OMF questions

1. OMF injuries, general data.

* The injuries of the OMF region occupy an increasingly important place in contemporary human
pathology and modern traumatology.
* In OMF traumas are studied:
-wounds of the soft parts of the face and the oral cavity
-traumatic dentoparodontal injuries
- mandibular fractures
-fractures of the middle floor of the face.
* There are a number of features of OMF traumatic injuries:
-risk of damage to the upper airways
-frequent association with intracranial and cervical spine injuries
-ocular, nasal, oral, otic lesions that require specific care.
-extremely rich vascularization of the region
-specific lesions of the cranial nerves, especially facial and trigeminal
-particularities regarding aesthetics and facial functionality
-specific anatomical relationships between skin, muscle and bone structures
-specific lesions of the excretory ducts of the salivary and lacrimal glands that can lead to complications.

2. The characteristic of OMF traumas by causes.

*
3. The anatomical-morphological peculiarities of the jaw and their importance in traumatic injuries.
* The upper jaw consists of 4 apophyses and the body in which the maxillary sinus is located,
participates in the formation of the orbit, nasal cavity, mouth. It joins the neurocranium through the
nozoethmoidal complex, the frontal bone, the temporal bone, the sphenoid. The nose rotates the jaw of
trauma taking on the force of the traumatic agent. The complex and the zygomatic arch protect the
anterior-lateral jaw. The upper jaw is positioned in the middle floor of the face. The soft parts of the
face cover the bony skeleton with a thin and uneven layer, and the Bichat adipose tissue diminishes the
strength of the traumatizing agent. The mimic muscles of the face do not allow the secondary
movement of the fractured fragments. The mobilizing muscles do not cause obvious movement. The
muscle tissue is very thin, uneven and the absence of antagonistic muscles directs the secondary
movements in one direction.
Bone tissue is composed of compact, spongy and laminar bone tissue. The cavities of the facial mass
(nasal, maxillary sinuses, ethmoidal cells, oral and orbital cavities) are symmetrical, multiple, of different
shapes, with different functions, with a mucosa that adheres to the periosteum. The periosteum in the
region of the alveolar process is joined directly to the bone so the fracture will be infected. Between the
resistance pillars is a thin, non-resistant laminar bone that orients the fracture lines.
Weaknesses: lacrimal bone, median part of the jaw, cybrous blade of the ethmoid bone, anterior,
posterior and medial walls of the jaw, lower wall of the orbit, lateral and median lamellae of the
pterygoid process of the sphenoid bone. After the loss of teeth and with age the bone weakens, the
alveolar process becomes thin, it atrophies.

4. The anatomical-morphological peculiarities of the mandible and their importance in traumatic

injuries.
5. Frequency of OMF injuries.
According to the OMF surgery department, trauma ranks 2nd with 33% (2004-2013). Jaw fractures
are most common because due to dysfunction patients go to the doctor, but periodically, the trauma
changes its place with the wounds (they occupy the first place).
3rd place - traumas of the nasoethmoidal complex;
4th place - trauma of the zygomatic;
5th place - upper jaw trauma;
6th place - dento-periodontal lesions

The average age of people with trauma is 34 years, mostly men.

6. Classification of OMF trauma - Alexandrov.

I. Mechanical trauma of the region (upper, middle, lower, lateral areas of the face)
1) By location:
* Of soft tissues
-language
-salivary gland
-nervii
-master vessels
* bone fractures: mandible, nasal bones, malaria, upper jaw, two and more bones
2) according to the character of the lesion
-oarbe
-tangentiale
-transxfisiante
-penetrating (oral cavity, orbit, maxillary sinus, nasal cavity)
3) according to the mechanism of action
-by firearm
II.combined lesions
III.combnustii
IV.degeraturi

7. The anatomical-morphological peculiarities of the malar bone, the zygomatic arch and their
importance in traumatic injuries.
* The zygomatic bone is located in the anterior side of the face, the layer of soft tissue is thin and can be
exposed to trauma. It is a hair bone, the most resistant facial bone, it contributes to the fixation of the
bones of the facial skull to the famous one. It has 4 apophyses: frontal, temporal, maxillary, orbital and
maxillary tubercle. Participates in the formation of the appearance of the face, it is inserted masticatory
and facial muscles, so the movements of the bone lead to aesthetic and functional disorders. It has a
rich vascularized and innervated periosteum with a role in vascularization and bone consolidation. The
orbital surface of the malar bone is the least vascularized and innervated.
In the body and the lower edge of the orbit, the medullary substance prevails, in apophysis-compact
bone substance. Instead of malarofrontal, temporomalar sutures, the spongy substance disappears.
More often the fractures of the malar axis occur instead of the sutures, so the medullary substance
makes contact with the external environment, respectively the fractures rarely complicate with
osteomyelitis.
On the orbital face there is a zygomatic-orbital foramen that continues with a branched channel in two
external channels: zygomatic-facial and zygomatic-temporal foramen.
The zygomatic bone participates in the formation of alveolomalar resistance pillars (from molars on the
zygomatic-alveolar suture, on the body of the malar bone and its aophyses); also participates in the
defense of maxiels of traumatic agents.
The zygomatic arch consists of the temporal apophysis of the malar and the zygomatic apophysis of the
temporal. In fractures the lines can be single, double, triple, the affected portion being clogged in the
step, in U, V. they move medially, inferiorly, rarely superiorly, exceptionally laterally.

8. The anatomical-morphological peculiarities of the nasal bones and cartilages, their importance in
traumatic injuries.
* The central prominence of the face, of different sizes and shapes-the nose-gives the face an
individualized special note. The nasal bones are even, they join together forming the nose, in the lower
part they are consolidated with the nasal cartilages. The upper part joins with the nasal margo of the
frontal bone. Between them, the nasal bones are joined with the perpendicular lamina of the ethmoid
bone, which is affected in trauma. The lateral margin of the nasal bones joins with the frontal rosette of
the upper jaw.
The topographic anatomical features that determine the median and prominent position of the nose,
the high fragility of the bones, the small size, the intimate relationship with the skull bones determine
an increased incidence of fracture of the nasal bones. The functional disorders are multiple (breathing,
olfactory, drainage, phonation, aesthetics, defense, resonance, mimicry, skull architecture) and depend
on the force of impact, the direction of the vulnerable agent, the structures involved in the trauma.

9. The anatomical-morphological peculiarities of the facial soft tissues and their importance in
traumatic injuries.

10. Anatomy of the trigeminal nerve, traumatic injuries at different levels.

* Pair V, mixed nerve. The motor fibers start from the motor nucleus in the bridge, the sensitive one -
the nucleus of the mesencephalic and spinal tract. Trigemen leaves the brain through two roots:
-sensitive root enters the trigeminal cavity where the Gasser ganglion is located where it branches into 3
branches:
a.oftalmica: from the ganglion it passes into the lateral wall of the cavernous sinus, then through the
superior orbital fissure it passes into the orbit where it becomes in:
= tear: innervates the skin, the conjunctiva of the upper eyelid in the region of the lateral angle of the
eye.
= frontal: has branches-the supraorbital nerve innervates the skin of the forehead, and the
supratrochlear nerve innervates the skin of the root of the nose, the lower part of the forehead, the skin
and the conjunctiva of the upper eyelid.
= nasociliary: gives nasal branches, long ciliary nerve to the sclera, short ciliary nerve to the eyeball,
infratroheal nerve to the root of the nose and the medial angle of the eyes.
b.maxilara: from the ganglion through the round hole it hits the pterygopalatine fossa where it gives
the branches:
= infraorbital: passes into orbit through the lower orbital fissure, in the ditch then the infraorbital canal.
It exits the canal through the infraorbital orifice on the anterior face of the jaw. Give the branches:
lower eyelids, upper nasal and labial branches. From the trunk branches the anterior, middle, posterior
alveolar nerve that forms the superior dental plexus.
= zygomatic: passes through the lower orbital fissure, or through the zygomatic-orbital orifice where it
gives: the zygomatic-temporal branch that annoys the skin and the lateral angle of the eye and the
zygomatic-facial branch innervates the anterior face of the zygomatic bone and the cheek.
 = ganglionic branches to the pterygopalatine ganglion that gives the branches: posterior, middle and
lateral nasals, the nasopalatine nerve on the nasal septum through the incisor canal to the mucosa of
the hard palate.
= large and small palatine through homonymous channels to the mucosa of the hard and soft palate
c.mandibular: mixed, comes out of the skull through the oval hole. Motor branches to the masticatory
muscles (masseter, deep temporal, lateral and median pterygoid, palatine wave tensor, tympanic
tensor). The sensitive branches are:
= buccal: between the ends of the lateral pterygoid muscles then on the external face of the buccinator
it innervates the mucous membrane of the cheek and the skin of the angle of the buccal orifice.
= lingual: (mixed), between the lateral and median pterygoid muscles passes on the inner face of the
mandible under the mucosa of the buccal floor and enters the lower part of the tongue. Give the
branches: lingual which innervates the anterior 2/3 of the mucous membrane of the tongue, the
sublingual nerve innervates the mucosa of the oral cavity and the anterior portion of the lower gums,
ganglionic branches to the submandibular and sublingual ganglion.
= lower alveolar: (mixed) passes on the external face of the lateral pterygoid muscle, through the
mandibular orifice passes into the canal from which it exits through the mental-mental nerve orifice
which ends in the skin of the chin and the lower lip. Gives lower dental and lower gingival branches.
* Injuries to the trigeminal nerve: nerve neuralgia with the presence of severe pain.

11. Anatomy of the facial nerve, traumatic injuries at different levels.

* Pair of VII. There are 2 nerves: own facial nerve made up of motor fibers and the intermediate nerve
made up of gustatory sensory fibers and vegetative nerve fibers.
-facial nerveit exits at the posterior edge of the bridge and enters the internal auditory canal, passes
the temporal canal and exits the bone through the stylomastoid orifice. Before leaving the hole, it
branches into:
= large stony appears on the anterior face of the pyramid through the hiatus of the large stony nerve
canal. It enters the pterygoid canal through a lacerated orifice where with the deep stony nerve it forms
the number of the pterygoid canal that reaches the pterygopalatine ganglion.
= tympanic horde: passes into the tympanic cavity and appears outside the stone-tympanic fissure then
adheres to the lingual nerve.
= the ladder innervates the staedius muscle in the tympanic cavity.
The facial nerve after leaving the stylomastoid orifice gives the motor branches: posterior atrial nerve,
digastric branch, stylohyoid branch. Then it enters the parotid gland and gives the branches:
= temporal nerves innervating the anterior atrial muscle, the frontal ventricle of the epicranium and the
orbicularis of the eye
= zygomatic innervates the orbicularis muscle of the eye and large zygomatic
= mouth that innervates the large and small zygomatic muscle, the levato muscle of the upper lip and
the angle of the mouth, the buccinator muscle, orbicularis of the mouth, nasal and rosette.
= marginal branches of the mandible innervate the depressor muscle of the lower lip and the angle of
the mouth, the mental muscle.
= the branches of the neck that innervate the platysma.
* Facial nerve injuries: facial nerve neuritis with the presence of total or partial paresis and facial nerve
neuralgia.

12. Subjective examination of patients with OMF trauma.

* Quiz: establishing the patient's identity - name, surname, age, sex, marital status, occupation, address.
* motivation: all the symptoms and signs that the patient presents are registered.
 * History of current disease: the patient tells how the disease started and evolved, the order of
symptoms, the succession, the evolution, the treatments followed, the results obtained are specified.
Pain is analyzed specifying the appearance, spontaneous or provoked, the agents that determine it, the
location, the irradiations, the intensity, the continuous duration or in the diurnal or nocturnal crisis,
associated disorders, the factors that calm it.
* Life history: hereditary family history (syphilis, TB, predispositions to coagulopathy), personal history:
physiological history (chronology of temporary and permanent tooth eruption, menstruation,
pregnancy, menopause), pathological history (eruption accidents, vicious habits, tooth disease and oral
cavity, early tooth loss, extractions, how to withstand anesthesia, tendency to excessive bleeding).
Specifying the ailments he suffered in the tercut and at present, the surgeries supported, if he follows
any drug treatment.

13. Objective loco regional examination of patients with OMF trauma.

The examination of the patient aims at establishing a correct diagnosis. It specifies the circumstances
in which the time elapsed since the accident occurred (accuracy is absolutely necessary - legal act),
establishes the existence or imminence of a serious complication and detects possible concomitant
cranio-encephalic, thoraco-abdominal injuries, limb injuries, etc.
Following the accusations, the history of the development of the disease, the signs and symptoms,
the preventive diagnosis is established.
Signs and symptoms can be:
• Pain, heat, redness, tumor, lesion function;
• deformations
• Hemorrhage (in jet, diffuse);
• Chewing and swallowing disorders;
• Respiratory disorders;
• Phonation disorders;
• Nervous disorders;
Subsequently, with the help of paraclinical examinations (mainly radiographic) and differential
diagnosis, the definitive diagnosis is established.

14. Paraclinical examinations of patients with OMF trauma.

* Pulp vitality tests: by thermal, electrical or dentinal milling processes.
* X-rays intraorental retrodental or occlusal and extraoral of the face, profile and base of the skull.
* Panoramic radiography: makes a film the image of the entire alveolodental region of the mandible
and the infrastructure of the jaw.
* Computed tomography allow obtaining images of thin layers at various depths.
* Sialografia: for exploration of the parotid and submandibular glands with contrast substance.
* Salivary scintigraphy- morphological exploration of the totality of the salivary parenchyma,
appreciation of the lesion site, appreciation of the functional value of the salivary glands.
* biopsy: by excision (for small superficial lesions), by incision (in extensive, deep lesions), by curettage
(in ulcerative or vegetative lesions), by aspiration (deep lesion difficult to reach).
* Exploratory puncture: diagnosis diagnosis of tumors of the soft parts and jaws, evacuation of a
hematoma, in purulent collections.
* Catheterization of fistulous tracts: degree of permeability of the trajectory, length, direction,
sinuosities, consistency of the walls, location of the bottom of the fistula.
* Catharism of Stenon or Warthon channels: channel permeability, the existence of foreign bodies.
* Anterior rhinoscopy: the appearance of the pituitary mucosa, the presence of pus, polyps or
hypertrophy of the ostium mucosa indicating sinus lesions.
 * transillumination: discovery of dental lesions, of the maxillary sinus, of the cheek.
* Bacteriological examination: of pathological products for the formation of the antibioticogram.

15. The basic forms and principles of organizing the medical assistance to the injured.
The treatment of patients with trauma in the OMF region provides for the restoration of the lost form
and function in the shortest possible time. Solving this goal includes the following basic steps:
- Correct repositioning of dislocated fragments;
- Their immobilization;
- Stimulating bone tissue regeneration in the fracture region;
- Prevention of any type of complication (osteomyelitis, false joint, traumatic sinusitis, phlegm or
abscesses, etc.).
Specialized help should be provided in the shortest possible time (first hours after trauma), because
the timely repositioning and immobilization of fragments ensures favorable conditions for bone
regeneration and soft tissue healing, also promotes hemostasis and prevents inflammatory
complications.
The organization of care for patients with OMF traumas must follow (...). the volume and character of
the assistance provided may change depending on the circumstances at the scene of the accident,
the location of the points and medical institutions.
distinguished:
1. First aid, which is provided directly at the scene of the accident, health posts, by patients (self-
employed or others) or health .;
2. The premedical aid is granted by the felcer (?) Or the medical assistance and has the purpose of
completing the actions undertaken previously;
3. First aid, which must be provided in the first 4 hours; it is performed by non-specialists (in local
hospitals, at the emergency hospital, etc.);
4. Specialized surgical assistance, which is granted in medical institutions no later than 12-18 hours
after the trauma;
5. Specialized help, which must be provided in a specialized institution no later than 24 hours after the
trauma.
(after Bernadsky)

16. Soft tissue wounds OMF, etiology, clinical anatomical appearance.

* Etiology:
-favoring causes : general condition of the patient-presence of certain general pathologies, mental
overwork, drunkenness
-certain determinants: traffic accidents, work accidents, aggressions, gunshot wounds, accidental falls,
horse bumps, sports accidents. Self-biting or animal bites, stinging wounds during dental treatment
(extractions, working with rotating tools).
* Anatomical clinical appearance:
-contuziile: closed lesions, without solutions of continuity of the skin or mucosa. Edema, diffuse swelling,
bruising, interstitial or localized hematomas.
-excoriatiile: superficial skin lesions by rubbing on a hard surface, may be intradermal inclusions of sand,
tar making traumatic tattoo. Raw surface, bleeding, painful, edema, bruising.
-cut wounds: smooth, linear or irregular edges, close or ajar, interrupting or not the continuity of the
orifices of the face.
-penetrating wounds: unipolar, have an entrance hole, a path and a soft part in the bottom, on the
fractured bone plane or in the maxillary sinus. In stung wounds the hole may be small, with clean edges,
no foreign bodies. More often the orifice is irregular, with broken edges, deep foreign bodies, the bony
plane can be fractured.
-transigating plagiarism: smaller reinforcement hole, sailors turned inside. Larger exit hole, irregular,
with synthesized flaps, thrown out, through which bone shards or soft parts can come out.
-contagious wounds: irregular, broken edges, with retracted skin tongues, sometimes with facial flap
take-offs or massive losses of substance. Accompanied by damage to vessels, nerves, salivary glands,
often associated with fractures of the jaws.
-wounds caused by explosions: multiple penetrating wounds with penetration of foreign bodies, often
with 1st degree burns and or powder impregnations in the facial tissue.

