Tasks for individual work during preparation to lesson.

4.1. List of basic terms, parameters, characteristic, which a student must master at preparation to lesson:

Term	Definition
1.PST	This is primary surgical treatment.
2.Wound	This is desordes of skin and mucose membrane.
3.Gunshot	This is wound which bear firearms.

4.2. Theoretical questions to lesson: 1. Classification of the bleedings. 2. Temporal methods of stop of the arterial bleeding. 3. Permanent stop of the bleeding. 4. Definition of the concept “surgical treatment of the wound” 5. Peculiarties of the surgical treatment of facial wounds. 6. Types of the surgical treatment. 7. Types of the stitches. 8. Methods of anaesthetizing during the surgical treatment of facial wounds. 9. General description of the bullet wounds. 10. Features of the bullet damages of soft tissues of maxillofacial area. 11. Classification of the bullet damages of soft tissues of maxillofacial area. 12. Methods of diagnostics of bullet damages of maxillofacial area soft tissues. 13. Peculiarities of clinical signs of blind wounds of maxillofacial area soft tissues. 14. Peculiarities of clinical signs of tangent wounds of maxillofacial area soft tissues. 15. Peculiarities of clinical signs of through wounds of maxillofacial area soft tissues. 16. Treatment and prevention of asphyxia when the wounds of soft tissues of maxillufacial area. 17. Determination of volume and order of medical help for injured person with the damage of maxillofacial area soft tissues at the stage of the first medical aid. 18. Determination of volume and order of medical help for injured person with the damage of maxillofacial area soft tissues at the stage of premedical aid. 19. Determination of volume and order of medical help for injured person with the damage of maxillofacial area soft tissues at the stage of the first medical aids. 20. Determination of volume and order of medical help for injured person with the damage of maxillofacial area soft tissues at the stage of the qualified medical aid. 21. Determination of volume and order of medical help for injured person with the damage of maxillofacial area soft tissues at the stage of specialized medical aid.

4.3. Practical works (task) which are executed on lesson: 1. To define the area of maxillofacial area damage. 2. To manage the mechanical, surgical, chemical, physical and biological methods of stop of bleeding. 3. To lay on the basic types of bandages. 4. To render the first aid. 5. To fill the primary medical card of injured person or patient. 6. To render the first, medical and qualified aid to the injured person with the wound of soft tissues.

5. 5. TABLE OF CONTENTS OF THEME:

Principles of Management

       The initial examination involves evaluating and stabilizing the trauma patient. Any life-threatening conditions should be identified and managed immediately. The conditions of the airway, breathing, and circulation are examined, followed by a general neurologic assessment with particular attention to cervical spine and cranial injuries.

       It is important to achieve hemostasis when stabilizing and evaluating the patient who has sustained trauma. Most bleeding will respond to application of a pressure dressing. Occasionally surgical exploration and packing of the wound under general anesthesia may be indicated. In rare instances vessels in the neck may need to be ligated. Indiscriminate clamping inside the wound should be avoided because damage to important structures such as the facial nerve orparotid duct may result. It is unusual for bleeding from soft tissue injuries to the face to result in a shock state. Lacerations involving the scalp can occasionally be difficult to control with pressure and may require clamping, ligation, or electrocautery.

       In soft tissue injuries not involving the face the length of time from initial injury to treatment is important. Secondary risk of infection increases with the lapse of time. Because of the rich vascularity of the face there is no “golden period” for suture repair of facial wounds. In fact healing of facial wounds is unaffected by the interval between injury and repair.

       Patients who are immunized and have received a booster injection within the last 10 years do not require tetanus prophylaxis if the wound is not tetanus prone. Tetanus-prone wounds are those with heavy contamination from soil or manure, devitalized tissue, or deep puncture wounds. If the wound is tetanus prone and the patient has not received a booster injection within 5 years prior to the injury, a 0.5 ml tetanus toxoid boost injection should be given. If the patient has not received a booster within 10 years prior, they should receive a booster injection for any wound. Patients who are not immunized should receive both a booster injection and 250 units of tetanus immunoglobulin, followed by a full course of immunization.

       Treatment of soft tissue injuries involves early reconstructive procedures addressing both the soft tissue and the underlying bony injury in a minimum number of stages. Occasionally it is better to delay soft tissue repair until the facial fractures have been addressed. In patients with large avulsion of tissue, definitive early reconstruction of the tissue loss with regional or microvascular flaps may be required.

