Comparative anatomy..... 280
Methods of inspection....... 282
Top and bottom jaws — the largest bones of a facial skull forming a bone basis of the person together with malars and defining its form. H take part in formation of bone walls of an oral cavity, nose, eye-socket. They are a part chewing and organs of articulation. The upper jaw (maxilla) serves as the place of an attachment of the majority of mimic muscles (face muscles, T.), and lower (mandibula) — masseters, muscles of a neck, language and a throat. The upper jaw connects not movably to bones front and a neurocranium (see), the mandible is connected movably with temporal bones by means of a pair temporal and mandibular joint (see).
of Ch. appear at cartilaginous fishes, at to-rykh links of the I branchiate arch will be transformed to maxillary cartilages — dorsal, or palatal and square, and ventral, or mandibular, limiting an actinostome and supplied with teeth. Sites of ossification in Ch. for the first time appear at sturgeon fishes. At bony fishes the forefront of a palatal and square cartilage connects to a base of skull, and as a result of formation of a number of cover bones (pre-maxillary, maxillary, etc.) the upper jaw forms. From the back end of a nebnokvadratny cartilage the square bone develops. The mandible at the lowest vertebrata is presented by several cover bones, to-rye are imposed on a mandibular cartilage. The joint bone which is jointed with a square bone is formed.
Fig. 1. An upper jaw (and — a look outside — a look from within): 1 — a frontal shoot; 2 — an infraorbital foramen; 3 — a klykovy pole; 4 — a front nasal awn; 5 — alveolar eminences; 6 — a skuloalveolyarny crest; 7 — a hillock of an upper jaw; 8 — an infraorbital furrow; 9 — a malar shoot; 10 — an orbital surface; 11 — a maxillary crevice; 12 — an alveolar shoot; 13 — a palatal shoot; 14 — a shell crest; 15 — the lacrimal furrow.
Due to the loss of branchiate breath at amphibians and the subsequent classes of vertebrata branchiate arches are reduced. The palatal and square cartilage stops being an element of an upper jaw. At amphibians the upper jaw is formed by predchelyust-ny and maxillary bones, and lower — tooth, angular and joint bones (ossa dentale, angulare et articulare;.
At kowtowing (crocodiles) on maxillary bones palatal shoots form, to-rye together with palatal bones form the secondary bony palate separating a nasal cavity from oral. The way of an attachment of jaws to a skull changes.
At mammals as a part of a mandible only one cover bone (os dentale) remains, the others are reduced. Joints between a mandible and temporal bones are for the first time formed. Premaxillary and maxillary bones grow together, on a mandible there are coronal shoots, roughnesses, poles, the corner of a jaw forms, and the person has, besides, a mental ledge. In the course of anthropogenesis there is a shortening of jaws and reduction of their massiveness (especially a mandible), the shift of jaws back. As a result of it the profile of the person becomes more direct, the corner of a mandible increases.
of the Jaw develop from a branchiate mandibular arch. The upper jaw is formed from its dorsal, and lower \by U-2014\of a ventral part. The upper jaw is stuffed up in fabrics maxillary and average nasal faces of an embryo of shoots. In the middle of the 2nd month of pre-natal development in them several ossification centers appear, to-rye soon merge with each other. The independent ossification center is in the incisal bone connecting at the newborn to an upper jaw an incisal seam. Highmore's (maxillary, T.) the bosom forms on 4 — the 5th month of pre-natal development (see Paranasal sinuses).
The mandible develops in the thickness of mandibular shoots. On 6 — the 7th week of pre-natal development there are several ossification centers, from to-rykh periosteal in the way the bone develops. The right and left half of a mandible connect connecting fabric, edges on 1 — the 4th year of life is replaced with a bone.
the Upper jaw represents a pair bone, consists of a body and shoots (fig. 1). The body of the maxilla (corpus) has the form of the truncated pyramid, contains a pneumatic cavity — a Highmore's bosom (sinus maxillaris). The front surface of a body of the maxilla is a little bent, from its profound site — a klykovy pole (fossa canina) the muscle of the same name begins. The infratemporal body surface of an upper jaw participates in formation of infratemporal and pterygopalatine poles. On its convex part — a hillock of an upper jaw (tuber maxillae) 3 — 4 openings conducting in tubules in to-rykh to back teeth open there pass vessels and nerves. The orbital surface of an upper jaw smooth, it has triangular shape and is a part of the lower wall of an eye-socket. Ahead the orbital surface comes to an end with infraorbital edge (margo infraor-bitalis), behind limits the lower orbital crack. From the middle of the rear edge of an orbital surface the infraorbital furrow begins, passes edges into the canal of the same name opening on a front surface an infraorbital foramen (foramen infraorbitale). On the lower wall of the channel the intra bone tubules containing vessels and nerves of front and average teeth begin. The nasal surface of an upper jaw takes part in formation of a lateral wall of a nasal cavity, on a cut are located an entrance to a Highmore's bosom — a maxillary crevice (hiatus maxillaris) — and a shell crest (crista conchalis). The lower nasal sink is attached to the last. Four shoots depart from a body of the maxilla: a frontal shoot (processus frontalis) going up (on its medial surface are a trellised crest, the average nasal sink, and the lacrimal furrow is attached to Krom); a medial and palatal shoot (processus palatinus) forming the most part of a bony palate (on its surface the opening of the incisal channel opens); lateral and malar shoot (processus zygomaticus),
Fig. 2. A mandible (and — a look outside, a part of an outside bone plate is removed — a look from within): 1 — cutting of a mandible; 2 — alveolar eminences; 3 — a mental ledge; 4 — a mental foramen with the probe entered through it to the canal of a mandible; 5 — a corner of a mandible; 6 — a branch of a mandible; 7 — a condylar shoot; 8 — a neck of a mandible; 9 — a head of a mandible; 10 — a coronal shoot; 11 — a maxillary and hypoglossal furrow; 12 — a mental awn; 13 — a biventral pole; 14 — the maxillary and hypoglossal line.
connecting to a malar; an alveolar shoot (processus alveolaris) departing down. The created alveolar
shoot is dugoobrazno bent and has the outer (vestibular) surface turned to an entrance of the mouth, and internal (palatal), directed to the sky. The arch of a shoot (arcus alveolaris) has eight tooth sockets (alveoli dentales). The form and size of tooth sockets corresponds to a form and size of fangs (see). To tooth sockets on a vestibular surface there correspond alveolar eminences (juga alveolaria). Alveoluses are separated from each other by bone interalveolar partitions (septa inter-alveolaria). Alveoluses of multi-rooted teeth contain interroot partitions (septa interradicularia) separating fangs from each other. The shape of an upper jaw is individually various: the narrow high jaw is inherent to people with the narrow person, wide low — is usually characteristic of the wide person.
