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1.A bitten wound. Characteristic. Features of treatment. There are two different types: Occlusion bites: when the teeth sink into the skin with enough force to break through the surface of the skin. Clenched or closed fist bites: when someone’s fist makes contact with another person’s teeth, This can lead to infections in the finger’s joints, tendons and/or bones, along with tendinitis and joint stiffness. *charactaristics: Intense pain and swelling. Pus around the wound. If the wound feels warm to touch (if it’s hot, the wound is likely infected). Reddening of the skin (erythema) in the wounded area. A fever, chills or generally feeling unwell. If you’ve been bitten on your finger and lose feeling in your fingertips or have trouble bending or fully straightening your finger, it’s likely a sign that you’ve damaged some tendons and/or nerves. *features of treatment : Exam: we will ask you about your medical history, including your history of immunizations, allergies and, if any, your medications. Cleaning: we will clean out and disinfect the wound again, before assessing it for any potential nerve, ligament, tendon and/or bone damage. Testing: we may take tissue cultures from the site of the wound to analyze for infectious organisms. If we find symptoms of joint or tendon damage, or if the wound appears to be infected, we may order a blood test or imaging tests, such as X-rays. Treatment plan: we will determine which, if any, medications are best for your particular situation. And we should close up the wound with non-absorbable stitches. In more severe cases, we may remove all dead tissue (debridement), followed by a skin graft to close the wound. Sometimes surgery is needed if there’s a fracture, joint/tendon damage or a severe infection. medication treatment : Antibiotics for soft-tissue infections (7 to 10 days), severe infections (10 to 14 days) and severe bone/joint infections (4 to 6 weeks). Amoxicillin (Augmentin®) is one type of antibiotic that can be used, though not for those who are allergic to penicillin. If you’re allergic to penicillin, you will likely be prescribed clindamycin, trimethoprim/sulfamethotrexateor ciprofloxacin Trimethoprim/sulfamethotrexate is most commonly used with children. 2.Principles of treatment of mandibular fractures. first there are some techniques that we should asses in order to correctly diagnose the case , such as Examination of the mouth with a good light, paying attention to the junction of the hard and soft, dental arches and the sulci, is important. Patients with fractures of the mandible between the mental foramen and the mandibular foramen often have reduced levels of sensation in the distribution of the inferior alveolar or lingual nerves and patients with zygomatic fractures often have areas of reduced sensation in the distribution of the infraorbital and anterior superior alveolar nerves. *Sublingual haematomas and tears at the gingival margin can be diagnostic of mandibular fractures. we also should examine the function of the jaw , for example an open bite can be a feature of a fractures in which the middle third of the facial skeleton moves backwards and downwards on the cranial base or of bilateral fractures of the mandibular condyles in which the pterygomasseteric sling shortens the ascending rami. and finally a radiograph examination will be necessary not only to reach a diagnosis but also to inform treatment decisions, for example, about where bone plates should be applied. *treatment : -non-surgical : such as haematomas, clean abrasions, small lacerations, undisplaced stable fractures and some displaced fractures, such as those of the mandibular condyle where the occlusion is not deranged or where the occlusion settles spontaneously -surgical : we use plates the principles of treatment are: ● reduction—repositioning fragments of bone to their anatomical positions ● fixation—making sure fragments remain in position until fractures have healed ● immobilization—preventing the broken bone from moving during the healing period ● rehabilitation—returning the patient to normal function after the fracture has healed. 