Неогнестрельные переломы
нижней челюсти
Non-firearm fracture of
mandible
BY: YONG HUI LIN, GROUP 17, 5 TH COURSE DENTISTRY
Statistics of injuries of the
maxillofacial region
OCCUPATIONAL/ INDUSTRIAL INJURY (ПРОИЗВОДСТВЕННАЯ ТРАВМА): damages related to
the performance of their labor production duties in industry or in agriculture.
◦ industrial 4.5% - 12.4%
◦ agricultural 1.2%.
NON-OCCUPATIONAL/ INDUSTRIAL INJURY:
◦
◦
◦
◦
household injury 22.5% - 92.1%
transport injury 2.3% - 18.2%
street injury 5.1% - 7.0%
sports 3.5% - 4.3%.
According to Yu.I.Vernadsky, fractures of
the lower jaw occur
1) in area of mandible angle, в области ее углов в (57-65%);
2) in area of condylar process, в области мыщелковых отростков в (21-24%);
3) in area of premolars and canine, в области малых коренных зубов и клыков в (16-18%);
4) in area of molarsв области, больших коренных зубов в (14-15%);
5) most rarely in incisors ,наиболее редко в области резцов
General characteristics of fractures
of the lower jaw
o Fractures of the bones of the maxillofacial region account for about 3% of the number of
injuries to the bones of the human skeleton
o Fractures of the mandible occur from 60% to 90% of the total number of injuries to the bones
of the facial skeleton
oAccording to T.M. Lurie, the largest number of fractures of the mandible occurs between the
ages of 17 and 40 (76%), and in childhood - up to 15%.
o About 80% of mandibular fractures occur within the dentition and are open, i.e. infected.
oFractures of the lower jaw are more often localized in the area of the angle and chin, but can
occur in any part of it.
oBoth unilateral and bilateral fractures of the mandible are almost equally common
(44% - unilateral, 49% - bilateral).
Classification of injuries of the
maxillofacial region
Depending on the time of injury, fractures of the lower jaw are:
- fresh, свежие (up to 10 days)
- old, застарелые (from 11 to 20 days)
- incorrectly fused, неправильно сросшиеся (more than 20 days).
By localization:
A.
Fractures of the jaw body (open, i.e. within the dentition):
i.
ii.
presence of a tooth in the fracture gap
absence of a tooth in the fracture gap.
◦
◦
◦
◦
B.
median (in the area of incisors); срединные
mental (in the area of the canine and premolar); ментальные
in the area of molars; в области моляров
in the area of the angle of the jaw (open and closed) ; в области угла челюсти
fractures in the area mandible ramus (closed):
i.
ii.
iii.
The condyle process (- base; - necks; - heads); мыщелкового отростка
The coronal process; венечного отростка
The ramus themselves (longitudinal or transverse). собственно ветви
C.
Unilateral , bilateral
D.
Single, double, multiple
By the nature of the fracture
A.
complete
Incomplete (subperiosteal);
By the nature of the fracture
B.
- without displacement of fragments; - with displacement of fragments
C.
- linear; - comminuted; - combined;
D. - isolated;- combined (with craniocerebral injuries, soft tissue injury, damage to other bones)
Depending on the direction of the
fracture gap
A.
On the jaw body
a.
b.
c.
B.
the fracture gap runs perpendicular to the longitudinal or horizontal axis of the jaw body;
the fracture gap passes at an acute angle (oblique line) to the longitudinal or horizontal axis of the jaw
body
the fracture gap runs parallel to the horizontal axis (transverse) of the jaw body (located in the area of
the branch proper, condyle and coronal processes of the lower jaw);
On compact bone of jaw
a. the fracture line runs symmetrically on the outer and inner compact jaw plates
b. the fracture line runs asymmetrically on the outer and inner compact jaw plates
C.
Association with presence of tooth
a.
b.
with the presence of a tooth in the fracture gap (the entire root of the toothor its cervical or apical part is
located in the fracture gap);
- in the absence of a tooth in the fracture gap
Classification according to
ICD-10
•:S02.60 Fracture of the lower jaw (closed)
• S02.61 Fracture of the lower jaw (open).
•A open fracture is located within the dentition,
which is explained by the peculiarities of
attachment of the oral mucosa to the bone tissue
of the lower jaw.
