Basic knowledge, abilities, skills, which are necessary for study themes (intradisciplinary integration)

Names of the previous disciplines	The got skills
1. Normal anatomy.	To know a structure of bones of the face, anatomy of chewing muscles, muscles of a neck, a structure of teeth. To show places of an attachment of muscles to the mandible.
2. Topographical anatomy and operative surgery.	Topographical anatomy of maxillofacial area as a whole and bones of the face. Principles operative access (admittance, admission) to different parts or regions in maxillofacial surgery. To give the topical diagnosis of fracture of the facial bones.
3. General surgery.	To make the plan of examination of the patient with traumatic damage. To be able to survey correctly the patient and to fill in the medical documentation.
4. Traumatology.	To be able to treat and to make the plan of conservative treatment of the victims with bones fractures of the face.
5. Orthopedic stomatology.	To know kinds splints and caps, that are applied to conservative treatment of victims with fractures of jaws. To make on models splints by S.S. Тigershtedt.

TASKS FOR INDIVIDUAL WORK DURING PREPARATION FOR THE LESSON.

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

The term	Definition
1. Reduction.	This comparison of fragments of the bones.
2. Fixing.	This fastening of fragments in correct position.
3. Immobilization.	Deducing (conclusion) of the organ from function.

4.2. Theoretical questions for lesson: 1. Ways of treatment of fractures of jaws. 2. Kinds and methods of immobilization of jaws. 3. Kinds of conservative methods of treatment of not ballistic trauma of jaws. 4. Kinds of splints, the indication and contra-indication to their appendix. 5. Other methods of conservative treatment of not ballistic trauma of jaws. 6. Mistakes and complications after conservative methods of treatment of crises челюстей.

4.3. Practical works (task) which are executed on lesson: 1. Manufacturing splints by Tigershtedt on models of jaws. 2. Practical training from application splints for a constant immobilization of fragments of jaws.

5. TABLE OF CONTENTS OF THEME:

Local clinical examination of the facial injury

The examination of a patient with a recent severe injury to the facial skeleton will be greatly facilitated if the patient's face is gently washed with warm water and cotton-wool swabs to remove caked blood. The congealed blood in the palate and buccal sulcus can be removed with cotton wool held in non-toothed forceps. Sometimes cotton-wool swabs dipped in hydro­gen peroxide will facilitate the removal of any particularly tenacious clots in the mouth and upon the teeth. If a denture is fractured, the fragments should be assembled to make sure that no portion is missing - possibly displaced down the throat. Only after careful cleaning has been carried out, both extra-orally and intra-orally, is it possible to evaluate the full extent of the injury. It is surprising how often the magnitude of the surgical problem diminishes as the overlying blood is removed and accurate visualization becomes possible.

External examination

The operator should take careful note of oedema, ecchymosis and soft-tissue lacerations. Any obvious bony deformities, haemorrhage or cerebrospinal fluid leak should be recorded. Many of the physical signs of a fractured bone result from the extravasation of blood from the damaged bone ends. This results in rapid early swelling from the accumulation of blood within the tissues and subsequent even greater swelling resulting from increased capillary permeability and oedema. Swelling and ecchy-mosis often indicate the site of individual fractures, particularly of the mandible or zygoma. There may be obvious deformity in the bony contour of the mandible, and if considerable displacement has occurred the patient is unable to close the anterior teeth together and the mouth hangs open. A conscious patient may seek to support the lower jaw with his hand. Many fractures are compound into the mouth and blood-stained saliva is frequently observed dribbling from the corners of the mouth, particularly if the fracture is recent.

The eyelids are gently separated and, if the patient is conscious, visual acuity is tested in each eye. The patient is asked to follow the clinician's finger with his or her eyes and to report if diplopia occurs. A note is made of any alteration in the size of the two pupils, and the light reflex is tested. The extent of any sub-conjunctival ecchymosis is recorded.

Gentle palpation should begin at the back of the head, and the cranium should be explored for wounds and bony injuries. The fingers should then be run lightly over the zygomatic bones and arch, and around the rim of the orbits. Areas of tenderness, step deformities, and unnatural mobility are noted. The nasal complex is next examined in the same manner.