17. Classification of facial soft tissue lesions.

* Anatomo-topographic region: wounds of the lips, tongue, buccal floor, cheek, parotidomasometric
region and
* The vulnerable agent: firearm, hoof, bite, traffic accident, aggression, ss
* Number and extent of wounds: single or multiple, limited or extended
* depth: superficial or deep
* Gravity: mild wounds that do not affect important anatomical elements such as nerves, salivary
glands, tear ducts or severe wounds with their damage and loss of substance
* Association or not with fractures of the underlying bone plane
* Time elapsed since the accident: recent (pine at 24 hours), old (after, with infection).
* The character of the wound: contusions, excoriations, cut wounds, penetrating, transfixing (bipolar),
contusion wounds (crushed), wounds produced by explosions.

18. Surgical treatment of facial soft tissue wounds.

* Primary surgical treatment of wounds:
-processing of the operative field: of the surface of the skin around the wound with antiseptic or
alcoholic solution of 70% from the wound to the periphery, from the upper to the lower point.
-insulation of the operating field: with aseptic sheets or diapers, only the exposed wound remains.
-local anesthesia and infiltration around the wound with antibiotics
-removing foreign bodies from the wound, processing with antiseptics, drying the wound
-incision, wound revision, hemostasis
-biopsy to perform the antibiotic program
-processing the wound with hydrogen peroxide water, furacillin
-application of the drain in the wound
-suturing the wound.

19. Emergency or immediate care of facial soft wounds.

-the wound region is boiled in case of need, it is cleaned with soap and water.
- antiseptic skin around the wound,
- sanitization of the oral cavity, mechanical cleaning and superficial antisepticization of the wound,
removal of foreign bodies from the wound
-stopping the bleeding from the wound
-temporary immobilization of fractures
-applying a sterile dressing and going to a specialized service

20. Complex, definitive treatment of facial soft tissue wounds.

* Contusion treatment: removal of foreign bodies by wide irrigations with antiseptics, application of
wet, cold compresses or ice pack, if there is an extensive tendency, apply a compressive dressing. Blood
collections are removed by puncture with a thick needle or the tip of a scalpel.
* Treatment of excoriations: removal of foreign bodies by irrigation with warm saline, soft cloth or
soap. The excoriation area is left open to form a ladder that protects the pine wound from etching or a
light sterile dressing is applied.
* Wound treatment: the primary surgical treatment of the wound is performed. (question 18).

21. Wound suturing, suture materials, suture application methods.

* Immediate primary suture: in the first 24 hours. Most commonly used suture with separate threads or
suture with U-threads (in the mattress).
-for cut wounds, uncontaminated without lack of substance: intradermal suture
-for skin sutures sutures with non-absorbable monofilament thread (polypropylene).
-for the wounds of the oral mucosa with resorbable threads multifilament (based on polyglycolic acid) or
resorbable monofilament (based on polydioxanone)
-for deep or penetrating sutures suture in several planes, from depth to the surface. Suture the
subcutaneous plane so that the skin edges of the wound come into contact without tension. Skin suture
with atraumatic needles with separate threads of nylon, horsehair or silk passed to the key points: the
cutaneous line of the labial mucosa, the nostril, the skin folds of the face, the ciliary edge and the
eyebrows.
* Delayed primary suture: from 24 hours to 3-7 days.
- position suture: a few sutures away from the edges of the wound that allows the placement of the
flaps as close as possible to the anatomical position.
* Secondary suture: more than 7-10 days. In extensive wounds with crushing of tissues, with lack of
substance that does not allow primary suturing. It consists in guiding the secondary healing through
limited excisions, of revival and release that hermit a healing of the tissues.

22. Dressing and care of patients with facial wound.

* Dressing:
- simple sutured superficial wounds are left uncovered or small bandages are applied, maintained with
adhesive tape. Usually a few sterile adhesive tapes are applied to the sutured wounds to reduce tension
on the suture lines and a lightly compressive dressing that limits edema and prevents hematoma
formation. The compressive dressing is left for at least 2-3 days.
-wounds with partial or positional sutures: apply the dressing as little as possible and it will be changed
often because the secretions from the wound soak it and it is difficult to bear.
* Patient care:
- oral hygiene: by mouthwash lagi with an irrigator, water syringe or Guyon syringe after each meal with
warm solutions, saline, weak antiseptics (potassium permanganate, hydrogen peroxide, chloramine,
furacillin, baking soda 1-2% .
-food: in patients with intermaxillary blockage, liquid or semi-liquid foods are administered. Gastric tube
supply.
-rest of the patient in bed, mechanotherapy if necessary.

23. Complications of facial soft tissue wounds, prophylaxis and treatment.

* Immediate serious complications:
-asfixia(foreign body penetration, tracheal compression, tongue drop). Treatment: the patient's head
tilts sideways, grabs the tongue, removing secretions, clots, foreign bodies from the mouth and pharynx.
Maintaining the tongue with Gueddel type oropharyngeal tube or with a silk thread passed through the
tongue and fixed to the clothes. Tracheotomy in more severe cases.
-hemoragia: abundant, massive, by damaging an important vessel. Treatment: identification, pinching
and ligation of the vessel. In diffuse bleeding through compressive coating. Digital compressions. In
epistaxis anterior or posterior tamponade of the nostrils.
-traumatic shockfollowing severe contusions, multiple injuries, massive hemorrhages. Treatment:
warming, hydration, heart tonics, plasma or blood infusions, sedatives, tranquilizers.
* Primitive complications:
-Infection it is constant in bitten, crushed, dirty wounds that communicate with the oral cavity.
-erizipelul: exceptional and always benign
-tetanosul. prophylaxis: tetanus serum.
-gangrene gas: extremely exceptional.
* Secondary complications:
-local infection: leads to suppurations in the superficial or deep lodges of the face, chronic fistulas due to
the retention of foreign bodies. Treatment: antiseptic treatment, antibiotic therapy.
-thrombophlebitis of deep venous plexuses, sepsis, pulmonary complications by aspiration. Specific
treatment.
-secondary hemorrhages: vessel damage of sharp bone fragment, infection and detachment of the
thrombus.
* Late complications: vicious, retractile or hypertrophic scars, loss of substance of the face, constrictions
of jaws through scarring flanges, fistulas, sialocele or salivary pseudocyst, facial nerve palsy, facial
neuralgia, phonation disorders, mastication, swallowing, mental disorders.

24. Dento-periodontal traumas, general data, etiology.

* General data: have a frequency of 3%, is increasing in children aged 1-2 and 7-8 years. They are
accompanied by bruises or wounds of the gums, cheeks, lips, tongue, fractures of the alveolar
processes. Dental periodontal lesions are variable and the clinical appearance depends on the intensity
and direction of the traumatic agent, the age of the patient.
* Etiology:
-favoring factors: dental malpositions, prognathism, ATM disorders, tooth fragility due to hypo and
hypercalcification. The fragility of the tooth is favored by depulping, fillings, coronoradicular devices,
chronic marginal periodontitis.
-Determined factors: accident, falls, assaults. Iatrogenic factors: mouth opener, tooth extractions,
anesthesia, fibrogastroscopy, during food intake.

25. Classification of dento-periodontal traumas.

* Classification of dental fracture according to Ellis:
-class I: enamel crack
-class II: fracture of enamel and dentin
-class III: fracture of the enamel, dentin with the opening of the pulp chamber
-class IV: fracture of the entire crown
* WHO classification:
-coronary fractures:
a. crack of enamel or enamel and dentin
b. coronary fracture without opening the pulp-uncomplicated chamber
c. crown fracture with pulp-complicated chamber opening
-root fractures:
a.fractures in the cervical region
b.fractures in the median region
 3. fractures in the apical region
-luxatii:
a.contusion d.luxatia with extrusions
b.subluxation e.luxation with intrusion
c.luxtia laterala f.avulsiunea.

26. Dental lesions, cracks, coronary fractures, corono-radicular fractures.

* Dental cracks: a partial or total crack of the enamel or of the enamel and dentin, are solutions of
partial continuity of the hard tissues, without losses of substance.
* Simple non-penetrating coronary fractures: does not affect the pulp chamber. From the incisor and
canine oblique fracture.
* Complicated coronary fractures, penetrating: the polar chamber opens, the enamel, the dentin and
the pulp are damaged. They are open fractures at the level of a pulpal horn or expose the coronary pulp
widely.
* Root fractures: in 1/3 cervical, medium or apical. The fracture line can be oblique or transverse, with
or without moving the fragments, open or closed.
* Penetrating coronoradicular fractures: oblique or longitudinal fracture line, with or without
displacement of fragments, penetrating into the pulp chamber.
* Comminutive fractures comprise several fragments.
* Non-penetrating coronoradicular fractures: the fracture line can be oblique or longitudinal, with or
without the movement of the fragments, not penetrating the pulp chamber.

27. Periodontal lesions.

* Periodontal contusions: rupture of some fibers of the periodontium and of the vessels. In the
periradicular space small hemorrhages, microhematoses, edema, inflammation phenomena.
* Partial dental dislocation: incomplete rupture of the alveolodental ligament, the tooth partially
displaced from the alveolus, less often with the bony walls of the alveolus, traumatized gingival
fibromucosa, the ruptured neurovascular bundle in the apex region.
* Total dental dislocation: rupture of the alveolodental ligament is complete.

28. Clinical and radiological study of dento-periodontal lesions.

* Dental cracks: they can react to thermal excitants, the examination is done with a magnifying glass, by
transillumination, with a dental probe and the electroodontodiagnostics in dynamics.
* Simple non-penetrating coronary fractures: accusations -sensitivity or transient pain on contact,
thermal and chemical excitants. The sharp edge of the crown traumatizes the lip or tongue. Clinically,
periodontal contusion is added.
* Penetrating complicated coronary fractures: trauma pulpitis clinica if the pulp was not affected until
the accident. Accusations: intense pain, spontaneous, with irradiation, exacerbated. It intensifies in
thermal, chemical, mechanical variations. Pulmonary hemorrhage in the first hours. Destroyed tooth
crown, with sharp edges that traumatize soft tissues.
* Root fractures: mild pain and insignificant mobility. Poor clinic. The vitality of the leg in the closed
fracture is maintained. Mobile tooth crown depending on the location of the fracture. Radiological:
highlights the fracture line, direction, degree of displacement, presence of tooth bud, root formation,
condition of the alveolar walls.
* Penetrating coronoradicular fractures: the small fragment remains fixed to the fibromucosa, causes
pain when chewing, phonation. Clinic characteristic of pulpits.
* Comminutive fractures comprise several fragments, with mobility, pain, trauma to neighboring soft
tissues.
* Non-penetrating coronoradicular fractures: the small fragment remains fixed to the fibromucosa,
causes pain when chewing, phonation.
* Periodontal contusions: hyperemic pulp, edema and periaapical hematoma with impaired blood
circulation. Deaf spontaneous pain, intensifies on contact with antagonists. Gingival bruising, bleeding
around the gingival margin. Tooth slightly mobile, displaced, tooth sensation increased. Reacts to
thermal problems with hyper or hyposensitivity.
* Partial dental dislocation: tooth displacements can be
-in the vestibular, oral sense with or without the alveolar wall fracture
-in the mesiodistal direction with lateral displacement when a tooth is missing
-in the shaft, with intrusion the tooth deepens in the alveolar process, or with extrusion the tooth comes
out of the alveolus.
Different mobility depending on the strength of the traumatic agent, its surface8, the patient's age.
Accusations: pain, displaced tooth, overocclusion, mobility, slightly detached gin, traumatized, bleeding,
profuse salivation, phonation disorders, mastication, occlusion.
* Total dental dislocation: tooth completely displaced from the alveolus. Broken neurovascular bundle.
The tooth intruded into a cavity of the face, in the soft tissues, expelled from the alveolus into the oral
cavity but fixed to the fibromucosa. Alveolar and fibromucous fracture. Empty alveolus, covered with
clot or bleeding covered with necrotic tissue. Traumatized soft tissues, bloody saliva.

29. The evolution of dento-periodontal traumas. Prognosis.

Enamel fractures do not regenerate. Dentin fractures: dentinogenesis takes place on the pulp, the pulp
chamber shrinks. Root fractures: instead of the fracture, a periodontal fibrous tissue is formed, a
pseudoarthrosis. In cervical fractures 1/3 prognosis is unfavorable, in cervical and apical fractures it is
favorable. Mild periodontal contusions with or without treatment at 1-2 weeks recover. Those
pronounced-when the treatment was performed 2 hours after the accident may occur dentoalveolar
ankylosis, root resorption and infection of the alveolus. The duration of incapacity for work with dental
fractures or dental periodontal dislocations is 8-10 days, in stationary 3-7.
Complications: damage to the dental bud, infection of the alveoli and adjacent soft tissues, periostitis,
osteomyelitis, sinusitis, migrating granuloma.

30.Treatment of dento-periodontal traumas.

* Treatment of dental cracks: by swabbing with coagulant solutions (chloroacetic acid, sodium fluoride,
bonding, calcium and fluoride varnish).
* Treatment of simple, impenetrable coronary fractures: smooth grinding-leveling of sharp edges and
EOD control in dynamics. Restoring the crown with a decorative crown. Two parapulpular holes can be
formed in the crown of the tooth, two pivots are fixed and the fractured fragment is applied. Endodontic
treatment when the pulp is necrotic.
* Treatment of complicated penetrating coronary fractures: preservation of the pulp by dressing with a
dressing with Ca hydroxide paste or Zn oxide. Pulpectomy or vital amputation, endodontic treatment,
restoration of the crown. Dislocation reduction and immobilization. Extraction in case of root resorption.
Sometimes the qualitative obturation of the canal and its replacement with immobilization.
* Treatment of root fractures: reduction of displacement and immobilization of the tooth. In fracture in
the cervical 1/3 endodontic treatment, intraradicular pin, artificial crown, removal of the tooth from the
occlusion. In other cases it is immobilized on neighboring teeth with wire, the crown is shaped. For
fractures in 1.3 medium-root extraction or endodontic implant. For root-endodontic apex fracture, apex
removal, pivot immobilization, removal from occlusion.
* Treatment of penetrating and communicative coronary root fractures: tooth extraction.
* Treatment of non-penetrating coronoradicular fractures: the small fragment is removed. Extraction.
Bont-bracket system.
* Treatment of periodontal contusions: the tooth is removed from the occlusion, immobilization of the
teeth, EOD. Endodontic later, if changes occur in the pulp.
* Treatment of partial dental dislocation: tooth repositioning, fibromucosal suturing, immobilization for
4 weeks. EOD in dynamics, endodontic when the pulp is necrotic. Immobilization of the tooth by its
ankylosis with composites - the mucosa is incised on the transition envelope, the flap is taken off, the
hole is drilled in the alveolus and the tooth, the hole is closed and the mucosa is sutured.
* Treatment of total dental dislocations: tooth replanting for 2 hours after trauma, tooth extractions. In
avulsion, it is treated endodontically, it is replanted, the crown is immobilized on neighboring teeth, the
wound is sutured, the crown is restored.

31. Alveolar ridge fractures, etiology, clinical examination, symptoms.

* Causes: assaults, falls, road accidents, work and sports accidents. Animal bites, firearms, iatrogenic
factors, catatrauma, pathological fractures.
* Alveolar ridge fractures after Clark:
-fracture of the edentulous alveolar process
-fracture of the alveolar process with insignificant displacement
-fracture of the alveolar process with major displacement
-fracture of the alveolar process with major depolarization and fracture of the jaw.
*Clinical: the fractured fragment shows pathological mobility, fixed by the periosteum or completely
detached. Hemorrhage from the gingival fibromucosa wound. Pain. Lip bruising, pathological occlusion.
Dystopian teeth on the fractured fragment as well as on the remaining arch. Teeth partially or totally
dislocated, avulsed or fractured.
* Clinical examination: subjective and objective data, orthopantomography with the highlighting of
fracture lines, involvement of teeth, nasal fossae, maxillary sinus (at the jaw), dislocation of the
fractured fragment.

32. Treatment of alveolar ridge fractures.

* Operating field treatment with antiseptics, anesthesia, manual fracture replacement, immobilization
with individual splint, acrylate palatal plates. The teeth are extracted, fixed with splints or treated
endodontically.

33. Mandibular fractures general data, statistics.

* General data: the mandible is the largest and strongest bone of the viscerocranium but due to its
prominent position it is most frequently exposed to craniofacial traumas. The anatomical and structural
peculiarities of the bone, the presence of the teeth and of the muscle complexes inserted on the bone
have an important role in the biodynamics of the mandibular fractures.
* Statistics:mandibular fractures are found in 70% of viscerocranium fractures. They have a higher
frequency in men 60-80% and affect especially young adults between 20-45 years. They are frequently
associated with soft tissue lesions especially in the labio chin region and in 20% of cases with other
viscerocranium fractures. According to Haug the frequency of mandibular fractures after localization
are:
-body of the mandible 29%, condyle 26%, mandibular angle 25%, chin symphysis and parasymphatic
area 17%, branch 4%, coronoid process 1%.

34. Classification of mandibular fractures.

* After Zbarj:
-line
-squamels, large, small shards with bone integrity disorder.
-Marginal, large, small scales while maintaining bone integrity.
-perforatorii
-with segmental defect
-with the eruption of large sectors
-various associations.
* According to the degree of interest of the bone and the fracture lines:
-partiale: detach limited portions of bone. There may be fractures of the alveolar ridge, fractures of the
basilar portion.
-Total: crosses the bone completely. Can be:
a.simple linear
b.cominutive
c.complete with the interest of the periosteum
d. incomplete in green wood without the interest of the periosteum.
* Depending on the location, the total fractures can be:
-median (middle symphysis)
-paramedians (parasymphatics)
-lateral (of the mandibular body)
-the angle
-of ascending branch
-of condil
-of coronoid process.

35. The etiology of mandibular fractures.

-traumas, aggression, traffic accidents, accidental falls, work accidents, sports accidents.
-spontaneously, in pathological bone when the resistance is low due to general or local diseases such as
osteodystrophies, osteoradionecrosis, osteomyelitis, tumors.
-during surgeries such as tumor removal, tooth extracts included or common when bone strength is low
or by incorrect technique.

