. Emergency care for a fracture of the zygomatic bone. Adequate pain relief, local cold. Hospitalization in specialized hospital for X-ray monitoring and subsequent treatment.

Lecture outline

Facial injuries in children

Facial injuries in children

Facial injuries in children

Facial injuries in children

Facial injuries in children

Periods of childhood

Periods of childhood

10. Periods of childhood

11. Periods of childhood

12. Periods of childhood

13. Periods of childhood

14. Features of facial injuries in children

15.

16. Features of facial injuries in children

17. Features of facial injuries in children

18. Features of facial injuries in children

19. Features of facial injuries in children

20. Features of facial injuries in children

21. Features of facial injuries in children

22. Features of facial injuries in children

23. Features of facial injuries in children

24. Features of facial injuries in children

25. Features of facial injuries in children

26. Features of facial injuries in children

27. Features of facial injuries in children

28. Classification of injuries to the maxillofacial area

29. Classification of injuries to the maxillofacial area

30. Classification of injuries to the maxillofacial area

31. Classification of injuries to the maxillofacial area

32. Classification of injuries to the maxillofacial area

33. Types of childhood injuries

34. Birth trauma

35. Birth trauma

36. Incorrect fetal position

37. Birth trauma

38. Birth trauma

39. Obstetric forceps

40. Vacuum extractor

41. Use of a vacuum extractor and obstetric forceps

42. Birth trauma

43. Birth trauma of soft tissues

44. Birth trauma of soft tissues

45. Torticollis

46. ​​Birth trauma of soft tissues

Children who have suffered a birth injury of the soft Birth injury of the skeletal system Consequences of a birth injury

Approved by the decision of the Problem Commission “On Issues of Surgical Dentistry and Pain Management” at the Scientific Council on Dentistry of the USSR Academy of Medical Sciences on March 16, 1984. The classification includes the following sections.

I. Mechanical damage to the upper, middle, lower and lateral areas of the face. 1. By localization. A. Soft tissue injuries with damage:

b) salivary glands;

c) large nerves;

d) large vessels. B. Bone injuries:

a) lower jaw;

b) upper jaw;

c) zygomatic bones;

d) nasal bones;

e) two bones or more.

2. According to the nature of the injury:

a) end-to-end;

b) blind;

c) tangents;

d) penetrating: into the oral cavity, nose, maxillary sinus;

e) non-penetrating: into the oral cavity, nasal cavity, maxillary cavity

f) with a tissue defect - without a tissue defect;

g) leading - accompanying;

h) single - multiple;

i) isolated - combined.

3. According to the clinical course of the wound process:

a) complicated;

b) uncomplicated.

4. According to the mechanism of damage. A. Firearms:

a) bullets;

b) fragmentation;

c) ball;

d) arrow-shaped elements. B. Non-firearms.

II. Combined lesions.

III. Burns (including electrical trauma).

IV. Frostbite.

Injuries can be isolated and combined, single and multiple, leading and concomitant, as well as combined.

Isolated injuries are injuries to one anatomical area.

Damage to two or more anatomical areas is called combined.

A single isolated wound occurs when one anatomical area is affected by one wounding agent.

A single combined injury occurs when several anatomical areas are affected by one wounding agent (for example, a wound to the head and arm from one bullet).

Multiple isolated injuries occur when one anatomical area is injured by multiple wounding agents (for example, multiple bullets or shrapnel).

Multiple combined injuries occur when several anatomical areas are damaged as a result of the action of many wounding agents (for example, a wound to the head, chest, etc. from several bullets or shrapnel).

Leading injuries determine the severity of the injury in the presence of several injuries.

Concomitant injuries occur simultaneously with the leading ones, but do not determine the severity of the injury in comparison with the leading ones.

Leading and accompanying injuries can change roles depending on the timing and effectiveness of treatment.

Combined are injuries to one or more anatomical areas that occur as a result of exposure to various damaging factors (for example, mechanical trauma and radiation injury or thermal exposure, or exposure to high-frequency currents).

Clinical course wounds and their outcome are determined by the volume of tissue affected and the mechanism of injury (type of wounding projectile). Gunshot wounds of the maxillofacial area are often accompanied by damage to large nerves and blood vessels, concussion or contusion of the brain, damage eyeballs, trachea, larynx, hearing organs, i.e. quite often refer to combined injuries.

During the Great Patriotic War, 97.1% of all facial wounds were from gunshots. In local wars gunshot wounds faces made up 85.5%.