Palpation should continue bilaterally in the condylar region and continue downwards and along the lower border of the mandible. Bone tenderness is almost pathognomonic of a fracture, even an undisplaced crack, but if there is more displacement it may be possible to palpate deformity or elicit bony crepitus.

Areas of loss of skin sensation should be noted. The infra-orbital nerve is frequently contused when the zygomatic complex has been fractured producing anaesthesia or paraesthesia of the cheek, lateral aspect of the nose, and half of the upper lip. Fractures of the body of the mandible are often associated with injury to the inferior dental nerve, in which case there will be reduced or absent sensation on one or both sides of the lower lip.

Intra-oral examination

It is impossible to assess intra-oral damage if the parts are obscured by blood. Conscious cooperative patients may be given a lukewarm mouthwash but in most cases the clinician will have to remove the clotted blood by gently cleaning the whole area with moistened swabs. Congealed blood and any fragments of teeth, alveolus or dentures are removed carefully by forceps, assisted by gentle suction if available.

A good light is essential. The buccal and lingual sulci are examined for ecchymosis. Sub-mucosal extravasation of blood is often indicative of underlying fracture, particularly on the lingual side (Fig. 1).

Figure 1. Haematoma in floor of mouth as a result of a mandibular fracture.

Ecchymosis in the buccal sulcus is not necessarily the result of a fracture as there is considerable soft tissue overlying the bone in this area and extensive bruising may follow a blow insufficient to cause a fracture. However, on the lingual side the mucosa of the floor of the mouth overlies the periosteum of the mandible which, if breached following a fracture, will invariably be the cause of any leakage of blood into the lingual submucosa. This then is a most valuable sign of bony injury in the body of the mandible.

Small linear haematomas, particularly in the third molar region, are reliable indicators of adjacent fracture. The mucosa overlying the root of the zygoma should be carefully examined as fractures of the zygomatic complex and Le Fort I fractures frequently produce a haematoma in this area. A haematoma in the palate is a reliable sign of a bony split associated with a fracture of the mid-face.

The occlusion of the teeth is next examined or, if the patient is edentulous, the alveolar ridge. Premature contact of the posterior teeth with a resultant anterior open bite will be obvious. Step defects in the occlusion or alveolus are noted along with any obvious lacerations of the overlying mucosa. It is important to examine all the individual teeth and to note any luxation or subluxation along with missing crowns, bridges or fillings. Individually fractured teeth must be assessed for involvement of the dentine or pulp. Finally, all teeth should be carefully examined with a mirror and probe to detect loose fillings, fine cracks or splits in the tooth substance. If teeth, portions of teeth, dentures, fillings, etc. are not accounted for, a radiograph of the chest must be ordered in case they have been inhaled.

Possible fracture sites in the mandible are gently tested by placing a finger and thumb on each side and using pressure to elicit unnatural mobility. If the patient can co-operate, he or she is asked to carry out a full range of man-dibular movements and any pain or limitation of movement recorded. Occasionally, even this detailed examination fails to confirm a mandibular fracture which is thought to be present from the history and presence of haematoma. In such cases the flat of both hands should be placed over the two angles of the mandible and gentle pressure exerted. This manoeuvre will always elicit pain when even a crack fracture is present, but the procedure should be one of last resort as it produces extreme discomfort if a mobile fracture is present.

In the upper jaw the tooth-bearing segment is gently manipulated to elicit unnatural mobility. A finger and thumb are then placed over the frontonasal suture line and any mobility of the facial skeleton tested by pressure from the fingers in the palate. A false impression of mobility of the mid-facial skeleton can be obtained, especially in the unconscious patient, by pressure in the palate alone, for the upper part of the head moves inside the epicranial aponeurosis producing the illusion of movement of the mid-facial skeleton. If the dento-alveolar segment moves independently of the remainder of the mid-facial skeleton, particularly if crepitus is elicited, it is indicative of a Le Fort I type fracture. The upper teeth should be tapped with the handle of a dental mirror. A characteristic 'cracked-pot' sound is elicited if there is a fracture above the teeth.