36. Mechanisms for producing mandibular fractures.

-flexiunea: the trauma produces a closing or opening of the mandibular arch with the fracture of the
bone at the place of application of the force or at a distance. The curvature of the mandible becomes
progressively more twisted, the internal and external cortex fracturing independently and
asynchronously.
-presiunea: direct fractures at the site of application of force, the bone yields by the action of impact.
-smulgerea: exceptionally, a very strong muscle contracture able to overcome the resistance of the
bone.
-of settling: leads to indirect fractures, the bone receives force in the long axis. Ex: intracapsular fracture
of the condylar head by compaction in the glenoid cavity, force applied from the bottom up.
-of shearing: indirect fractures based on the principle of action and reaction. Ex: vertical impact on the
angle of the mandible produces the vertical fracture of the branch.

37. Mechanisms of displacement of bone fragments in mandibular fractures.

38. The main factors that influence the movement of bone fragments.
-the force of the trauma that produces the primary displacement
-contraction of the muscles inserted on the mandible, the elevators ascend the fragment on which they
are inserted, the suprahyoids descend having a centripetal action.
-the location and direction of the fracture line can lead to vertical and horizontal displacements leading
to agrenation or exaggerated displacement.
- teeth implanted on the fractured fragments or the antagonistic arch can oppose the exaggerated
displacements.

39. Types of displacement of bone fragments in mandibular fractures.

* Primary travel: under the action of a vulnerable agent with high kinetic energy that produces direct or
indirect fracture with displacements.
* Secondary travel: under the influence of an active factor such as the muscles inserted on the
mandible, the preum and apasive factors such as the location and direction of the fracture line, dental
status.
* By the direction of travel: vertical, horizontal, anterior, posterior movements.

40.Subjective symptomatology (accusations), common to all mandibular fractures.

* pain: it is alive, strong, it is accentuated by the movements of the mandible or at the pressures
exerted on the bone.
* bleeding from the oral cavity or from the wound present on the outside at the level of the mandible
* Functional disorders: embarrassment in swallowing, phonation disorders, inability to chew.
* Aesthetic disorders , deformation of the face, the presence of edema, the presence of soft tissue
wounds, hematoma, swelling.
* Loss of sensitivity of anesthesia or hypoaesthesia on the territory of the lower alveolar nerve.
* Tooth mobility or loss of trauma.

41. Objective symptomatology, common to all mandibular fractures.

* Signs of disruption of bone continuity:
-bone deformities of the lower floor of the face.
-abnormal mobility of bone fragments
-bone crackles
-decreasing or absence of transmission of movements in ATM
-modification of the occlusion ratio
* Functional disorders:
-pain when performing the clinical examination
-orders in phonation, embarrassment in swallowing
* Signs associated with the injury:
-soft edema, bruising, hematomas, excoriations or perimandibular wounds, hemorrhages
-sensitivity disorders on the lower alveolar nerve pathway, hypoaesthesia, anesthesia.
-dental dislocations or fractures, hematomas, wounds of the fixed and mobile mucosa at the level of the
alveolar process and the bottom of the vestibular sac.
* Probes:
-highlighting painful points
-bone discontinuity
-clogging or bony prominences
- gaps between fragments
-abnormal mobility of the fragments, sometimes bone crackles.

42. Symptomatology of median fractures (mid-symphysis) in the mandible.

* Located between two lower central incisors, quite rarely 2.9% because the chin symphysis is a place of
resistance of the mandible. They occur by closing or exaggerating the mandibular arch. Primary
movements can occur vertically or horizontally, secondary movement is absent. Present chin bruises in
the bottom of the vestibular or sublingual sac, a gingival fibromucosal wound between the central
incisors. At the closing of the arches the fragments move away due to the divergent tractions of the
lifting muscles, at the opening it is approached by the centripetal action of the suprahyoids, achieving
harmonic occlusion. At the primary displacement one fragment is ascended - the occlusion is present,
the other is lowered and lingualized in inocclusion.

43. Symptomatology of mandibular paramedian fractures.

* Between central and canine incisors, 15.5%. Primary or secondary movement under the action of
muscle force, the fragments are not symmetrical. The big one is pulled back and down, making
inocclusion vertically and horizontally. The small fragment is pulled up by the masseter and temporally
and inside by the pterygoids normal occlusion ratio. There is a fibromucosal wound at the level of the
fracture site, abnormal mobility of bone fragments, genio-labial bruises and in the anterior 1/3 of the
buccal floor.

44. Symptomatology of lateral fractures (of the body of the mandible).

* Between canines and wisdom teeth 31%. Primary and secondary trips. The large fragment is pulled
down and back to the fractured part by the suprahyoids, the small one up and back by the temporal and
internal pterygoid and inside by the external pterygoid. If the displacements are large, the mandibular
canal with hemorrhages and hypoaesthesia on the terminal branches of the lower alveolar is of interest.
Clinically swelling in the genial and submandibular region, in the focus of fracture, bruising or
hematomas in the oral floor, dysphagia, rarely respiratory disorders. Modified occlusion. The large
fragment in inocclusion, the small one in normal occlusion, lingualized or much ascended. When moving
horizontally, the body of the mandible and the deviation of the chin are shortened.

45. Symptomatology of mandibular angle fractures.

* Favored by bone curvature, late eruption or inclusion of the wisdom tooth. 17-25%. Through direct or
indirect trauma applied to the chin. If the fracture line passes in full muscle insertion, no dislocations
take place, if important displacements occur before insertion: the large anterior fragment is pulled
down and back by suprahyoids, laterally by the external pterygoid on the healthy side. The small
fragment pulled up and before the masseter, temporal and internal pterygoid.
In fractures without displacements - swelling of the masseter parotid region, trismus and moderate
dysphagia, pain at lateral pressure on the angle or anterior pressure on the chin.
In fractures with displacements - voluminous swellings peribulo mandibular, trismus, bruises or
hematomas in the buccal floor. The mobility of the fragments is difficult to perceive. The large fragment
in vetical inoclusion and laterodeviated towards the fracture. Distal fragment much ascended or with
minimal displacements when the direction of the fracture line is favorable.
46. Symptomatology of fractures of the ascending branch of the mandible.
* 2-5%, direct or indirect mechanism, oblique fracture line, vertical, horizontal. The vertical ones are
longitudinal located in the internal masseter and pterygoid muscle mass, from the basilar edge of the
pine to the sigmoid notch without displacements. The horizontal ones are transverse, usually in the
middle 1/3 of the branch, the oblique ones with the line from the sigmoid pine notch to the posterior
edge of the branch. The horizontal and oblique ones with the shortening of the branch by upward
traction of the internal masseter and pterygoid, the inferior fragment and the displacement of the small
anterior and median fragment by the contraction of the temporal and the external pterygoid. The
midline is diverted to the diseased side, premature contact on the last molars. There is swelling of the
parotid-masseter region, pain at lateral pressures on the ramus, trismus. Frontal inoculation returned to
pressure on the chin or stronger contraction of the muscles performing the occlusion in two strokes.
Teeth in distal contact on the side of the fracture. If the mandibular canal under the Spix spine is
interested, there may be sensitivity disorders on the path of the inferior alveolar nerve.

47. Symptomatology of condylar apophysis fractures.

* 9.1% -36%, 3 clinical forms:
-intracapsularawith the appearance of a crushing of the condylar head with multiple detached
fragments, the covering of the articular surfaces destroyed, the capsule intact or with decapitation-
transcondylar, here the upper fragment is telescopic. Crushes of the condylar head often associated
with fracture of the glenoid cavity, perforation of the external auditory canal, lesions of the meniscus.
Presence limitation of mandibular movements, pain on palpation, condyle movements are perceived as
clogged, otorrhea. No occlusion disorders.
-extracapsularamay be of interest to the condyle neck - high subcondylar fractures, the basis of the
condylar apophysis. The head of the neck is displaced or dislocated from the glenoid cavity. The lower
portion is ascended by the action of the internal and temporal pterygoid muscle, the mandibular
ascending branch is shortened. The chin is deviated towards the fractured part, pain at the lateral
auricular pressure, on palpation in the external auditory canal the movements of the condyle are
absent, the occlusion in two times.
-low subcondylarmay be with dislocations of fragments. The oblique fracture line down and back from
the sigmoid notch to the posterior edge of the mandibular branch. Symptoms similar to condlian neck
fracture.

48. Symptomatology of coronoid apophysis fractures.

* Rarely, they occur as a result of lateral trauma by clogging the temporozygomatic arch or tearing by
the temporalis muscle. Coronoid fractured completely with the oblique fracture line from the sigmoid
notch down and anterior to the base of the apophysis when the temporalis muscle pulls the fractured
portion of the coronoid apophysis up and forward, under the zygomatic arch there is a painful limitation
of the mouth opening, or incomplete fractures.

49. Drug treatment of mandibular fractures.

* Antibiotic prophylaxis to fight infection and avoid complications: lincomycin, morphocycline,
vibramycin, cephalexin.
* pain relievers to reduce pain: tramadol, ketamine, carbamazepine.
* Non-steroidal anti-inflammatory drugs to reduce edema: indomethacin, ibuprofen, naproxen.
* Administration of tetanus serum in case of contact with soil or other contaminated materials.
* vitamin therapy: vit. B1, B6, vit. C
* Immunostimulants: thymosin.

50. The phases of callus formation and the factors that influence it.
-protein fibrin callus (hemorrhagic-exudative phase) lasts 6-8 days. Hematoma is formed, the
appearance of an immediate inflammatory reaction that leads to the proliferation of neoformation
vessels and differentiation of mesenchymal cells.
-fibrous callus or chondroid (fibro-chondroid phase) between 6-8 days and 16-18 days. Maturation of
chondroblasts and their transformation into chondrocytes.
-primitive bone callus (temporary ossification phase) after 16-18 days.
- definitive bone callus (final ossification phase) after 4 weeks.
* Factors:
-the patient's age: older, slower.
-certain physiological conditions: pregnant, lactating women, more difficult.
-constitutional type: for picnics (hyperstenic), for those with stature deficits, slower.
-food factors: in case of lack of protein in food.
-mechanical factors: incorrect reduction and immobilization, late immobilization, sometimes prolonged
immobilization lead to delayed consolidations.

Tanea D.

51.Emergency treatment in jaw fractures.

The treatment consists in the reduction and temporary immobilization of the fracture, thus preventing
the secondary displacement of the already existing fracture and the removal of various functional
disorders that can endanger the life of the injured (hemorrhage, asphyxia, shock, concussion). , and the
administration of antititan serum, to combat analgesic pain. Release of any anatomical or mechanical
obstruction from the airways or tracheostomy.

Fracture reduction: which consists in repositioning the fragments in the anatomical position.

Emergency immobilization can be performed at the accident site or in the dental office

Objectives: -reduction of pain

-reduction of hemorrhage

-reducing the risk of suffocation (by falling tongue)

-allows easier emergency transport

Emergency immobilization methods: 1-chin-head bandage

2-frond chin

3-monomaxillary interdental ligatures

4-intermaxillary interdental ligatures

5-single-maxillary devices

6-bimaxillary devices
7-mandibulo-cranial devices.

52.Particle reduction methods, indications.

* Manual-under peripheral trunk anesthesia, then kind there are gears, telescopes, tilts.

* Intermaxillary elastic traction-kind repositioning can be done without difficulties or a slow

disengagement of fractured fragments is followed.

* Reduction of bleeding-less often, namely in cases of fracture kind is on an edentulous segment in the
area of the mandibular angle, retromolar, in the case of soft tissue interpositions between fractured
heads or in late establishment of treatment, kind has already begun to form fibrous callus .

53. Methods of immobilization of fragments in mandibular fractures.

* orthopedic: -prefabricated devices and devices

* emergency immobilization: mento-cephalic bandage, chin frond, monomaxillary interdental ligatures

(Hippocratic ligature "in 8" panroy scale "ligature, bridge ligation), intermaxillary (LeBlanc ligature-
fixation of the mandible at the level of the symmetrical jaw on one side and other, Ernst ligation 2 teeth
from jaws +2 mandibular teeth, Ivy ligation-for teeth with low retentivity even for frontal ones), single-
maxillary devices (single vestibular splint, double oral vestibular splint, bracket springs), bimaxillary,
cranial mandibular devices (chin frond with cape, Darcisac device, Ginestet helmet).

* permanent immobilization - by orthopedic means (monomaxillary, intermaxillary and mandibulo-

cranial devices)

* Surgical-ostiosinteza.

54. The main requirements in making splints.

* It must ensure a perfect immobilization

* splint is required to be adapted between the equator of the tooth and the edge of the gum

* not to irritate the tissues of the oral cavity

* to be modeled after the dental arch so as not to traumatize the marginal periodontium

* the material from which it is made should be soft, easy to shape

* to be easily sanitized

* not to oxidize.

55. Indications for surgical treatment of mandibular fractures.

Surgical treatment is used when the prosthetic devices cannot ensure an efficient reduction and
immobilization. It is indicated in: comminutive fractures, fractures with important displacements,
retrodental or angle fractures, gear fractures that are difficult to reduce, fractures with soft partitions,
fractures the edentati.

56. Methods of osteosynthesis.

* Wire osteosynthesis - through a submandibular incision the fracture focus is discovered, the bone
fragments are reduced in the correct position, then it is drilled 1 cm from the fracture focus in each
bone fragment orifice and each part. The wire connection passed through the orifices must to be
perpendicular to the fracture line. After suturing the wound, the mandible is immobilized on the jaw by
the device applied preoperatively.

* Osteosynthesis with the plate: it is applied on the basilar or vestibular edge and it is fixed to the bone
by screws with step and sharp tip. The miniaturalized Visse plates are applied on the vestibular face of
the bone fixing the fractured ends with 2 screws that pass through the plate. each side.

* Osteosynthesis with metal brooch-brooch passes between the mandibular canal and the basilar
cortex, crossing the fracture focus and joining the 2 bone fragments.

57. Methods of osteosynthesis of mandibular fractures in case of total edentation.

If the fractures are not accompanied by movements in the case of prosthesis wearers, the mandible will
be immobilized on the jaw by means of prostheses associated with a traction with a chin frond, kind
patients do not have prostheses for immobilization, prostheses or acrylic plates with occlusion wave are
made.

If the displacements are large or there is an obstacle in the correct reduction of the fragments,
osteosynthesis with wire or metal plate is indicated, after which the prostheses and traction with chin
frond can be applied. In case of important displacements of the fractured heads an acrylic splint fixed
with circummandibular threads (perimandibular hooping)

58. Immediate complications in mandibular fractures.

Shock - especially in polytraumatized;

Asphyxia-when there are foreign bodies or secretions in the oral cavity, or after double fractures of the
mandibular arch when the tongue falls into the pharynx causing a mechanical asphyxia;

Concussion - due to vibrations of the impact of brain mass;

Hemorrhage - in the case of fractures with large dislocations, the vessels in the mandibular canal are
damaged;

Nerve injuries - in fractures with large gaps that also affect the mandibular canal, hypoaesthesia or
anesthesia occurs by elongation, compression or even sectioning of the lower alveolar nerve between
the fractured ends.

59. Secondary complications in mandibular fractures.

* Infection - is favored by the fact that fractures in the dentate portion are open in the oral cavity,
contaminating the oral septic environment from the first hours after the accident. Fractures can also
cause mortification of teeth in the vicinity of fracture foci leading to secondary infection .Jaw fractures
can be complicated by osteitis or osteomyelitis, being favored by the oral septic environment, the
presence of foreign bodies or detached bone fragments, the reduction and late immobilization of
fractured bone fragments.

* Secondary hemorrhages, late-7 days.

60. Late complications in mandibular fractures.

* Delayed consolidation-maintenance of abnormal mobility of bone fragments after 8-10 weeks after
reduction and immobilization (causes: general factors-avitaminosis, deficiencies of phospho-calcium,
protein metabolism, insufficient pituitary, etc .; local factors-interposition of soft parts between
fragments fractured bones, late and incorrect reduction and immobilization, etc.)

* Pseudarthrosis-type lack of consolidation exceeds 6 months. Usually occurs in fractures with bone loss
and in fractures in which the immobilization was performed incorrectly.

* Vicious-kind consolidation was not performed immobilization or was performed incorrectly.

Mandibular deformities, occlusion disorders with physiognomic alterations, mastication and phonation
occur.

* Constriction of the mandible - after fractures of the branch, condyle or coronoid process.

* Temporo mandibular ankylosis-after intracapsular fractures of the condylar apophysis, by the

formation of callus between the glenoid cavity and the condyle.

* Vicious, retractable or hypertrophic scars.

61. Patient care in mandibular fractures.

In the case of single-maxillary devices - maintaining a rigorous oral hygiene.

In the case of intermaxillary blockages-patients it is necessary to provide them with a proper diet, soft,
pureed, but complete, rich in protein, mineral salts and vitamins to ensure faster kit formation of the
callus. Oral hygiene will be maintained by frequent washing. with weakly antiseptic or alkaline solutions.
Water jets from an irrigator are very useful, with a favorable mechanical effect for removing food debris,
but also for massaging the gums. Brushing is allowed as long as the ends of the connecting wires do not
move.

62.Terms of consolidation of mandibular fractures depending on the anatomical-clinical forms.

63. Temporo-mandibular dislocation general data, classification.

Temporo mandibular dislocation - the loss of normal relations between the articular surfaces with the
exit of the condyle from the glenoid cavity, can be done in several directions, depending on the
movement of the mandibular condyle. Dislocation is an often painful condition that affects both the
joint and its muscles. which controls the various movements of the mandible: speech, mastication, etc.
It was statistically observed that the affected women are twice as numerous as men. There are three
anatomoclinical forms of dislocations: anterior, posterior and lateral. The predominant symptom is pain.
This is sometimes accompanied by limitations or blockages of joint movements, cracking of the joint,
fatigue of the joint muscles, perception by the patient of a major change during the bite.