•A closed fracture is located outside the dentition,
may be in the area of the angle or branch of the
lower jaw
Type of fracture
• Fracture is a partial or complete violation of the continuity (integrity) of the bone. Перелом - это
частич ное ил и полное нарушение непрерывности (целости) кости.
•Traumatic fracture (травматический перелом) of the lower jaw occurs due to the impact of a
force on it that exceeds the plastic capabilities of the bone tissue.
•Pathological fracture (патологический перелом): If the jaw breaks under the influence of an
effort not exceeding physiological.
•Direct fracture (прямой) occurs at the point of application of force,
•Indirect/ reflected fracture: (непрямой или отражённый) fracture occurred if at some
distance from the place of impact.
The mechanism of fractures in area of
mandible
o There are four mechanisms of fracture of the lower jaw: inflection,
shift, compression, separation. (перегиб, сдвиг, сжатие, отрыв.)
o As a result of the force, the jaw breaks in its "weak" places
o The displacement of the fragments of the lower jaw occurs under
the action of the applied force,the gravity of the fragments and
under the influence of the traction of the muscles attached to the
broken fragments.
o The effect of muscle traction is manifested in complete fractures of
the lower jaw. There is no displacement of fragments in subperiosteal fractures.
o The movement of the jaw is carried out due to the influence of two
groups of muscles: elevator (posterior group) and depressor
(anterior group) muscles the lower jaw.
Elevators muscles (lifting the lower jaw)
Задняя группа мышц (поднимающих нижнюю челюсть)
1.
M. Masseter : With its bilateral contraction, the mouth is closed.
2.
M. Temporalis : With the contraction of the temporal muscle, the lower jaw rises
upwards and shifts slightly posteriorly.
3.
M. pterygoideus medialis : With a bilateral contraction of these muscles , the lower
jaw shifts upwards and extends-moving forward. With unilateral - the jaw shifts in
the direction opposite to the contracting muscle.
4.
M. pterygoideus lateralis : With simultaneous contraction of both muscles, the
extension occurs lower jaw forward. If only one muscle contracts, then the lower jaw
shifts sideways, i.e. in the direction opposite to the contracting muscle.
Depressor muscles (lowering the lower jaw)
Передняя группа мышц (опускающих нижнюю челюсть)
1. M. mylohyoideus
2. M. digastricus
3. M. geniohyoideus
4. M. genioglossus
 shifts the lower jaw downwards and posteriorly.
1.
Displacement of the lower jaw upwards (closing of the jaws): temporal, masseter, medial
pterygoid muscles.
2.
Lowering of the lower jaw: digastric, geniohyoideus, mylohyoideus muscles.
3.
Displacement of the lower jaw forward: lateral pterygoid, medial pterygoid (with bilateral
contraction), masseter (superficial layer).
4.
Displacement of the lower jaw backward, previously extended anteriorly: temporal
(posterior bundles), digastric and geniohyoid muscles.
5.
Displacement of the lower jaw to the left: the right lateral and medial pterygoid muscles, the
left temporal, digastric, mylohyoid and geniohyoid muscles.
6.
Displacement of the lower jaw to the right: the left lateral and medial pterygoid muscles, the
right temporal, digastric, mylohyoid and geniohyoid muscles.
The mechanism of fractures in area of
mandible
• Diagram of the mechanisms of fractures of the lower jaw (according
to Wassmund):
A - a direct fracture due to an inflection in the area of the lower jaw
body
B - a double indirect fracture due to an inflection in the area of the
lower jaw body and condyle
C - an indirect fracture due to an inflection in the chin area
D - a bilateral fracture of the lower jaw due to an inflection in the area
of the angle on the left (straight) and chin on the right (indirect)
E - bilateral indirect fracture of the mandible in the region of the
condylar processes
1- fracture of the lower jaw branch due to shift (сдвиг)
2 - fracture of the ramus due to compression (сжатие)
3 - fracture of the coronal process due to separation (отрыв)
The mechanism of the shift (сдвиг)
o As a result of the shift, a longitudinal fracture of the lower jaw branch occurs. In this case, the
impact force is applied from the bottom up in the area of the base of the lower jaw, anteriorly
from the angle on a narrow section in the projection of the coronal process, i.e. on a section of
bone that has no support.
oThis section of the fracture is shifted relative to another section of this bone, which has a
support.