The mandible — unpaired, a horseshoe form a bone, has a body and two branches (fig. 2). In a body of the mandible distinguish the basis (basis) and an alveolar part (pars alveolaris) containing 8 tooth sockets on each party. The bases of the right and left half of a jaw form a basal arch of various form that is one of the main signs characterizing a jaw (narrow and long, wide and short). On the middle of an outer surface of a body of the mandible there is a mental ledge (protuberantia mentalis), on both parties to-rogo there are mental hillocks and mental foramens (foramina mentalia). Below a mental foramen the slanting line (linea obliqua) passing into a first line of a branch of a mandible begins. On an inner surface of a body of the mandible near the centerline there is a mental awn (spina mentalis), to a cut geniohypoid and genioglossal muscles are attached. Below and lateralny the biventral pole (fossa di-gastrica) is located, from it the biventral muscle begins. Above this pole the maxillary and hypoglossal line (linea mylohyoidea) — the place of an attachment of a maxillary and hypoglossal muscle is located. The structure of an alveolar part of a mandible is similar to a structure of an alveolar shoot of an upper jaw. In spongy substance channels of a mandible (canales mandibulae) are located, to-rye begin mandibular foramens (foramina mandibulae) on inner surfaces of its branches and come to an end with mental foramens (foramina mentalia). Small tubules depart from channels in thickness of a jaw, in to-rykh pass vessels and nerves to teeth. The body of the mandible in back department passes at an angle (angulus mandibulae) into a branch of a mandible (ramus mandibulae). The size of a corner of a jaw happens various and makes from 102 to 150 °. On an outer surface of a branch in the field of a corner there is chewing tuberosity (tuberositas masseterica), to a cut the masseter, on an inner surface — alate tuberosity (tuberositas pterygoidea) serving as the place of an attachment of a medial alate muscle is attached actually. The upper part of a branch of a mandible comes to an end in front coronal otrostzhsh (processus coronoideus), the temporal muscle, behind — a condylar shoot (processus condylaris) is attached to Krom. The condylar shoot consists of a neck (collum mandibulae) and a head of a mandible (caput mandibulae) having a joint surface. On medial side of a neck of a condylar shoot the alate pole (fovea pterygoidea) is located, in a cut the lateral alate muscle is attached. Coronal and condylar shoots are divided by cutting of a mandible (incisura mandibulae).
Ch.'s blood supply is carried out generally by branches of a maxillary artery (a. maxillaris). Additional branches to a mandible depart from facial and lingual arteries (branches of an outside carotid artery), each of to-rykh feeds a certain site of a mandible. Ch.'s vessels anastomose with arteries of soft tissues of the person.
Outflow of blood comes from Ch. on the veins of the same name in an alate texture (plexus pterygoideus) or a maxillary vein (v. maxillaris), a zanizhnechelyustny vein (v. retromandibularis), and also a facial vein (v. facialis), to-rye fall into system of an internal jugular vein (v. jugularis interna).
Veins an upper jaw have an anastomosis with veins of an eye-socket, a nasal cavity, a mouth and sine of a firm meninx.
The innervation of an upper jaw is provided by hl. obr. branches of a maxillary nerve (n. maxillaris) which is the second branch of a trifacial (see). The lower alveolar nerve (item alveolaris inferior) representing a branch of a mandibular nerve (n. mandibularis) is the main source of an innervation of a mandible.
The lymph drainage from Ch. is carried out in regional limf, nodes — submandibular, parotid, deep cervical, and from front departments of a mandible — in mental limf, nodes of the and opposite side (see tsvetn. the tab. to St. Person, t. 13, Art. 240 — 241).
Morfofunktsionalny features. A structure of spongy and compact substance variously in different sites Ch. It is connected with features of distribution of a functional load. Compact substance on walls of alveoluses of an upper jaw is presented by the laminas (outside and internal) penetrated by the collagenic fibers participating in fixing of teeth and contain numerous openings for vessels and nerves. Between plates of compact substance there is a spongy substance. Crossbeams of spongy substance in the field of sidewalls of alveoluses have the horizontal direction, in the field of a bottom — steep. From an alveolar shoot of a crossbeam of spongy substance pass into other
shoots and walls of a Highmore's bosom. Upper, medial, anterolateral and posterolateral walls of a bosom on a big extent consist of laminas of compact substance, to-rye fork near infraorbital edge, in the place of transition of a jaw to shoots where between them there is a spongy substance. The lower wall of a Highmore's bosom corresponds to alveoluses of 3 — 5 last in dentition of teeth. Compact substance of an upper jaw is considerably thickened in places of the largest functional tension. These sites called by kontroforsa provide the increased Ch.'s durability and hypodispersion of pressure arising during the chewing.
The mandible consists of outside and internal plates of compact substance, between to-rymi there is a spongy substance. Compact substance has the greatest thickness in the field of the basis of a body of the mandible. The greatest number of spongy substance contains in a head, a neck and in the field of a corner of a mandible, the smallest — in a coronal shoot. Bone crossbeams of spongy substance are located according to pressure profile, arising during the chewing. In a body of the mandible bone crossbeams are directed to the basis of a jaw with an inclination towards its corner. A part of crossbeams from a body of the mandible passes into branches and extends to coronal and condylar shoots.
Age features. An upper jaw of the newborn short and wide, the alveolar shoot is not developed, contains rudiments of milk and second teeth. The Highmore's bosom has the insignificant sizes. Are characteristic of a mandible of the newborn the corner between a body and branches making from 140 to 150 °, the small sizes of branches, an undeveloped alveolar part with rudiments of teeth. Growth of jaws most intensively happens in the period of a teething and comes to an end by the time of eruption of the third painters. In process of growth of an upper jaw the alveolar shoot forms, the volume of a Highmore's bosom, height of a jaw, intermaxillary, or incisal increase, the bone grows together with a jaw. Growth of a mandible is followed by development of an alveolar part, increase in height of branches, bodies of a jaw, reduction of a corner between a body and branches of a jaw. At senile age in connection with loss of teeth there is an atrophy of alveolar shoots and reduction of height of bodies of both jaws, reduction of a mental ledge of a mandible, height of its branches and increase in its corner.
Radioanatomy. Because Ch. have irregular shape, carry out their X-ray analysis not only in standard projections — direct and side, but also in special (axial, semi-axial, slanting tangential, contact, etc.). Ch.'s images developed in the plane of a picture in the absence of essential distortions allow to receive panoramic exposures (see Pantomografiya). For a research of an upper jaw and a condylar shoot of a mandible the X-ray analysis is combined with the tomography (see) which is carried out in a lobby and side projections.
Structure of a bone tissue of an alveolar shoot of an upper jaw close-meshed, it is preferential with the vertical course of bone crossbeams. In direct pictures in the middle of an interdental partition between the central upper cutters the strip of an enlightenment — an intermaxillary (incisal) seam is visible. The incisive foramen comes to light as an oval or roundish enlightenment at the level of tops of roots of the central cutters. The malar shoot of an upper jaw in the form of the turned loop is projected on area of the first upper big molar (painter). On roots of painters the shadow of a body of a malar is imposed that complicates interpretation of roentgenograms. The bottom of a Highmore's bosom on the roentgenogram has an appearance of a compact plate, edges extends to the first small molar (premolar tooth) and even to a canine, passing in a mezhal-vaolyarny partitions (see fig. 4 to St. Skull, Art. 296).
On the roentgenogram of a mandible in a side projection on its bottom edge there passes the accurate intensive homogeneous strip of compact substance 3 — 6 mm wide. Towards corners of a mandible thickness of a shadow decreases, however in the field of the rear edges of branches accurate thin strips of compact substance of a bone are visible (see fig. 4 to St. Skull, Art. 296).
An alveolar part of a mandible has the pointed form in the central departments and a form of the truncated pyramid in a zone of the lower premolar tooths and painters. The interalveolar partitions covered with the lamina of compact substance are most accurately visible on orthopan-tomograms (see fig. 1 to the Art. of Pantomografiya, t. 18, Art. 277). In the central department of a mandible the dense bone structure of a mental eminence is defined, and lateralny according to the lower premolar tooths and painters — large cell structure of spongy substance it is preferential with the horizontal course of bone crossbeams. Tuberosity in places of an attachment of muscles come to light as the dense intensive linear shadows in a zone of painters located on an outer and inner surface of a jaw. The channel of a mandible is presented in the form of a strip
of an osteoporosis 4 — 6 mm wide with accurately expressed lower wall and less accurate upper. Funneled form inlet opening (mandibular foramen, T.), located above a corner on a branch of a jaw, it is found not always. A mental foramen in the form of the roundish or oval center of an osteoporosis to dia. 4 — 6 mm with an accurate rim are projected at the level of the lower premolar tooths.