3. Stages of care for the wounded in the maxillofacial area there are three stages .stage I is early recovery and takes place in the postanesthesia care unit (PACU). The following parameters must be monitored continuously: Oxygen Saturation: Hypoxia can occur in the postoperative period and the patient must be kept on oxygen for 1–2 h (2–6 L/min) to prevent this. Oxygen may be delivered using a face mask or through nasal prongs. Pulse, blood pressure: Increase in these parameters may indicate pain. Serious complications (Infarction, Malignant hyperthermia) may produce a drastic change in these parameters and must be recognized. ECG waveform: To monitor cardiac status. Postanesthesia tremors/shivering: This can occur on the table during recovery from anesthesia. It can occur if the patient is hypothermic, and is commonly associated with the use of halogenated anesthetics. Management consists of rewarming the patient. Tramadol and meperidine may be used to stop uncontrollable shivering . .stage II is intermediate recovery, and takes place in the ward. It is essential to infuse intravenous fluids during this period to maintain the ongoing fluid requirements, till the patient resumes oral intake of fluids. Maintenance fluids are essential to maintain proper pH and electrolyte balance and for adequate organ perfusion. .stage III is late recovery that occurs after discharge. in this stage anibiotics treatment is required to prevent any kind of enfection reaccurence such as Amoxicillin and metronidazole are used. 4. A stab wound. Characteristic. Features of treatment. Characteristic : Stab wound Stab wound is caused by sharp pointed object and has the large depth and small area of the injured skin and mucosa. *The pain syndrome is slight, *hiatus is absent, *the external bleeding is absent, * hematoma can develop. features of treatment : Treatment must be of a multi-disciplinary nature: it begins at the trauma unit to provide airway maintenance, hemodynamic stabilization, and if necessary, neurological ophthalmological and vascular evaluation since stab wounds ar rare , one case was registered where a penetration occurred. Penetrating lesions on the middle facial third, where intracranial extension is suspected, must be assessed and treated following multi-disciplinary criteria. Therefore, the following is recommended: , so we start by cleaning the stab wound with antiseptic for example chlorhixidine, and we take out the dameged soft tissue and we check where the pentration reached if it reached sinsitive parts or not , and after we make sure the the area of damage is clear and that the bleeding has stopped we can make a flap surgery to cover the area of the wound and we make sutures and we make dressing using untibacreial creams and the patient should be addresed an antibiotic therapy for example metronidazole and amoxicilin till the would is fully recoverd . 5.the structure of the lower jaw : 6.Traumatic disease. Clinic. Principles of treatment. Traumatic disease - a symptom complex of traumatized patients with severe, multiple injuries; it is a pathological process caused by severe shock-related mechanical trauma, in which the sequential change in the key factors of pathogenesis determines the regular sequence of periods of clinical course. Clinic: In the clinical course of traumatic disease, there are periods: -Shock period - a period of acute functional and systemic disorders that are caused by severe trauma, lasting 12-48 hours. : haracterized by a sharp pain syndrome, the patient sharply paler, sweaty, dynamic (possible arousal), blood pressure drops dramatically, accelerates and weakens the pulse, heart tones are deaf, shortness of breath, oliguria -The early post-shock period - the period of threat of organ and multiple organ failure - lasts 3-7 days after injury. : characterized by the development of multiple organ failure and development of (DIC) syndrome; fat embolism; renal-hepatic failure; heart failure with central hemodynamic disorder; consequences of early post-traumatic endotoxicosis. -Period of infectious complications or high risk of their development (period of secondary immunodeficiency) - duration of 1 week - up to 1 month. : characterized by Purulent-septic complications -The convalescence period is a duration of several weeks to several months treatment : There are basic principles of treatment of victims: - the earliest start of infusion therapy that prevents the deepening of shock, hypoxia and acidosis. In order to restore microcirculatory tissue perfusion and elimination of hemostatic disorders use rheologically active media: saline solutions, reopolignokin, reognoman. Colloidal and crystalloid plasma substitutes contribute to the restoration of circulating blood volume and the restoration of microcirculatory perfusion. Whenever possible, start restoring blood volume and plasma loss (erythrocyte mass, fresh blood, fresh native plasma, etc.); - rapid evacuation of the wounded to the specialized medical institutions of the surgical profile (front hospital base); - performing emergency surgery in a single set of countermeasures. In general, surgical treatment of