The mechanism of compression (сжатие)
o The compression mechanism can manifest itself if the acting and opposing forces are directed
towards each other.
oWhen force is struck from the bottom up along the base of the lower jaw body in the area of an
angle on a wide area, the ramus of the lower jaw fixed in the articular cavity is compressed, as a
result of which it breaks in the transverse direction - more often in the middle section.
The mechanism of separation (отрыв)
o When the force of impact is directed from top to bottom on the chin area and at the same time
the teeth are tightly compressed.
oIn this case, there is a reflex contraction of all the masticatory muscles.
oA powerful temporal muscle, being attached to a thin coronal process, can tear it off from the
branch of the jaw.
oNot all authors recognize the reality of the implementation of such a mechanism of fracture of
the coronal process.
Diagnosis
1.
Anamnesis
2.
Complaint
3.
Examination
4.
Palpation
o In order to clarify the localization and nature of the fracture, the degree of displacement of the fragments, the direction
of the fracture line, the nature of the relationship of the tooth with the fracture gap, it is necessary to conduct
radiography of the lower jaw in the overview (frontal-nasal laying) and lateral(each half of the jaw) projections.
i.
Orthopantomography of the mandible in at least 2 different projection
ii.
Intraoral X-ray (in case of fracture in area of mental)
iii.
Tomography (to clarify the direction anddegree of displacement of the small fragment, it is necessary to do a layered
examination of the temporomandibular joint)
Clinical symptoms of non-firearm
fractures of the lower jaw.
o Complaints: usually diverse and depend on the location of the
fracture and its nature.
• swelling in the parotid tissues
• pain in the lower jaw, which increases when opening and closing the mouth,
incorrect closing of teeth and especially with the load on the jaw (chewing,
biting), sometime impossible to eat or drink.
• bleeding from the oral cavity and malocclusion(closing of antagonist teeth).
• The sensitivity of the skin of the lower lip and chin may be impaired,
numbness of skin in chin and lower lip.
• Difficulty in breathing, swallowing
• In the presence of a concussion, there may be dizziness, headache, nausea
and vomiting.
Examination of patients
External inspection
o Presence of facial asymmetry on the damaged side (due to edema, hematoma, infiltration, etc.)
o Integrity of the external skin (bruises, abrasions, wounds)
o hyperemia, hemorrhages in the thickness of the skin – bruises
o Determine/clarify with the victim for the time of the swelling appearance or discoloration of
the skin.
o With a fracture, the amplitude of movements(vertical and lateral) of the lower jaw is limited.
o When opening the mouth, the chin may shift towards the fracture.
Palpation
Pain in palpation, swelling
Examination of patients
Internal inspection
o Incorrect closure of the teeth of the upper and lower jaws (malocclusion)
o change in the bite depends on the localization of the fracture site (unilateral or bilateral; single,
double or multiple, etc.), its nature (without displacement or with displacement of fragments,
complete or subperiosteal, etc.).
Clinical and diagnostic algorithm with
fracture of lower jaw
1. External and intraoral examination
2. Palpation of ramus and lower edge of jaw
3. Pressure on chin when half-open of mouth
4. Compression of angle of mandible
5. Breaking movement on middle line
6. Breaking movement in area of angle
Fracture of the lower jaw body
o Special diagnostic sign is the formation of a hematoma not only in the vestibule of the mouth,
but also on the lingual side of the alveolar part.
o In case of soft tissue injury, itis determined only from the vestibular side.
o Sometimes a laceration of the mucous membrane of the alveolar part is found in the oral
cavity, which spreads into the interdental space, where it passes fracture gap.
oAn absolutely reliable sign of a fracture it is a symptom of the mobility of the jaw fragments.
1.
The doctor fixes the fingers of both hands in the area of the mandible base and side of the
teeth at area of the presumed fracture fragments.
2.
Then carefully makes the fragments shake "on a break“«на излом»,while there is a
violation of the integrity of the dental arch due to the displacement of the fragments.
Врач фиксирует предполагаемые отломки пальцами обеих рук в области основания
челюсти и со стороны зубов. Далее осторожно производит покачивание отломков «на
излом», при этом происходит нарушение целостности зубной дуги вследствие смещения
отломков.
oDetermination of pathological mobility of the mandible in case of its fracture:
a, b) in the mental department; c) in the mandible angle
oОпределение патологической подвижности нижней челюсти при ее переломе:
а,б) в ментальном отделе; в) в области угла.