Methods of inspection
of the Disease, damage and disturbance of development of Ch. are shown by hl. obr. changes in the soft tissues surrounding them, bodies of the maxillofacial area and an oral cavity. In this regard in process a wedge, inspections of the patient (the anamnesis, assessment of the general condition of the patient, etc.) make careful survey of the person (see) and oral cavities (see Roth, an oral cavity), at Krom it is possible to find change of the sizes, Ch.'s configurations, pathological processes in cover fabrics (an inflammation, damage, hemorrhage), disturbance of mobility of the lower Ch. and its shift at dislocation, the shift or ratio distortion of dentitions at a change.
By means of a palpation (as a rule, bimanual) reveal disturbance of contours of Ch., their asymmetry, increase in volume of certain sites at inflammatory process or a new growth. At Ch.'s change the shift and mobility of its fragments is observed.
The sizes and Ch.'s configuration, a form of dentitions and their ratio are determined visually, and also by measurements, at to-rykh sometimes use specially made plaster masks and models of jaws (see the Bite).
The leading role in diagnosis of diseases and Ch.'s damages belongs rentgenol. to methods of a research, including a profile telex-ray analysis (see). The possibility of use of methods of ultrasonic diagnosis is studied (see). At a research of bodies of the maxillofacial area use methods of functional diagnosis:
vatelny tests (see Chewing), an electromyography, a reografiya, measurements of sensitivity of a pulp of tooth (see Teeth), etc.
In jaws the same types of pathology, as in other sites of a skeleton and the fabrics adjoining to them meet: malformations, damages, diseases, tumors; at surrounding Ch.' damage fabrics or a temporal and mandibular joint (see) disturbance of mobility of a mandible can be observed. Along with it in maxillofacial area there are so-called dontogenous diseases connected with damage of teeth, roots to-rykh are located in the thickness of jawbones (see Teeth).
Malformations. Distinguish inborn malformations of Ch. and anomaly of development and growth.
Inborn malformations. Absence of average department of an upper jaw, a mandible or total absence of the person and both Ch. (aprosopy) extremely seldom occurs among inborn malformations. Newborns with uglinesses such are usually impractical (see the Person).
Isolated cases of formation of multiple alveolar shoots or even maxillary arches — polignat I are described. The craniofacial dysarthrosis is characterized by disturbance of process of ossification of fibrous connection between a base of skull (see) and bones of a facial skeleton, it is shown by mobility of face bones in relation to bones of a neurocranium. As a rule, at the same time more or less expressed underdevelopment of an upper jaw and malars is observed. At an achondroplasia (see the Chondrodysplasia) there is a growth disorder and ossification of a cartilaginous base of skull that leads to retraction and deformation of all average department of the person, hl. obr. an upper jaw, with a normal growth of the arch (roof) of a skull and a mandible. The described malformations are completely not removable. The uglinesses caused by them can be corrected partially by means of the adjusting plastic (cosmetic) surgeries.
Disturbances of development of Ch. are observed also at clavicular and cranial, maxillofacial, craniofacial and maxillary and cranial dysostoses (see). Dysostoses remain during all life and do not give in to operational correction.
Inborn facial clefts are formed as a result of disturbance of formation of the person at early stages of an embryogenesis. From them are localized by Nek-rye not only in soft tissues, but also extend to jaws (see the Person). Most often the isolated or through crevices of the sky meet. The last pass through all sky and top -
Fig. 3. Various anomalies of development and growth of jaws: and — excessive development
of an upper jaw (an upper macrognathia); — an underdevelopment of an upper jaw (an upper micrognatia); in — excessive development of a mandible (the lower macrognathia); — an underdevelopment of a mandible (the lower micrognatia); d — uneven (asymmetric) development of a mandible; e — an open bite.
To Nü a lip (see the Sky). Elimination of inborn facial clefts and Ch. make by means of plastic surgeries, success to-rykh depends on their correct planning (see the Person, the Sky).
Anomalies of development and growth of jaws meet often. On average at 30% of all children of school age more or less expressed aberrations of the sizes, forms and Ch.'s ratios, dentitions or separate teeth are noted. However it is difficult to draw a clear boundary between options of norm and manifestations of anomalies. Among anomalies of development of Ch. distinguish excessive development of one of Ch. (an upper or lower macrognathia, or a prognathism), their underdevelopment (an upper or lower micrognatia, or distoclusion). Earlier applied the terms «progeny», «microgenia», «opistogeniya», «opi-stognatiya» to designation of similar anomalies, to-rye consider outdated now.
Along with these main types of deformations their various combinations, and also uneven (asymmetric) development of Ch., disturbance of a smykaniye of dentitions (fig. 3) can take place.
The reasons of anomalies of development of Ch. are very various. They can be inborn, and sometimes hereditarily caused, to develop as a result of neuroendocrinal disturbances (e.g., excessive development of Ch. at an acromegalia) and after the postponed diseases,
in particular rickets. Emergence of anomalies of Ch. is promoted by such factors as the broken nasal breath (at polyps of a nose and nasopharynx, adenoides), addictions — the wrong position of the head during sleep, usual biting of a lip, suction of a finger, etc.
The disturbances of development of Ch. leading to their deformation can be caused by damage of sites Ch. in children as a result of an injury (including at the time of delivery), inflammatory diseases (Ch.'s osteomyelitis, arthritis of a temporal and mandibular joint), and also there are a consequence of formation of hems in the fabrics surrounding Ch. after inflammatory, necrotic processes, injuries, burns. Heavy deformations of Ch. can develop after their radiation injury in a growth period.
Deformation of the person can be connected with disturbance of development both upper or a mandible, and at the same time both jaws. Distortion of a form of a mandible and its alveolar part can lead to secondary deformation of an upper jaw and disturbance of symmetry not only the lower, but also upper part of the person. The underdevelopment of a mandible often happens is caused by emergence at children's age of the deforming osteoarthrosis or anchylosis of a temporal and mandibular joint (see). In such cases typical deformation of the person is combined with restriction or lack of mobility of a mandible.
At Ch.'s deformations excessively acts forward or the relevant department of the person sinks down that causes cosmetic defects and functional (at the wrong ratio of dentitions) disturbances (fig. 3).
For definition of character and extent of disturbance of development of each of Ch. use a method profile a body of a X-ray analysis with the analysis of the anthropometrical parameters characterizing the sizes and
a form Ch., their ratio among themselves and with a base of skull.
At treatment of anomalies of provision of dentitions use the special devices strengthened on teeth and alveolar shoots and regulating their situation and development (see. Orthodontic methods of treatment). Sometimes orthodontic treatment is combined with operational (removal of the accessory or incorrectly located teeth, is more rare movement of the displaced teeth). In treatment of dentoalveolar anomalies is important to lay down. gymnastics of face muscles. Operational treatment is carried out at deformations of Ch. causing essential functional disturbances and cosmetic defects. Operations for anomalies of development and Ch.'s deformations consist, as a rule, in a section (osteotomy) of incorrectly developed bone, movement of its disconnected pieces and their fixing in the correct situation for the term sufficient for full consolidation of a bone.
At excessive development of an upper jaw cut a frontal part of a body of a jaw or an alveolar shoot together with teeth usually at the level of the first small molars, to-rye delete. In the field of alveoluses of the extracted teeth excise wedge-shaped sites of a bone and move all frontal department back then at a proper correlation of upper teeth with lower it is fixed by tires. If foreteeth are strongly deformed or destroyed, it is possible to remove, make them a resection of the acting part of an alveolar shoot and to replace defect of dentition with a removable or bridge-like denture (see Dentures).
At an underdevelopment of an upper jaw were until recently usually limited to orthodontic treatment or production of a denture with the frontal site of dentition which is taken out forward and reinforced edge of the basis of a prosthesis in the field of an alveolar shoot. In a crust, time are developed and methods of operational treatment are implemented into practice.
One of the most frequent indications to osteoplastic operations is excessive development of a mandible. Operative measures make in a body of a jaw or its branches. The osteotomy of side departments of a body of the mandible with excision of sites of a bone on both sides to its shortening is applied seldom, preferring more perfect interventions on branches of the lower P.