       Anatomic Evaluation

       Following the initial evaluation and resuscitation, injuries to the soft tissues should be evaluated during the secondary survey. Patients sustaining trauma often have associated soft tissue injuries. Facial injuries can be superficial but may extend to involve adjacent structures including bones, nerves, ducts, muscles, vessels, glands, and/or dentoalveolar structures. Associated injuries, including vascular injury, may develop acutely or days after the injury.

       A thorough head and neck examination determines the extent of associated facial wounds. Peripheral cranial nerves are commonly involved with lacerations that involve the face. The facial nerve divides the parotid gland into deep and superficial portions. Any injury to the gland should raise suspicion for associated facial nerve injury. The facial nerve exits the stylomastoid foramen and divides into five branches within the parotid gland. Because of the significant peripheral anastomosis, repair of facial nerve injuries involving distal branches anterior to the canthal plane is unnecessary.

       Injury to the parotid gland can lead to leakage of saliva into the soft tissue. The parotid duct is approximately 5 cm in length and 5 mm in diameter. It exits the gland and runs along the superficial surface of the masseter muscle and then penetrates the buccinator muscle to enter the oral cavity opposite the upper second molar. Treatment of parotid duct injuries depends on the location of the injury. These injures should be repaired in the operating room with the aid of magnification. If the injury involves the proximal duct while it is still in the gland, the parotid capsule should be closed and a pressure dressing placed. If the injury is located in the midregion of the duct, the duct should be repaired. Injuries involving the terminal portion of the duct five branches within the parotid gland from the lateral canthus should be repaired should be drained directly into the mouth. Lacrimal probes are useful in cannulating the duct and identifying injuries. A polymeric silicone (Silastic) catheter is placed to bridge the defect. The severed ends are then sutured over the catheter, which is left in place for 10 to 14 days. The parotid capsule should be closed to prevent formation of a parotid duct fistula or sialocele. Lacerations are closed primarily and a pressure dressing is placed to prevent fluid accumulation.

       There are several protocols for evaluation and treatment of penetrating injuries to the neck, face, and temporal bone. If there is suspicion that deep critical structures have been injured, the appropriate protocol should be followed.

           Sequence of Repair and Basic Technique

       A decision is made to repair the wound in the emergency department or to perform the repair in the operating room under a general anesthetic. Large complicated lacerations demand ideal lighting and patient cooperation. In injuries where there is a concern that deep structures have been damaged, a general anesthetic affords the best opportunity for exploration and repair. The patient may require repair of other traumatic injuries in the operating room, and on many occasions, definitive repair of associated facial soft tissue injuries can be performed at the same time.

       Lidocaine is a popular local anesthetic and ranges in strength from 0.5 to 2%. It is usually administered with epinephrine 1:100,000. Lidocaine has a rapid onset of action, a wide margin of safety, and a low incidence of allergic sensitivity. A thorough evaluation of the seventh cranial nerve should be undertaken prior to injection of anesthetic or administration of a general anesthetic. Injecting local anesthetic prior to cleaning the wound will allow more effective preparation. Local anesthetics containing epinephrine have been used successfully in all areas of the face but may not be optimal in areas where tissue monitoring is critical or where extensive undermining of the soft tissue is necessary. One should avoid injecting directly into the wound when important landmarks could be distorted. Regional nerve blocks are beneficial in minimizing the amount of local anesthesia required and also prevent distortion of the tissues.