polytrauma consists of: emergency operations aimed at addressing the direct threat of life (mechanical asphyxia, bleeding and etc.), which are performed against the background of intensive antitussive and resuscitation measures; early delayed operations aimed at eliminating the causes of life-threatening complications (after removing the patient from traumatic shock for 2-3 days after the post-shock period); delayed second-line operations. All surgeries aimed at eliminating the syndrome of mutual aggravation of the lesions should be completed within the first 2-3 days; - performing early delayed operations immediately after removal of the wounded from the shock of the emergence of relative stabilization of hemodynamics. The purpose of this stage is to eliminate the syndrome of mutual aggravation of lesions; - consolidation of the process of long-term compensation. Extremely energyintensive mechanisms of immediate compensation in the development of traumatic disease are depleted by the end of 2-3 days, and the stored bioenergy potential is gradually switched to long-term (sustainable) compensation; - prescribing preventive multicomponent antibacterial therapy in the early post-shock period; - prognosis and prophylactic treatment of complications on the basis of key pathogenetic mechanisms of each period of traumatic disease. 7.Chopped wound. Characteristic. Features of treatment. another name of it is open wound : An open wound is an injury involving an external or internal break in body tissue, usually involving the skin and there are four types : 1.abrasion :when your skin rubs or scrapes against a rough or hard surface 2.laceration: is a deep cut or tearing of your skin. 3.puncture: is a small hole caused by a long, pointy object, such as a nail or needle. Sometimes, a bullet can cause a puncture wound. 4.avulsion: is a partial or complete tearing away of skin and the tissue beneath. treatment : Depending on the location of your wound and the potential for infection, we may not close the wound and let it heal naturally. This is known as healing by secondary intention, meaning from the base of the wound to the superficial epidermis.. Although the healing may not look pretty, it prevents infection and the formation of abscesses. Another treatment for an open wound includes pain medication. Your doctor may also prescribe penicillin or another antibiotic if there’s an infection or high risk for developing an infection. In some cases, you may need surgery. if a surgery is needed we start with cleaning and possibly numbing the area, your and thin we close the wound using skin glue, sutures, or stitches. 8. Temporary immobilization in fractures of the mandible. Any movement in the fracture line after reduction may disturb or tear the granulations or osteoid tissue. It may also cause the bone to heal with a deformity. Immobilisation should therefore be complete, and continued until union has taken place, which in the mandible is about 4 – 6 weeks, and it is achieved with maxillomandibular fixation (MMF). maxillomandibular fixation (MMF): components : screws are inserted into the bony base of both jaws in the process of fracture realignment and immobilisation. The screw heads act as anchor points to fasten wire loops or rubber bands connecting the mandible to the maxilla. Traditional interdental chain-linked wiring or arch bar techniques provide the anchorage by attached cleats, hooks, or eyelets techniques: 1. It is important to consider the patient specific anatomy via radiographic imaging for the best treatment strategy. 2. Identify the vertical location of locking screw placement at the mucogingival junction to minimize potential soft tissue overgrowth. Upon eventual fixation of the entire system, the lugs of the arch bars should be aligned with the clinical crown of the tooth 3. Select the desirerable horizontal locations of screws in between tooth roots to avoid dental injury It has been shown that manual insertion of MMF screws in contact with tooth roots does not create permanent damage to the root or dental complications (However, care should be taken, via pre-operative radiographic imaging and tactile feel intraoperatively, to avoid direct screw insertion through critical structures. 4. Removal of the unused screw arms can assist the patient with hygiene and limit the areas of potential soft tissue overgrowth. Also, manipulation of the frenum and soft tissue may further reduce irritation and/or overgrowth due to contact with the implant. 9. Traumatic shock. Clinic. Principles of treatment. Traumatic shock is a traumatic condition, which is accompanied by major impaired function of the vital organs, first of all blood circulation and breathing. clinics : depends on the phase and it has 2 phases , erectile and torpid. 