Excessive or uneven development of a chin at a normal ratio of dentitions is eliminated by excision of the acting its part through a section of soft tissues. For the purpose of shift back of the central department of a mandible make an osteotomy in the field of its branches with use of access through outside cuts at an angle of a jaw or through cuts from an oral cavity.
In 1924 the Czech surgeon Kostech (T. Kostecka) offered the closed osteotomy of branches of a mandible. At this operation the bone is cut by means of a chain saw, to-ruyu carried out under a branch of a mandible by a special needle, without cutting soft tissues and without baring the surface of a bone.
Finds more and more broad application and practically forces out earlier used ways sagittal, or plane, a section of branches of a jaw. At the same time the internal compact plate is sawn boron in its upper part (higher than the level of entry of a neurovascular bunch into a mandibular foramen), and an outside plate — in a lower part of a branch or Ch.'s corner, after that the branch is split parallel to its plane. The formed bone fragments move to the necessary situation and fasten with bone seams that provides reliable contact between fragments and their strong connection. The sagittal osteotomy can be applied not only at excessive development of a mandible, but also at its underdevelopment (in this case the central department is moved not back, and forward), and also to elimination of an open bite.
At an underdevelopment of a mandible the choice of an operative measure is defined by character and extent of deformation of a jaw and its certain sites. If deformation of a mandible is followed by an anchylosis of a temporal and mandibular joint, it is reasonable to make operation at children's age that allows to provide mobility of a jaw. The corresponding functional load stimulates its growth, and also prevents progressing of disturbance of its form. At the underdevelopment of a jaw which is not connected with essential dysfunctions, surgery is usually performed later when growth of bones of a facial skeleton is generally finished.
Operations for an underdevelopment of a mandible include interventions on the bone, and also the surgeries for the purpose of correction of outlines of the person which are not affecting a bone.
Operative measures for the purpose of lengthening of a bone are shown at the expressed underdevelopment of a mandible. In this case make an osteotomy of a body of a jaw with movement of its central site and with substitution of the formed defects between the ends of disconnected fragments a bone transplant forward.
At less expressed shortening of all jaw or one of its half carry out an osteotomy (according to both or on the one hand) with movement of pieces of a bone and their connection in the situation corresponding to the correct outlines of the bottom of the person, in particular a chin.
The operations which are carried out for the purpose of change of outlines of a mandible without section and change of a shape of the jaw have less radical character, but in some cases allow to receive in the simplest way very satisfactory results. Elimination of deformations is reached by replanting under a periosteum of a jaw of transplants from a cartilage or implants from biologically inert polymeric materials (see). At the correct planning of operation and exact modeling of implants it is possible to recover symmetry of the person completely. Such interventions are not connected with change of the created bite and do not affect function of the chewing device.
At an open bite (see) make or a bilateral vertical osteotomy of a body or branches of a mandible with the excision of wedge-shaped sites in upper parts allowing to raise the central fragment or to lower back departments of a body of a jaw before establishment of contact of the lower teeth with upper, or a sagittal (plane) osteotomy of branches of a jaw. If the open bite is connected with an underdevelopment of an upper jaw, what is more rare, operational treatment consists in operational bringing down of its frontal department or is limited to orthopedic actions (a prosthesis with the lowered dentition).
Prevention of anomalies of development of Ch. consists in elimination of the factors breaking their uniform growth (removal of polyps, adenoides, disaccustoming from addictions, treatment of rickets and endocrine disturbances), early identification of disturbances of a bite and their correction, timely treatment of diseases of teeth (sanitation of an oral cavity), use of dentures for children at defects of dentitions.
Injuries of jaws happen closed and opened. Bruises, dislocations, the closed changes belong to the closed damages.
Ch.'s bruises are followed by pain, hemorrhage in surrounding soft tissues. Treatment consists in ensuring rest of the injured jaw and topical administration of cold in the first days after an injury. Forecast favorable.
The lower Ch.'s dislocations more often happen bilateral, usually they arise at excessive opening of a mouth (yawning, vomiting). Unilateral dislocation can be caused by strong blow.
At bilateral dislocation the victim cannot close companies, chewing is impossible, swallowing is complicated. At onethird-party dislocation of companies it is warped, the chin is displaced in the healthy party. Treatment consists in reposition of dislocation with further fixing of a jaw on
1V2 — 2 week a mitella (see. In isochno-nizh not maxillary joint). Forecast, as a rule, favorable.
Ch.'s changes make apprx. 2% of all fractures of bones of a skeleton. Changes of a mandible are more often observed (according to various statistical data, from 56 to 82% of cases of all fractures of jaws). Rate of decay of a bone can be various: from cracks and subperiostal changes before smashing or a separation of considerable part Ch.
Changes of a mandible often are located in «weak» anatomic zones: a neck
of a mandible, area of a corner, a body of a jaw at the level of canines and painters (fig. 4). Changes of a body of the mandible within dentition, as
Fig. 4. Diagrammatic representation of typical changes of a mandible: 1 — a median change; 2 — a mental change; 3 — a change ahead of a corner of a jaw; 4 — a change behind a corner of a jaw; 5 — a change of a branch of a jaw; 6 — a fracture of a neck of a jaw.
the rule, happen open since at the insignificant shift of fragments there is a rupture of the mucous membrane covering an alveolar part. Typical symptoms of a change of a mandible are morbidity in the place of a change, the shift of fragments with disturbance of a bite in attempts to move a mandible, deformation of a bone and mobility of fragments at a palpation.
Shift of fragments at the lower Ch.'s changes is connected with uneven distribution of draft of the muscles which are attached in different sites of a jaw. So, at localization of a change in side departments of a body of a jaw its bigger fragment under the influence of the muscles of a mouth floor which are attached generally in a chin is displaced down, and as a result of unilateral action on it alate muscles — towards lines of a change. The smaller fragment including a branch of a jaw to a cut all muscles raising a jaw are attached, it is displaced up, forward and turns towards an oral cavity. Typical shift under the influence of muscles is observed also at other localizations of a change. In rare instances when draft of different groups of muscles is counterbalanced, considerable shift is not observed. Special danger is constituted by shift back of average fragment at bilateral fractures of a body of a jaw: the language which lost support of the muscles of a mouth floor attached to this fragment can sink down, closing an entrance to a throat that leads to asphyxia (see). Quite often fractures of a body of Ch. are combined with clinically less expressed changes of branches and condylar shoots.
The diagnosis of a change is specified by means of a X-ray analysis. At the same time do pictures of all jaw in two projections for the purpose of identification double or multiple fractures. A high-informative method is the orthopan-tomography. On roentgenograms Ch.'s change is shown by deformation of a bone as a result of the shift of fragments, structural change of a bone tissue in the form of depression or consolidation (at laterposition of fragments or the driven change), a rupture of a compact layer (fig. 5). The change is considered open if on the roentgenogram the line of a change passes through a periodontal crack. Repeated roentgenograms allow to watch dynamics of healing.
At treatment of patients with changes of a mandible bone fragments establish in the correct situation and fix them (immobilization). The medical immobilization at changes of a mandible is made most often by imposing on tooth tires from a soft aluminum wire or special metal preparations. Rather seldom at incomplete changes, cracks or changes without shift within dentition it is possible to be limited
to Fig. 5. The panoramic roentgenogram of a mandible at a fracture of a body and an alveolar shoot on the right: the line of a change is specified by an arrow.
splinting on one injured jaw. In most cases tires impose on both jaws, tying them to teeth a thin wire, and then for the hooks symmetrized on tires hook on rubber rings that provides exact (on a bite) reposition of fragments and their immobilization (intermaxillary extension). There are also other types of the tires strengthened on teeth or, at their absence or insufficient quantity leaning on alveolar shoots (see Splintage in stomatology). Patients with the tires imposed on the injured jaw need, except the general leaving, in special a gigabyte. control of a condition of an oral cavity, its regular wiping, removal of the food remains, frequent washing (irrigation) weak disinfecting solutions. By it appoint liquid food, various on structure, rather caloric and containing proteins and vitamins. At difficulty of meal patients use an invalid's cup with the wide rubber tube which is put on it (see Leaving, care of dental patients). Tires impose for the term of not less than 4 — 5 weeks then (at a wedge, signs of consolidation) intermaxillary extension is gradually weakened and remove tires.