       After adequate anesthesia has been obtained, the wound is thoroughly débrided. Nonvital tissue is conservatively excised in an attempt to salvage most of the tissue. Devitalized tissue potentiates infection, which inhibits phagocytosis. Persistent infection at a wound site leads to the release of inflammatory cytokines from monocytes and macrophages, which delays wound healing. An anaerobic environment results and limits leukocyte function. Soft tissue wounds are often contaminated with bacteria and foreign material. Treatment of these injuries involves copious irrigation and is aimed at minimizing the bacterial wound flora and removing any foreign bodies. With respect to infection rates, studies have shown no statistical difference in wounds irrigated with normal saline when compared to other solutions. Pulsatile-type irrigation devices may be helpful to remove debris, necrotic tissue, and loose material. Hydrogen peroxide impedes wound healing and has poor bactericidal activity. A good rule is to avoid irrigating the wound with any solution that would not be suitable for irrigating the eye. Careful and meticulous cleaning of the wounds primarily will avoid unfavorable results such as “tattooing,” infection, hypertrophic scarring, and granulomas. A scrub brush and detergent soap may be necessary to remove deeply imbedded foreign material. However, soaps may cause cellular damage and necrosis. A surgical blade may be helpful to scrape foreign material that is deeply embedded. Polymyxin B sulfate can be used to remove residual grease or tar in wounds. Proper cleaning and good surgical technique are imperative in minimizing infection. Infections are rare when the wound is closed so that no dead space, devitalized tissue, or foreign bodies remain beneath the sutured skin. Hydrogen peroxide is minimally bactericidal and toxic to fibroblasts even when diluted to 1:100. Diluted hydrogen peroxide is useful in the postoperative period in cleaning crusts away from incision lines in order to minimize scarring.

       Common methods for closing wounds include suturing, applying adhesives, and stapling. It is preferable to suture complex facial lacerations secondary to esthetic considerations. A layered closure is almost always necessary and eliminates dead space beneath the wound. If the dead space is not obliterated, accumulation of inflammatory exudates may occur. This leads to infection, which in turn may cause tension across the epidermis. Tension can cause necrosis of the skin edges due to impairment of the vascular supply and may cause an increase in scarring.

       Injuries involving anatomic borders such as the vermilion of the lip must be reapproximated precisely. Examples of these landmarks include eyebrows, lip margins, and eyelids. Lacerations should be closed by placing a suture in the center of the laceration to avoid creating excessive tissue on the end of the laceration (dog-ear). Deep layers should be reap-proximated with 3-0 or 4-0 buried resorbable sutures. The superficial skin is closed with 5-0 or 6-0 suture. It is important to avoid causing puncture marks when grasping the wound edges. Margins should be undermined to allow slight eversion of the wound margin. Skin sutures should be removed 4 to 6 days after placement. By this time the wound has regained only 3 to 7% of its tensile strength and adhesive strips help support the wound margins.

       At 7 to 10 days following suture removal the collagen has begun to crosslink. The wound is now able to tolerate early controlled motion with little risk of disruption. As the wound heals it will contract along its length and width and become inverted due to collagen and fibroblast maturation. Initial management is aimed at producing a slightly everted wound edge. The wound continues to remodel up to a year following injury but never regains greater than 80% of the strength of intact skin.

       Tissue adhesives are gaining in popularity. Some studies have suggested similar cosmetic outcomes in wounds treated with octylcyanoacrylate when compared to standard wound closure techniques for non–crush-induced lacerations treated less than 6 hours after injury. Closure of lacerations with octylcyanoacrylate is faster than standard wound closure methods. However, its use should be avoided in complex lacerations involving the face, where there are esthetic concerns.

       Suture materials and different surgical techniques do not show substantial differences in relation to outcome. General characteristics of the patient (ie, sex and age) and of the wound (ie, length and site) seem to be important predictors of adverse tissue reaction. Suboptimal appearance is associated with wounds that are infected, wide, incompletely approximated, or have sustained a crush injury. The total number of bacteria is more important that the species of bacteria contaminating a wound. Greater than 10⁵ aerobic organisms per gram of tissue are needed for contamination, and crush-type wounds are 100 times more susceptible to infection.

       Delayed primary closure may be necessary in some instances. Patients who may benefit from a delayed procedure include those with extensive facial edema, a subcutaneous hematoma, or those with wounds that are severely contused and contain devitalized tissue. Secondary revision procedures are usually undertaken months later to allow for scar maturation.

       Clinical examination and radiographs are used to diagnose fractures of the face. Facial fractures are ideally treated prior to soft tissue repair. If repair of the facial bones is delayed, it is optimal to close the lacerations initially. The wounds can be reentered and revised if needed to access the fracture site.

           Types of injuries

       Abrasions

       Shear forces that remove a superficial layer of skin cause abrasions. The wound should be gently cleansed with a mild soap solution and irrigated with normal saline. These superficial injuries usually heal with local wound care. It is important to determine whether foreign bodies have been embedded in the wound. Failure to remove all foreign material can lead to permanent “tattooing” of the soft tissue. After the wound is cleansed the abrasion is covered with a thin layer of topical antibiotic oinment to minimize desiccation and secondary crusting of the wound.