1. Erectile phase :lasts for 15-20 minutes. It is characterized by: excitement, screams, increased physical activity of the victim, efforts to do something, the functions of the victim are intense. This phase is a sign of the compensatory capacity of the organism injured 2.torpid phase : The body begins to store the remnants of its energy and other capabilities to ensure the activity of only vital organs and systems. The patients are slowed down, do not move or shout, but quietly fade away, and in this phase patients will experience hypoxia, Hypovolemia, decrease in AT, tachycardia, decreased urination, subsequent skin fading, cyanosis and decrease in BP. Treatment : Treatment. Immediate action in the treatment of traumatic shock is aimed at eliminating circulatory and respiratory disorders, as well as related disorders. 1. Stop bleeding with a harness, bandage, artery by hand, clamp, perform skull trepanation, laparotomy, thoracotomy to permanently stop bleeding and eliminate other life-threatening disorders. In the maxillofacial region, the most dangerous are the carotid artery and its branches. 2. Restore impaired hemodynamics in BCC by carrying out intensive infusion transfusion therapy, the volume of which should exceed blood loss (to compensate for the loss of tissue fluid), transfusion of blood components, antitussive fluids, plasma substitutes (saline, electrolytic solutions) (2-4 liters per 1 hour, only up to 0.5-3 liters). For increase of oncotic pressure and prevention of edema of a brain and lungs polyglucine, gelatinol, protein preparations are used. Continued infusion to stabilize systolic pressure by 90, venous - 50 mm RT. st., urinary recovery to 20 ml in 1 hour. The volume of transfused blood should not exceed 2 liters. 3. To reduce the impulse from the lesion site make anesthetic local and central blockages, introduce painkillers and sedatives. It is important to take into account the possibility of allergy to the anesthetic and not to overdose it (morphine is not shown in patients with trauma to the skull and respiratory failure). 4. Hypoxia is eliminated by restoration of airway patency by available methods - cleansing of the mouth and nose of the pharynx, incubation of the trachea, tracheotomy, artificial ventilation of the lungs, inhalation of moist oxygen and air, introduction of respiratory analeptics (lobelin), bronchial drainage. 5. To prevent: a) brain swelling, which is dangerous in the first days after a traumatic brain injury, prescribe mannitol, lasix, steroid hormones (12-48 mg of dexamethasone); b) brain hypoxia - intravenously inject 20% sodium oxybutyrate solution with 5% glucose solution (75100 mg / kg). 6. To maintain the hormonal system, appoint ACTH (15-20 units), hydrocortisone 100-200-300 units. Norepinephrine, mesotone are used to increase AT (especially in traumatic brain injury). 7. Correct the condition of coagulation and blood coagulation systems. To increase blood coagulation, a 10% solution of calcium chloride, medical gelatin, aminocaproic acid and other drugs are administered. At signs of development of thrombosis, thrombophlebitis, thromboembolism of cerebral vessels, heparin, fibrolizin etc. are administered intravenously. 8. Neuroleptics (aminazine, propazine) are prescribed only for psychomotor excitation and arterial hypertension. 9. Disorders of the acid-base state are corrected: with acidosis enter intravenously 200-400 ml of 4% sodium hydrocarbonate solution (soda), alkalosis - 5% solution of ascorbic acid in 40% glucose solution, 10% solution of potassium chloride, plasma, vitamins. 10. According to the testimony perform surgical interventions (group 1 - operations on lifegiving; group 2 - operate after removing from shock (repon, fix and immobilize 75 fragments in fast, simple and reliable ways); group 3 - surgery not shown; group 4 - hopeless (receive symptomatic treatment). 11. To prevent septic complications use massive doses of antibiotics: penicillin, zeporin, monomycin on the background of forced diuresis (lasix, hemodesis, glucose). 