According to international classification, the entire human body is conventionally divided into 7 anatomical regions: head, neck, chest, abdomen, pelvis, spine, limbs. In turn, the following areas of the head are additionally distinguished: skull and brain, maxillofacial area, ENT organs and organs of vision. Given the proximity of their location, facial injuries are most often combined. These include injuries in which, along with the maxillofacial area, at least one of the areas is damaged: the skull, brain, organ of vision, ENT organs - and in the treatment of which the participation of a neurosurgeon, ophthalmologist or otolaryngologist is necessary.

Small arms are conventionally divided into 2 groups:

Small arms of various calibers, the damaging element of which is bullets;

Explosive ammunition, the damaging elements of which are fragments and a blast wave.

Projectiles weighing 4-5 g at a flight speed of 200 m/s or more are considered lethal, i.e. impact force 15 kg/m. Currently, rifles of 5.56 and 7.62 caliber with bullets weighing 3-4 and

Depending on the flight speed, projectiles are distinguished:

Low speed (up to 700 m/s);

High speed (700-990 m/s);

Ultra-high-speed (more than 1000 m/s).

An energy of 70-80 J is sufficient to damage tissue. At the same time, for example, a TT pistol of 7.62 caliber with an initial bullet speed of 300 m/s (low-speed, weight 8 g) has an energy of 400 J, which is more than 8 times higher energy required to damage tissue.

For the formation of a wound, the kinetic energy of the wounding agent is important, which is calculated by the formula:

E = (M x V 2) : 2,

where M is the mass of the bullet, V is its initial speed.

Thus, the initial speed of the traumatic agent (bullets, fragments) mainly determines its kinetic energy and, consequently, its impact force and the volume of tissue destruction.

When a wounding agent (bullet, fragment) enters the body, it causes tissue damage of the following types.

1. Direct impact on tissue (direct destruction), which is commonly called “direct impact”. It is manifested by the formation of a wound channel with rupture of its walls, their crushing and death, as well as infection.

2. Indirect impact on tissue, called “lateral or hydrodynamic impact”, as well as “molecular shock of tissue”. A side impact occurs due to the formation of a temporary pulsating cavity (TPC), causing disruption microcirculation in the tissues surrounding the wound canal, and pronounced pathomorphological changes in the wall of the wound canal (thrombosis of small vessels, hemorrhage, cell lysis, necrosis, etc.). The volume of the affected area of ​​a side impact depends mainly on the kinetic energy of the traumatic agent and, to a lesser extent, on the structure of the affected tissues.

Thus, the formation of a wound occurs in 2 stages. At the first stage, a direct strike is primarily carried out due to the head shock wave. It is a compressed

in front of the flying traumatic agent there is a column of air, which, in contact with the skin, causes it to rupture, after which the bullet or fragment rushes behind the air column into the resulting skin wound, expands it, moves forward, into soft fabrics, destroys them and delaminates, thereby creating a wound channel. Following the destruction of soft tissues (skin, tissue, fascia, muscles, tendons), destruction of bones and organs may occur.

Along the walls of the wound canal, a zone of primary tissue necrosis is formed due to the direct impact of the traumatic agent on them.

It should be noted that during the movement of a bullet (fragment), tissue contents consisting of destroyed cells accumulate in front of it. In this area it is formed high blood pressure, as a result of which liquid tissue contents penetrate between the walls of the wound canal and the traumatic agent, and then exit through the inlet. After the traumatic agent leaves the tissue, destroyed tissue also flies out through the exit hole. As a result, if the bone is damaged, the exit hole will be significantly larger than the entrance hole.

The impact of a direct impact is very short and lasts only 0.0001 to 0.001 s.

At the second stage of damage formation, when the projectile leaves the wound channel through the exit hole or remains at the end of the wound, another force acts on the tissue along the wound channel in the form of a lateral (hydrodynamic) impact due to the formation of a runway.

The resulting VPP leads to very frequent strong contacts (impacts) of the walls of the wound canal (like clapping hands), causing the death of adjacent tissues due to damage to cells, capillaries and small vessels. This phenomenon is also called “molecular shock”, which leads to pronounced morphological (mainly hemorrhage, capillary thrombosis and tissue necrosis) and functional disorders in tissues at a considerable distance from the wound channel.

This creates a zone of secondary, or sequential, tissue necrosis. It is located outward from the wound canal tissues exposed to the direct action of a bullet (fragment). Its width is directly proportional to the kinetic energy of the traumatic agent and can reach several centimeters.

