Symptoms of a bruised zygomatic bone

Facial injuries are quite common. A jaw bruise is an injury without violating the integrity of the skin and bone tissue.

The main difference between it and a fracture is that the victim is able to close and open his mouth, although this causes serious pain. Only an experienced specialist can identify the problem and carry out differential diagnostics.

Most often, such injuries have a favorable prognosis, but it is necessary to undergo a comprehensive study to exclude possible complications. In addition, you should strictly follow medical recommendations and appear in a timely manner for preventive examinations if necessary.

Pain is the main symptom of injury

Causes of bruises in the maxillofacial area

Most injuries occur unexpectedly and to varying degrees of severity.

Most often they are observed in the following cases:

• falling onto a hard surface;
• due to collision with objects;
• various impacts (road traffic accidents, domestic fights, contact sports).

Falls are the most common causes of injuries to the maxillofacial area

The severity of such injuries largely depends on the affected area, the type of object that affected the bone tissue and age-related changes in facial tissue.

Damage to the maxillofacial area

The development of surgical treatment methods , especially for neoplasms of the maxillofacial area, has required widespread use of orthopedic interventions in the surgical and postoperative period. Radical treatment of malignant neoplasms of the maxillofacial region 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 of treatment was shown.

The timing of restoration operations varies. Despite the tendency of surgeons to perform the operation as early as possible, a certain amount of time must be allowed when the patient is left with an unrepaired defect or deformity while awaiting surgical treatment or 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. During the surgical treatment of patients with injuries to the maxillofacial area, auxiliary tasks often arise: 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 the successful results of the widespread use of dental splints by dentists 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.

The main method of conservative treatment is 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 and severe atrophy of the 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 splinting arch is soldered to a ring or to a 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 in 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 different designs of dental splints have appeared. 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. A classic example of such a device is the Vankevich tire. 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 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 and during reconstructive surgical interventions.

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. Advances in clinical practice, materials science, and technology for manufacturing dentures have a positive impact on the development of maxillofacial prosthetics. For example, methods for restoring dentition defects with solid-cast clasp dentures have found application in the 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 upper body as a support for orthopedic devices 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 correct selection and application 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 : fragments are closely juxtaposed with each other, healing ends with 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 : connective tissue and bone tissue grow between the fragments. The x-ray shows the bone between the fragments.

Type D : the space between the fragments is filled with granulation tissue: either from the inflamed pulp or from gingival 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 treatment principles 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. If there are a large number of stable teeth, the intraoral part of the device can be made in the form of a wire dental splint, and in the case of multiple absences 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 of teeth, surgical treatment methods are indicated.

Orthopedic treatment of a Le Fort type II fracture is carried out in a similar manner if the fracture was not displaced.

In the treatment of fractures of the upper jaw with posterior displacement | di there is a need to stretch it anteriorly. In such cases, the design of the apparatus consists of an intraoral part, a head plaster cast with a metal rod located in front of the patient's face. The free end of the rod is curved in the form of a hook at the level of the front teeth. The intraoral part of the device can be either in the form of a dental (bent, soldered) wire splint, or in the form of a dentogingival splint, but regardless of the design, in the anterior section of the splint, in the area of ​​the incisors, a hooking loop is created to connect the intraoral splint with the rod coming from the head bandage .

The extraoral supporting part of the device can be located not only on the head, but also on the torso.

Orthopedic treatment of upper jaw fractures of type Le Fort II, especially Le Fort III, should be carried out very carefully, taking into account the general condition of the patient. At the same time, it is necessary to remember the priority of treatment measures according to vital indications.

• Fractures of the lower jaw

The main goal of treating fractures of the lower jaw is to restore its anatomical integrity and function. It is known that the best therapeutic effect is observed with early connection to the function of the damaged organ. This approach involves treating fractures in conditions of lower jaw function, which is achieved by reliable (rigid) fixation of fragments with a single-jaw splint, timely transition from intermaxillary to single-jaw fixation and early therapeutic exercises.

With intermaxillary fixation, due to prolonged immobility of the lower jaw, functional disorders occur in the temporomandibular joint. Depending on the timing of intermaxillary fixation, after removal of the splints, partial or complete restriction of movements of the lower jaw (contracture) is observed. Single-jaw fixation of fragments does not have these disadvantages. Moreover, the function of the lower jaw has a beneficial effect on the healing of fractures, thereby reducing the treatment time for patients.

The description of the advantages of single-jaw fixation does not make them the only way to fix fragments of the lower jaw. There are certain contraindications to them: for example, with fractures of the lower jaw in the area of ​​the angle, when the fracture line passes through the attachment points of the masticatory muscles. In such cases, intermaxillary fixation is indicated, otherwise contracture may occur due to reflex-painful contraction of the masticatory muscles.