Secondary headaches, ears, dizziness may occur.

64. Anterior temporo-mandibular dislocations, etiology, symptomatology and diagnosis.

Anterior dislocation is the most common, it can be unilateral or more often bilateral.

* Etiology:

-exaggerated opening of the mouth (yawning, laughter, blows or less often falls on the jaw mouth being
open)

-medical maneuvers (strong pressure on the mandible during tooth extraction, excessive opening of the
mouth in order to perform a laryngoscopy, tracheal intubation)

-trauma applied to the branch (exceptional).

* Symptomatology: in bilateral dislocation the patient complains of a sharp pain accompanied by the
perception of an intra-articular noise followed by the impossibility of closing the mouth. At the clinical
examination we observe the wide open mouth and incontinence of saliva. 3-4 cm, molars can be in
contact, the chin is lowered and pushed forward, flattened and elongated cheeks, masseter and
temporal muscles are tense, palpation does not perceive the movements of the condyle, mastication is
impossible, swallowing embarrassed, and phonation difficult. At unilateral dislocation we notice a facial
asymmetry due to the deviation of the chin from the healthy side, the flattening of the cheek and the
subzygomatic prominence from the diseased side, the relaxation of the soft parts from the healthy side.

* Diagnosis: differential in unilateral dislocations with condylar neck fractures associated with condylar
head dislocation back and forth and facial paralysis or spastic contracture of masticatory muscles.
Radiography is necessary in older dislocations, as it specifies the possible concomitant dislocation of the
condylar , in recent times radiography is not indispensable, the diagnosis being quite simple.

65. Methods of treatment of anterior temporo-mandibular dislocations.

It is usually orthopedic (reduction of dislocation and temporary immobilization of the mandible). The
reduction is made by lowering the mandibular condyle and passing it under the temporal condyle, after
which it is returned to the glenoid cavity.

In exceptional cases surgikal (consists in opening the joint and tilting the condyle with a strong decollete
or rasuse until it returns to the glenoid cavity, if the condyle does not enter the glenoid cavity which is
filled with connective tissue, the scar tissue is excised and the meniscus is removed.

Nelaton technique: inserting both wraps wrapped in protective compresses applied bilaterally on the
lower molars, and with the other fingers grip the basilar edge to the angle of the mandible, lower and
push the mandible, hopefully posteriorly with the chin up, kind of cracking means that the condyle a
reached the glenoid cavity and the mouth closed abruptly.

After the reduction of the dislocation, it is mandatory to temporarily immobilize the mandible for 8-10
days with a chin frond that will limit the opening movements of the mouth.

66. Posterior temporomandibular dislocations etiology, symptomatology, diagnosis and treatment.

They are very rare and are usually accompanied by a fracture with a blockage of the anterior wall of the
external auditory canal.
* Etiology: strong blows or falls on the chin, the mouth being closed, is favored by the existence of
disorders in the interdental joint or the absence of molars.

* Symptomatology: posterior dislocation with fracture of the anterior wall of the external auditory
canal: otorrhea with decreased auditory acuity or even deafness, half-open mouth with distance
between upper and lower incisors by about 10-20 mm, flattened cheeks, blocked mandibular
movements. externally it is occupied by the condylar head, and anteriorly by the tragus a depression is
observed due to its retrusion.

In dislocations without fracture of the anterior wall of the auditory canal: closed mouth, erased chin
relief, angle of the mandible in contact with the anterior edge of the sternocleidomastoid muscle,
retruded lower incisors, with the incisal edge in contact with the fibromucosa of the palatal vault, and
the mandibular condyle palpates external.

* Diagnosis: radiological examination. Differential diagnosis with fractures of the glenoid cavity of the
temporal bone.

* Treatment: orthopedic - the reduction is done by catching the mandible with the police applied in the
vestibular grooves and exerts a downward pressure followed by a previous traction, in this way the
condyle is mobilized, bringing it back to the glenoid cavity.

67. Chronic recurrent temporo-mandibular dislocations, etiology, symptomatology, diagnosis and

treatment.

* Etiology: anatomical functional or pathological conditions that allow the condyle to slip beyond its
usual limits: erased glenoid cavity, shallow, temporarily wiped condyle with almost horizontal posterior
slope, meniscus deformation, capsule and loose periarticular ligaments, slightly resistant.

There are 2 forms of recurrent dislocations: condylomeniscal (occur in the submeniscal floor,
mandibular condyle moves before the meniscus that remains in the glenoid cavity) and
meniscotemporal (occur in the suprameniscal floor, mandibular condyle and meniscus slide before the
temporal condyle, making a complete dislocation).

* Symptomatology: dislocations occur quite frequently, several times a day. At the opening of the
mouth the patient perceives a crack, which is produced by the jump of the mandibular condyle. There is
a painful fundus in the TMJ that exacerbates during dislocation. the dislocation perceives the intra-
articular cracks, the petrageal depression and the prominence of the chin are evident.

*-Radiological diagnosis.

* Treatment: conservative: immobilization of the mandible with a chin frond, for 3-4 weeks, at the same
time a limitation of the condyle excursions is tried. For this purpose, periarticular sclerosing injections
are made.

Surgical: if the dislocation is due to a large laxity of the capsule and excessive mobility of the meniscus,
the capsule is plicated (capsuloraphy) with meniscus fixation (meniscus), if the meniscus is formed,
sclerosis, with irregular thickening, meniscectomy is recommended.

68. Temporal-mandibular lateral dislocations, etiology, symptomatology, diagnosis and treatment.

They are exceptional, because dislocations outside or inside are prevented by the resistance given by
the anatomical elements of the joint (longitudinal root of the zygomatic process, interpterigoid fascia,
etc.). Internal or external displacements occur in violent traumas applied laterally on the mandible and
are possible only in case of fractures of the condyle neck and because of this the fracture
symptomatology will predominate, the chin is deviated from the side of the lesion, the occlusion is
crossed.

* Treatment: the degree of displacement of the fractured and dislocated fragments is taken into
account.

69. Fractures of the middle floor of the face, general data, classifications, statistics.

The middle floor of the face consists of the maxillary bone, zygomatic, nasal, lacrimal bones, ethmoid,
vomer and pterygoid apophyses, is a unitary block, closely related to the neural skull. Rarely are
fractures at this level located in a single bone.

*Classification:

-fractures with dento-alveolar component: a) alveolar ridge fracture, tuberosity, palatal arch; b)
subzygomatic lower horizontal fractures (LeFort I); c) medium horizontal fractures (low craniofacial
disjunctions - LeFort II)

-combined central and lateral fractures: a) suprazygomatic fractures (high craniofacial disjunctions -
LeFort III); b) intermaxillary disjunctions; c) suprazygomatic fractures associated with intermaxillary
disjunctions with fractures of the orbital ceiling and frontal bone.

-fractures that do not interest the teeth and alveoli: a) of the central region (nasal bones, nasal septum,
maxillary or ethmoid frontal process); b) zygomatic-maxillary complex.

* Statistics: Lefort I-22%; Lefort II-61%; Lefort III-17%. The incidence of middle-floor fractures is lower
than in the mandible (between 11-30%). Bernadschii indicates the presence of 9% fractures of the upper
jaw.

70. Jaw fractures, general data, horizontal, vertical, oblique, pyramidal, comminutive fractures.

Fractures of the upper jaw are much less common, such as those of the mandible, malar or nasal bones.

Horizontal, pyramidal fractures (Lefort 1,2,3) (see question 73,74,75)

The vertical fractures (Walther) consist in the association of 2 horizontal fracture lines (Lefort 1,2,3) with
a vertical fracture, usually median, dividing the middle floor into 4 fragments.

Comminutive fractures: they are of a great variety, the fracture lines are atypical, they are accompanied
by lesions of the moist tissues and even by losses of the bone substance.

71.Etiology of jaw fractures, production mechanisms.

* Etiology-road accidents, aggressions, falls, work accidents and sports are the most common factors,
rarely cause traumatic injuries animal bites, firearms, iatrogenic factors, pathological fractures.

* Mechanism of production: most often occur through a direct mechanism, the trauma acting either on
the jaw or on the nasal or zygomatic prominences. The direction of the vulnerable agent, the intensity of
the trauma and the place of application can cause partial or total fractures, with or without dislocations.
of the middle floor of the face. The indirect mechanism rarely encountered, the fracture occurs as the
mandible violently hits the jaw through the dental arches.

72. Clinical anatomical forms of jaw fractures.

* Partial fractures:

1. fractures of the alveolar ridge

2. of tuberosity

3.the palatal vault

* Total fractures:

1.Lefort I

2.Lefort II

3.Lefort III

4. medio-sagittal fractures

5.multiple and comminutive

* After Lefort:

1. fracture of the upper jaw (Lefort I)

2. pyramidal fracture -Lefort II:

a) pyramidal fracture and nasal bones

b) pyramidal fracture and nazoethmoidal complex.

3.Lefort III-craniofacial disjunction

4. Lefort IV-Lefort II or Lefort III with skull base fracture.

73. Symptomatology of horizontal jaw fractures (Lefort I).

The fracture line starts from the piriform opening, passes over the alveolar apophyses through the
external wall of the nasal fossae and the superior base of the maxillary sinus, canine fossa, maxillary
tuberosity, pterygoid apophysis in the lower portion, vemerus and septal cartel, of the rest of the facial
mass.

* Clinical: labiogenic bruises in the vestibular sac, palatal arch, paraalveolar and palatine wave. Pain at
rest and pressure in the vestibular sac and retrotuberosity. The patient can not break food with his
teeth. and gingival mucosa, foreign body sensations in the pharynx, disordered nasal breathing, nausea.
Asymmetry caused by edema of the soft tissues of the upper lip. palpation of the alveolar process, is
better highlighted by the zygomatic-alveolar suture.

74. Symptomatology of jaw fractures (Lefort II).

The fracture line passes through the nasal bones, the ascending apophysis of the maxilla, the lacrimal
bone, the orbital rim, the median wall of the orbit, the inferior wall of the orbit, the anteriorolateral wall
of the maxillary sinus, below the zygomatic arch, towards tuberosity, pterygoid apophysis or ethmoid
complex without damaging the base of the skull.

* Symptomatology: palpebral, suborbital and conjunctivo-bulbar bruises, bruises in the bottom of the
upper vestibular sac, deformation of the face by clogging the middle floor, mobility of the jaw in block,
with the nose and floor of the orbit. Patients may have epiphora and epistaxis on both nostrils,
emphysema subcutaneous.

75. Symptomatology of jaw fractures (Lefort III).

The fracture line passes through the nasal bones, the ascending apophysis of the jaw, the inner wall of
the orbit, the outer wall of the orbit, the frontal apophysis of the malar, up to the pterygoid apophysis.
the base of the skull. These fractures are caused by trauma to the root of the nose.

* Symptomatology: - large blockage of the middle wall, the face appear flattened; high mobility of the
facial mass horizontally and vertically, with mobility of the nose, malar bones and eyeballs. At the
closing and opening of the mouth, the nose and eyeballs rise and fall, retrognathism, frontal reverse
occlusion, frontal inocclusion, bruising and palpebral edema "in the glasses". as a result of retrobulbar
hematoma, enophthalmia.

76. Intermaxillary disjunctions or mid-sagittal fractures of the jaw.

It involves the dentoalveolar arch, the nasal floor, the palatal arch and the body of the upper jaw on the
midline.

The fracture occurs when the lower arch is inscribed in the upper one, in the blow applied on the lower
and upper chin. There is a sudden widening of the upper dental arch with a split on the midline.

Clinical picture: gingival fibromucosal wound between the central incisors, which extends into the
palatal arch, vestibular ecchymoses and the palatine wave, abnormal mobility with bone crackles.

77.Diagnostic principles in jaw fractures.

The accusations, the history of the development of the disease, the clinical examination, the functional
disorders allow us to establish the preventive clinical diagnosis. The paraclinical examinations confirm or
deny the preventive diagnosis, namely:

- the puncture of the region is performed in case of a hematoma or a superinfection

-electroodontodiagnosis is performed on the teeth in the fracture line or on those with periodontal
lesions.

-renghen: upper jaw-semiaxial projection, computed tomography and three-dimensional.

-laboratory examination (hematocrit index shows hemorrhage)

-antibioticograma

-termometria

-electrocardiogram (patients over 40 years, those with heart problems).

78. Emergency treatment in jaw fractures.

The treatment consists in the reduction and temporary immobilization of the fracture, thus preventing
the secondary displacement of the already existing fracture and the removal of various functional
disorders that can endanger the life of the injured (hemorrhage, asphyxia, shock, concussion). , and the
administration of antititan serum, to combat analgesic pain. To stop the hemorrhage, the anterior and
posterior tamponade of the nose is necessary. Release of any anatomical or mechanical obstruction
from the airways or tracheostomy. Emergency immobilization blocks the middle floor based on the skull
with the mandible. for this purpose the mento-cephalic bandages and the chin frond, the sling, the
device are used.It is also possible to use in vertical and oblique fractures the ligatures from the wire to
the bridge, which unite groups of teeth on either side of the fracture line, monomaxillary splints fixed by
tooth ligatures, precast splints.

79. Definitive treatment in jaw fractures.

It is performed by orthopedic, surgical or combined methods.

The reduction of the fractures of the upper jaw is performed by several methods: manual, orthopedic,
instrumental and surgical.

Manual reduction: purpose-restoration of fractured fragments in anatomical position. The quality of the
reduction can be assessed by dental occlusion, restoration of continuity and bone contour, height
between the alveolar processes.

Orthopedic reduction: it is done with the help of intermaxillary, intermaxillomandibular or

intercraniomaxillary elastic traction. Individual splints are made with different forms of hooks that are
applied on the dental arches. The intermaxillary elastic traction rings are oriented so as to reduce
fracture.

Instrumental reduction: reduction of the zygomatic bone with the help of the Limberg kirlig.

Surgical reduction: the focus is opened, the bone abutments are reduced and immobilized with wire,
mini-plates, rods.

The immobilization of the fracture aims at resting the fractured fragments to form an interfragmentary
bone callus. Horizontal fractures, type Lefort 1,2,3 are immobilized by orthopedic methods:

1. Vasiliev splints (pre-made), individually made splints, palatal plates.

2. cephalic device - gypsum cap or canvas, Guinestet helmet, Budin helmet.

3. Oral device-palatal plate with 2 metal bars fixed by it, metal splint, metal splints, single-maxillary
splint.

Oblique or vertical fractures: palatal plates, metal splints, single-maxillary splints, splints with elastic
tractions in fractures moving horizontally.

Surgical treatment: it is used less often, in some multiple fractures, in patients with lesions of the skull
cap, to which cephalic devices cannot be applied. Wire osteosynthesis is used, the fracture foci being
discovered through the existing facial wounds or through incisions. .After the discovery and reduction of
fractures, the fragments are baked with metal wires for osteosynthesis.
80.Indications and surgical methods in the treatment of jaw fracture.

* indications: edentulous, scaly fractures, multiple fractures, fractures that do not undergo orthopedic
treatment, consolidated vicious fractures, obvious mobility of teeth, trauma by firearm, patients with
mental disorders, skull fractures.

* Parafocus methods: remote suspension in order to fix the fractured facial bones to the other intact
bones of the skull. The upper dental arch is fixed to the fixed parts of the skull by metal wires passed
through the soft facial parts. Several methods of suspension are known, and namely: the piriform orifice
or the anterior nasal spine in case of Lefort 1 fractures, the inferior and lateral orbital rim, the zygomatic
arch, the skull bones: frontal and temporal.

* Intrafocusing methods: osteosynthesis with metal wire, with metal plates and screws, with
transmaxillary and transnasal brooches. Osteosynthesis with metal wire: a 0.2-0.4 mm stainless steel
wire passed in the bridge, perpendicular to the fracture paths through the holes created on each bony
abutment after which we twist them under pressure, laterally from the crack of the fragments.
Osteosynthesis with metal plates: they achieve a good three-dimensional stability until the formation of
bone callus, they provide support for bone transplants in fractures with loss of substance.

ALINA

101. Inflammatory processes of the temporo-mandibular joint: general data, etiology, classification.

Inflammatory processes can affect only certain components of the TMJ or can affect the entire joint.
Usually inflammatory conditions are located unilaterally. Most of them are caused by occlusal-articular
imbalance, followed by changes in meniscus-condyle position and the appearance of inflammatory
phenomena.

Classification:

1.Capsulitis and synovitis

2.Retrodiscita

I) Acute nonspecific arthritis:

1 Traumatic arthritis;

2.infectious arthritis;

3he rheumatoid arthritis

4 gouty arthritis

II) Specific arthritis:

1. Gonococcal arthritis

2 arthritis during acute polyarticular rheumatism

3 syphilitic arthritis

4 tuberculous arthritis

5 actinomycotic arthritis

III) Degenerative arthritis of the arthritic type (arthrosis)

102.Acute nonspecific arthritis: general data, etiology and pathogenesis, classification, pathological
anatomy.

They are usually one-sided.

Etiopathogenesis is due to the penetration of pathogens into the joint cavity.

Ways of penetration of germs into the joint cavity:

-direct: through open traumas

-in the neighborhood: by spreading infectious processes (mandibular osteitis, tympanic bone osteitis,
external auditory canal boil, suppurative otitis media, parotid abscesses)

-hematogenous: during infectious diseases (scarlet fever, measles)

Pathological anatomy-inflammatory process first affects the synovium and then the articular disc and in
some forms, joint surfaces and even bone. Initially these elements are infiltrated and then ulcerative or
proliferative lesions appear; the purulent septic process exceeds the capsule and extends to the
periarticular tissues.