Fracture of the lateral part of the lower
jaw body
o Occur more often in the area of impact, i.e. direct fracture.
oThe mouth is slightly open, the chin is slightly shifted from the midline towards the fracture.
oIn the lower part of the buccal and submandibular areas on the side of the fracture, swelling is
determined due to post-traumatic edema, or inflammatory infiltration, which depends on the
virulence of the microflora and immune status.
oMay present of bruise on the skin in this area (a manifestation of a hematoma), or it is
hyperemic due to developing purulent inflammation.
oWhen palpating the base of the lower jaw body, a bony protrusion is determined in the
projection of the premolars or canine, less often - the first or second molars.
oOpening the mouth in full is difficult due to the increasing soreness due to the displacement of
fragments.
oAt the same time, the chin may deviate towards the fracture
Fracture in the area of the angle of the
lower jaw
o Complaints of patients with a fracture of the mandible in the angle area do not differ
significantly from those in localization of the fracture in the lateral part of the jaw body.
oAs palpation of bone protrusion is not possible to carry out since it can be masked by a muscletendon sheathof the masticatory muscle.
oSo, should pay special attention to the definition of the most painful point, in this case, at the
base of the jaw body in the angle area
Treatment of patients with
fractures of the lower jaw
The purpose of treatment is to create optimal conditions for the fusion of fragments in the
correct position in the shortest possible time, ensuring full restoration of the function of the
lower jaw
Main stages
1.
To reposition and fix the fragments of the jaw for the period of consolidation of fragments
(removal of the tooth from the fracture line and primary surgical treatment of the wound
2.
To create the most favorable conditions for reparative regeneration in the bone tissue in the
fracture zone
3.
To prevent purulent inflammatory complications in the bone tissue of the lower jaw and
surrounding soft tissues
Methods of fracture treatment
I.
Orthopedic methods (conservative):
i.
◦
◦
ii.
◦
◦
Temporary (transport) methods
extra-oral (parietal chin bandage,standard transport
bandage, etc)
intra-oral (interdigital ligature fastening (Межчелюстная
фиксация
Therapeutic (permanent) methods of immobilization
surgical, extra-laboratory (standard and individual bent
wire) splints
orthopedic (dental, supra-gingival) splints, devices, etc. of
laboratory manufacture. (шины Порта, Вебера,
Ванкевич и др., капповые аппараты)
II.
Operative methods (osteosynthesis):
i.
ii.
iii.
iv.
v.
vi.
Trans-focal osteosynthesis (Чрезочаговый
остеосинтез
Bone osteosynthesis (Накостный
остеосинтез )
Intraosseous osteosynthesis (Внутрикостный
остеосинтез
Transosseous osteosynthesis (Чрескостный
остеосинтез
Extra-focal osteosynthesis (Внеочаговый
остеосинтез
Fixing compression – distraction devices
(Фиксирующие компрессионно –
дистракционные
III. Surgical and orthopedic method of Black
Primary surgical treatment of the fracture line
Первичная хирургическая обработка линии перелома
Bimaxillary splinting with intergnathic
extension (бимаксилярное шинирование с
межчелюстным вытяжением):
Clinical assessment of the tooth condition:
1. Local anesthesia
2. Ruptures of the mucous membrane and
gums
1. Mobility
2. Antiseptic treatment of fracture gap and oral
3. Fractures of the walls of the alveoli
cavity
3. Decide the fate of the tooth in the fracture 4. Degree of exposure of root cement
gap.
Targeted radiography of the tooth
Electric pulp test in dynamics
Teeth located in the fracture line
Indications for the removal of teeth from the fracture line
I.
Teeth that is ineffective to treat in conservative treatment and support inflammatory
phenomena
II.
Broken roots and teeth or teeth completely dislocated from the teeth socket with periapical
chronic inflammatory foci
III.
Teeth with marginal periodontitis of moderate severity
IV. If the exposed root is in the fracture gap or the impacted tooth interferes with the
reposition of bone fragments lower jaw
The edges of the socket are suture together with polyfilament suture and suture the socket
tightly can reduce the likelihood of infection and the development of purulent inflammatory
complications, so the fracture is transferred from open to closed.
Temporary immobilization of fragments
It is carried out at the scene of an accident, in an ambulance, in any non-specialized medical
institution by secondary medical workers or doctors (средними медицинскими работниками или
врачами), and can also be performed as a mutual aid
The main purpose of temporary immobilization is to press the lower jaw to the upper one with the
help of various bandages or devices
Types of temporary immobilization of fragments of the lower jaw
1.
