Fractures of the upper jaw account for about 7% of all fractures of the bones of the face. Fragments are displaced depending on the direction of the traumatic force, the severity of the fragments themselves, and to a lesser extent on the traction of the chewing and facial muscles attached to the upper jaw.
There are five types of upper limb fractures according to Limberg . The first type is a fracture of the zygomatic bone; the second is a fracture of the nasal bones; the third is a low transverse fracture of the upper jaw from the pear-shaped opening to the pterygoid process of the main bone; the fourth – a fracture in the suborbital zone, a complete separation of the upper jaw with nasal bones; fifth – a subbasal fracture at the junction of the upper jaw and zygomatic bone with other bones of the skull or complete craniofacial separation. Fractures of the fourth and fifth type, as a rule, are accompanied by combined craniocerebral injuries (fractures of the base of the skull, concussion and bruises of the brain). According to the classification of Lefora , fractures of the upper jaw are divided into three types, of which Lefort I corresponds to the third, Lefort II to the fourth, Lefort III to the fifth type (according to Limberg ).
Almost all fractures of the upper jaw are open – tears of the mucous membrane of the oral cavity, nose, maxillary sinus.
The clinical picture. Severe pain when closing the jaws, open bite, lengthening and flattening of the face due to displacement of fragments down, mobility of fragments, swelling and hematomas around the eyes (symptom of “glasses”), a change in sensitivity in the innervation of the second branch of the trigeminal nerve during fractures in the infraorbital foramen, bleeding from the nose (possibly from the ears), pain when pressing on the pterygoid process of the main bone, with bilateral fractures, the eyeball falls along with the lower edge of the orbit; enophthalmos (diplopia) with unilateral fractures; fractures, dislocations of the teeth of the upper jaw. On palpation, crepitus, subcutaneous emphysema, mobility of the alveolar process, and with more severe types of fractures and the entire upper jaw, are found.
Often encountered in fractures of the upper jaw, orbit, and zygomatic bone, the symptom of “points” occurs immediately after an injury. And with isolated fractures of the base of the skull with a combined injury, hemorrhage does not extend beyond the circular muscle of the eye and appears 24-28 hours after the injury. With fractures of the base of the skull, liquorrhea is usually observed from the nose, external auditory canal and in the area of wound surfaces of the oral mucosa. In the case of suborbital fractures, the mobility of the nasal bones, the symptom of Malevich are determined (with fractures of the walls of the maxillary sinuses and tapping on the teeth on the damage side, the sound of a cracked pot is determined). With subbasal fractures, dysfunctions of the orbital, maxillary, oculomotor, olfactory, and even optic nerves occur. The X-ray examination clarifies the diagnosis. More often, fractures of the upper jaw and its processes are combined with injuries of the zygomatic bone. The frontal process usually breaks with the body of the bone. The lower orbital margin is deformed.
With isolated fractures of the body of the upper jaw, the integrity of the bottom of the orbit may be impaired and its portion will sag into the maxillary sinus. Damage of this type is sometimes combined with damage to the cells of the ethmoid labyrinth. With fractures of the anterior sinus wall, a decrease in its transparency is detected. To detect these lesions, lateral radiographs should be taken. Damage to the walls of the orbit during fractures of the upper jaw and its processes occurs not only under the influence of direct traumatic force, but can develop several days after the injury due to pressure on the thin walls of the orbit of the hematoma and edematous fluid. With fractures of the root of the nose and orbit, the frontal sinus can also be damaged. Usually the blow falls on the alveolar bone. The displacement is small and directed along the traumatic force. The line of enlightenment passes, as a rule, at the level of the roots of the teeth and has the appearance of an irregular curve. It is narrow and is lost in the pattern of bone tissue.
The presence of intact teeth makes it difficult to diagnose radiographs. A transverse fracture of a tooth root or tooth dislocation facilitates the recognition of isolated lesions of the alveolar process. Sometimes the fracture of the alveolar process has a vertical direction and can pass through the wall of the alveoli. In these cases, unilateral expansion of the periodontal gap helps to facilitate fracture recognition. Analysis of clinical data and the mechanism of injury allows you to clarify the type and nature of the fracture. The clinical picture of fractures of the upper jaw is all the more difficult, the higher the fracture line is located and the more significant the bone mass is separated from the base of the skull. The most common fractures of the alveolar process of the upper jaw – about 52% of all fractures; with fractures of the third type – in 20% of patients; the fourth – in 16%; fifth, 8%. In children, there are more often fractures of the third and fourth types in combination with a craniocerebral trauma, hammered fractures of the teeth of the upper jaw.
Treatment. The volume of assistance depends on the general condition of the patient. First aid after stopping bleeding, anti-shock measures and preventing asphyxiation consists in trying to carefully adjust the fragments to establish the correct bite, followed by their temporary fixation. All methods of immobilization in fractures of the upper jaw are reduced to fixing it to the base of the skull. While maintaining the integrity of the lower jaw, it can be used as a splint with bandages (circular gauze and gypsum chin standard transport, elastic according to Urban ). In case of fractures of both jaws, a transport bandage of the type of a rigid chin sling reinforced with bandages to the head support cap along Yadrovaya is shown. In the absence of teeth, removable prostheses of the patient can be used. For this, a steel wire (in the form of a “mustache”) is attached to the denture with the help of quick-hardening plastic, which makes it possible to strengthen the denture to the head cap. Therapeutic immobilization of fragments of the upper jaw is carried out by the standardized Zbarg apparatus , various modifications of the Rudko apparatus with tooth plates made of quick-hardening plastic, as well as a head support cap. If necessary, surgical methods of treatment can be used: suspension of the upper jaw to the orbital edge of the frontal bone in modifications of Faltin Adams, fronto-maxillary osteosynthesis according to Chernyatina- Svistunov ; osteosynthesis of fragments of the upper jaw by Kirchner steel spokes according to Makienko, fixation by mini-plates.