At the same time, when using intermaxillary fixation of mandibular fragments, timely transition to a single-jaw splint is important. The timing of the transition depends on the type of fracture, the nature of the displacement of fragments and the intensity of reparative processes and ranges from 10-12 to 20-30 days.

The choice of design of an orthopedic device in each specific case depends on the type of fracture, its clinical characteristics, or is determined by the sequence of therapeutic interventions. For example, in case of a median fracture of the body of the lower jaw with a sufficient number of stable teeth, manual reduction is performed on the fragments and the fragments are fixed using a single-jaw dental splint. The simplest design is a bent wire splint in the form of a smooth bracket, secured to the teeth with ligature wire.

In case of a unilateral lateral fracture of the body of the lower jaw, when a typical displacement of the fragments occurs: upward of the small one under the influence of the masticatory, medial pterygoid, temporal muscles and downward of the large one as a result of traction of the digastric, geniohyoid muscles, the design of the fixing apparatus must be strong. It must resist the pull of these muscles, ensuring the immobility of the fragments during the function of the lower jaw.

This problem is quite satisfactorily solved by the use of a single-jaw soldered wire splint on crowns or rings.

In case of a bilateral lateral fracture, when three fragments are formed, there is a danger of asphyxia due to the retraction of the tongue, which moves back down along with the middle fragment; urgent reposition and fixation of the fragments is required.

When providing first aid, you should remember the need to stretch the tongue and fix it in the forward position with an ordinary pin.

Of the possible options for immobilizing fragments in this type of mandibular fracture, the optimal one is intermaxillary fixation using dental splints: soldered wire splints with hooking loops, bent aluminum splints with hooking loops, standard Vasiliev tape splints, splints with hooking protrusions made of fast-hardening plastic. Their choice depends on specific conditions, availability of material, technological capabilities and other factors.

Fractures in the area of ​​the angle, branches of the jaw and condylar process with slight displacement of fragments can also be treated with the listed devices that provide intermaxillary fixation. In addition to them, other devices are used to treat fractures of this location - with an articulated intermaxillary joint. This design eliminates the horizontal displacement of a large fragment during vertical movements of the lower jaw.

Treatment of multiple fractures of the lower jaw is carried out using a combined method (operative and conservative). The essence of orthopedic measures lies in the reposition of fragments, retention of individual fragments in accordance with the occlusal relationships of the dentition. Reposition of each fragment is carried out separately and only after this the fragments are fixed with a single splint. Fragmentary reduction can be performed using dental splints. To do this, splints are made with hooking loops for each fragment and a splint for the upper row of teeth. Then, using a rubber rod, the fragments are moved to the correct position. After matching, they are connected with a single wire splint and the entire block is fixed to the splint of the upper dentition according to the type of intermaxillary fixation.

Orthopedic treatment of mandibular fractures with a bone defect is carried out using all the main methods of treatment of maxillofacial orthopedics: reduction, fixation, shaping and replacement. Their sequential use in the same patient can be carried out with different devices or with one device - a combined multiple action.

When using orthopedic devices that perform one or two functions (reposition, reduction and fixation), there is a need to replace one device with another, which significantly complicates the treatment process. Therefore, it is advisable to use combined-action devices. For fractures of the lower jaw with a bone defect, when there is a sufficient number of stable teeth on the fragments, a mouth guard apparatus is used. It allows for consistent reposition of fragments, their fixation, and formation of soft tissues. The design of the device (I.M. Oksman) is known, with the help of which it is possible to carry out both reposition and fixation of fragments, and replacement of bone tissue defects. However, this does not mean at all that single- or dual-function devices have completely lost their significance.

In case of a lateral fracture of the body of the lower jaw with a bone defect and in the presence of supporting teeth on the fragments, the problems of reposition and fixation can be successfully solved using the Kurlyandsky apparatus.

Treatment of fractures of the lower jaw with a bone tissue defect in the absence of the possibility of constructing tooth-supported devices is carried out surgically or in a combined way. Among orthopedic devices, the Vankevich splint has received wide recognition.

In most cases, the outcomes of fracture treatment are favorable. For non-gunshot fractures after 4-5 weeks. the fragments heal, although the fracture gap can be determined X-ray even after 2 months.

To obtain such a favorable outcome, three main conditions must be met:

• accurate anatomical comparison of fragments;
• mechanical stability of the connection of fragments;
• preservation of blood supply to fixed fragments and function of the lower jaw.