103. Symptomatology of acute arthritis, diagnosis, evolution and complications.

The clinical picture is characterized by a symptomatic triad:

1) .pain; 2) .restriction of mandibular movements; 3) .signs of acute inflammation.

1) The pains located in the region of the diseased joint are spontaneous, intense, pulsating, radiate in
the ear, the temporal region and the genius. The pains are exacerbated at the attempt to move the
mandible.

2) The movements in the ATM are at first reduced and then become impossible due to: a) the pains that
cause them b) the interest of the closing muscles of the mandible. The patients had an analgesic
attitude: half open mouth, jaw slightly deviated from the healthy side. Chewing is impossible and
phonation difficult ; abundant salivation, embarrassment in swallowing.

3) Signs of acute inflammation-preauricular swelling that can bomb in the external auditory canal; the
skin covering the joint are congested. On palpation a painful kneading is perceived sometimes
fluctuating. Palpator the external auditory canal is very painful. Patients have fever, chills, etc.

Evolution, complications.
1) Mild congestive forms that do not reach suppuration are reversible and in 10-15 days the symptoms
recede and functions are fully restored.

2) Purulent forms tend to externalize and extend to adjacent tissues. Suppuration may open
spontaneously in the skin, before the tragus or in the external auditory canal may also extend to the
middle ear, mastoid, temporal bone, mandibular ascending branch, parotid.

Diagnosis is made on the basis of local and general signs. Radiographically in the early stage can be
found at most an enlargement of the joint space; in advanced stages there are irregularities and even
erosion of the contour of the mandibular condyle or the walls of the glenoid cavity. diagnosis to
convince us that it is pus, for therapeutic purposes to identify the causative germs and test their
sensitivity to antibiotics.

104.Treatment of acute arthritis.

In the initial stage of congestion, a local and general resolving treatment is made. Applications with
pruritus, possibly roentgenterapia in anti-inflammatory doses, where ultrashort, laser. Broad-spectrum
antibiotics are administered. In subacute forms, non-specific vaccine therapy is indicated. rest by
applying a chin frond. In the purulent forms confirmed by puncture, which is not cured only by local
resolving treatment and general treatment, arthrotomy is indicated. The joint is opened by a pretragian
incision and the purulent collection is drained. After the retrocession of acute phenomena it is necessary
to make active and passive mobilization of the joint and mechanotherapy, to prevent the installation of
constriction or ankylosis.

105 Chronic arthritis: etiopathogenesis, symptomatology.

Due to the lack of clinical signs of inflammation and the presence of dystrophic-degenerative lesions,
which affect all components of the joint, it was considered to be called arthrosis. In reality these
conditions begin and evolve for a long time in the form of nonspecific subacute arthritis in which
inflammatory clinical phenomena they are erased, uncharacteristic, later they become chronic,
producing a series of morphological changes of the periarticular and articular elements.

Etiopathogenesis-complex mechanism; most authors emphasize the role of traumatic factors. dental,
migration of teeth, prostheses and defective fillings that produce premature contact of the teeth,
blockages of the interdental joint with forced straightening of the movements of the mandible. articular
and paraarticular. From the beginning there is overload of the articular capsule which becomes
loose.Capsulo-ligament laxity entails mechanical overload of the meniscus, which will also undergo
transformations of subacute arthritis. Meniscus transformations are followed by changes in the articular
cartilage and even the bone heads. Local sufferings play an important role (rheumatism, chronic
evolutionary polyarthritis). ) and general (endocrine, metabolic disorders) in changes in bone heads.

Symptomatology - the clinical picture is dominated by pain, cracks and disorders in joint mechanics.

Pain-may be located in the region of the joint triggered by jaw movements or may look like facial
neuralgia without precise localization appearing irregularly and with different irradiations. Sometimes
the pain radiates to the ear, temple, forehead, kidney, tongue, throat. Oral and pain are varied :
continuous pain; painful background on which there are from time to time actual pain of varying
intensity described as pressure or lacinatory pain. Sometimes the pain is pronounced in the morning at
the first movements of the mandible and in the evening when the joint is tired; however the nights are
calm. The pressure on the joint exacerbates the pain spontaneously or triggers it when it does not exist.
Likewise, the pressures exerted on the masseter and temporally are extremely painful.

The cracks are noises or intra-articular cracks. They are felt on palpation, during the opening and closing
movements of the mouth, the examiner's fingers being inserted into the external auditory canals. At the
moment of the crack, the patient has a slight pain and sensation of moving the mandibular condyle. The
cracking occurs due to the impact of the mandibular condyle by the temporal condyle, at the moment of
the accentuated opening of the mouth the two bony elements no longer being separated by the
meniscus, come in direct contact, producing the characteristic noise.

Disorders in the mandibular mechanics translate into limiting and doubling the opening movement
which consists in an interruption of the opening of the mouth at an amplitude of 5-15 mm, the opening
then continuing to be difficult. Patients tend to be less prone to bite to the head and lateral movement
of the chin on the opposite side of the lesion or to the least affected part in case of bilateral
osteoarthritis.

Patients may also show neurological signs: headache, migraine, sinus signs: rhinorrhea, infraorbital pain,
salivary signs: sialorrhea, asia.

106 Chronic arthritis: diagnosis, evolution, treatment.

Evolution - atrophic lesions can lead to the installation of a mandibular constriction or irreducible
dislocations, as well as pseudotumor deformities of the mandibular condyle.

Diagnosis - The existence of the crack attests the interest of the joint. It is often difficult to distinguish
joint pain from neighboring pains (otic, parotid, dental, mandibular, sinus). Periarticular anesthetic
infiltration and intermaxillary blockage, followed by sedation of painful phenomena can be seen
establishing the diagnosis.

Treatment-Prophylaxis of chronic temporomandibular arthritis is done by removing the traumatic

occlusal-articular factors through correct prostheses, removal of defective prostheses, selective
grinding, occlusion elevations or descents, guiding movements of the mandible movements.

The treatment is aimed at removing the pain. The application of occlusal splints or palatal plates with
retroincisal plate put the joint at rest for a while and the pain recovers. If not intervened in the next 2-3
weeks to establish a guide and a convenient height of The pains can be relieved by periarticular
infiltrations with weak anesthetic solutions but reappear after a few hours if the joint has not been put
to rest. Rest can also be achieved by applying a chin leaf. If there are lesions of the bone heads. intra-
articular injections with hydrocortisone and penicillin can be given.

Meniscectomy, capsuloraphy or even resection of the mandibular condyle are exceptional methods that
are used when all therapeutic means are exhausted.

107 Mandibular constriction: etiology and pathogenesis, classification.

The constriction of the mandible is the permanent, total or partial limitation of the movement of the
mandible due to some diseases or sequelae after pathological processes of the periarticular tissues.

Etiopathogenesis-May be caused: periarticular, muscular and cutaneous-mucous.

Periarticular constriction occurs after suppuration or joint or periarticular trauma, after surgery on ATM
or incorrect treatment for ATM disorders, there is a sclerocicatricial transformation of the joint capsule
and ligaments that become inextensible, thus limiting mandibular movements.

Muscle constriction can be installed either by sclerosis of the lifting muscles or by hypertonia of these
muscles. Sclerosis of the lifting muscles of the mandible occurs as a result of muscle trauma,
intramuscular foreign bodies, viciously consolidated mandibular fractures, vicious callus, prolonged
perimandibular suppurations. Sclerotic transformation of muscle fibers that lose their elasticity, become
rigid. Prolonged hypertension can result in loss of elasticity and contractility, followed by retractility and
sclerotic transformation of the fibers of the lifting muscles of the mandible. Hypertonia can be due to an
irritating injury to the motor nerves. , either a permanent excitation of the motor neurons or the
inhibition of the central motor neuron.

The constriction due to the cutaneous-mucosa is due to the retractable, sclerotic scars of the cheeks and
masseter region, of the subcutaneous tissue, of the jugal mucosa. Following some traumas with loss of
substance, some burns of the face, some prolonged suppurations, some excised or irradiated tumors
remain scars or sclerotic flanges, retractable that impede movements.

108 Symptomatology of mandibular constriction, diagnosis.

Symptoms-limiting movements, especially those of descent and less lateral and propulsive movements.
The patient can not open his mouth due to an obstacle he perceives periarticularly, in the thickness of
muscles or cheeks. Forced opening of the mouth causes pain. The mandible tends to to deviate laterally
from the side of the lesion. At the inspection can be seen thickened, retractable scars, adherent to the
deep planes; endobuccally are present scars or bridles of the oral mucosa. The movements of the
mandibular condyle have a small amplitude, depending on the degree of constriction. for a long time,
there is also a erasure of the reliefs of the temporal muscles and masseters.The general condition is not
affected. Most patients manage to eat, consuming soft foods. Radiologically no injuries are observed in
the TMJ can be seen instead the possible causes that led to the installation of constriction.

The positive diagnosis is established based on clinical and radiological signs. The differential diagnosis
will be made with trismus and ATM ankylosis.

109 Conservative and surgical treatment in mandibular constriction.

Conservative methods aim at loosening scar tissue and mobilizing the mandible. Mechanotherapy
associated with physical agents is used. Mechanotherapy is done using devices that passively open the
mouth. These devices are inserted between the dental arches and activated to mobilize the mandible.
Heister-type dental arch spacers or special devices (Lebedinsky apparatus). The dilation is slow,
progressive and blind, dosing the force very well and avoiding brutal maneuvers, which could cause
pain. The amplitude of dilation is increased by 1-2 mm per day, and the exercises are continued for 30-
40 days. To more easily overcome the opposite resistance of the scar, it is recommended to inject
hyaluronidase into the full scar mass.Massage on the scar area or physical agents can also be associated
(ultrashort, CO2 laser with anti-inflammatory effect, X-ray in anti-inflammatory doses). After obtaining
the results, it is necessary to continue mechanotherapy to prevent recurrences.

Surgical methods are used only after mechanotherapy and treatment with physical agents have not
given results, aiming to remove the obstacle that prevents mandibular movements. They are expected:
simple section of the skin or mucous membranes, cross section of the bridles and longitudinal suture;
section of bridles and covering of bleeding surfaces with free Ollier-Tiersch grafts, slippery skin flaps in
the vicinity, disinsertion of the masseter and internal pterygoid muscles in cases of their sclerotic
sclerosis given by the sclero-cicatricial transformation of the temporalis muscle fibers. Mechanotherapy
is mandatory postoperatively.

110 Temporo-mandibular ankylosis: etiopathogenesis, classification.

Ankylosis is the permanent limitation of the movements of the mandible due to the organization of a
bone tissue that welds the mandible to the temporal bone, which leads to the disappearance of the
joint.

Etiopathogenesis-occurs more frequently in childhood, is more often unilateral and rarely bilateral.
Causes of ankylosis: after trauma, after loco-regional infections, after chronic evolutionary polyarthritis.
Traumatic injuries followed by temporo mandibular ankylosis are in order of frequency: intra-articular
fractures , fractures of the glenoid cavity, bone and meniscus injuries due to obstetrical trauma, joint
wounds. These traumas are most often indirect. The most common causes of postinfectious ankylosis
are: otomastoid suppurations, suppurations located around the ascending mandibular branch, scarlet
fever. infections destroy the articular elements, especially the cartilage and the meniscus, so that,
between the bare bone surfaces,a fibroconjunctival tissue is organized at first, which later turns into a
more or less voluminous bone callus. The average time to install a post-traumatic ankylosis is 5 months
for direct trauma and 18 months for indirect trauma and is faster at children and slower in adults.

111 Symptomatology of mandibular temporomandibular ankylosis.

Total absence of mandibular movements. In partial ankylosis, the dental arches can be removed at a
distance of 0.5-1 mm. In unilateral ankylosis, the chin is deviated on the diseased side. The
hemimandibula on the diseased side is shorter, thinner, but appears prominent. , and the one on the
healthy side, of normal length, with an open mandibular angle, appears flatter. The interincisal line is
deviated from the diseased side. On palpation, the bone block is perceived on the diseased side and on
the healthy side the condyle movements are transmitted very little or sometimes not. In bilateral
ankylosis the chin relief is erased; the baribula is much retruded and the patients have a characteristic
aspect of bird profile. The interincisive midline is preserved and the lower incisors are much
vestibularized, arranged obliquely in fans, they come in contact with palatal fibromucosa.Due to the lack
of self-cleaning, the teeth have massive deposits of tartar with chronic marginal periodontitis. There are
important functional disorders: mastication is suppressed, defective phonation, the voice is whistling
between the teeth and has a low intensity.

112 Treatment of temporomandibular ankylosis.

To prevent ankylosis in children it is good to institute a correct treatment of traumatic and inflammatory
diseases that can lead to ankylosis. Any fall or blow to the chin must be followed by a thorough
examination of the joint. In case of condylar fracture, immobilization will be followed by
mechanotherapy. It is necessary that after regional infectious accidents to establish an active therapy,
specific to prevent the formation of ankylosis.

In organized ankylosis, the only treatment indicated is the surgical one. Thus, the aim is to create a new
joint, in order to restore the movements of the mandible. Several surgical methods were used, some of
which were completely abandoned, the results being unsatisfactory: simple sections of the branch.
mandibular ascent at various levels did not give good results because between the bleeding surfaces a
bone callus is formed. The modeling resections of the bone block and the formation of a new joint as
close as possible to its normal place usually lead to recurrences. To prevent recurrence, fascia
interposition was proposed. wide, fats, muscles, silicones. It seems that silicones would give lasting
results so the silicone foil would induce the formation of a connective capsule on the bone
surfaces.Valerian Popescu uses arthroplasty with total skin interposition. The skin inserted between the
two bleeding surfaces prevents the restoration of the bone callus, induces cartilaginous metaplasia with
the functional structuring of the neoarticulation elements. Mechanotherapy until spontaneous
resumption of movements is mandatory.

113 Pain in the OMF territory: general data, pathophysiology, classification.

Pain is defined as an unpleasant sensory and emotional experience, associated with real tissue damage,
but also through threat or imagination.

Pain being subjective can only be measured and expressed in subjective terms. For these reasons it is
difficult to differentiate between a real pain, somatic and a mental or simulated.

Depending on the location of the pain, we distinguish:

1 local pain - representing a somatic, superficial pain that coincides with the tissue area irritated by
physical or chemical factors.

2 projected pain-representing a painful response located precisely in the peripheral distribution area of
the sensory nerve that transmitted the primary afferent impulses.

3 transmitted pain-pain is transmitted to the periphery in a place other than the causal one and not
along a precisely defined anatomical pathway.

Pathophysiology of pain

Pain is a warning signal to the body, which involves three major components: 1 perception 2 emotional
or emotional state 3 reaction.

Depending on the characteristics of the pain (origin) we distinguish:

1 Somatic pain;

2 neurogenic pain;

3 psychogenic pains.

In the oral-maxillofacial pathology there are various types of pain

a) epicritic-as in essential trigeminal neuralgia.

b) protopathic-caused by occlusal-articular imbalance or vascular syndromes

c) mixed, associated.

114 Essential trigeminal neuralgia: etiology and pathogenesis.

Essential trigeminal neuralgia is known by various names: idiopathic trigeminal neuralgia, painful facial
tick, epileptiform neuralgia, prosopalgia, primary trigeminal neuralgia. The onset and dominant
symptom is pain of an unusual intensity and intensity. advanced age, the female sex being more often
affected. A curious and unexplained Inca fact is the predisposition for the second branch of the
trigeminal nerve for the right side of the face.

Ethio-pathogenesis-painful crisis is triggered by the excitation by a weak stimulus of a restricted area-

cutaneous, gingival or mucous-always the same and which is called the painful area or trigger zone.
Stimulation can be represented by a slight touch, a vibration or a distortion of said tissues.

The causes and mechanisms of essential trigeminal neuralgia are unknown and much discussed. In a
large number of patients, the presence of irritable factors located in the postganglionic fibers, in the
Gasser ganglion or even in the pontocerebellar angle was observed. Among these factors would be:
compressions of the vessels, which have changed with age, caliber, shape and structure that come into
direct contact with nerve formations, some tumors such as angiomas, meningiomas, etc.

Other authors consider that the paroxysmal lightning discharges would be due to a short transaxonal
circuit of the action current along the nerve fibers. The phenomenon would be favored by atrophies of
the myelin sheaths following light and long-lasting compressions. These atrophies of the myelin sheaths
would allow the passage of the current of action from a nerve fiber to the neighboring one through false
synapses or the excitation of small, non-myelinated fibers that are involved in the conduction of painful
stimuli.

The hypothesis of the central origin of trigeminal pain is increasingly discussed with its epileptiform
character or as a positive response to treatment with atiepileptic medication. trigeminal neuralgia has a
peripheral cause and a central physiology.

115 Symptomatology of trigeminal neuralgia.

The onset of pain is sudden, sudden, of a violence and intensity that have no equivalent in human
medicine. Paroxysm surprises the patient in full health, unannounced by prodromal signs. The schedule
of pain is day and not night. The duration of the crisis from the beginning is several fractions of second,
it disappears instantly, without echo, leaving full health. The recurrence of paroxysm is possible after a
variable interval, of weeks, months or even years, the period in which the patient can be in a perfectly
normal state. between crises it decreases, finally reaching sub-incoming crises, and the duration of the
crisis itself passes from fractions of seconds to seconds and minutes.

The location of the pain is strictly related to the territory of a trigeminal branch. But related to this
problem, it should be noted that after the disease has aged and after the treatment, the location of the
pain is not as rigorous as at the beginning.