10.Crushed wound. Characteristic. Features of treatment. Crushed wound The mechanism of this damage is equal to contused and lacerated wounds, but the degree of injury is maximal. Crushed wounds can be infected heal worse. characteristics : Bleeding Bruising Compartment syndrome (increased pressure in an arm or leg that causes serious muscle, nerve, blood vessel, and tissue damage) Fracture (broken bone) Laceration (open wound) Nerve injury Infection (caused by bacteria that enter the body through the wound) treatment: Stop bleeding by applying direct pressure. Cover the area with a wet cloth or bandage. Then, raise the area above the level of the heart, if possible. If there is suspicion of a head, neck, or spinal injury, immobilize those areas if possible and then limit movement to only the crushed area 11.Clinical picture of mandibular fractures. Fracture classification. There are unilateral, bilateral, single, double, multiple fractures of the mandible. fractures, patients' complaints may be varied depending on the location of the fracture and its nature. Patients are always disturbed by pain in a particular area of the mandible, which is exacerbated during its movement. Eating and chewing food, especially solid foods, is painfully painful, sometimes impossible. Some patients note the numbness of the skin of the chin and lower lip (more often with nerve rupture), incorrect closing of the teeth. There may be dizziness, headache, nausea. 12.Torn wound. Characteristic. Features of treatment. another name of it is open wound : An open wound is an injury involving an external or internal break in body tissue, usually involving the skin and there are four types : 1.abrasion :when your skin rubs or scrapes against a rough or hard surface 2.laceration: is a deep cut or tearing of your skin. 3.puncture: is a small hole caused by a long, pointy object, such as a nail or needle. Sometimes, a bullet can cause a puncture wound. 4.avulsion: is a partial or complete tearing away of skin and the tissue beneath. treatment : Depending on the location of your wound and the potential for infection, we may not close the wound and let it heal naturally. This is known as healing by secondary intention, meaning from the base of the wound to the superficial epidermis.. Although the healing may not look pretty, it prevents infection and the formation of abscesses. Another treatment for an open wound includes pain medication. Your doctor may also prescribe penicillin or another antibiotic if there’s an infection or high risk for developing an infection. In some cases, you may need surgery. if a surgery is needed we start with cleaning and possibly numbing the area, your and thin we close the wound using skin glue, sutures, or stitches. 13.Types and classification of dental braces. there are two classification : 1. Mobile braces: there is only one type which is invisalagin and clear aligners. it is transparent and removable . 2. Fixed braces it has many types like : a. lingual braces b.self ligating braces. c.cearmic braces. d.metal braces 14.Asphyxia. Types, causes, treatment. Asphyxia - an acute or subacute pathological condition that results from oxygen starvation with carbon dioxide accumulation in the body; characterized by severe respiratory, circulatory and nervous system disorders types and causes. 1) aspiration - when it enters the respiratory tract mucus, blood, vomiting. 2) dislocation - at a fall of a tongue, for example as a result of trauma of the lower jaw (double mental break, separation of the chin); 3) valve - due to the formation of a valve from the flaps of the soft palate and other tissues of the oropharynx; 4) obstructive - as a result of airway obstruction by foreign objects; 5) stenotic - due to contraction or narrowing of the respiratory tube with inflammatory or allergic edema, hematoma, etc. Treatment: Depending on the mechanism of occurrence of asphyxia treatment is to eliminate its cause. With aspiration asphyxia - the suction of fluid from the respiratory tract, and when bleeding - its stop. With dislocation asphyxia - displacement of the tongue in front (stitching at a distance of 1 cm from the edge of the tongue and to the side of the line or puncture with a pin) and fixation in the elongated position; repositioning and immobilization of jaw bone fragments. With valve asphyxia - soft tissue flaps are stitched or cut off. At stenotic asphyxia - dissection of the centers of edema, elimination by hematoma. With the slow development of asphyxia, the use of diuretics is effective. With obstructive asphyxia - remove foreign bodies with tools (tweezers, clamp) or flip the victim upside down and in the presence of a cough reflex, the foreign body may fall out 4 15.Fractures of the alveolar process. classification: • partial - the fracture line passes through the outer compact plate and sponge; • complete - the fracture line passes through the entire thickness of the alveolar process; • separation of the alveolar process; • fracture of the alveolar process, which is combined with dislocation or fracture of the teeth; • Fracture fracture. Fractures of the alveolar process can occur both on