If even one of these conditions is violated, the outcome of treatment may be unfavorable in the form of fusion of fragments in the wrong position or complete non-fusion with the formation of a false joint of the lower jaw.

Prolonged intermaxillary fixation of fragments and other reasons can lead to contracture of the lower jaw.

• Improperly healed jaw fractures

The main reason for improper healing of jaw fractures is a violation of the principles of treatment, in particular, incorrect comparison of fragments or their unsatisfactory fixation, as a result of which secondary displacement of the fragments occurs and their fusion in the wrong position.

The morphological picture of healing of incorrectly juxtaposed and poorly fixed fragments has its own characteristics. In this condition of the fracture, cellular activity is much higher, the connection is achieved due to a large influx of fibroblasts appearing in the tissues surrounding the fracture. The resulting fibrous tissue then slowly ossifies and the fibroblasts transform into osteoblasts. Due to the displacement of fragments, the relative position of the cortical layer is disrupted. Its restoration as a single layer is slowing down, since a significant part of the tissue is resorbed and most of it is reformed from the bone.

With improperly healed fractures, it is reasonable to expect a deeper and longer-lasting restructuring in the dental system, since the direction of the load on the jaw bones changes, pressure and traction are distributed differently. First of all, spongy bone undergoes restructuring. Atrophy of underloaded and hypertrophy of newly loaded bone crossbars occurs. As a result of such restructuring, bone tissue acquires a new architectonics, adapted to new functional conditions. Restructuring also occurs in the area of ​​periodontal tissues. Often, a functional load changing in direction and magnitude can lead to destructive processes in the periodontium.

When jaw fractures heal incorrectly, there is a risk of developing TMJ pathology due to functional overload of its elements.

Incorrectly healed fractures are clinically manifested by deformation of the jaws and disruption of the occlusal relationships of the dentition.

In case of improperly healed fractures with vertical displacement of fragments, signs of an anterior or lateral open bite are observed. Fragments displaced in the horizontal plane in the transversal direction cause the closure of the dentition as a crossbite or a pattern of palatal (lingual) displacement of a group of teeth.

Relatively minor occlusal disorders can be corrected by prosthetics. Vertical discrepancies can be leveled with both fixed and removable prostheses: metal crowns, aligners, removable dentures with a cast occlusal overlay. For transversal occlusion disorders and a small number of remaining teeth, a removable denture with a duplicated dentition is used. The closure of the teeth is ensured by artificial teeth, and natural teeth serve only as a support for the prosthesis.

Orthodontic methods can also be used to eliminate occlusal disorders. Hardware, hardware-surgical methods for correcting bite deformities can have a high positive effect in the treatment of improperly healed jaw fractures.

• False joints

The morphological picture of the healing of a fracture ending in the formation of a pseudarthrosis is sharply different from that observed with complete healing of fractures. With false joints, signs are clearly visible that indicate low reparative regeneration of bone tissue: the absence of a sufficient number of osteogenic elements in the fracture area, the state of ischemia, the proliferation of scar tissue, etc.

Orthopedic measures for pseudarthrosis as the main method of treatment are used in cases where there are contraindications to bone grafting or it is postponed for a considerable time. Contraindications to osteoplastic surgery are mainly related to the general condition of the body (weakness and exhaustion) and the patient’s refusal to undergo surgery.

The choice of prosthesis design depends on the presence and condition of the remaining teeth, the size and topography of the defect. However, there is a general principle for designing dentures for false joints: making dentures from two halves, corresponding to two fragments, and movably connecting them to each other. This design is due to the fact that a single base leads to overload of supporting tissues and teeth due to multidirectional displacement of each fragment. With a movable connection of the two halves of the prosthesis, the functional overload is reduced.

Many methods have been developed for movably connecting prosthesis bases. The original designs of prostheses were proposed by I.M. Oksman. This is a prosthesis with a single-joint connection and a two-articular connection. The first design is used for low mobility, the second for large displacement of jaw fragments.

Dental prosthetics are mandatory when treating a false joint surgically. In this case, orthopedic treatment is an integral part of complex rehabilitation therapy.

• Contracture of the lower jaw

Treatment of contractures is conservative, surgical and combined. Conservative treatment consists of medications, physiotherapeutic methods, therapeutic exercises and mechanotherapy.

Damage to the lower jaw

This injury is the most common. It occurs in both children, adults and the elderly. The important point is to identify the type of damage as soon as possible and provide first aid. The further prognosis and duration of treatment will depend on this.

A mandibular contusion is a soft tissue injury in the lower parts of the face. As a result, an internal hematoma is formed due to the rupture of small blood vessels.