круговая бинтовая теменно-подбородочная повязка (circular bandage parietal chin bandage)
2.
стандартная транспортная повязка (состоит из жесткой шины- пращи Энтина) standard
transport bandage (consists of a rigid splint- sling Entina
3.
мягкая подбородочная праща Померанцевой Урбанской
4.
межчелюстное лигатурное связывание зубов проволочными лигатурами (interjaw ligature
binding of teeth with wire ligatures)
круговая бинтовая теменноподбородочная повязка (circular bandage
parietal chin bandage)
стандартная транспортная повязка (состоит
из жесткой шины- пращи Энтина)
праща Померанцевой Урбанской
Межчелюстное лигатурное связывание
зубов проволокой,наложение лигатуры и
межчелюстное связывание
Reposition and permanent immobilization of
fragments of the lower jaw
1.
The reposition of bone fragments of the lower jaw is carried out bimanually under adequate
anesthesia
2.
The criterion for correct reposition is the restoration of the bite
3.
If the displacement of fragments persists on control radiographs and there are indications for
osteosynthesis, the final reposition of bone fragments is carried out by an open method during surgery
4.
Conservative (orthopaedic) and surgical methods are used to immobilize fragments of the mandible.
5.
Application of a repositioning pad in the molar area on the fracture side in fractures of the articular
process with displacement or on the distal fragment shifting upwards
6.
Most often for permanent fixation of fragments of the mandible with its fracture , dental wire splints
are used(conservative immobilization method)
Smooth splint brace (Гладкая шина
скоба) is used for:
1.
linear fractures of the lower jaw located within the dentition (from the central incisors to the
premolars)
2.
with fractures of the alveolar process of the upper and lower jaws (there should beat least 3
stable teeth on each side of the intact jaw)
3.
with fractures and dislocations of teeth
Splint with a spacer bend
(Шинa с распорочным изгибом)
It is made and used in the same cases as a smooth splint brace:
1.
in the absence of one or more teeth at the fracture site
2.
if there is a defect in the bone tissue
 The spacer bend is always located only in the area of the jaw
fracture
 The edges of the spacer bend rest against adjacent teeth (in order
to avoid displacement of fragments) and its depth should
correspond to the width of the lateral surface of the tooth located
along the edge of the defect.
Spacer bend
(Распорочный изгиб)
Splint with hook loops
(Шина с зацепными петлями)
i.
It is applied to both jaws and made for fractures of the lower jaw in area of frontal dentition
or behind it, both with and without displacement of fragments.
ii.
5-6 hooks (loops) are made on each aluminum tire, which are located in the area of even
teeth (second, fourth and sixth). The length of the loops is about 3-4 mm and they are at an
angle of 35-40 ° to the axis of the tooth.
iii. Rubber rings are put on the hook loops (they are cut
from a rubber tube with a diameter of about 8 mm).
iv. It is necessary to tighten the ligature wires every 2-3
days, and also (or as needed) it is required to change
the rubber traction every 5-6 days.
Disadvantages of splint with hook loops
(Недостатки Шины с зацепными петлями)
A.
injury to the mucous membrane of the lips
and cheeks with hooked hooks (loops)
B.
Due to the oxidation of tires and clogging
them with food residues, difficulties arise
with the hygienic content of the oral cavity
C.
the need for individual preparation
D.
with a deep bite, they interfere with the
correct closure of the dentition
E.
Availability additional retention points
F.
eruption of soft tissues by ligatures
G.
the appearance of galvanic currents, etc.
A. травмирование слизистой оболочки губ и
щек зацепными крючками (петлями)
B. вследствие окисления шин и засорения их
остатками пищи возникают сложности с
гигиеническим содержанием полости рта
C. необходимость индивидуального
изготовления
D. при глубоком прикусе мешают
правильному смыканию зубных рядов
E. Наличие дополнительных ретенционных
пунктов
F. прорезывание мягких тканей лигатурам
G. появление гальванических токов и др.
Стандартные назубные ленточные
шины
i.
Standard stainless steel splint with ready-made hook i.
loops were proposed by B.C. Vasiliev in 1967
ii.
Tire thickness : 0.38-0.5 mm.
iii.
The fixation of the splints to the teeth is carried out ii.
with a ligature wire previously described by the iii.
method.
iv.