the upper and lower jaw. Most often the frontal alveolar process of the upper jaw breaks. The fragment of the alveolar process of the jaw in the frontal area is shifted back (towards the sky or tongue), and in the lateral section - inside. On the upper jaw broken the fragment may shift outwards if the direction of the traumatic force is affected through the teeth of the mandible. TREATMENTS: are carried out under local anesthesia (more often to the conductor, rarely - infiltration). Finger alignment of the broken fragment of the alveolar process is performed. With a sufficient number of persistent teeth on the damaged and undamaged area of the jaw, it is necessary to impose a smooth tireclamp. The number of teeth included in the tire on the intact section of the alveolar process should not be less than that of the broken fragment. In other cases, it may be made of high-speed plastic tire-kappa. 16. Traumatic damage to teeth. all tooth injuries are divided into the following groups: 1. Incomplete fractures of teeth (without opening of pulp): there will be, • cracks of enamel and dentin; marginal fracture of the crown and tear enamel; • crown fracture, enamel and dentin detachment. 2. Complete fractures of the teeth (with the opening of the pulp): • open (in the mouth) - fractures with partial defect of the crown; - fragmentation or defect of the crown; - fragmentation or defect of crown and root; • closed (while maintaining the integrity of the crown) - fracture of the root. 3. Dislocations of teeth: • incomplete (partial) dislocation of tooth; • dislocation of the tooth (separation) and separation of the edge of the alveolar process. 4. Pinching of teeth. When a tooth is struck, hemorrhage into the pulp can occur and may result in necrosis (Necrosis), which leads to the development of inflammatory processes in the periapical region. the jaw, which is accompanied by a rupture of the tissues of the surrounding tooth. It is necessary to distinguish incomplete, full and killed dislocations of a tooth. Most often there are dislocations of the front teeth on the upper and lower jaws, which occur during mechanical influences (falling, impact). But it can also occur with the improper use of the elevator or tongs when removing teeth, as well as with increased stresses on the tooth when biting or chewing on solid foods. dislocation is accompanied by damage (rupture) of the periodontal tissues and the neurovascular bundle. With incomplete dislocation there is a displacement of the tooth in the lingual (palatine) or buccal side, but the tooth has not lost its connection with the hole. Part of the periodontal fibres is torn and the rest is stretched. The neurovascular bundle may rupture, but its integrity may be undisturbed (especially when the tooth is rotated about the axis). With a full dislocation, the tooth completely ejects from the hole and loses its connection with it, but it can be retained only due to the adhesive properties of the two wet (Blood-soaked) surfaces. There is a rupture of all fibres of the periodontal and neurovascular bundle. Maybe accompanied by a fracture of the alveoli and tooth loss from the hole. 17.Primary bleeding. Causes, methods of temporary and permanent stop. Primary bleeding Primary haemorrhage occurs immediately following an injury. the cause of it is an injury. First aid for primary bleeding is to apply a pressure bandage to a bleeding wound. In case of profuse bleeding, use a finger pinch of the vessel that supplies the blood to the anatomical site. The common carotid artery is pressed with fingers to the transverse process of VI of the cervical vertebra. . At this point, the thumb presses the artery to the spine, with the other fingers located on the back of the neck. The facial artery is pressed slightly forward of the intersection of the anterior margin of the actual chewing muscle with the inferior edge of the mandible, the superficial temporal - 1 cm, stepping forward and upwards from the goat ear. In order to impose pressure on the common carotid artery, it is necessary to raise the patient's arm from the intact side and bend it in the elbow. On the neck in the projection of the common carotid artery on the injured side impose a dense roll of gauze or cotton wool and firmly bandaged circular rounds of bandage, which pass through the arm, protecting the larynx, trachea and common carotid artery on the intact side from compression. You can also stop the bleeding by bandaging the wound in a wound or by applying a clamp to it. 18.Innervation of the mandible, anatomy. anatomy : the mandibular nerve has two divisions: anterior and posterior, -Anterior division .Nerve to medial pterygoid muscle .Nerve to tensor veli palatini .Nerve to tensor tympani .Masseteric nerve .Deep temporal nerves .Nerve to lateral pterygoid muscle .Buccal nerve -Posterior division .Auriculotemporal nerve .Lingual nerve .Inferior alveolar nerve Innervation ; .Sensory: Skin of the buccal region, sensory supply to the tongue (anterior ⅔), temporal region; .Motor: Masticatory muscles, mylohyoid muscle, anterior belly of digastric muscle, tensor veli palatini muscle, tensor tympani muscle. 