In the event of a bruise, the bone tissue remains intact and the teeth and gums are not injured. Usually occurs as a result of impact on the maxillofacial area with a blunt object.

Bruise of the jaw after a blow to the lower parts of the face on the left side

The severity of the injury is largely influenced by the moment of impact. Severe consequences are observed with highly tense muscles. In this case, they rupture, forming an extensive hematoma with a pronounced pain reaction.

Main symptoms

Any disease has its own fundamental signs. Symptoms of a bruise of the lower jaw are usually quite striking. The main sign is sharp pain, abrasions, damage to the cheek or lip.

If the blow falls on the area of ​​the dental arch, then gaping wounds form on the soft tissues on the side of the oral cavity. The lower lip looks swollen, sagging and hyperemic.

To make a correct diagnosis, differential diagnosis is necessary. It is important to exclude fractures of the bone areas of the jaw, eye socket and nose.

After a strong blow, the victim should not be left unattended. It is imperative to monitor his general condition. Together with complaints and external examination, a preliminary diagnosis can be established.

In addition to local signs, general manifestations should also be taken into account:

• damage in the form of scratches and hyperemia in the jaw area;
• swelling in the lower part of the face;
• the presence or absence of hematoma of varying volume;
• malaise and swollen lymph nodes;
• sharp or constant pain even at rest;
• impairment in mouth opening, eating and speaking;
• increased pain response from touching the damaged area, as well as movement of the jaw to the left or right side.

Attention!!! The main differential diagnostic sign of a bruise from a fracture is that the jaw bones do not change their anatomical structure. In addition, the line of bone integrity violation can be determined by palpation.

If the injury is severe, the victim must in any case be taken to a doctor for examination to clarify the condition. It is important to carry out rapid transportation with preliminary first aid.

Introduction

Damage to soft tissues accompanies human life.
A bruise is a closed mechanical damage to soft tissues caused by short-term exposure to a damaging factor, which is not accompanied by the formation of wounds. When a bruise occurs, small vessels always rupture, followed by hemorrhage, the severity of which can vary. Damage to soft tissues, regardless of the cause that caused them, constitutes the majority of visits to primary health care institutions. Bruises usually occur when falling or hitting hard objects. In children of the first years of life, household and play injuries, bruises of the soft tissues of the face and neck predominate. At older ages, the main types of injuries are transport, sports, and street injuries [1]. Damage to superficial soft tissues is always accompanied by swelling of the injury site as a result of the skin being soaked in lymph, blood and local aseptic inflammation. The amount of swelling depends on the area of ​​damage to the subcutaneous tissue at the site of the injury. For example, in the area of ​​the cranial vault, due to the thin layer of subcutaneous fat, edema is insignificant, while even mild bruises of the face are accompanied by the development of pronounced edema [2]. Bleeding that continues deep into the tissue often leads to additional trauma to adjacent tissues as a result of their compression, which is accompanied by a gradual increase in pain and dysfunction. A bruise sometimes accompanies other injuries (fracture, etc.), so you should always exclude more complex injuries and evaluate the consequences of injuries [2, 3]. Soft tissue injuries are accompanied by pain of varying intensity. Thus, with bruises of large nerves and their endings, the pain is always sharp, shooting. With bruises of the torso and limbs (shoulder, thigh), tense hematomas can form, with bursting pain, sometimes with superficial numbness.

Treatment of soft tissue bruises is traditionally aimed at eliminating the above symptoms and excluding more severe pathology [4]. Currently, there are treatment standards - clinical guidelines for the provision of emergency medical care for soft tissue injuries, where a special place is given to the issues of immobilization, wound care and pain relief [5]. The administration of opioid and non-opioid analgesics is recommended in combination with antihistamines (metamizole sodium, trimeperidine, diphenhydramine). It is necessary to perform immobilization as soon as possible. Even with minor injuries, it is better to apply a tight bandage to the bruised area or immobilize with an orthosis. This will ensure peace of the bruised segment, normalize microcirculation, and reduce motor activity. Some orthotic products have a micromassage effect, which also has a beneficial effect on reparative processes. Along with this, analgesic therapy is carried out. These activities must be performed within the first 3 days. Then it is possible to use warming procedures and physiotherapeutic measures. Local therapy with ointments and gels can be used from the 1st day if they do not have a warming effect and do not increase vascular permeability.