Standard teeth splint band are devoid of some of the iv.
previously listed disadvantages and are widely used.
v.
Indications for the use of tape tires are the same as for v.
wire tires.
Стандартные назубные ленточные шины из
нержавеющей стали с готовыми зацепными
петлями были предложены B.C. Васильевым в
1967 г.
Толщина шин 0,38-0,5 мм.
Фиксация шин к зубам проводится лигатурной
проволокой ранее описанным способом.
Стандартные назубные ленточные шины лишены
некоторых ранее перечисленных недостатков и
находят широкое применение.
Показания к использованию ленточных шин такие
же как к проволочным.
В.Т. Долгих (2000) выделяет три основных вида патологического
воздействия металлических включений, находящихся в полости рта
на окружающие ткани и на организм в целом:
1. Электрогальваническое - образование гальванических микротоков в результате разности
потенциалов металлов (сплавов), находящихся в полости рта;
2. Токсико-химическое - вызванные гальваническими токами химические процессы, происходящие в
полости рта, разрушают сплавы металлов (наблюдается коррозия металлов);
3. Аллергическое - образующие продукты коррозии сплавов металлов способны сенсибилизировать
организм, вызывая различные аллергические реакции.
1. Electro-galvanic - the formation of galvanic microcurrents as a result of the potential difference of metals
(alloys) located in the oral cavity
2. Toxic-chemical - chemical processes caused by galvanic currents occurring in the oral cavity destroy metal
alloys (metal corrosion is observed)
3. Allergic - forming corrosion products of metal alloys can sensitize the body, causing various allergic
reactions.
Splints made of fast-hardening plastic
Зубодесневые и надесневые шины
шина Вебера
шина Порта
шина Ванкевич.
• In case of insufficient number of teeth on the lower jaw or their absence, dental and supra-gingival splints are
made (in laboratory conditions).
Indication and Contraindication
Indications for use:
fractures in the body area and ramus of the lower jaw with displacement of fragments and
without displacement of fragments.
Contraindications:
• fracture of the condylar process of the lower jaw
• comminuted fractures
шина Вебера
Weber’s Splint
o It is most often used among them.
o The plastic splint covers the teeth, tightly adheres to the gingival edge
o Indications for its use: Treatment of patients with fractures of the lower jaw of the alveolar
process that fractures occurring within the dentition and there are several stable teeth on each
fragment of the jaw.
шина Порта
Port’s splint
o The Port’s splint (supragingival splint) is used for fracture of the lower jaw in patients with
toothless jaws.
o It consists of base plates on the alveolar process of the upper and lower jaws, which are
fastened into a single block, and in the anterior part of this splint there is a hole for eating.
o It is necessary to apply a parietal - chin bandage or a standard chin sling and a head cap for
using the Port splint to firmly fix the fragments of the lower jaw.
Surgical treatment of fractures of the lower jaw
Хирургическое лечение переломов нижней
челюсти
1. Bone suture
1. Костный шов
2. Kirschner’s splint
2. спицы Киршнера
3. Titanium mini plate
3. минипластина
4. Extra-oral equipment
4. внеоротовая аппарат
5. compression-distraction
5. компрессионнодистракционные аппараты
devices
Хирургическое лечение переломов
нижней челюсти
Osteosynthesis (Остеосинтез) is a surgical method of joining bone fragments and eliminating their
mobility with the help of fixing devices.
Indications for osteosynthesis
1.
insufficient number of teeth for splints or absence of teeth on the lower and upper jaws
2.
the presence of movable teeth in patients with periodontal diseases that prevent the use of a
conservative method of treatment
3.
fractures of the mandible in the neck of the condylar process with an irreparable fracture, with
dislocation or subluxation (incomplete dislocation) of the jaw head
4.
interposition - insertion of tissues (muscles, tendons, bone fragments) between fragments of a
broken jaw, preventing the reposition and consolidation of fragments
5.
comminuted fractures of the lower jaw, if the bone fragment cannot be matched to the correct
position
6.
Disparate (несопоставляемые), as a result of displacement, bone fragments of the lower jaw.
Костный шов
Для костного шва применялась проволока из
нержавеющей стали, а в последние годы —нихром,
тантал, титан и другие материалы.
В зависимости от локализации и характера перелома
костный шов используется в разных модификациях:
восьмеркообразный, петлеобразный, крестообразный,
двойной, трапециевидный (возможно их сочетание).