       Reepithelialization without significant scarring is complete in 7 to 10 days if the epidermal pegs have not been completely removed. If the laceration significantly extends into the reticular dermal layer, significant scarring is likely.

       Contusions

       Contusions are caused by blunt trauma that causes edema and hematoma formation in the subcutaneous tissues. The associated soft tissue swelling and ecchymosis can be extensive. Small hematomas usually resolve without treatment; hypopigmentation or hyperpigmentation of the involved tissue can occur, but is rarely permanent. Large hematomas should be drained to prevent permanent pigmentary changes and secondary subcutaneous atrophy.

       Lacerations Lacerations are caused by sharp injuries to the soft tissue. Lacerations can have sharp, contused, ragged, or stellate margins. The depth of penetration should be carefully explored in the acute setting. Closure is performed using a layered technique. If the margins are beveled or ragged they should be conservatively excised to provide perpendicular skin edges to prevent excessive scar formation. Rarely is there an indication for changing the direction of the wound margins by Z-plasty at the time of primary wound repair. Flap-like lacerations occur when a component of the soft tissue has been elevated secondary to trauma. Eliminating dead space by layered closure and pressure dressings is especially important in these “trapdoor” injuries.

Avulsive Injures

       Avulsive injures are characterized by the loss of segments of soft tissue. Undermining the adjacent tissue, followed by primary closure, can close small areas. When primary closure is not possible, other options are considered. These include local flaps or allowing the wound to heal by secondary intention followed by delayed soft tissue techniques. If a significant amount of soft tissue is missing, then a skin graft, local flaps, or free-tissue transfer may be necessary.

       Animal and Human Bites

       Dog bites are most common in children and the midface is frequently involved. Canines can generate 200 to 450 psi when biting, and examination for fractures should be performed. Management of bite injuries involves liberal amounts of irrigation and meticulous primary closure. Wound irrigation and débridement are important in reducing infection.

       Animal and human bites are most often polymicrobial, containing aerobic and anaerobic organisms. Dog bites are often open and lend themselves to vigorous irrigation and débridement. Cats have a large quantity of bacteria in their mouth, with the most frequent and important pathogen being Pasteurella multocida. Cat bites are associated with a twofold higher risk of infection than the more common dog bite wounds. Because their bites usually cause puncture wounds, they are difficult to clean. Having the patient follow up 24 to 48 hours after the initiation of therapy allows the surgeon to monitor the wound for any signs of infection.

       Antibiotic prophylaxis for animal bites continues to be debated with few good prospective studies available. Amoxicillin-clavulanate is the current drug of choice for bite wounds. Antibiotic prophylaxis should be directed at Pasteurella multocida for infections presenting within 24 hours of injury. For wounds that present after 24 hours of injury, Streptococcus and Staphylococcus species are more common, and antibiotic prophylaxis with a penicillinase-resistant antibiotic should be chosen.

       Immediate closure of bite injuries is safe, even with old injuries. There is approximately a 6% rate of infection when bite wounds are sutured primarily in lacerations where there are cosmetic concerns. Extensive animal bite wounds involving the face should be treated according to the criteria of esthetic reconstructive surgery. Rabies prophylaxis should be given for bite wounds that occurred from an unprovoked domestic dog or cat that exhibits bizarre behavior or from an attack by a wild animal such as a raccoon, skunk, bat, fox, or coyote.

6. MATERIALS FOR SELF-CONTROL:

A.Tasks for self-control:

№	Basic assignments.	Instructions
1.	Ethiology of damage of soft tissues.	To list the etiological factors that contribute to injury.
2.	Classification of nun-gunshot and gunshot damage of soft tissues.	To name classification of nun-gunshot and gunshot damage of soft tissues.
3.	The clinical course of nun-gunshot and gunshot injuries of soft tissues.	To list the clinical manifestations that accompany the nun-gunshot and gunshot injuries of soft tissues.
4.	Treatment of non-gunshot and gunshot injuries of soft tissues.	To propose the plan of treatment of patients with injuries of soft tissues.

B. Tasks for self-control: 1. To the serviceman with the penetrable damage of cheek area surgical interference was conducted in 18 hours after, and several stitches on a wound were put at the second days after interference. What type of surgical treatment took place in this case? What type (according to the time) of suture was put in? (Answer: early surgical treatment, primary deferred stitches).