Soft tissue bruises, and therefore pain, are inherently interconnected. Pain is a unique psychophysiological state of a person that occurs as a result of exposure to super-strong or destructive stimuli and causes functional or organic disorders in the body. Moreover, pain is subjective in nature, its perception is based on personal experience associated with damage in the early period of life. Its perception is determined not only by the source of pain, but also by such, at first glance, non-obvious factors as the psychophysical and emotional characteristics of the individual, his cultural level, family training and many others. Most often it is characterized as a psychophysical state of a person, which is a characteristic reaction to various organic and functional disorders caused by the action of various stimuli. Pain is both a physical sensation and an emotional reaction to it. Pain expert Margot McCaffrey's pithy definition is "anything that a patient says hurts them."

The functioning of the nociceptive system is mediated by neurochemical mechanisms realized by endogenous peptides and mediators, including histamine, substance P, kinins, prostaglandins, leukotrienes, potassium and hydrogen ions [4–6]. When pain occurs, the processes of hypercoagulation and lipid peroxidation are activated, the content of proteolytic enzymes increases, which causes tissue destruction. Pain contributes to the development of tissue hypoxia, degenerative processes and disruption of microcirculation in tissues. This, in turn, increases the alteration of injured tissues [7].

Thus, pain is a complex psychophysiological phenomenon, which, both from an ethical and legal standpoint, requires treatment aimed at relieving pain [8]. Understanding the complexity of its nature, mechanisms of development and regulation allows us to take a differentiated approach to the issue of choosing analgesic therapy.

One of the most effective means of protecting peripheral nociceptors that does not cause depression of vital functions are non-steroidal anti-inflammatory drugs (NSAIDs). The modern concept of effective pain relief for bruises and other types of injuries involves a multimodal approach - influencing various parts of the pain impulse. In this regard, it is advisable to combine the administration of NSAIDs with opiates or opioids for severe pain syndrome, for example, in case of shockogenic traumatic injuries.

Nonsteroidal anti-inflammatory drugs are the drugs of choice for the treatment of mild to moderate pain. Their anti-inflammatory effect is based on inhibition of cyclooxygenase (COX). One of the representatives of NSAIDs is ketoprofen, produced in various forms (tablets, injections, external ones). The triple effect - anti-inflammatory, analgesic and antipyretic - is due to blocking the enzymes COX-1 and COX-2 and, partially, lipoxygenase, which leads to suppression of the synthesis of prostaglandins (including in the central nervous system, most likely in the hypothalamus) and thromboxanes. Ketoprofen stabilizes in vitro

and
in vivo
liposomal membranes, at high concentrations
in vitro
suppresses the synthesis of bradykinin and leukotrienes. It does not have a negative effect on the condition of articular cartilage [9].

From the point of view of the ratio of anti-inflammatory and analgesic activity, ketoprofen seems to be the optimal molecule. Thus, according to an experimental study using a model of toothache, ketoprofen has the most pronounced anti-inflammatory effect compared to many NSAIDs, while the clinical effectiveness indicator (total reduction in pain after 4 hours) is the greatest for ketoprofen [10]. It is important to note that these experimental data were confirmed by data from a meta-analysis of 13 RCTs: with regard to the relief of moderate and severe pain, ketoprofen is significantly superior to diclofenac and ibuprofen [11].

Despite the fact that ketoprofen is a “traditional” non-selective NSAID, it is less capable of causing NSAID-associated gastrointestinal and cardiovascular complications - data from a Finnish population-based study assessing the causes of 9191 events in the upper gastrointestinal tract ( including cases of bleeding, ulcers and perforation). According to the results obtained, the likelihood of developing serious gastrointestinal complications when using ketoprofen was lower compared to other NSAIDs, such as diclofenac. Ketoprofen demonstrated a similar or even lower risk of developing gastrointestinal pathology than a number of selective NSAIDs [9–11]. The minimal negative effect of ketoprofen on the cardiovascular system has been demonstrated in a number of large-scale epidemiological studies.

In a study of the analgesic effect of ketoprofen in the acute period of injury in victims with various skeletal injuries, the onset of analgesic effect was noted within 12.2 ± 2.6 minutes after intramuscular application of 100 mg of ketoprofen. The use of 200 mg reduced the wait for the development of analgesia to 8.2±2.2 minutes. At the same time, in patients with severe musculoskeletal injury, ketonal was used at a dose of 200 mg in combination with intravenous tramadol (100 mg), and the analgesic effect was realized in 5.8 ± 0.9 minutes, which was faster compared to tramadol monotherapy at the same dosage (6.0±1.2 min) [12].

Purpose of the study:

determine the effectiveness of analgesic therapy for bruises of the upper and lower extremities.

Damage to the upper jaw

The nature of injury in this area is more complex. Its danger lies in the fact that serious complications may occur. It is quite easy to distinguish a bruise of the upper jaw from the lower one.

This is determined by the location of the pain and the consequences of trauma. However, it should be taken into account that unpleasant sensations can radiate to the lower part of the face. But the main difference here will be the absence of impaired mobility of the lower jaw.