The osteosynthesis (see) at Ch.'s changes is applied at absence or the insufficient number of teeth on bone fragments, and also in need of early recovery of the function damaged Ch. Osteosintez carried out by means of a bone seam, metal cores and spokes, metal plates or a framework, besides, use out of oral devices. Researches on use of a glue osteosynthesis — a fastening of the ends of fragments are conducted by polymeric glue (see. Seamless it is connected iye).
Imposing of a bone seam is possible in the absence of defect of a bone and by dense comparison of the ends of fragments. The bone seam a wire from tantalum or stainless steel with a diameter of 0,5 — 0,7 mm is imposed through the section baring Ch.'s edge in the field of a change. The wire is entered through 2 or 4 openings, about -
sverlenny boron at distance of 1 — 1,5 cm from the ends of fragments of a bone (fig. 6, a). Instead of a wire synthetic strong thread from polymeric materials can be used. The osteosynthesis by means of the metal pins and spokes entered at the same time into both fragments (fig. 6, b), is less widespread since it often leads to damage of vessels, nerves and fangs. Connection of fragments of a mandible by means of the metal plates or a framework screwed on a bone by screws (fig. 6, c) from material not subject to corrosion, is possible in the presence of contact between the ends of fragments and at rather small defects. After healing of a change of a plate delete.
Extraoral fixing by means of the devices which are rigidly connecting fragments of a jaw is shown at many
splintered changes and defects of a mandible. Out of oral fixing use irrespective of existence of teeth on fragments. It allows to keep the movements of a jaw during treatment that provides the functional load promoting acceleration of regeneration of a bone and also facilitates to the patient meal and care of an oral cavity. For extraoral fixing several types of devices are offered. The USSR widely uses Rudko's device representing two screw clamps imposed on edge of a jaw during operation without perforation of a layer of compact substance of a bone and connected by special hinges and bars of various length and a form (see fig. 8 to St. Dental equipment, t. 24, Art. 280). There are advanced designs of such device fixed by means of the screws or pins entered into thickness of a bone. Also several systems of the devices allowing not only to fix Ch.'s fragments, but also to make their compression (compression) and gradual cultivation (distraction) for lengthening of a bone are developed.
Fractures of an upper jaw are most often localized in its least strong sites. A feather
of Lomami are typical upper, average and lower (fig. 7).
Fractures of an upper jaw are followed by its shift, mobility in relation to a skull, disturbance of a bite, is frequent bleeding from a nose, a mouth and can be combined with bruises or concussion (see the Contusion of a brain, the Concussion of the brain), and in especially hard cases — with fractures of base of the skull (see. Craniocereberal injury).
At fractures of an upper jaw fixing make by pulling up it to a calvaria. The standard spoon tires with extraoral cores fastened with a soft bandage in the form of a hat are a little effective for this purpose. It is more reliable to use the extraoral individual nazubny or zubonad-gingival tire attached to a plaster bandage on the head with on -
Fig. 6. The scheme of different types of an osteosynthesis at changes of a mandible: and — a bone seam a wire (1 — unary, 2 — double crosswise); — a vnutrikost-ny fastening of fragments a metal pin; in — a fastening of fragments by means of a metal frame.
power of an elastic energy for reposition and rigid cores for fixing. Several designs of devices for this purpose are offered, however in connection with complexity and bulkiness they were not widely used. Use also methods of an osteosynthesis by means of a bone seam, metal spokes or pulling up of an upper jaw for the nazubny tire by means of wire loops to motionless sites of a facial skull — a malar, a zygoma, edge of an eye-socket.
Fig. 7. Diagrammatic representation of typical fractures of upper jaw: 1 —
an upper change (it is specified by a dotted line); 2 — an average change (it is specified by points); 3 — the lower change (it is specified by the solid black line).
The forecast at Ch.'s changes depends on a damage rate of jawbones and surrounding soft tissues; with the timely and qualified help, as a rule, the forecast favorable.
Burns. At burns of maxillofacial area (thermal, chemical) and damage of fabrics
of this area by electric current and ionizing radiation give first aid and carry out treatment by the general rules, as at similar injuries of other localization (see. Beam damages, Burns, Electric trauma). Defects and deformations of jaws, to-rye result from deep burns, further eliminate in the operational way.
Features fighting povrezh d e N and y. Features of fighting damages of Ch. are defined by an anatomo-topographical structure of maxillofacial area and the nature of damage. Among gunshot wounds of this area distinguish wounds only of soft tissues of the person, wound of soft tissues in combination with injury of bones of a facial skeleton (jaws, a malar), and also the combined wounds of maxillofacial area with damage of other parts of a body (see the Person). Wounds can be through, blind, tangent, and also single and multiple, getting and not getting into an oral cavity. Bruises at gunshot wounds of various departments of the person can be combined with their defeat by other types of weapon (the combined defeats). Gunshot wounds are followed by dysfunction of chewing, swallowing, breath and the speech, and also often proceed with a loss of consciousness, are complicated by shock, massive bleedings. Sometimes there is heavy asphyxia (see) demanding urgent intervention (release of respiratory tracts from foreign bodys, deligation on language, a tracheostomy). Use of modern types of firearms aggravates weight of wounds.
First aid at wound and damage of maxillofacial area includes fight against bleeding (see), asphyxia (see), shock (see), an immobilization of the injured jaw.
The temporary immobilization at Ch.'s changes is carried out by imposing of a bandage from bandage or improvised materials (a kerchief, a scarf), at the same time the injured jaw is fixed to unimpaired. For temporary fixing at changes of a mandible for a period of up to 2 — 3 days tie top and bottom Ch.'s teeth by wire ligatures (an intermaxillary alloyed fastening).
Treatment wounded in the maxillofacial area is carried out in hospitals for wounded in the head, a neck and a backbone. Rich blood supply and an innervation of fabrics of maxillofacial area, their high regenerator ability obespechi-
howl bystry healing of wounds. In this regard at primary surgical treatment it is necessary to spare as much as possible both soft, and bone tissues for the purpose of their use at the subsequent plastic surgeries. The remained teeth can be used for an immobilization of fragments of jaws (see the Immobilization, Splintage in stomatology). Assistance at wounds of maxillofacial area at stages of medical evacuation — see the Person. Often obezobrazheny faces, permanent disturbance of chewing, swallowing and the speech, damage of a facial nerve are a consequence of wound of Ch.
Diseases. Disturbance of mobility of a mandible of different degree (from easy restriction to a full immovability) is observed at permanent reduction of masseters (see the Lockjaw), Ch.'s tightening by hems (see the Contracture), changes in a temporal and mandibular joint (see), up to an anchylosis (see), at defects and deformations of H. Disturbance of mobility of a mandible sharply reduces efficiency of chewing that leads to change of activity of all bodies of the alimentary system. After elimination of the reason which caused disturbance of mobility of a mandible, its functions are, as a rule, recovered. About
Inflammatory diseases. Nonspecific inflammatory diseases of Ch. are in most cases caused by distribution inf. the process developing in teeth. Implementation of contagiums in a bone can happen intradentalno — via the channel of a fang at an inflammation and a necrosis of a pulp (see the Pulpitis) as a result of a complication of caries or paradentalno — through dentogingival pockets at a periodontal disease (see Periodontosis), and also at an inflammation of peridental fabrics (e.g., at the complicated teething of wisdom).
At a pulpitis in the fabrics surrounding a top of a fang inflammatory process can develop; at a necrosis of a pulp, as a rule, there is an infection of these fabrics and the acute or chronic inflammation of the periodontium covering a root develops (see the Periodontium it).