Для его наложения применяют как внеротовой, так и
внутриротовой разрез. Рекомендуется при наложении
шва на кость соблюдать следующие условия:
1) отверстия для проведения шовного материала нужно
делать не ближе 1 см от линии перелома;
2) желательно, чтобы шов пересекал щель перелома
посередине между краем нижней челюсти и основанием
альвеолярного отростка;
3) отверстия для проведения костного шва следует делать
в зонах, исключающих повреждение нижнечелюстного
канала и корней зубов.
Bone suture
•
Stainless steel wire was used for the bone suture, and in
recent years — nichrome, tantalum, titanium and other
materials.
• Depending on the localization and nature of the fracture,
the bone suture is used in different modifications: octal,
loop-shaped, cruciform, double, trapezoidal (a
combination of them is possible).
• For its application, both an extraoral and intraoral
incision are used. It is recommended to observe the
following conditions when applying a suture to the bone:
1) holes for suture material should be made no closer than
1 cm from the fracture line;
2) it is desirable that the suture crosses the fracture gap in
the middle between the edge of the lower jaw and the
base of the alveolar process;
3) holes for bone suture should be made in areas that
exclude damage to the mandibular canal and the roots
of the teeth.
Различные модификации костного шва,
используемые для
соединения отломков нижней челюсти.
Рентгенограммы больных.
Various modifications of the bone suture
used to
connect the fragments of the lower jaw.
Radiographs of patients.
Варианты иммобилизации отломков
нижней челюсти с помощью костного шва
(схема)
Внутрикостное введение металлических
спиц (спицы Киршнера, Илизарова , гвозди
Богданова)
Техника операции при чрезкожном остеосинтезе заключается в следующем: мануально
сопоставляются отломки, и ассистент удерживает их в правильном положении.
Выбирается направление спицы, которой прокалываются мягкие ткани до упора с костью.
Можно вводить спицу как из медиального фрагмента в дистальный, так и наоборот. Важно,
чтобы спица вошла не менее чем на 2 см в каждый фрагмент. После того, как спица
уперлась в кость, включается реостат бормашины. Вращаясь спица проходит через костную
ткань.
Момент прохождения спицы через щель перелома ощущается, как «провал», после чего
спица входит в другой фрагмент. Затем бормашину выключают, со спицы снимают
фиксирующие устройства. Конец спицы скусывают и ее остаток погружают под кожу. Для
большей стабильности и исключения ротации можно вводить две спицы.
Послеоперационное лечение проводится по общепринятой схеме. Спицы удаляют через
1,5–2 месяца в амбулаторных условиях через небольшой прокол кожи.
Рентгенограммы нижней
челюсти больных с
переломами, которым
проведен остеосинтез
путем внутрикостного
введения
металлических спиц.
Radiographs
of the mandible of patients with
fractures who underwent
osteosynthesis by intraosseous
insertion
of metal spokes.
Спицы Киршнера
Krishner’s pin
Остеосинтез
отломков верхней
челюсти с
помощью
костного шва (а, б)
и спицы (в)
Использование внутрикостных винтов
Накостный остеосинтез
металлическими пластинками
Bone osteosynthesis with titanium mini plates
• применение черепно челюстно лицевых титановых
миниимплантатов
• Набор включает в себя: минипластинки толщиной 0,6 мм,
дли ной от 13 до 72 мм и шириной 4 мм, различной
формы (I, L, Т, X, Y, С формы и др.) с 4 - 16 от верстиями под
шурупы на каждой пластинке, а также минишурупы
диаметром 2 мм и длиной 3- 9мм, изготовленные из
титана и его сплавов, разрешенных к применению
Минздравом
• the use of craniofacial titanium mini implants
• The set includes: 0.6 mm thick mini-plates, from 13 to 72 mm
long and 4 mm wide, of various shapes (I, L, T, X, Y, C shapes,
etc.) with 4- 16 versts for screws on each plate, as well as
mini-screws with a diameter of 2 mm and a length of 3- 9mm,
made of titanium and its alloys approved for use by the
Ministry of Health
Indications for applying mini-plates: any fractures of the jaws with the exception of finely fractured
ones.
The most effective use of mini-plates is in large-scale and oblique fractures, in defects of the body
and branches of the mandible with preservation of the condyle process and reconstructive
operations.