The symptoms of a bruise of the upper bone tissues are very similar to the previous problem. There is an inflammatory process and pain, swelling, and sometimes enlargement of regional lymph nodes. Even if there are no obvious signs of bruises, you need to go to the clinic.

The photo shows fractures of the upper jaw with severe bruises

The doctor must first rule out a fracture. In the upper jaw, such injuries are dangerous for brain damage.

For example, a Le Fort 3 fracture is a separation of the bones of the skull and face. Without professional medical care, death can occur in this case.

First aid for a fracture of the zygomatic bone and its treatment

The zygomatic arches are a complex formed by the temporal and zygomatic processes. A fracture of the zygomatic bone is a common injury that can occur not only during a blow during a conflict, but also in a dangerous situation at work, at home, during an accident or at sports competitions. Such injuries are quite life-threatening due to the proximity of the brain and increased blood supply.

Types and characteristic symptoms of injury

According to its characteristics, a fracture of the zygomatic arch can be:

• open isolated with or without offset;
• closed with or without offset;
• combined fracture with or without displacement;
• combined fracture with damage to other facial bones and the maxillary sinus;
• traumatic defect of the zygomatic arch and bone with impaired mobility of the lower jaw and facial deformation.

Depending on the time elapsed after the injury, fractures are divided into fresh, which were received within the last 10 days, old - from 11 to 30 days, non-united and improperly fused - after 30 days. Signs of a fracture are as follows:

1. Pain in the middle third of the face, intensifying when opening the mouth.
2. Deformation of the facial bone due to tissue damage and displacement of fragments.
3. Nosebleeds due to violation of the integrity of the maxillary sinus.
4. Restricted mobility of the lower jaw.
5. Damage to the masticatory muscles, which manifests itself in the form of swelling of the zygomatic region, swelling, hemorrhages, and wounds.
6. Numbness in the area of ​​the wings of the nose, upper lip, infraorbital region.
7. Hemorrhage in the retina, blurred vision as a result of damage to the eyeball, double vision.
8. 2 days after the injury, Purtscher syndrome may occur, which is expressed in a sharp drop in vision, changes in the retina, its detachment, even atrophy of the optic nerve.

First aid

First aid provided immediately after an injury is quite important because it eliminates the risk of possible complications. It consists of applying cold to the damaged area, administering an anesthetic injection and transporting the victim to the emergency room in a side-lying position. If debris is visible from the wound, it cannot be reduced. A bandage should be applied and the patient taken to a medical facility.

In case of severe bleeding, it is necessary to clamp the artery, which is done by the victim himself. If the condition of the injured person does not allow this, then the person providing assistance fixes the lower jaw with a bandage, using a bandage or a piece of fabric. This fixation will prevent the debris from moving and reduce pain.

Treatment methods

At the medical center, the patient is given a preliminary palpation, then an x-ray is taken, which shows the degree of destruction of bone tissue and the possible consequences of the injury.

Consultation with an ophthalmologist is also recommended, since damage may affect the area of ​​the eye orbits.

Treatment methods for a zygomatic arch fracture can be conservative or surgical. For minor injuries to the facial bone or minor displacements, a conservative method is prescribed, the use of which involves rest and the use of anti-inflammatory drugs, which also have an analgesic effect. For severe pain, medications are administered intramuscularly. An ice pack is placed on the affected area. For the first 2 days, the cold is used 6 times a day for 20 minutes, on the 3rd day the patient is sent for physiotherapy.

Surgical treatment can be non-operative and operative. Non-operative, or bloodless, intervention is indicated for fresh, easily reduced fractures, when the surgeon reduces the zygomatic bone using the thumb or index finger. In another case, a special spatula or medical spatula wrapped in gauze is used, with the help of which the arch, zygomatic bone or its fragments are set. This option is most effective in the first 3 days after injury.

For old fractures (more than 10 days), surgical intervention is used when the zygomatic bone is reduced through an incision made behind the zygomatic-alveolar ridge. Using a strong short elevator advanced under the displaced bone, it is reduced to its original position. In severe cases, several operations are required to install a plate or a special fixator.

After reduction and fixation of the zygomatic bone, rest and restriction of solid food intake are ensured. Cold is applied to the affected area, anti-inflammatory drugs, neuroprotectors and a course of physiotherapy (electrophoresis, ultrasound, pulsed and magnetic therapy, UHF) are prescribed, which complement the treatment and relieve swelling.