Tissue death in this zone occurs gradually due to cavitation damage to subcellular structures (molecular concussion), subsequent disruption of microcirculation (thrombosis and capillary hemorrhage) and tissue proteolysis due to the release of enzymes in the zone of primary necrosis.

In the zone of secondary necrosis, there is a pronounced inhibition of metabolic processes, metabolic disorders nerve endings and the formation of a large number of non-viable tissues.

The effect of the VP lasts 0.04-0.19 s (i.e. 300-500 times longer than the effect of a direct blow), therefore, even after the wounding projectile leaves the tissue.

The zone of secondary necrosis is followed by a zone of parabiosis. Here the tissues retain their vital functions, although for some time they are in a parabiotic state due to a gunshot wound. This condition is reversible, since thrombosis and capillary hemorrhage do not occur or the severity of these changes is quite insignificant. When performing primary surgical treatment (PST) of a gunshot wound, tissue must be excised to this area to prevent the development of inflammatory complications.

Behind the parabiosis zone is unaffected tissue (Fig. 1-1).

The wound channel can have not only a straight, but also a tortuous direction due to the possible deflection of the bullet during movement as a result of its contact with bone tissue. This phenomenon is called “primary deviation”. In addition, the tortuous direction of the channel can arise due to varying degrees of contraction of muscles, ligaments and fascia after the passage of a traumatic agent through them. In this case, we are talking about “secondary deviation” of the wound channel.

Rice. 1-1. Wound channel zones(diagram): 1 - zone of primary necrosis (post-traumatic); 2 - zone of secondary necrosis (molecular shock); 3 - zone of parabiosis; 4 - unaffected tissue

Thus, a gunshot wound is characterized by the presence of the following 4 zones (see Fig. 1-1) and the following signs:

Skin damage;

Possible presence of foreign bodies in the wound;

Primary and secondary deviation of the wound channel;

Microbial contamination of fabrics.

Summarizing the above, we can note the following.

The degree of destruction of tissues and organs depends on the kinetic energy of the wounding agent. The larger it is, the more significant the tissue destruction.

New types of small arms have a significantly higher initial speed of flight of the traumatic agent than older ones, and therefore have greater kinetic energy. The bullet quickly transfers this energy to damaged tissues and organs, causing significant destruction in them.

The VP causes a so-called interstitial explosion, which determines the degree of tissue damage along the wound channel, destroys tissue within a fraction of a second and continues to act after the wounding projectile leaves the tissue through the exit hole. Therefore, gunshot wounds to the face are accompanied by the formation of significant defects in soft tissues and bones, and the formation of a large number of non-viable tissues. These injuries lead to serious functional disorders and disfigure the appearance of the victim. Early complications such as asphyxia, shock, bleeding, etc. often occur, which subsequently lead to the patient’s disability or death.

The degree of tissue destruction depends both on the power of the traumatic agent and on the morphological structure of the damaged tissues (their elasticity, strength). At the same time, due to its high strength and fibrous structure, the fascia can be preserved, but the muscle tissue can be completely destroyed. At the same time, bones and teeth, offering great resistance to the bullet, absorb a significant amount of kinetic energy from the wounding projectile and are destroyed with an explosive effect. Their fragments can turn into “secondary wounding projectiles”, which, acquiring kinetic energy, subsequently independently destroy surrounding tissue.

Blood filling such large vessels as the internal carotid artery And jugular vein, can receive energy according to the law of hydrodynamics and cause a direct blow to the brain tissue

brain This can lead to concussion and other injuries, as well as cause ruptures of blood vessels in the neck and head.

Nerves are highly elastic and resistant to rupture, but due to direct or lateral impacts, conduction disturbances may occur in them, which leads to paresis or muscle paralysis.

Gunshot wounds can be through, blind and tangential.

Penetrating gunshot wounds, as a rule, occur when a bullet passes only through soft tissue and has two holes: entry and exit. When bone tissue is damaged, a through wound occurs if the traumatic agent has significant kinetic energy that can not only destroy the bone, but also leave the body.

Penetrating wounds account for 36.5-47.4%. The size of the entrance hole is usually much smaller than the exit hole, especially when bone tissue is damaged. This is due to the fact that the traumatic agent that has penetrated into the tissues gives them part of its kinetic energy. Bone tissue, having received a certain supply of energy and becoming a secondary wounding projectile, causes additional anatomical destruction. Destroyed soft and bone tissues move along with the bullet along its trajectory, increasing in volume, and at the exit create additional tissue destruction.