As the disease ages, the clinical picture becomes more complex: if initially the crisis is triggered
spontaneously, without being triggered by later stimuli, it is triggered under the influence of common
tactile stimuli, such as touching a certain area of the face, blood flow, etc. It then outlines skin or
mucous membranes relatively well circumscribed as trigger areas (trigger or discharge area) that can be
located in any part of the territory innervated by the trigeminal nerve. Patients afraid of not starting a
new crisis cover their face, avoid brushing your teeth and eating in a precarious physical condition. In
most cases the painful drama is associated with hemifacial muscle contracture are also possible
phenomena such as hyperlacrimation, nasal hypersecretion or stuffy nose.Immediately after the end of
the paroxysm follows the so-called refractory period in which any stimulus applied in the trigger area
does not trigger a new crisis. A specific feature is the lack of objective clinical or paraclinical elements of
organic suffering of the trigeminal nerve.

116 Conservative methods in the treatment of trigeminal neuralgia.

Drug treatment uses anticonvulsant medication. One of the anticonvulsant medications used to treat
trigeminal neuralgia is oxcarbamazepine, topiramate. Baclofen is useful in those who do not tolerate
carbamazepine or as an adjunct to one of the anticonvulsants.

Carbamazepine: starting dose 300mg \ day, maintenance dose 1500-2000 mg / day

Baclofen: 15mg \ day; 80mg \ day

117 Physiotherapeutic methods, drug blockage in the treatment of trigeminal neuralgia.

1. Anesthetic chemical blockage - peripheral trunk infiltration with additional novocaine with sedative
and hypnotic medication.

2. Tissue therapy-introduction of subcutaneous sciatic nerve homograft in the subscapular area.

3. Transcutaneous electrical nerve stimulation is based on the principle of acupuncture. So after using
the device in the given area, a paresthesia is installed that suppresses the pain.

4. Trigeminal neurolysis - aims to suppress nerve conductivity by lysis.

There are 3 ways to nerve lysis

1) chemical neurolysis is done with absolute alcohol or anhydrous glycerol.

2) thermal neurolysis-a) low temperature: cryotherapy or freezing,

b) high temperature-thermocoagulation by injection of hot liquids, by electric cleaning or by

radiofrequency lesions of the ganglion.

3) compression neurolysis - follows the lysis of the Gasser ganglion by a microcompression with a
balloon.

118 Surgical methods (peripheral neuroectomies) in the treatment of trigeminal neuralgia.

The three terminal branches of the trigeminal-supraorbital, maxillary and mandibular nerve are easy to
approach when they come out of the bone holes. To obtain a longer period of calm it is not enough to
interrupt nerve conductivity by neurotomy because in a relatively short time the sensory nerves
regenerates. With the healing of the nerve wound and the resumption of the transaxial circuit, painful
seizures are installed. Consequently, it is necessary to suppress a longer portion of the nerve thread,
which contributes to increasing the duration of pain remission. The intervention is called neurectomy.

119 Symptomatic or secondary facial neuralgia.

These neuralgias are due to precise causes. At the level of peripheral endings, certain peculiarities
characteristic for the respective condition. In the oral-maxillofacial affections the pains are accompanied
by the characteristic signs of the respective disease and by a careful examination the diagnosis can be
made with certainty. Pain in dento-periodontal diseases is characteristic for the respective lesions.
Extradental pains: tumors of the jaws, maxillary sinusitis, suppurations of the soft parts, perishable
abscesses, etc. they can mimic the appearance of neuralgia.

120 Neuritis and traumatic injuries without or with interruption of nerve continuity (causes,
evolution, clinical picture, treatment.)

121 Trigeminal nerve neuritis (etiology, clinical picture, treatment).

Neuritis is an inflammation of the nerve. It can be caused by trauma, regional inflammatory processes
including those of odontogenic origin, various infectious diseases and toxicosis, allergies to dentures.

Clinical picture-pain in the region of the affected nerve projection, hypoaesthesia of the teeth, gums,
skin tissue of the lips and chin, paresthesias, tingling and stinging. of the mucous membranes of the oral
cavity.

The basic symptom in the case of neuritis is the pain, which appears suddenly, permanently, stinging,
which intensifies when pressed on it. Periodically it may intensify or decrease from time to time but
remains persistent over time. there are paroxysms and missing trigger areas. In severe forms the patient
may have painful shock in mild forms patients do not have major disorders.

Treatment depends on the etiology, but the treatment is based on anti-inflammatory therapy. In case of
trauma, the factors that traumatize the nerve are removed or it is sutured in case of rupture.

In case of inflammation, the disease that caused the local infection is treated. Likewise, in allergies and
intoxications, the causal factors are eliminated.

In the treatment of neuritis, physical treatment methods are used such as: fluctuation, lidase
electrophoresis, vitamin B, anesthetic substances. Complex treatment can also be used using the
following preparations: salicylates, galantamine, dibazole, prozerin.

122 Facial nerve neuritis (etiology, clinical picture, treatment). See trigeminal nerve.

123 Indications for tooth extraction in mandibular fractures.

I) the teeth from the fracture focus are extracted at the moment of immobilization in the following
situations

2. teeth with corono-radicular fractures and which are irrecoverable;

3. teeth dislocated during trauma (grade II, III)

4. Teeth that prevent the reduction of fragments in the correct position.

II) Teeth from the fracture site that are extracted 12-15 days after intermaxillary immobilization
 1. teeth from the fracture focus that contribute to the stabilization of the fragments and do not allow
their ascension, but have corono-radicular destruction, chronic periapical foci, interradicular fractures in
pluriradicular teeth

2. semi-included teeth, located at the level of the fracture focus - especially molars 3 in mandibular
angle fractures when they were not extracted before the application of orthopedic treatment because it
would have led to instability of bone fragments.

LIOSHA

150.Organization of OMF surgical assistance in the national army of the Republic of Moldova.

The basis of the stom assistance in the military units is represented by the rehabilitation of the soldiers. It is
performed once every half year according to the plan. Military units that do not include a dentist at the medical
point are rehabilitated by dentists from neighboring or nearby military units, sometimes for this purpose civilian
dentists can be called. Military units (in which there is no stomata) that are far from hospitals, and units with
medical points serve the mobile dental offices (USSR).

* 10 group soldiers, led by sergeant-sanitary instructor

* 30 company soldiers, led by a lieutenant, and 3 sanitary instructors

* 90 platoon soldiers, led by a captain, 9 sanitary instructors

* 300 battalion soldiers, led by a major, 27 sanitary instructors and felcer

* 1000 soldiers-regiment (division, brigade), led by a colonel or brigadier general, medical point of the brigade-
led by the chief doctor, the attending physician and the dentist.

151.Organization and volume of oral surgery assistance in dental offices (mixed) within the medical services
of large units.

The totality of dental services in the military units can be represented by the following positions:

• Examine the new incorporated soldiers and note the soldiers that require assistance
• Treatment and filling of decayed teeth, with pulp, periodontitis
• Extraction of affected teeth and dental roots, which are not subject to conservative and surgical treatment
• Outpatient and inpatient treatment of soldiers with inflammatory diseases OMF
• Removal of dental deposits and complex treatment of periodontitis with the application of all contemporary
remedies
 • Treatment of diseases of the mucous membrane and the tongue
• Timely detection and complex treatment of patients with OMF tumors
• Providing qualified and specialized first aid in the case of OMF injuries
• Training the soldiers in cav hygiene
• Evidence of statistical data regarding OMF diseases
• Training of dentists and dental technicians in military units.

152 Organization, volume and functions of OMF surgical assistance in time of war or calamities
(pre-hospital and hospital stages).
Pre-hospital stage:

• Self-help and mutual aid (by the health instructor), (10 soldiers)
• First aid provided by the felcer
• First aid
Hospital stage:

• He is sent to the respective medical centers - qualified medical help

• Specialized military hospitals - qualified specialized medical assistance

153. Peculiarities of gunshot wounds of the face.

1) the inlet port is smaller than the outlet port
wound channel shapes:

- bipolar (transfixianta)
- blind
- tangentially
- solitary
- multiple
- penetrating
- Non-penetrative

2) Primary necrosis (wound edges)

Mechanism: -mechanical destruction
-thermal energy (burns) in which the kinetic force of the bullet passes
3) Secondary necrosis (molecular concussion region)
- after washing the wound, apply 2 tubular drains, which are kept for 10-12 days, on one is introduced soil for
washing the wound, on the other the pus is extracted
4) distant lesions (bullets cause damage to the tissue. Around this wound they press on the vessels; or mains thus
transmit strong oscillations on the whole vascular system →in the brain, the spleen begins to burst the vessels - micro
hemorrhages)
- treatment as in concussions → 10-20 days - bed regimen, sedatives, dehydrators, and maintaining BP below
normal blood pressure.
5) all wounds through the gun seal st infected.
6) bone fractures often have a multi-skeletal character ...
7) we often find foreign bodies in the plague.
 154. Anatomical-physiological features of OMF lesions caused by a firearm.
Anatomical-physiological features:

- Abundance of nerve branches→shock, paresis, functional disorders.

- Intense vascular network→hemorrhage, embolism, blood clots, swelling
- Present m. Mimici→ plagi biante

(I) canon –The appearance of the trauma does not correspond to the severity of the wound ...

- teeth can become second shells

- cavity piece-source of infection
- the vicinity of the vital organs-the brain
- neuro-vascular buses
- airways (edema, asphyxia0
- visual, olfactory, auditory organs
- feeding and dictating with difficulty
- the existence of cavities (nasal, buccal, maxillary)
- salivary glands (salivation intensifies in case of trauma)

155. Classification of OMF war wounds and injuries (general data, basic principles).
I. Wound gunshot wounds:
1) Dependence on affected tissues:
a) Soft tissue wounds
b) Soft tissue wounds with damage to the skeleton:
- mandible
- maxilla
- Both jaws
- Zygomatic bone
- At the same time, damage to some bones of the facial skeleton
2) Dependence on the character of the lesion:
a) penetrating
- Isolated without affecting the organs of the facial mass (eyes, tongue, salivary glands, etc.)
- With damage to the organs of the facial mass
b) Not penetrating / blind:
- Associated (simultaneously with wounds of other regions of the body)
- unitary
- Penetrating into the nasal, oral, sinus cavities.
- Not penetrating.
c) tangential
3) Weapon addiction (which caused the injury):
a) bullet
b) shell
II. Wounds not caused by firearms.
III. Combined wounds
IV. burns
V. frostbite

156. Classification of injuries by firearm of the mandible.

In the case of gunshot injuries, bullets or shells, having a high kinetic force, often affect the mandible, fracturing
it concomitantly in several places, provoking, more often, squamous fractures (up to 70% of all fractures). There
are the following types of mandibular fractures:

1) Linear type fractures

2) Squamous fractures (small and large splinters) with disruption of axillary integrity.
 3) Marginal fractures (with different character) with preservation of the integrity of the jaw.
4) Perforating fractures (hole shape)
5) Fractures with segmental defect of the jaw.
6) Lack of significant portions of bone tissue from the integrity of the jaw.
7) The association of these types of fractures.

157. Classification of facial soft tissue injuries caused by firearms and during calamities, frequency,
evolution.
The soft tissue lesions of the OMF region have a number of peculiarities:

- There is a permanent edema (due to the pronounced vascular network)

- Due to the mimic muscles→ waterfall wounds, simulating lack of tissue.
- Injuries / defects of the lower lip→ permanent saliva leakage→skin irritation and swelling.
Dependence on affected tissues:
a) Soft tissue wounds
b) Soft tissue wounds with damage to the skeleton:
Dependence on the character of the lesion:
c) penetrating
- Isolated without affecting the organs of the facial mass (eyes, tongue, salivary glands, etc.)
- With damage to the organs of the facial mass
d) Not penetrating / blind:
- Associated (simultaneously with wounds of other regions of the body)
- unitary
- Penetrating into the nasal, oral, sinus cavities.
- Not penetrating.
e) tangential

Weapon addiction (which caused the injury):

a) bullet
b) shell
Dependence on the affected region and frequency: (data from World War II)
- Cheek 41.2%
- Associated traumas of several facial regions 37.2%
- Mouth corner and mandible angle 9.6%
- Barbia 5.6%
- 4.0% lips
- Mandibular regions 1.4%
- Other regions of the girl 1.0%

158. Classification of injuries by firearm of the jaw, frequency, evolution.

Jaw fractures:

I) Alveolar teeth and apophyses

II) Defective maxillary body in the dental arch
- With unilateral opening of the sinus
- With bilateral sinus opening
III) Typical of Le Fort.
IV) With damage to other organs (ENT, CNS, ophthalmic)
V) With various shapes of large / small scales
VI) With subtotal defect
VII) With total defect
 Frequently:
During the years 1998-2002 in the OMF section. 108 patients with upper jaw fractures were registered:
- Le Fort I ----- 22%
- Le Fort II ---- 61%
- Fort III ---- 17%
• Of all the fractures in the OMF and middle region, 11-30%
• evolution:
In the case of trauma by the firearm of the jaw, the main trauma belongs to the area where the force was applied
(wet bullets / shells acted, etc.) if the force was applied in the area of high resistance.→ disorders in the contact areas
(may be with low resistance)→on the apophyses starting from the jaw. The formation of a canal is characteristic of
gunshot wounds. Depending on the direction of the canal at the same time as the jaw, the bones of the base of the
skull, the brain, the ENT organs, the orbits, various blood vessels and nerve formations can be traumatized.
In general, middle-floor fractures have a great healing potential, consolidating faster than those of the mandible.
It is due to the spongy structure of the bone and the special vascularization. Thus, the fibrous callus is formed in 8-
10 days, after 4 satamins, having produced the consolidation with the disappearance of the abnormal mobility.

159. General symptoms of gunshot wounds of the OMF region.

Due to the high vascularization of given regions there are massive hemorrhages with the onset of anemia,
general weakness (in case of massive blood loss) asphyxia, concussion or stroke, emboli. Installation of traumatic
shock. Disorders appear on the nervous background due to the loss of functions (phonation, swallowing, feeding)
and the disorder of facial aesthetics.

Psychic disorders on the background of physiognomic disorders.

160. Local symptoms common to all firearm injuries in the OMF region.
Particularly serious are injuries with the destruction or removal of entire facial fragments (lips, cheeks, chin,
nose) when several components are included in a single massive bleeding lesion. Usually such injuries are caused
by massive shells. Tangential wounds cause cascading wounds but they can cause injuries that completely remove
jaw fragments, soft tissues, nose or tangential wounds by its character are similar to cut wounds, but on closer
examination, we find: small tears, destruction, contusions of the edges and tissues adjacent to the lesion, infection
of the wound with impregnation of dust particles of "rifle".

Due to the proximity to vital organs, blind wounds have a very dangerous character because they can cause
trauma, in the first invisible period of the brain, the walls of large blood vessels of the face and neck, nerves,
esophagus, trachea or Danger. a purulent or purulent necrotic process in the depth of the affected tissues.

161. Types of OMF gunshot wounds.

• Wound gunshot wounds:
• Dependence on affected tissues:
c) Soft tissue wounds
d) Soft tissue wounds with damage to the skeleton:
- mandible
- maxilla
- Both jaws
- Zygomatic bone
- At the same time, damage to some bones of the facial skeleton
• Dependence on the character of the lesion:
f) penetrating
- Isolated without affecting the organs of the facial mass (eyes, tongue, salivary glands, etc.)
 - With damage to the organs of the facial mass
g) Not penetrating / blind:
- Associated (simultaneously with wounds of other regions of the body)
- unitary
- Penetrating into the nasal, oral, sinus cavities.
- Not penetrating.
h) tangential
• Weapon addiction (which caused the injury):
c) bullet
d) shell
• Wounds not caused by firearms.
• Combined wounds
• burns
• frostbite

162. Methods of diagnosis of gunshot wounds.

• Diagnosis:
• Collection of the anamnesis
• Studying the documentation
• Studying the wound canal
• Palpation of the region (foreign body placement)
• sounding
• Radiography (minimum in 2 incidences)
• radioscopy
• endoscopy
• Fistulography
• Use of the radio probe
• TC
• The clinical signs can be varied, the integrity of both soft and hard tissues can be disturbed, and can
vary from small to large. Presence of canal orifices, proper and secondary canals, primary and
secondary necrosis.
- Tangential wounds - approximately linear (like the cut ones). Irregular wound edges, small tissue tears, dirty
wound impregnated with gunpowder.
- Blind wound - the presence of the inlet, the canal and the foreign body. The appearance of purulent processes.
Frequently the foreign body is encapsulated.

163. Psycho-emotional peculiarities of the wounded by firearms of the OMF region.

❖ Face - appreciates individuality.

❖ Combined trauma - physical and moral trauma.
❖ Training of medical staff, training of relatives
❖ Fight with the mirrors
❖ Creating information panels with images before and after treatment.

164. Peculiarities of the clinical evolution of firearm lesions of the OMF soft parts (by region, areas of
destruction, periods).

The wounds of the Maoi tissues of the OMF region have a number of peculiarities:
-in the case of wounds in the region of the lips and permanent cheek, it is characteristic to develop a
pronounced edema, which makes it difficult to eat and dictate

-creating cascading wounds (due to mimic muscles)

-characteristic for trauma to the lower lip and corner of the mouth, especially with tissue loss is the permanent
leakage of saliva that irritates the wound and skin

-common for all soft tissue wounds of the lateral region is that the tissues have a lower regeneration capacity
and a lower resistance to infection compared to the middle region of the face

-wounds of the lateral region in most cases are affecting the parotid gland and facial nerve, which aggravates
the clinical picture and can lead to severe consequences (disorder of mimicry due to muscle paralysis and
salivary fistulas)

-massive cheek defects lead to pronounced functional disorders (phonation, eating disorder; fetid odor;
permanent hypersalivation; facial paralysis)

-wounds of the submandibular region permanently result from the presence of pronounced edema,
infiltration, blood leakage and the tendency to develop inflammatory diseases. May be accompanied by
damage to the vessels, nerves of the submandibular salivary gland, larynx and pharynx

- the wounds of the nose are quite varied, they are permanently associated with other lesions. Among other
things, all nasal wounds have a favorable prognosis, compared to infrequent infectious complications

-the wounds of the tongue have very serious consequences. The lateral surfaces are most affected, then the
apex, less often the dorsal surface and the root of the tongue. When the oral floor is injured, the ventral of the
tongue is often affected. In case of lingual edema-danger of asphyxia.