Rehabilitation and recovery

For mild injuries, bed rest is not required. During the recovery period after a fracture, the diet includes chicken broth, yogurt, kefir, milk, and mashed potatoes. If there is difficulty opening the mouth, feeding through a tube is allowed. With surgery, rehabilitation is delayed. If a plate has been installed, then the adaptation of the surrounding tissues to the foreign material plays an important role.

In difficult cases, fixation lasts up to 12 days. The recovery period can last up to 1.5 months. After removing the retainer, the jaw must be developed. It is recommended to use chewing gum for this. Strengthens bones by taking calcium supplements.

Possible consequences

If you do not seek help in a timely manner and the necessary measures are not taken, the consequences of a fracture can be quite negative. With an old injury, deformation of the facial bones of the skull occurs and a stable asymmetry of the face is formed, which reduces the aesthetic appearance of the injured person. Left untreated, it can lead to an infection in the sinuses. Maxillary sinusitis often occurs, which is poorly treated and leads to gradual resorption of bone tissue.

The most dangerous consequence of a fracture of the zygomatic orbit may be Purcher's syndrome, which affects the eyes, which threatens complete loss of vision and lifelong disability. Therefore, after a head injury, it is important to consult a surgeon as soon as possible to exclude the possibility of deep damage to the bone tissue.

It is also worth visiting a doctor if, after some time after the fracture, the pain in the cheekbone area does not go away.

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Diagnostic measures

If minor injuries to the maxillofacial area occur, they do not require contact with a dentist or surgeon, or urgent hospitalization. If there is severe and prolonged pain, the area of ​​damage should be examined by a specialist.

The following are used as diagnostics:

• taking anamnesis;
• general examination by a surgeon, orthopedic dentist, traumatologist;
• special examination by an otolaryngologist, neurologist and other specialized specialists as necessary;
• X-ray examination of the maxillofacial area;
• CT scan;
• analysis of blood, urine, saliva.

Based on the data obtained, a general picture of the victim’s health is formed and a specific treatment is recommended.

The main therapeutic direction will be the following:

• taking painkillers;
• applying a pressure bandage;
• ensuring maximum peace for the victim;
• prescription of physiotherapeutic procedures;
• local and general anesthesia;
• elimination of hematoma and infiltrate.

Diagnostic methods

To determine a fracture of the zygomatic bone, methods such as visual inspection and palpation are used. In difficult cases, an X-ray examination is prescribed to clarify the severity of the damage, as well as determine the optimal recovery tactics. The resulting image reflects a violation of tissue integrity, as well as a likely decrease in the transparency of the axillary areas and the continuity of the outer radius of the orbit near the affected area.

Features of treatment

The treatment plan is determined by the symptoms of the pathology, the results obtained during the X-ray examination, as well as the assessment based on the results of the medical examination. The priority task is to restore the intact bone structure. In situations where the anomaly is characterized by a displacement of the cheekbone, surgical intervention is prescribed, the purpose of which is to correct the position of the separated elements.

If the injury is not associated with displacement, it is possible to limit oneself to conservative therapy, which involves taking medications selected based on the indications of the clinical picture. The agents used include anti-inflammatory, analgesic, antibacterial substances, and neuroprotectors. In situations where there is a possibility of contact between the wound and a dirty surface, administration of tetanus serum is also recommended. Standard conservative treatment tactics include:

• Ensuring a calm state for a period of 10-14 days, with partial fixation of the jaw;
• Use of low-temperature compresses in the first 48 hours;
• Eating liquid foods and prescribing physiotherapeutic procedures.

In case of severe pain, analgesics are also prescribed. In the future, magnetic therapy, electrophoresis and UHF, as well as other procedural measures, can be used to relieve swelling and pain.

Surgical intervention involves the use of one of the author’s techniques, which include the Keene, Duchant, Dubov and Limberg protocols. Within each operation, the preparatory stage is important, during which the risk to the patient’s health is assessed, the appropriate type of anesthesia is determined, and an action plan is drawn up. The rehabilitation period involves the use of painkillers and antibiotics, as well as a course of physical therapy.

First aid and treatment of bruises

Ice pack on problem area

Once the location of the damage has been identified, it is necessary to begin simple manipulations. Of course, they will depend on the nature of the damage. If there are open wounds, first of all they must be washed and treated with antiseptic.

Suitable products for this include hydrogen peroxide, Chlorhexidine, Miramistin, Bepanten. Before applying the antiseptic, the wound can be washed with soapy water. The bleeding area must be covered with a clean cloth or, if available, a sterile bandage.

Then apply cold to the affected area through the cloth. This can be an ice pack or a regular towel soaked in cold water, which is applied through a waterproof film.