19.The early secondary bleeding. Causes, methods of temporary and permanent stop. Early secondary bleeding occurs when the thrombus is severed during the transport of the victim or due to the rupture of the vessels in the absence of reliable transport immobilization of the jaw fragments, can occur in the first 24-48 hours after the injury. - the imposition of a pressure bandage; - the elevated position of the limb; - digital pressure of the artery throughout; - maximum limb flexion in the joint; - stop bleeding with a tourniquet; stop bleeding with a tourniquet; - stop bleeding from the carotid artery according to the method of Mikulich. 20.Classification of mandibular fractures (by timing, location, nature, direction of the fracture line). Fracture classification. There are unilateral, bilateral, single, double, multiple fractures of the mandible. Among the single fractures there are fractures of the branch of the mandible (articular, coronary processes, the branch itself) and its body (within the dentition). Depending on the direction, the slit fractures may be transverse, longitudinal, oblique, zigzag The fracture of the mandible may be complete, passing through the entire thickness of the bone tissue, and incomplete (fracture), when the integrity of the compact plate of any bone section is not broken. 21.Late secondary bleeding. Causes, methods of temporary and permanent stop. Late secondary bleeding may occur as a result of purulent melting of the blood clot or the wall of the partially damaged vessel after 7-14 days or as a result of erosion of the vessel 3-4 weeks or later. . Late secondary bleeding can be reliably stopped only by ligation of the main vessel throughout, rarely by the ligation of the bleeding vessel in the wound with two ligatures and fixation to the soft tissues. After stopping bleeding, patients are prescribed a strict bed rest for 7-10 days, establish an individual post 22.Surgical treatment of wounds. we start by achieveing hemostasis when stabilizing and evaluating the patient who has sustained trauma. Most bleeding will respond to application of apressure dressing. Occasionally surgical exploration and packing of the wound under general anesthesia may be indicated. and if there any kind of Lacerations we apply clamping, ligation, or electrocautery and then we give the patient anti-titanus to prevent any king of complication , In patients with large avulsion of tissue, definitive early reconstruction of the tissue loss with regional or microvascular flaps may be required. After adequate anesthesia has been obtained, the wound is thoroughly debrided. Nonvital tissue is conservatively excised in an attempt to salvage most ofthe tissue. Devitalized tissue potentiates infection, which inhibits phagocytosis. Repair of facial soft tissue injuries can be performed under local anesthetic with dosage 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. One should avoid injecting directly into the wound when important landmarks could be dislocated and distorted. and we start closing the wound , 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. 23.Chewing muscles, anatomy. The muscles of mastication are muscles that attach to the mandible and thereby produce movements of the lower jaw. they are innervated by manibular nerve and supplied by maxillary artery . and they are : Temporalis,: The temporalis muscle functions mainly as an elevator of the mandible masseter, : The major function of the masseter muscle is to elevate the mandible, with a minor contribution to protrusion of the mandible. medial pterygoid : The major functions of this muscle are elevation of the mandible and side-toside movements when grinding and chewing. The medial pterygoid is also involved in protrusion of the mandible. lateral pterygoid : The function of the lateral pterygoid depends on the degree of its contraction. Bilateral contraction of the lateral pterygoid muscles protrudes and depresses the mandible. A unilateral contraction on a particular side, in conjunction with the ipsilateral medial pterygoid muscle, moves the mandible to the opposite side. This allows for alternating side-to-side movements during chewing.