Acute purulent periodontitis can lead to distribution inf. process out of limits of a tooth socket. More often exudate gets on system of bone tubules from a tooth socket into a periosteum of a jaw owing to what the acute purulent periostitis develops (see).
Acute purulent periostitis (ustar. parulis, gumboil) it is shown by tooth pain, feeling of «the grown tooth», painful infiltrate in a periosteum with the subsequent formation of subperiostal abscess, a sharp hyperemia and hypostasis of soft tissues in the field of a transitional fold of an entrance of the mouth (or on internal, oral, the surfaces of a jaw), considerable hypostasis of soft tissues of the person in the respective area. Usually body temperature to 38 ° increases, in blood the leukocytosis, a deviation to the left, acceleration of ROE is noted. The first rentgenol. a symptom of a periostitis — emergence of a narrow strip of an ossifitsi-rovanny periosteum along edge of a jaw. Further there is an assimilation of periosteal stratifications to cortical (compact) substance. After opening or spontaneous break of a suppurative focus in a periosteum and removals of the painful tooth which was a source of an infection (see the Exodontia), process quickly stops. On average the acute periostitis of a jaw proceeds 3 — 5 days.
Acute dontogenous osteomyelitis of a jaw develops at distribution patol. process of a tooth socket in spongy substance of a bone. At the same time the acute reaction of the next teeth on percussion and a touch is noted, they become mobile. On the surface of a bone there are diffuse infiltrates, the considerable face edema is observed. At further development of process in side departments of a body of the mandible in a zone of an innervation of a mental nerve (a half of an under lip and a chin) sensitivity owing to a neurothlipsia by inflammatory infiltrate in the mandibular channel (Vincent's symptom) is often broken or lost. Process develops violently, is followed by the high temperature, a fever, considerable changes of composition of blood testimonial
of acute inflammatory process. On the roentgenogram symptoms of osteomyelitis come to light in 8 — 14 days after the beginning of a disease: bone crossbeams of spongy substance are greased, indistinct. Later in spongy substance sites of destruction of a bone of various extent can develop.
Opening of infiltrates of a periosteum, odontectomy, protivospalitelny therapy facilitate disease, but can not always stop development of process in a bone. As a rule, at considerable defeat the acute stage proceeds 10 — 14 days. If there does not occur recovery, process passes into subacute and chronic stages. Affected areas of a bone nekrotizirutsya and exposed to sequestration (see the Sequester). At the same time around the dead learning -
Fig. 8. The panoramic roentgenogram of a mandible at chronic osteomyelitis: 1 — periosteal reaction on edge of a jaw; 2 — the spongy sequester in an alveolar part of a jaw.
the stka of a bone forms the so-called sequestral capsule. On the roentgenogram the sequestral cavity with the spongy or cortical sequester in the center is visible as the center of destruction of a bone tissue with a strip of consolidation on the periphery (fig. 8).
Depending on character of a course of chronic osteomyelitis processes of destruction of a bone (a destructive form) or its new growths (a productive form, or the hyperplastic osteomyelitis) meeting at children more often can prevail. At formation of fistulas and release of pus and small bone sequesters the general condition of the patient improves, normalized body temperature, infiltration and hypostasis of soft tissues decreases. At disturbance of outflow of pus through fistulas there is an aggravation with typical signs of an inflammation.
Hematogenous osteomyelitis of a jaw meets less often than dontogenous. It develops usually at children against the background of heavy inf. diseases, it is characterized by heavier current and defeat of more extensive sites of a bone, than at dontogenous osteomyelitis. A wedge, manifestations and the principles of treatment of hematogenous osteomyelitis of Ch. same, as at dontogenous osteomyelitis.
Traumatic osteomyelitis of Ch. results from their damages and changes (in particular, fire osteomyelitis) and, as a rule, proceeds on type hron. osteomyelitis (see).
The inflammatory processes which are localized in Ch. can extend to adjacent soft tissues and surrounding kletchatochny spaces that causes development of abscesses and phlegmons of maxillofacial area and an upper part of a neck (see the Person, Shay). Sometimes spread of a dontogenous infection to soft tissues does not cause in them the acute inflammatory phenomena, and leads to formation of fistulas (so-called tooth fistulas) in the sites adjoining the H, sometimes very remote, napr on a neck. Fistulas in gums, a mucous membrane of an entrance of the mouth are quite often observed at chronic periodontitis. As a rule, developing of the fistulas with plentiful release of pus opening both in an oral cavity and on face skin and necks, is characteristic of chronic osteomyelitis. With elimination of the inflammatory center fistulas are usually closed independently, the involved hems are sometimes formed, to-rye it is necessary to exsect with the cosmetic purpose.
Treatment of patients with nonspecific inflammatory processes includes an operative measure in the center of an inflammation in Ch., antiinflammatory and fortifying therapy. At an acute periostitis make opening of infiltrate of a periosteum, removal of a painful tooth at any stage of process, as a rule, along with a section.
At acute osteomyelitis of a jaw the early odontectomy, the inflammation which was a source, broad opening of infiltrates and suppurative focuses in a periosteum and surrounding soft tissues, and also carrying out a complex of the antiinflammatory actions applied at osteomyelitis of other bones is necessary (see Osteomyelitis). At chronic osteomyelitis operational removal of sequesters is made only after full department of sequesters and formation of rather strong sequestral capsule protecting a jaw from patol. change or appearance of defects. If the capsule is weak, then before operation impose nazubny or naddesnevy tires. Mobile teeth should not be extracted. They are fastened with the tire, and after elimination of inflammatory process when tooth becomes stronger the formed hems, it is necessary to check viability of a pulp, and in case of her death to trepan tooth and to seal up the channel or channels of a root.
Prevention of nonspecific inflammatory diseases of Ch. consists, first of all, in systematic sanitation of an oral cavity and an exception of possible sources of a dontogenous infection.
The specific inflammatory processes arising in Ch. have various etiology. The actinomycosis in a face and a neck occurs approximately at 58% of patients with an actinomycosis. Primary defeat of Ch. an actinomycosis seldom occurs at adults and is quite frequent at children. It is shown by a small thickening of a bone, morbidity, at localization of process in the field of an attachment of masseters — a lockjaw (see). On the roentgenogram the centers of destruction of rounded shape which do not have accurate contours are found. At an actinomycosis of a mandible the centers of destruction alternate with sites of a limited osteosclerosis, the bone is thickened as a result of assimilation of periosteal stratifications.
At an actinomycosis of soft tissues of the person, hypodermic or intermuscular cellulose sometimes in patol. process jawbones are involved (more often lower). The secondary actinomycosis of Ch. is shown by an ossifying periostitis with education regional uzur in compact substance of a bone. Accession of a purulent infection can lead to development of osteomyelitis with sequestration of superficial sites Ch. Diagnosis of an actinomycosis is based on the comprehensive examination of the patient including clinical, radiological, and also laboratory researches (microscopy patol. material for the purpose of detection of infestants, allocation of culture of radiant fungi). The treatment combined its basis is made by an immunotherapy. At inefficiency of conservative treatment and development of osteomyelitis an operative measure is shown. The forecast depends on a current of a basic disease (see the Actinomycosis).
Ch.'s tuberculosis develops for the second time at hematogenous, is more rare lymphogenous distribution of contagiums from primary center which is usually located in lungs. Tubercular process in most cases begins with damage of gums and peridental fabrics (tubercular periodontitis). Further it can extend to an alveolar shoot and a body of a jaw where proceeds as chronic osteomyelitis, is characterized by a slow sluggish current, formation of small sequesters and sets of the fistular courses. Sometimes there is a spontaneous fracture of a jaw. On the roentgenogram come to light multiple, the small sizes, the indistinct centers of destruction, inside to-rykh are located low-intensive small shadows of sequesters. At tuberculosis of a mandible massive calciphied periosteal stratifications are observed. The diagnosis is made on the basis of data of clinical and radiological researches. Are important identification of primary tuberculous focuses in other bodies for diagnosis, allocation of the causative agent of tuberculosis from patol. the centers and these tuberculinodiagnoses (see). Treatment is complex, includes antituberculous remedies (see), fortifying therapy, in nek-ry cases there is a need for an operative measure (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints). The forecast depends on a form and a stage of the basic tubercular process.