2. After the surgical treatment of wound in supramandibular area got 2 days back, a surgeon put in deaf stitches and prescribed antibiotics. What error took place in the doctor’s actions? (Answer: putting in deaf sutures).

3. Giving help to the patient with the plural damage of the face soft tissues, doctor began interference with the surgical treatment of wound and putting in the stitches on the area of cheek, and in the last turn he put in several stitches on the wound of lower lip. What was the error in his actions? (Answer: with the plural face damaged the stitches should be immediately put in the area of the natural openings).

C. Materials for test control. Test tasks with the single right answer (a=II): 1. What damage is called a wound: A. Skin injury with bleeding. B. Damage of skin integrity. C. Damage of skin and mucous membrane integrity. D. Breaking of bone continuity. E. Damage of mucous membrane. (Correct answer: C).

2. Bullet wounds of maxillofacial area are divided into: A. Through, blind, tangent, penetrable in the cavity of mouth, nose, sinuses. B. Bruises, lacerated, chopped, cut, stab, and bitten wounds. C. Wounds of lower and upper jaw, zygomatic and nasal bones. D. Bruises, lacerated, chopped, cut, stab, and bitten wounds. E. Isolated trauma, trauma of bones of maxillofacial area, combined trauma. (Correct answer: A).

3. Bullet wounds of maxillofacial area according to the type of weapon are divided into: A. through, blind, tangent, penetrable in the cavity of mouth, nose, sinuses. B. Bruises, lacerated, chopped, cut, stab, and bitten wounds. C. Wounds of lower and upper jaw, zygomatic and nasal bones. D. Wounds caused by bullet, fragmentation bomb explode, mine blast, wounds caused by spherical and arrow-shaped elements. E. Isolated trauma, trauma of maxillofacial area bones, combined trauma. (Correct answer: D).

D. Educational tasks of 3th levels (atypical tasks): 1. At patient after primary surgical treatment of penetrating wounds of the cheek appeared fistula, from which (especially at the time of reception of food) is released clear liquid. At the mouth from the duct of parotid gland saliva are not released. (Answer: complete salivary fistula).

2. Victims with penetrating gunshot wound to the mouth was hospitalized after 42 hours after the injury. General condition is not violated. There is a wound 2.0 x1, 5cm on the left cheek area. Name the type of suture which used in this case. (Answer: a delayed primary suture).

 

THEME 9. DAMAGES OF MANDIBLE IN PEACE-TIME AND UNDER THE EXTREME CONDITIONS: ANATOMY OF DAMAGES, CLASSIFICATION, CLINICAL COURSE, DIAGNOSTICS, MEDICA L AID FOR INJURED PERSON AT THE PLACE WHERE TRAUMA IS GOT, AT THE STAGES OF MEDICAL EVACUATION. SURGICAL TREATMENT OF WOUNDS WHEN THE LOWER JAW IS DAMAGE D, PRINCIPLES OF PLASTIC SURGERY. ACHIEVEMENTS OF NATIVE SCIENTISTS, EMPLOYEES OF DEPARTMENT.

1. ACTUALITY OF THEME: one of the important problems of modern oral surgery there are a clinic, diagnosis, treatment and prevention of damage to the maxillofacial region, particularly fractures of the lower jaw, which is the highest percentage of all the facial and neck injuries in peacetime. This is associated with a significant increase in the frequency of road accidents, domestic trauma, the use of different types of knives and the growth of street crime and tensions in society. The study of the subject will allow the future doctor is clearly focused on issues clinics, diagnostic methods of first aid to victims the trauma of the lower jaw, in the subsequent practice will avoid many complications primarily related to improper conduct of the doctors in the early stages of providing assistance (late diagnosis, poor and part-time emergency aid).

2. CONCRETE AIMS: 1.1. To analyse clinical displays, to familiarize with statistics of fractures of lower jaw in peace-time. 1.2. To explain the ethiology and pathogeny of lower jaw fractures in peace-time. 1.3. To propose basic and additional methods of inspection of patients with the lower jaw fractures in peace-time. 1.4. To interpret the classification of lower jaw fractures in peace-time. 1.5. To analyze the end and convalescence of patients while using different methods of treatment. 1.6. To complete the plan of treatment of patients with the lower jaw fractures in peace-time.