Prerioadele:

I - approximately 48 hours after injury, traumatic edema without pronounced signs of inflammation of
infectious etiology. This period is considered the most favorable for primary surgical treatment and in some
cases for primary plastic surgery.

II - from the 3rd day until the final cleaning of the wound and the creation of visible granulations. It is
characterized by the presence in the wound of inflammatory processes with infiltrations in the wound of the
surrounding tissues, exudate, sometimes pus, and in the case of wounds penetrating the oral cavity the
appearance of necrotic infection. At the end of days 8-12 the wound is clean serum and visible granulations
appear. Purpose of treatment-limiting inflammatory processes and accelerating the evacuation of necrotic
tissues

III - granulation of the wound. Secondary wound processing and early operations are indicated

IV - epithelialization and wound healing

165. Clinical evolution of firearm bone skeletal lesions.

 Clinical evolution

General symptoms

➢ Lively, strong pain, accentuated by movements or pressure;

➢ Abundant hemorrhage of various types;
➢ Functional disorders (phonation, mastication, swallowing, breathing, visual, auditory, nervous
activity);
➢ Pathological mobility;
➢ Occlusion disorders;
➢ Sensitivity disorders;
➢ Edema and the presence of the INFECTIOUS process;
➢ Lack of substance and the presence of foreign bodies;

166. General and local treatment of gunshot wounds to the soft parts of the face.

The main purpose of wound treatment is to optimize healing conditions and consists of:

➢ Local regeneration optimization measures:

• Aseptic dressings;
• analgesics;
• Ensuring the calm of the traumatized place (immobilization)
• Surgical debridements;
• Surgical wound debridement includes the following steps:
✓ Preparation of the operating field by washing, if necessary berbering and antiseptic processing;
✓ Anesthesia (general, truncated or local);
✓ Abundant washing of the wound with substances intended for this procedure and removal of
foreign bodies;
✓ Wound enlargement incision to be able to visualize the extent of the lesions (the procedure is
performed if necessary);
✓ Excision (refreshment) of wound plans;
✓ Thorough hemostasis;
✓ Suturing with the restoration of damaged anatomical structures;
✓ Drain.
• Chemical debridements;
• Local drug stimulation of epithelialization
➢ General regeneration optimization measures:
• antibiotic therapy;
• General drug stimulation of regeneration;
• Immunotherapy.

167. The main requirements and peculiarities of the surgical processing of firearms wounds of the OMF
region.
▪ Peculiarities of processing and surgical toilet of wounds reg. FMO.
▪ I period (preparation of the patient for surgery):
- removing dirty clothes
 - hair milling

- face treatment with antiseptics

- irrigation of the oral cavity

- wound irrigation

- wearing operating clothes

▪ II period (surgery):
- facial skin treatment with alcohol 70 degrees (from top to bottom, from wound to
periphery, from processed 3 times)

- wound isolation

- local anesthesia

- removal of foreign bodies

- proper surgical processing

- processing the skin with alcohol around the wound

- incision on the larger diagonal of the wound

- wound revision: + permanent cessation of hemorrhage

+ excision of primary and secondary necrosis

+ removal of blood clots

+ control of second channels

+ removal of small scales and foreign bodies

+ establishing the character of bone fractures

+ establishing lesions of the mucosa and other organs

- processing of bone wounds:

+ repositioning of fragments

+ fixation (osteosynthesis, osteoplasty)

- suturing the mucosa of the oral cavity (hermetic double suture)

- antiseptic treatment of the wound (exchange of gloves and tools - wound isolated from the
oral cavity)

- infiltration of the wound walls with antiseptics, antibiotics (from skin to wound)

- suturing the wound in layers

with the installation of drains.

168. Primary surgical treatment of gunshot wounds of the OMF region.
1. WOUND INCISION - its transformation into a crater
to open the channel path and have

access to all damaged outbreaks;

2. EXCISION - removal of all non-viable tissues, which are the substrate for the spread of foci of
secondary necrosis on the perimeter of the canal itself;

- thorough hemostasis with the removal of massive intratissue and subfascial hematomas;

- removal of foreign bodies and free bone fragments;

- adequate drainage of all wound canal pockets;

3. RECONSTRUCTION AND RESTORATION of formations

injured anatomical;

169. General and local clinical picture (features) of firearm lesions of the bones of the facial skeleton.
Clinical evolution

General symptoms

➢ Lively, strong pain, accentuated by movements or pressure;

➢ Abundant hemorrhage of various types;
➢ Functional disorders (phonation, mastication, swallowing, breathing, visual, auditory, nervous
activity);
➢ Pathological mobility;
➢ Occlusion disorders;
➢ Sensitivity disorders;
➢ Edema and the presence of the INFECTIOUS process;
➢ Lack of substance and the presence of foreign bodies;
➢ The presence of multiple sequelae;
➢ The presence of foreign bodies;
➢ The presence of the wound canal;
➢ Presence of the area of primary and secondary necrosis (molecular concussion);
➢ The presence of the infectious process;
➢ The speed of changing the clinical picture

170. Local and general treatment of wounded with lesions of the bones of the facial skeleton.
General treatment of bone injuries with a firearm

o Analgesics (analgin, ketorolac, tramadol);

o Antibiotics (lincomycin, oxacillin, amoxicillin);
o Antifungals (fluconazole, ketoconazole);
 o Desensitizers (suprastin, taveghil, diprazine);
o immunomodulatory;
o Vitamin therapy;
o Proteolytic enzymes;
o Infusion solutions (0.9% NaCl, 5% glucose, CaCl2).

Local treatment of bone wounds with a firearm

➢ Primary surgical treatment of wounds:

• Operating field processing;
• Performing local or general anesthesia;
• Removal of foreign bodies;
• Removal of the area of primary and secondary necrosis;
• Antiseptic wound treatment;
➢ Repositioning of bone fragments;
➢ Immobilization of bone fragments;
➢ Drain application;
➢ Applying the dressing.

171. Methods of immobilization of bone fragments in firearm lesions of the splanhnocranial bones.
Bone immobilization methods

• Emergency immobilization: chin frond, chin-cephalic dressing, bimaxillary fixation of splints (individual
ICTO, Rowe, Vasiliev, etc.);
• Orthopedic immobilization;
• Surgical immobilization (Osteosynthesis) :
✓ with metal wire;
✓ with absorbable or non-absorbable plates;
✓ chemical (substances based on a mixture of resin with bone meal and fibrin powder).

172. Peculiarities of care and feeding of the wounded with injuries of the OMF region.
▪ power:
❖ Enteral method: - oral
- endogastric

- duodenal

- rectal

❖ Parenteral method: - intravenous

- subcutaneous

- intramuscular

• Adequate and balanced qualitative and quantitative nutrition;

• Bed regime;
• Use of liquid foods rich in lipids, proteins, carbohydrates, mineral salts, vitamins;
• Feeding with straw or nasogastric tube;
 • Psychological care of the patient

173. Dressings, drains used in the care of wounded with OMF lesions (indicated, purposes).
Sterile, compressive or decompressive dressings are used (depending on the topographic location of the
lesions) Special systems are used through perforated tubes - in case of wounds with the presence of the canal.
In the case of superficial tissue wounds (skin, superficial muscular layers) the drainage is free, the lesion being
wide open, or with a rubber band (in the case of foreign body scales)

174. The succession of stages of processing different tissues in gunshot wounds.

1) Processing of the operative field-alcohol 3 times-skin; furacillin, potassium permanganate, hydrogen
peroxide.
2) Isolation of the operating field with sterile material
3) Anesthesia (general or peripheral trunk with premedication)
4) Washing the wound with antiseptic solution
5) revision:
-hemostaza;
-removal of foreign bodies;
6) Reposition of fragments
7) Immobilization of small fragments
8) repeated wound washing with antiseptic solutions
9) layered sutures:
-resolvable thread resolutely (catgut) -mucosa and deep layers
-non-absorbable atraumatic thread-skin
-in case of open fracture the fracture is reduced, we suture the mucosa (we change the instruments and
we process the wound with antiseptics) and then we suture the other tissues
10) draining
11) infiltration with antibiotics
12) be antitetanic
13) sterile dressing

175. Rehabilitation of gunshot wounds in the OMF region.

Physical culture-specialists trained in this field

The need for the existence and creation of special trainers

Social rehabilitation (psycho-emotional training) is spent by doctors

Preventing that the treatment process will involve several stages of surgical and drug treatment

176. Associated and combined trauma through firearm, peculiarities, diagnosis and treatment.
 • Combined injury- concomitant action on the organs of two or more harmful factors (mechanical
trauma + combustion + electric current + irradiation, etc.)
• Associated trauma-the action of a harmful factor on the body that causes damage to several forms of
tissue and certain regions

177. Methods of diagnosis of foreign bodies in blind wounds.

178. OMF thermal injuries, general data, particularities.

Thermal burns: they are due to the action of heat on the skin and tissues in their contact with a thermal agent.
The heat becomes harmful to living tissues when it exceeds 46 gr C.

 Frequency of facial burns during war.

 In the Second World War, OFO burns were:
 Aviators - 1%
 Tankers - 35%
 In the war in Afghanistan, OFO burns accounted for 5%.
 During the explosion in Hiroshima and Nagasachi, omf burns accounted for 75%.
 In peacetime burns omf constitute 5-10% of trauma.
Peculiarities of the burnt omf region:

Skin due to:

 Different nerve relief - at the three facial stages - will determine between 1 - 4 degrees of depth
in combustion (more pronounced in the nasal spine, eyelids and less pronounced in the
parotidomasometric region); it is not recommended the massive removal of the mortified
tissues in the first 2-3 weeks after the combustion, thus the soft tissues will be massively
exposed, as a consequence the painful shock, the sequelae will be installed.
 Intense vascularization - pronounced edema prone to infection will form.
 Increased elasticity - wounds become larger than the affected area, and grafts (excised by the
skin) become smaller than the area taken.
 Increased mobility - may decrease in sclerosis processes (scars, secondary sclerosis) with the
formation of aesthetic defect. The scars regulate the innervation of the skin at different
morpho-functional layers.
 The presence of glands (sweating, sebaceous) - whose products of nitrogen metabolism (urea,
salts) irritate the burnt wound.
 The presence of the upper respiratory tract - which is affected requires tracheostomy.

 The systemic manifestations generated by the burn injury are generically called "general burn
disease". They occur when the burn covers over 25% of the body surface in the case of a healthy
adult, but are also common in smaller areas (10-15%) in the case of young children, the elderly
or adults with inhalation injuries. The onset of "general illness" includes the patient in a group
with a poor prognosis, defining "major" burns.

179. Classification of thermal injuries. Frequency of facial burns during war and calamity.
 BURN CLASSIFICATION:
* In relation to the vulnerable agents, the burns are classified in:

- thermal: produced as a result of the action of heat

 - chemicals: result of the action of some chemical substances (acids, bases)
- electrical: appeared under the action of electric current
❖ In our country, burns are classified into four degrees of perfume:
Grade I

- damage to the epidermis with minimal and reversible lesions; the skin protection function is intact or
very little altered.

Clinical: erythema, edema, pain.

Evolution: spontaneous healing without scarring

Grade II

- deeper damage to the epidermis to the basal layer due to which the skin regenerates.

Clinical: flicten is added

Evolution: it can become infected, otherwise it heals without scarring.

Grade III

- affects the entire epidermis and part of the dermis.

Clinical: bloody blister, pain, amplified edema.

Evolution: sometimes they can heal spontaneously but with

vicious scars, often complicated by infection in the absence of qualified treatment

Grade IV

- coagulation necrosis of all skin layers and damage to the underlying tissues (muscles, even extremities
and bones.)

Clinical: brown-black eschar

Evolution: spontaneous healing is not possible.

180. Burns disease.

The systemic manifestations generated by the burn injury are generically called "general burn disease". They
occur when the burn covers over 25% of the body surface in the case of a healthy adult, but are also common in
smaller areas (10-15%) in the case of young children, the elderly or adults with inhalation injuries. The onset of
"general illness" includes the patient in a group with a poor prognosis, defining "major" burns.

periods:

I - shock - erectile (excitation)

- torpid (inhibition)
II - toxemia (toxins are absorbed from the burned surface)
II - septic-toxemia (of consequences)

181. Peculiarities of the clinical evolution of thermal lesions in the OMF region.
 Clinical evolution of thermal lesions of the OMF region on the battlefield.
Stage 1

 the first three days, the period of post-combustion shock.

With erectile and torpid periods.

It is characterized by severe fluid loss and dislocation.

 If the treatment is correct, at the end of this period the patient must present:
 -circulatory and respiratory parameters as close as possible to normal
 -conscious consciousness, absence of psychomotor agitation
 -reset hardness (50ml / h)
 - intestinal transit resumed
Stage 2

 days 4-21, metaaggressive, dysmetabolic period.

It is characterized by a catabolism that takes place in conditions of hypoxia, overworked organs and in the
presence of toxic residues directly from the local lesion or from poor metabolism and purification.

This period is characterized by a series of special stages:

 days 4-6-remission of edema, if the patient was properly cared for, causes polyuric crisis
(attention to support the heart and kidney function)
 -day 9-is the day when a precise diagnosis of the depth of the local lesion can be made.
 -day 12-can characterize the onset of renal decompensation
 -digestive complications can occur at any time for the patient with severe burns
 - thromboembolic complications can occur immediately after the accident and extend after the
period of 21 days.
At the end of this period, the burned patient must present himself as follows:

 - grade 3 burns healed (superficial ones have already healed in the first 2 weeks)
 - the grade 4 stairs completely dispersed and the beginning of the establishment of a granular
bed able to receive in the following days a skin graft
Stage 3

 -days 21-60-surgical period.

 If the patient has been properly cared for both locally and generally, he enters a period of very
fragile metabolic balance. The graft between days 21-28 ensures a good evolution of the patient
and is a test that confirms that the treatment was properly conducted. .
 In the conditions of the modern local treatment of the burn, stage 3 overlaps more and more
over stage 2, the formation of the granular wound being considered by many authors as a local
complication.
Stage 4

-chronic shock.

It is a way of evolution caused by the loss of the operative moment, by an inadequate care or by an extremely
serious burn. It is considered that the patient entered the period of chronic shock if 60 days after the accident
he presents granular wounds on large regions.
Following the existence of these wounds, severe malnutrition, immune collapse and metabolic imbalances set
in. In the case of very severe burns, in young children, in the malnourished, in the elderly or in other treated
people, it is possible to find aspects of chronic shock before the 60 days.

182. General and local clinical symptoms in OMF thermal lesions.

 Clinical evolution of thermal lesions of the OMF region on the battlefield.

Stage 1

 the first three days, the period of post-combustion shock.

With erectile and torpid periods.

It is characterized by severe fluid loss and dislocation.

 If the treatment is correct, at the end of this period the patient must present:
 -circulatory and respiratory parameters as close as possible to normal
 -conscious consciousness, absence of psychomotor agitation
 -reset hardness (50ml / h)
 - intestinal transit resumed
Stage 2

 days 4-21, metaaggressive, dysmetabolic period.

It is characterized by a catabolism that takes place in conditions of hypoxia, overworked organs and in the
presence of toxic residues directly from the local lesion or from poor metabolism and purification.

This period is characterized by a series of special stages:

 days 4-6-remission of edema, if the patient was properly cared for, causes polyuric crisis
(attention to support the heart and kidney function)
 -day 9-is the day when a precise diagnosis of the depth of the local lesion can be made.
 -day 12-can characterize the onset of renal decompensation
 -digestive complications can occur at any time for the patient with severe burns
 - thromboembolic complications can occur immediately after the accident and extend after the
period of 21 days.
At the end of this period, the burned patient must present himself as follows:

 - grade 3 burns healed (superficial ones have already healed in the first 2 weeks)
 - the grade 4 stairs completely dispersed and the beginning of the establishment of a granular
bed able to receive in the following days a skin graft
Stage 3

 -days 21-60-surgical period.

 If the patient has been properly cared for both locally and generally, he enters a period of very
fragile metabolic balance. The graft between days 21-28 ensures a good evolution of the patient
and is a test that confirms that the treatment was properly conducted. .
 In the conditions of the modern local treatment of the burn, stage 3 overlaps more and more
over stage 2, the formation of the granular wound being considered by many authors as a local
complication.
Stage 4
 -chronic shock.

It is a way of evolution caused by the loss of the operative moment, by an inadequate care or by an extremely
serious burn. It is considered that the patient entered the period of chronic shock if 60 days after the accident
he presents granular wounds on large regions.

Following the existence of these wounds, severe malnutrition, immune collapse and metabolic imbalances set
in. In the case of very severe burns, in young children, in the malnourished, in the elderly or in other treated
people, it is possible to find aspects of chronic shock before the 60 days.

183. Peculiarities of first aid in case of thermal injuries of the OMF region on the battlefield.
 rapid evacuation from the thermal environment, taken away, to clean air and lying horizontally
 - extinguishing the fire on the clothes with the existing means
 - exploring vital functions, breathing, circulation and supporting them (if necessary, artificial
respiration, heart massage)
 - if possible, opioid analgesics (morphine), tetanus seroprophylaxis are administered if the
patient has not been immunized in the last 6 months, antibiotics (ceftriaxone), cardiac
preparations, oxygen and infusions with crystalloid solutions
 - applying a towel soaked in cold water over the burned areas to reduce pain and thermal
gradient
 application of sterile dressing or bandage (mento-cephalic)
 - if he presents other traumas, he will proceed to temporary hemostasis and immobilization of
fractures
 - transport to the hospital is mandatory for any burn with an area of more than 5%. No food or
liquids are administered orally during transportation.