Ch.'s defeat at syphilis (see) it is observed extremely seldom. In the secondary period of syphilis diffusion inertly current periostitis, in the tertiary period — a gumma of a periosteum or gummous osteomyelitis is possible. At the same time severe pains, a diffusion thickening of an affected area of a jaw with the subsequent its softening in connection with disintegration of a gumma are noted. Fistulas are formed, the bone tissue in the center of defeat almost completely resolves therefore the otkhozhdeniye of more or less large sequesters is almost not noted. At localization of a gumma on an upper jaw perforation of a hard palate or a wall of a Highmore's bosom is possible. On roentgenograms at a periosteal gumma the multiple roundish centers of osteoporosis with narrow layers of the sclerosed bone crossbeams between them are visible; at disintegration of a large intra bone gumma the single defect of a bone of rounded shape limited to a zone of an osteosclerosis comes to light. The diagnosis is confirmed by results serol. reactions. Treatment specific. Operative measure is shown only in the presence of large sequesters, according to indications make splintage of teeth. The forecast depends on weight of a basic disease.
Cysts. In jawbones the cysts (see the Odontocele) representing cavities with the connective tissue wall covered from within by an epithelium are quite often formed. Usually cysts accidentally find on roentgenograms. Cysts of the considerable sizes are shown by swelling of a bone, its deformation, thinning of bone walls, to-rye become pliable and during the pressing publish a so-called pergament crunch. In case of an empyema of cyst there is a typical picture of acute inflammatory process. Treatment of cysts of Ch. operational: or full removal of a cyst with a cover (see the Cystectomy), or partial excision of a cover of a cyst (see Vesicotomy), at Krom a gleam of a cyst is connected to an oral cavity (at the same time the cyst gradually decreases in sizes). The fangs turned into a cavity of a cyst seal up and resect their tops, at a viable pulp teeth keep. Forecast favorable.
Tumors. Distinguish benign and malignant tumors of H. Along with tumors, to-rye meet in any departments of a skeleton, in Ch. there are new growths, gistogenetichesk connected with dental germs (see. Dontogenous tumors). Opukhole similar deformation of Ch. is observed at a fibrous osteodysplasia of jaws (see).
Top and bottom Ch.'s tumors differ from each other on morfol. to the characteristic and localization. So, tumors of an upper jaw develop from a mucous membrane of a Highmore's bosom, a tumor of a mandible more often — from fabric elements of a jaw or periosteum. The most often benign tumors arise in a mandible, malignant — in upper.
A wedge, manifestations depend on localization of a tumor. A current in an initial stage often asymptomatic. Only with development of tumoral process characteristic symptoms appear: pains with irradiation in teeth upper or a mandible, disturbance of sensitivity of tissues of lips, a swelling of a cheek, the complicated nasal breath, mobility of teeth and their shift.
Dobroka ches TV enn ye
about ii at x about l and. Such high-quality new growths of Ch. as an ameloblastoma meet more often (see. And a damantinoma), an osteoblastoclastoma (see), an osteoma (see), giant-cell epulis (see), a hemangioma (see).
The osteoblastoclastoma is localized more often on a mandible in her body, is more rare than branches, sometimes on an upper jaw. Growth of a tumor in a bone happens quite slowly, usually asymptomatically. The tumor at disturbance of symmetry of the person as a result of deformation of a jaw is found. Teeth in the field of a tumor sometimes become mobile and are displaced. The osteoblastoclastoma can reach the big sizes. Radiological distinguish cellular and osteolytic options of a structure of a tumor.
The osteoma is located with hl. obr. in paranasal sinuses, is more rare in a mandible. Differs in slow growth. Comes to light at considerable deformation of a jaw. Sometimes prelums of nerves result from pain.
Primary vascular tumors of Ch. — a hemangioma develop in a mandible more often. The tumor is, as a rule, characterized medical flax-nsh by development and in an initial stage proceeds asymptomatically. Wedge, manifestations arise during the thinning of a plate of compact substance of a jaw or germination of a tumor out of its limits. Sometimes at an undetected tumor at the time of an odontectomy or at other jaw operation or an injury perhaps massive bleeding. At germination of a tumor out of limits of a jaw mobility of teeth, their shift is noted, the mucous membrane of an oral cavity or skin of a cheek gets a cyanochroic shade.
Rather seldom in Ch. meet a chondroma (see) and intra bone fibroma (see). The chondroma is localized more often in front departments of a hard palate, in coronal shoots and a body of the mandible. The tumor grows slowly and the long time is not shown clinically. The diagnosis is established with the help rentgenol. researches, at Krom the roundish center of destruction of a bone tissue decides on equal, accurate contours. On its background the dot shadows corresponding to deposits of salts of calcium are noted.
Intra bone fibroma belongs to slowly growing benign tumors. It is long proceeds asymptomatically. Is located, as a rule, in a body of the mandible. At achievement pains arise a tumor of the big sizes and a prelum of a mandibular nerve.
The diagnosis of benign tumors of Ch. is established on the basis by a wedge, pictures and data rentgenol. researches. Confirms the diagnosis tsitol. a research of the material received at a puncture biopsy (see). Additional data at identification of a hemangioma can be obtained by means of an angiography (see).
Treatment of patients with benign tumors of Ch. operational; the volume of operation depends on the sizes and localization of a tumor. Such tumors as an osteoma, intra bone fibroma, can be removed by enucleating. In most cases carry out resections of a jaw, various on volume: without disturbance or with disturbance of its continuity, a resection of a half (half exarticulation of a mandible) or a full exarticulation of a mandible. After an operative measure make splintage (see Splintage in stomatology) with the subsequent bone plastics or prosthetics.
Treatment of hemangiomas of Ch. is directed first of all to reduction of blood supply of a tumor. Carry out sclerosing therapy (introduction to a tumor of alcohol), carry out embolization krovosnabzhayushchy a tumor of vessels. Perhaps cryogenic treatment (see the Cryosurgery), at Krom the tool is entered directly into a tumor. According to indications make an operational oncotomy within a healthy bone tissue with preliminary bandaging of the bringing blood vessels and outside carotid arteries.
The forecast of benign tumors of Ch. at radical treatment, as a rule, favorable. Osteoplastic recovery of Ch. and rational prosthetics result in good functional results.
Malignant tumors of Ch., according to various data, make 1 — 1,5% of all new growths of the person.
Malignant neegshtelial-ny tumors of Ch. develop directly from bone and cartilaginous tissue, a periosteum, marrow and other tissues of a jaw. Nek-ry tumors are formed of dental germs (dontogenous tumors). Cancer is most often localized in an upper jaw, is preferential in a Highmore's bosom (see Paranasal sinuses), and is much more rare in a mandible. The malignant epithelial tumors arising in a mucous membrane of a Highmore's bosom and an oral cavity can grow for the second time into
Ch. Klien, the course of cancer of Ch. depends on localization, a stage of development of a tumor. So, at cancer of a Highmore's bosom the wedge, symptoms are absent during longer time, than at cancer of a mandible. Primary intra bone (central) cancer of a mandible is characterized by bystry developing of pain, edges has the irradiating character, and at intact teeth the reason its long time can remain obscure. One of symptoms of an intra bone tumor is patol. mobility of teeth. In rare instances at load of jaws or an injury can arise patol. change of a mandible. At a prelum a tumor of a mandibular nerve the feeling of numbness of an under lip appears. Sprouting a bone tissue, the tumor infiltrirut soft tissues of a mouth floor, grows in submaxillary (submandibular, T.) and parotid glands. At tumoral infiltration of masseters opening of a mouth is complicated. Innidiation of cancer of jaws happens in regional limf, nodes of a neck and is observed already in an initial stage of a disease.