The advantage of mini-plates over a bone suture is that during the operation, the periosteum peels
off only from one (vestibular) surface of the jaw, which significantly reduces violation of
microcirculation in the fracture area. At the same time, a strong bond of the fragments is ensured.
Показания для наложения мини-пластин: любые переломы челюстей за исключением
мелкооскольчатых.
Наиболее эффективно использование минипластин при крупнооскольчатых и косых
переломах, при дефектах тела и ветви нижней челюсти с сохранением мыщелкового отростка
и реконструктивных операциях.
Преимущество мини-пластин перед костным швом состоит в том, что в ходе операции
надкостница отслаивается только с одной (вестибулярной) поверхности челюсти, что
значительно уменьшает нарушение микроциркуляции в области перелома.
Схема вариантов
применения
титановых минипластин
для остеосинтеза
костей лицевого скелета
Окружающий шов
Surrounding suture
Окружающий шов из тонкой металлической проволоки или полиамидной нити может быть
применен при косых переломах нижней челюсти в пределах беззубого участка
альвеолярного отростка.
При помощи толстой полой иглы для переливания крови из поднижнечелюстной области
проводят две лигатуры вокруг тела нижней челюсти и выводят их че-рез слизистую
оболочку в полость рта, сопоставляют отломки (чаще с помощью пластмассовой шины, но
можно и без нее) и завязывают лигатуры узлом.
The surrounding suture made of thin metal wire or polyamide thread can be used for oblique
fractures of the lower jaw within the toothless section of the alveolar process.
Using a thick hollow needle for blood transfusion from the submandibular region, two ligatures
are carried out around the body of the lower jaw and they are removed through the mucous
membrane into the oral cavity, fragments are compared (more often with a plastic splint, but it
is possible without it) and ligatures are tied with a knot.
Показания к наложению окружающего шва:
Indications for the application of the surrounding
seam:
• отсутствие зубов или недостаточное количество устойчивых зубов на отломках;
• травматический остеомиелит;
• нагноение костной раны;
• патологический перелом.
• lack of teeth or insufficient number of stable teeth on fragments;
• traumatic osteomyelitis;
• suppuration of the bone wound;
• pathological fracture.
To apply the surrounding seam, a wire or (preferably) nylon ligature with a diameter of 0.6-0.8
mm is used, which is carried out using an arched curved thick hollow needle without a cannula.
Фиксирующий аппарат В.Ф. Рудько
Extraoral Fixing device V.F. Rudko
 Он состоит из: крючков - зажимов с шипами, стержнем и винтом (для захватывания края нижней
челюсти в области отломка); муфт - шарниров (одеваются на стержень крючка - зажима) и
металлического стержня (для соединения крючков - зажимов через муфты - шарниры).
 Для наложения этого накостного аппарата делается разрез в поднижнечелюстной области,
послойно расслаиваются мягкие ткани и обнажаются отломки нижней челюсти, фиксируются на
фрагментах челюсти крючки - зажимы (отступя 2 см от щели перелома) при помощи винтов.
 На стержень одевают муфты шарниры и устанавливают отломки в правильное положение.
 В муфты шарниры вставляют металлический стержень и закрепляют его.
 Рану послойно зашивают наглухо.
 Винт один раз в неделю необходимо подкручивать, т.к. в месте захвата крючков зажимов
возникает разрежение кости (остеопороз) и фиксация отломков ослабевает.
 Аппарат снимают через 1 - 1,5 месяца после его наложения. Для снятия аппарата необходимо
рассечь мягкие ткани
Аппарат В.Ф. Рудько
Компрессионно-дистракционные аппараты
Compressor-distraction device
Показания для остеосинтеза с помощью
компрессионнодистракционного метода:
• свежие переломы нижней челюсти
• замедленная консолидация отломков
(вследствие плохой иммобилизации отломков или
особенностей репаративной регенерации у
больного)
• травматический остеомиелит (до или после
секвестрэктомии)
• дефект нижней челюсти (травматический
неогнестрельный, огнестрельный,
послеоперационный)
• ложный сустав.
Indications
for
osteosynthesis
using
the
compression distraction method:
• fresh fractures of the lower jaw
• delayed consolidation of fragments (due to poor
immobilization of fragments or features of
reparative regeneration in the patient)
•
traumatic
osteomyelitis
(before
or
after
sequestrectomy)
• lower jaw defect (traumatic gunshot, gunshot,
postoperative)
• false joint.
Компрессионно-дистракционный
аппарат