184. Medical assistance to the injured with thermal injuries of the OMF region and their treatment at the
stages of medical evacuation.
❖ rapid evacuation from the thermal environment, taken away, to clean air and lying
horizontally
❖ - extinguishing the fire on the clothes with the existing means
❖ - exploring vital functions, breathing, circulation and supporting them (if necessary, artificial
respiration, heart massage)
❖ - if possible, opioid analgesics (morphine), tetanus seroprophylaxis are administered if the
patient has not been immunized in the last 6 months, antibiotics (ceftriaxone), cardiac
preparations, oxygen and infusions with crystalloid solutions
❖ - applying a towel soaked in cold water over the burned areas to reduce pain and thermal
gradient
❖ application of sterile dressing or bandage (mento-cephalic)
❖ - if he presents other traumas, he will proceed to temporary hemostasis and immobilization
of fractures
❖ - transport to the hospital is mandatory for any burn with an area of more than 5%. No food
or liquids are administered orally during transportation.

185. Peculiarities of the associated lesions of the maxillofacial region.

Combined lesions are lesions produced by the simultaneous action of 2 or more toxins. With the use of
weapons of mass destruction, the number and variety of these traumas has increased considerably as a result
of the combination of wounds caused by classic weapons with specific noxious substances caused by nuclear,
chemical or bacteriological weapons.
In modern warfare the chemical weapon is a means of mass destruction. Following the contamination of the
wounded with toxic fighting substances, combined wounds appear.

Toxic substances are classified according to their action on the body in:

- Neuroparalytic

- Bladder

- Suffocating

- Toxic

186. Combined lesions of the OMF region, peculiarities of appearance, clinical evolution, treatment.
187. The main factors that determine the severity of facial burns.
▪ The severity of burns depends on:
▪ Factors related to the thermal agent:

Temperature

State of aggregation

Action time

▪ Factors related to the body:

- Burned surface
- depth
- Burn location - burns located on the functional areas (hands, feet), perineum, face are more
severe due to the sequelae potential
- Biological terrain - age, pre-existing conditions
- Other simultaneous injuries - trauma, fractures, airway burns.

188. Methods for determining the surface of thermal injuries.

Currently, Wallace's method is used (rule of 9), after which the body surface is divided into 11 regions, each
region representing 9%.

▪ head + neck = 9%
▪ Upper limbs = 18% (9% x 2)
▪ Lower limbs = 36% (18% x 2)
▪ Anterior trunk = 18%
▪ Posterior trunk = 18%
perineum + genitals = 1

189. Actinic disease: etiology, pathogenesis.

Actinic disease - a general disease of the body that occurs as a result of short-term action on the body (1-2 to 3
days) of the torrent of neurons and gamma rays, in doses exceeding 1 gray.

1grey = 100 razors

1 race = 1 renghen

1 renghen-ionization →creation in a cm3 of air at atmospheric pressure 760mm / Hg and temperature 0

degrees C - 2.8 x10_9 pairs of ions.

The degree of disease of the body with ionizing gases depends on:

- Irradiation dose
- Respectivity of the distribution on the surface of the organism
- Form of irradiation
- The individual properties of the body
- Presence of aggravating factors (age, concomitant pathologies)

Pathogenesis:

I phase - primary reactions →15-30minute →1-2 days (nictemiral) occurs due to the direct action on the cells
of the nervous system, ionizing rays that lead to their repolarization

- accused: weakness, headache, nausea, vomiting, diarrhea, unpleasant taste in the mouth,
dryness, vertigo, decreased appetite and work capacity, apathy, adynamism, thirst.
- Note: hyperemia of the skin and mucous membranes, edema, corneal hyperemia, tongue with
deposits, tachycardia, arrhythmia, decreased BP, collapse, temperature rise, movement
disorders, ataxia, coordination disorders, lymphocytopenia, relative neutrophilic leukocytosis,
hormonal secretions and secretions disorders
Phase II - latent prodromal (false well-being →1-2zile →2-3 weeks

- The mechanism: there are reserves in the depot bodies

- accused:general weakness, loss of appetite and work capacity, decreased lymphocytes and
platelets, erythrocytopenia (towards the end of the period)
Phase III - culmination (of clinical manifestations) -2-3 weeks →individually for each (2-3 months)

-the decisive role belongs to infections and hemorrhages

- the accusations of period I are intensified

-chexis occurs, spots on the skin or mucous membranes, microhemorrhages, ulcers, nasal, pulmonary, gastric,
renal, conjunctival and meningeal hemorrhages

-after Fialcoski- stomatitis, glossitis and necrotic changes also appear in the oral cavity

- Clinical: - Bronchitis occurs, abscess pneumonia, sepsis

Laborato: -tachycardia, arrhythmia, positive Cancelovski symptom (drop-hemorrhage), ECG disorders,

completely inhibits the forms of hematopoiesis. Coagulation alteration, ESR -50-70 mm / h, disorder of all
metabolic forms (typical intoxication), total inhibition of immune processes, autoallergic intoxication, changes
the body's reaction to drugs
Phase IV - consequences - can last 3-5 months

-death caused by actinic tissue dysfunction with the septic infectious component leading to hepato-renal
failure, encephalopathy, toxic disorders with respiratory and vascular failure

- diagnosis is based on: CT, data of dosimetric measurements, radiological calculations.

190. Clinical forms, severity of actinic disease.

I shape-easy -150-200 razors (1-2grey)

II form -medium -200-400 raz.

III forma –grav -400-600 raz.

IV form - extreme of gravity 600 →... raz

191. Clinical picture of actinic disease.

I phase - primary reactions →15-30minute →1-2 days (nictemiral) occurs due to the direct action on the cells
of the nervous system, ionizing rays that lead to their repolarization

- accused: weakness, headache, nausea, vomiting, diarrhea, unpleasant taste in the mouth,
dryness, vertigo, decreased appetite and work capacity, apathy, adynamism, thirst.
- Note: hyperemia of the skin and mucous membranes, edema, corneal hyperemia, tongue with
deposits, tachycardia, arrhythmia, decreased BP, collapse, temperature rise, movement
disorders, ataxia, coordination disorders, lymphocytopenia, relative neutrophilic leukocytosis,
hormonal secretions and secretions disorders
Phase II - latent prodromal (false well-being →1-2zile →2-3 weeks

- The mechanism: there are reserves in the depot bodies

- accused:general weakness, loss of appetite and work capacity, decreased lymphocytes and
platelets, erythrocytopenia (towards the end of the period)
Phase III - culmination (of clinical manifestations) -2-3 weeks →individually for each (2-3 months)

-the decisive role belongs to infections and hemorrhages

- the accusations of period I are intensified

-chexis occurs, spots on the skin or mucous membranes, microhemorrhages, ulcers, nasal, pulmonary, gastric,
renal, conjunctival and meningeal hemorrhages

-after Fialcoski- stomatitis, glossitis and necrotic changes also appear in the oral cavity

- Clinical: - Bronchitis occurs, abscess pneumonia, sepsis

Laborato: -tachycardia, arrhythmia, positive Cancelovski symptom (drop-hemorrhage), ECG disorders,

completely inhibits the forms of hematopoiesis. Coagulation alteration, ESR -50-70 mm / h, disorder of all
metabolic forms (typical intoxication), total inhibition of immune processes, autoallergic intoxication, changes
the body's reaction to drugs
Phase IV - consequences - can last 3-5 months

-death caused by actinic tissue dysfunction with the septic infectious component leading to hepato-renal
failure, encephalopathy, toxic disorders with respiratory and vascular failure

- diagnosis is based on: CT, data of dosimetric measurements, radiological calculations.

192. Diagnostic principles in actinic disease.

Diagnostic

Procedures performed:
Biopsy: skinis indicated to confirm the diagnosis and exclude invasive cellular carcinoma for
advanced lesions (pronounced hyperkeratosis, increased erythema, induration or nodularity. Biopsy
is also indicated for lesions that do not respond to treatment.

Fluorescence: with the use of a photosensitizing agent it is used in photodynamic-PDT therapy

described as a diagnosis for atinic keratosis. Affected and occult areas of normal skin emit pink
fluorescence on the Wood lamp or phototherapy lamp.

Histological examination: Actinic keratosis is characterized by dysplasia and altered epidermal

architecture. The keratinocytes of the basal layer are abnormal and variable in size and shape.
Cellular polarity is altered if nuclear atypia is observed. These alterations can extend to the
granular layer. The epidermis has hyperkeratosis and parakeratosis with irregular acanthosis. In
general, hair follicles, sebaceous glands and apocrine and eccrine ducts are not involved.

Differential diagnosisis caused by the following diseases:

- basal cell carcinoma,

- squamous cell carcinoma,
- diseaseBowen,
- lupusdiscoid erythema,
- porokeratoza,
- seborrheic keratosis,
- wartsnongenital.

193. Peculiarities of trauma treatment in patients with actinic disease.

Treatment

Actinic keratosis can occur unaltered, spontaneously remit, or progress to invasive squamous cell
carcinoma. These changes are unpredictable. Although the risk of progression of actinic keratosis is
small-10% a patient can have many lesions and the risk becomes significant. In addition, actinic
keratosis can be clinically indistinguishable fromlentigomalignant and squamous cell carcinoma.
Therapy is generally well tolerated and simple, so treatment is guaranteed.
Appropriate treatment is generally chosen based on the number of lesions present and its
effectiveness. Additional variables considered include lesion persistence, age, categoryskin
cancerand tolerability to the mode of treatment. The treatment consists of 2 main categories:
surgical and pharmacological. The patient should be educated to avoid sun exposure from 10:00
a.m. to 3:00 p.m. You must use sunscreen and clothing.

Pharmacological therapy.
It has the advantage of being able to treat large areas with many lesions. The disadvantage
includes prolonged treatment, irritation and discomfort. 4 drugs have been approved for the
treatment of actinic keratosis. Topical 5-fluorouracil, topical diclofenac gel, 5% imiquimod cream
and topical PDT dynamic phototherapy with delta-animolevulinic acid.

The most used therapy is the one with 5 fluorouracil,known to inhibit thymidylate synthetase and
cause active proliferative cell death. There are several formulas available that contain 5% cream
substance and 2% solution, 1% cream or solution and the latest cream with 0.5%. the most popular
formula is 5% cream which is applied twice a day. During the treatment phase the lesions become
more erythematous and can cause discomfort. Small subclinical lesions become visible. This
treatment can be temporarily disfiguringulcerationerythematous and formation ofcrusts. However,
when the patient finishes the treatment, the lesions heal in 2 weeks.

imiquimodis a topical agent that regulates the release of cytokines and invokes a nonspecific and a
specific immune response. It is applied twice a week for up to 4 months, although it is enough for a
month. The reaction to the drug is idiosyncratic, with some patients barely responding while others
develop marked inflammation. Subclinical lesions become inflamed. In patients with severe
inflammatory response the dose is reduced to one application per week, while preserving efficacy
and increasing tolerability.

Topical diclofenac gelis a non-steroidal anti-inflammatory drug approved for the treatment of
actinic keratosis. The mechanisms of action against keratosis are unknown. It is effective when
applied twice a day for 3 months. a shorter therapy is dramatically less effective. The main
advantage is that it does not cause inflammation and is thus well tolerated.

Dynamic phototherapy-PDTuses a light-sensitive component that accumulates in keratosis cells

where it can be activated by an appropriate length of radiation. Delta-aminolevulinic acid is a
component of the heme biosynthesis pathway that accumulates preferentially in dysplastic cells.
Once inside the cells, a powerful photosensitizer is converted to protoporphyrin IX. With exposure
to special light, free oxygen radiation is generated and cell death results. Patients experience pain
in the treated areas. The lesions may become erythematous and crusty. Patients with
immunosuppression may also benefit from this treatment to prevent non-melanoma skin cancers.

Surgical therapy.
The goal of this therapy is to completely eradicate actinic keratosis usually by physically destroying
it without damaging healthy skin. When the diagnosis is unclear and an invasive tumor is suspected,
a biopsy is indicated.

Cryosurgeryrefers to the use of a cryogen to lower skin temperature and cause cell death. The
cryogen used is liquid nitrogen. Keratinocytes die at -50 degrees C. Other skin structures such as
collagen, blood vessels and nerves are more resistant to the deadly effects of the cold. Melanocytes
are more sensitive than keratinocytes, which is why cryosurgery usually leaves white spots.
curettagecan be used to treat lesions suggestive of invasive cancer. Tangential or conventional
excision can be used, which also allows sampling for histology. These treatments require local
anesthesia, produce a wound that requires regeneration time and scarring.

Cosmetic proceduresin which the entire epidermis is removed, sometimes with a portion of the
dermis are effective for actinic keratosis. Includes medium and deep peels, dermabrasion and
ablation laser. All of these procedures carry the risk of infection and scarring.

194. The role of the OMF surgeon and the stomatologist in the treatment of actinic disease.

195. General principles in the treatment of actinic disease.

196. Mutual aggravation syndrome in combined trauma.
197. Factors that determine the contraindications to military service.
Certificate issuance rules

The certificate in case of trauma is issued to the patient throughout the treatment, until the restoration of
work capacity, but not more than 180 days during a calendar year. After the expiration of the 180 calendar
days, if there are good reasons for the possibility of recovery, avoiding the degree of disability and maintaining
the work capacity of the insured, patients are sent to the Council of Medical Expertise for Vitality to obtain the
decision to extend the certificate.

The councils of medical expertise of vitality, when establishing the disability, issue to the person in question
the invalidity certificate, as well as the individual rehabilitation plan, which the necessary recommendations
for accomplishment.

Persons not included in disability groups are issued a certificate with the decision of the medical expertise
councils.

198. Tracheotomy, conicotomy methods and variants, indications and contraindications.

The surgery that aims to open the cervical trachea is called a tracheotomy.

The tracheal orifice kept open by inserting a tracheal cannula for more than 7 days is called a tracheostomy. Most often, due
to acute obstructive upper respiratory failure, this emergency practice intervention.

Depending on the place of opening of the trachea, we distinguish:

- high tracheotomy, when the opening of the trachea is done superstymically (maximum emergency situation);

- middle tracheotomy, intervention located at the level of the thyroid isthmus (after dissection and ligation);

- subistemic tracheotomy, performed under the thyroid isthmus, an intervention often performed in young children.
 Under normal conditions, however, it is recommended to practice a medium tracheotomy, because the postoperative
complications are reduced.

indications Tracheotomies are varied, from conditions that require maximum emergency interventionto conditions in
which tracheotomy is a preliminary method to other interventions.

- Acute and chronic laryngeal dyspnea is the main indication for tracheotomy.
- Mechanical airway obstruction:
- Respiratory failure due to persistent secretions or inadequate breathing
Surgical technique

The position of the patient he is lying on his back, where respiratory failure allows it. If the respiratory
insufficiency worsens in the posterior declining position, the upper half of the body can rise to the
vertical, the patient being administered pernasal or oral oxygen.
T impious operators:

- mid-cervical incision, from the incision of the thyroid cartilage to the sternal fork. In cases preceding a laryngeal intervention
(eg total laryngectomy), the incision of the skin and skin of the neck may be horizontal at about 1.5 cm from the sternal fork;

- detachment of the fatty plane, with ligation or cauterization of the dissected blood vessels;

- detachment of the pretracheal muscles;

- sectioning and detachment of the middle cervical fascia until the highlighting of the thyroid capsule;

- dissection of the thyroid isthmus, its detachment from the anterior wall of the trachea, clamping at its ends with two long
Pean forceps, followed by sectioning the two forceps and ligation of the two isthmic abutments. Most often, the thyroid isthmus
is located near the tracheal rings 2-3-4.

- released by the thyroid isthmus, the tracheal rings 2-3-4 are sectioned in the middle, after aprevious endotracheal
anesthesia performed through interinellular membrane 2-3 or 3-4;

- making a tracheal flap that opens to the outside and suturing it to the lower edge of the skin incision (suprasternal);

- control of hemostasis (danger of blood aspiration);

- wound the wound, suture the edges of the wound, especially the upper one, the lower one being left unsaturated, to
prevent the eventual postoperative subcutaneous emphysema (especially in people with severe cough reflex or lung pain) and -
introduction of the tracheal cannula.

c o m p l i c a t e ca t i i l e

this surgery can be:

a. Intraoperators:

- bleeding from the thyroid gland, blood vessels or excess tumortracheal walls;

- damage to the cricoid cartilage, which can lead to subglottic stenoses;

- damage to the pleural dome located above can lead to pneumothorax;

 199. The role of the dentist in the medical and social rehabilitation of war wounded.

200. Physiotherapy and curative physical education in the treatment of OMF traumas.
Physiotherapy includes:

• -special physical exercises (gymnastics)

• -massage
• -electrophoresis
• -fono-hand drill
• -parafinoterapie
• -bath therapy
The patient's physical education consists in explaining the patient:

• Correct exercises (order of exercises)

• Do not overload the body
201. Food, care, diet, follow-up over time, peculiarities of rehabilitation of the wounded in the OMF
region.
▪ power:
❖ Enteral method: - oral
- endogastric

- duodenal

- rectal

❖ Parenteral method: - intravenous

- subcutaneous

- intramuscular

• Adequate and balanced qualitative and quantitative nutrition;

• Bed regime;
• Use of liquid foods rich in lipids, proteins, carbohydrates, mineral salts, vitamins;
• Feeding with straw or nasogastric tube;
Psychological care of the patient

rehabilitation:

- Physical culture-specialists trained in this field

- The need for the existence and creation of special trainers
- Social rehabilitation (psycho-emotional training) is spent by doctors
- Preventing that the treatment process will involve several stages of surgical and drug
treatment