A wedge, the course of secondary cancer of a mandible is in many respects caused by the accompanying inflammatory process in a mucous membrane of alveolar edge of a jaw where small ulcers are formed. Further ulcers increase and shaking of teeth is observed.
Sarcoma (see) arises usually at young age, most often meets on a mandible. The wedge, symptoms, than cancer is characterized by more bystry development. The sarcomas which are localized on alveolar otrostka upper or a mandible, differ most in rapid growth that is promoted by their continuous traumatizing. For a short time the tumor without ulceration and disintegration reaches the considerable sizes, deforms a bone, extends to a mucous membrane of a cheek or a mouth floor and a hard palate. The act of chewing and a smykaniye of teeth is violated. Quite often Ch.'s sarcomas which developed from spongy substance or elements of marrow move apart plates of compact substance Ch., causing sharp protrusion of a jaw and the expressed asymmetry of the person. The sarcomas which arose from a periosteum usually grow knaruzh, removing soft tissues of a cheek, deformation of a bone happens not at once. Quite often in connection with disintegration of a tumor or its injury there are secondary bleedings. Ch.'s sarcomas most often metastasize in the hematogenous way to lungs, but metastasises can be found also in other bodies and fabrics.
Diagnosis of malignant tumors of Ch. is based on data of clinical and radiological researches. At diagnosis of tumors of an upper jaw make a front and back rinoskopiya, a manual research of a nasopharynx. Essential additional information is obtained at a faringoskopiya and a rinoskopiya by means of a fiber optics. An obligatory diagnostic method is rentgenol. the research, a cut includes (according to indications) a contrast X-ray analysis. Is of great importance tsitol. a research of the contents of a Highmore's bosom received by means of a puncture or the liquid extracted from a bosom after its washing by antiseptic solution. At diagnosis of intra bone cancer of a mandible and sarcomas plays a significant role rentgenol. a research, and also a puncture of a tumor or a biopsy with the subsequent morfol. research.
Differential diagnosis of malignant tumors of Ch. is carried out with benign tumors and opukholepodobny educations. It is based preferential on data tsitol. and rentgenol. researches.
Treatment of malignant tumors of top and bottom Ch. has the specific features. Medical tactics is defined by prevalence of a tumor and it morfol. characteristic.
At treatment of malignant tumors of an upper jaw apply generally combined method: a preoperative remote gamma therapy (see) in a dose 4000 — 4500 I am glad (40 — 45gr) with the subsequent electrosurgical resection of an upper jaw (see the Electrosurgery). Operational treatment is performed in 4 — 5 weeks after radiation. In the preoperative period make a prosthesis-obtu-rator (see Obturators), to-ry later final healing and formation of operational defect replace with a resection prosthesis. In the presence of regional metastasises in limf, nodes of a neck in one step with a resection of a jaw make Krayl's operation (see Krayl operation) or fascial futlyarnoye excision of cellulose of a neck on the relevant party. The last operation is carried out in the presence of movable single limf, nodes, it allows to keep grudino - a clavicular and mastoidal muscle, an internal jugular vein and an eleventh cranial nerve. At cancer of a Highmore's bosom, especially at widespread tumors, in a complex to lay down. actions include chemotherapy (vinblastine, a methotrexate and Bleomycinum).
At intra bone cancer or sarcoma of a mandible if the tumor does not destroy an outside plate of compact substance, carry out a resection of the relevant department of a mandible or its half exarticulation with single-step bone plastics. At tumors of the bo'lyny sizes which are especially going beyond a mandible, reasonablly combined treatment: a preoperative remote gamma therapy in a dose 4000 — 4500 I am glad (40 — 45 Gr) with the subsequent resection of a mandible. In the presence of metastasises in regional limf, nodes of a neck carry out the single-step combined operation: a resection of a mandible with Krayl's operation or fastsialnofutlyarny excision of cellulose of a neck the uniform block. In case of secondary cancer of a mandible at a resection of a jaw make broad excision of surrounding soft tissues. After radical operation fragments of a jaw fix by means of various tires. Simultaneous plastic recovery of an integrity of a mandible is shown in the presence of enough soft tissues for an environment of a bone transplant.
The forecast at malignant tumors of Ch. depends from morfol. characteristics of a tumor, timeliness of treatment, observance of terms and staging to lay down. actions. At the low-differentiated cancer and an osteosarcoma results of treatment of neud letvo to Rita of l ny.
by Main types of operative measures on Ch. are tooth operation and alveolar shoots; jaw operations without disturbance of its continuity (removal of tumors, sequesters, operations for Ch.'s cysts and diseases of a Highmore's bosom); operations with disturbance of a continuity of a bone of Ch. (an osteotomy at deformations, incorrectly accrete fractures, ankiloza of a temporal and mandibular joint,
Ch.'s resection of various volume at tumors); operations with Ch.'s defects (bone plastics).
Training of patients for planned operations consists in preliminary sanitation of an oral cavity (see), production of the necessary orthoses and devices (fixing, the basic, creating tires, protective plates for operations in the sky, etc.), the general training of the patient (see. Preoperative period).
The most widespread operation — • an exodontia (see) is carried out by means of special tools — tooth nippers and elevators (see. Dental tools).
Operations on alveolar shoots and adjacent sites Ch. make from an oral cavity. At the same time apply a local or conduction anesthesia (see Anesthesia local), and according to indications — an anesthesia (see). More extensive operations on Ch. carry out under conduction anesthesia with premedication or under anesthetic.
The section of a bone Ch. (osteotomy) is made the usual special (lanceolated) borons or circular saws fixed by means of diskoderzhatel in a tip of a drill more rare a chain flexible saw (like Gigli). Ways of a section of a bone and fastening (welding) of its fragments by means of ultrasound and the laser are developed and tested.
At body operations and a branch of a mandible most often use extraoral quick access. An upper jaw operations, as a rule, carry out using intra oral access and only at very extensive operations, napr, a full resection of a jaw concerning cancer, resort to outside cuts with cutting off of soft tissues of the corresponding part of an average face zone.
An important element of operations of a pas
of Ch. which are followed by disturbance of their continuity is the immobilization of fragments of a bone, for implementation a cut use the same methods that at treatment of changes: Ch.'s splintage or an osteosynthesis (see) by means of bone seams or extraoral devices.
Ch.'s defects arising after an injury and also owing to osteomyelitis, removal of tumors, etc., eliminate in the operational way. At defects of an upper jaw use rags of soft tissues, fila-a tovsky stalk, a cartilage, seldom a bone, and also the prostheses filling the formed cavity.
At defects and nearthroses of a mandible, prrkhvodyashchy to considerable functional disturbances, make bone plastics (see). Applied free change of autografts from an edge or a crest of an ileal bone earlier (see the Transplant). In a crust, time in practice the developed H is implemented. N. Bazhanov (see t. 20, additional materials), N. A. Plotnikov, P.3. Arzhantsev, etc. a method of change of the heterografts preserved by lyophilizing (see). The site of a bone intended for change is given by the razkhmer and a form corresponding to defect and place it for the ends of fragments of H bared from hems and refreshed to a layer of spongy substance. After their reposition the transplant is strengthened, previously having connected it to the ends of fragments a wire seam. The immobilization of fragments of Ch. is carried out by means of the extraoral device or nazubny tires. In cases of total absence of a branch of a jaw or a condylar shoot apply a transplant, one end to-rogo has a cartilaginous cover. The way of change of a part of the heterogeneous lyophilized jaw together with all complex of tissues of temporal and mandibular joint is developed. At extensive defect of a bone of Ch. and soft tissues of the person the plastics is begun with substitution of defect of soft tissues, and then replace a bone.
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