Elements of treatment and means used

Immediately after injury, first aid must be provided. Usually, all bruises of the upper and lower jaw can be treated quite well without medical intervention. However, in case of severe lesions, it is still worth contacting specialists for examination.

Table No. 1. Painkillers:

Name of the drug Active substance Additional action Directions for use

Ketonal

Ketoprofen. Anti-inflammatory and decongestant. Apply a thin layer to the skin 2-3 times a day.

Fastum gel

Ketoprofen. Anti-inflammatory, improves blood circulation. Rub in the gel until completely dry 2 times a day.

Dolgit

Ibuprofen. Relieves swelling and inflammation. Apply with gentle massage movements, 3 times a day, up to 3 weeks.

Finalgon

Nonivamide, Nicoboxil. Improves blood circulation, recommended on the 3rd day after injury. After application, it is recommended to cover the affected area with a warm cloth.

Indomethacin

Indomethacin. Anti-inflammatory. Children apply no more than 1 cm of gel, adults no more than 15 cm, 2 times a day.

First of all, cold is applied to the lesion. Low temperatures will help not only relieve swelling and stop bruising, but also provide partial pain relief.

For the most effective elimination of unpleasant sensations, it is necessary to take analgesics internally or apply special ointments externally. Modern drugs are available in the form of gels. They are easy to use, absorb quickly and do not stain clothes.

It is good to use products that contain Heparin. It helps to quickly get rid of infiltration and eliminate the phenomenon of swelling. Heparin-based drugs should not be used by persons with bleeding disorders.

If the gel contains horse chestnut extract, it is contraindicated for people suffering from kidney disease and pregnant women. To prevent side effects from using the gel or ointment, the attached instructions should be studied in any case.

Table No. 2. Coolants:

Name of the drug Active substance Additional action Directions for use

Ben-Gay

Menthol, methyl salicylate. Painkillers, anti-inflammatory Apply in large quantities 3-4 times a day.

Flexall

Aloe vera extract, menthol, camphor, vitamin E. Quickly relieves pain and has an anti-inflammatory effect. Apply in a thin layer without rubbing.

Bystrum gel

Ketoprofen, Trometamol, essential oils. Decongestant and painkillers. Rub in with smooth movements until completely dry.

Reparil gel

Escin, salicylic acid. Decongestant, anticonvulsant, painkillers. Apply with light massage movements, 3-4 times a day, no more than 14 days.

The price of medications in the form of gels and ointments ranges from 220 rubles to 350 rubles. One package is completely enough for a course of treatment.

It is difficult to predict when a particular injury will occur. To reduce the risk of bruises and other injuries, precautions should be taken. In winter, move carefully on slippery sidewalks; in summer, when engaging in active sports, think through the possible consequences.

Folk remedies

There are several proven, simple and at the same time effective ways to have the positive effects of alternative medicine. They are indispensable products for pregnant women, children, as well as people who have a severe allergic reaction to medications. You can make a choice based on personal preferences or doctor’s recommendations.

Treatment at home for bruises can be carried out using the following means:

• Table salt solution. Compresses are prepared from it, which are used for any complexity of bruises. To prepare, a tablespoon of salt is dissolved in 150 ml of boiled water. Then take a sterile bandage, soak it in the solution and apply it to the problem area. The compress is covered with a thick cloth on top. The gauze pad with salt can be left overnight.
• Grated potatoes. The tubers should be washed and cleaned first. Grate one tuber on a coarse grater, place in linen cloth and wrap several times. After applying the bruise, cover the top with a thick towel. Compressor exposure time is 30-40 minutes. For best results, make 3-4 applications in a row.
• Cabbage leaf. Before applying it, you should knead it a little or make cuts on it to let the juice out. The sheet is applied to the sore spot 2-4 times a day until it dries completely.
• Onion and garlic. The two ingredients are ground and mixed together. The resulting slurry is added with half a tablespoon of salt; it is recommended to wrap the mixture in gauze and place it in the area of ​​the bruise.
• Beetroot and liquid honey. Finely grated root vegetables are mixed with a tablespoon of natural honey. The procedure is carried out 1-2 times a day for 2 hours.
• Laundry soap. This remedy helps reduce the pain response. The soap is grated and mixed with raw chicken yolk. I apply a compress every half hour up to 6-8 times a day. You can also rub a damp cloth with laundry soap and apply an application to the bruised area.
• Apple vinegar. This is one of the most effective remedies. To prepare the solution, you need to take 2 teaspoons of vinegar and dilute it in 1 liter. water. Soak a clean cloth in the solution and apply 3-4 times a day for half an hour.

Popular folk remedies for bruises

The video in this article shows how to properly apply a warm and cold compress for bruises.