Penetrating wounds are 8 times more likely to be caused by bullets than by shrapnel. With penetrating wounds, especially with damage to bone tissue, the highest mortality rate and the lowest number of discharged patients with complete recovery were observed.

Particularly large damage to the face was noted with shrapnel wounds.

Blind wounds occur when the kinetic energy of the traumatic agent is low or the energy is quickly released as it passes through the tissues. A blind wound is characterized by the presence of an entrance hole and a wound channel that ends blindly in the tissues. There is no outlet. When examining a blind injury, a traumatic agent is always detected in the wound.

Blind wounds occur on average in 33.1-46.2% of cases. Most often they are mild and in some cases do not require radical surgical treatment. However, if a fragment or bullet is located near the brain, large vessels, larynx,

trachea and nerve trunks, there is a danger of their damage or subsequent development of a severe inflammatory process, which is observed in 40% of cases. That is why it is necessary to determine the location of the fragments, and blind wounds are considered potentially serious.

Blind wounds are more often shrapnel wounds (89.5%), less often bullet wounds (10.2%). In local wars, wounds from bullets were noted in 43.5% of victims, and from shrapnel - in 56.5%.

Multiple blind small-fragmentation wounds cause permanent facial disfigurement and are classified as severe. In 9.3% of cases of multiple blind wounds of the face, foreign bodies lay in the area of ​​the vascular bundle, which was a potentially serious prognostic sign.

To diagnose blind wounds, anamnesis, study of received documentation, palpation of tissue in the area where the fragment is located, digital examination of the wound canals, probing, fistulography and vulnerography are used.

It is necessary to remember the possibility of deviation of the wound channel, which is accompanied by its shortening or lengthening, as well as fragmentation, which significantly complicates the search for a fragment during PSO.

Blind tongue wounds account for 3.2% of all blind wounds.

If the foreign body does not provoke inflammatory process, then it may not be subjectively determined by the injury. When localizing foreign body in the deep parts of the tongue, as well as in the peripharyngeal and retropharyngeal spaces, there is a real danger of the development of phlegmon in these areas, and therefore removal of the foreign body is necessary and is performed according to urgent indications.

Indications for removing bullets or fragments:

1) localization of the fragment near a large vessel;

2) localization of the fragment near the esophagus, pharynx, larynx, if it complicates speech, swallowing, breathing;

3) the presence of an acute inflammatory focus caused by a foreign body.

Tangential wounds to the face occur when a traumatic agent passes superficially in relation to the tissues. As such, the inlet and outlet openings are not defined, but there is an extensive wound surface. Wounding projectiles cut through the soft tissues of the face throughout the wound. Along its edges one can identify small tears that form scalloped contours,

crushing and bruises. Sometimes a tangential wound resembles a chopped wound. Like all wounds, it can become contaminated with explosive particles.

Tangential wounds occur in 14.4-19.5% of cases; they are usually classified as mild. However, a small part (5%) of tangential wounds may be accompanied by the formation of tissue defects; they are classified as severe, especially in the case of shooting off the nose or chin. Complications occur in 30.2% of victims with these wounds.

Wounds penetrating into the oral cavity, nose, and maxillary sinus occur in 48.6% of cases, they are always infected, and their course is always severe. It should be noted that with penetrating wounds, 55.1% of victims return to duty, while with non-penetrating wounds - 80.5%. Penetrating wounds resulted in 3.5-4.5 times more complications compared to non-penetrating wounds.

Wounds with soft tissue defects during the Great Patriotic War accounted for 30.9%, with bone defects - 13.9%.

Splintered bone fractures after gunshot wounds of the face were most common (87.8% of cases), linear ones less common (12.2%). It should be noted that gunshot wounds to the face with damage to the jaws are classified as relatively severe.

Isolated gunshot injuries to the maxillofacial area account for 40.2% of the total number of wounds, combined injuries to the face - 42.8%.

When nuclear weapons are used, the number of victims with burns and radiation injuries, as well as non-gunshot wounds due to the impact of the shock wave and secondary wounding projectiles, increases, i.e. There is an increase in the number of combined injuries.

The greatest number of complications was caused by through wounds (70%), the least by blind wounds (43.5%) and the least by tangential wounds (30.2%) in relation to each group separately.

Related information.