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Contracture of the lower jaw: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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Contracture of the lower jaw (Latin contrahere - shrink, contract) - a sharp restriction of mobility in the temporomandibular joint due to pathological changes in the soft tissues surrounding it and functionally associated with it.
Often, the contracture of the lower jaw is combined with intraarticular spikes (ie with ankylosis).
[What causes the contracture of the lower jaw?
The contraction of the lower jaw arises on the basis of changes in the skin, in the surrounding subcutaneous tissue, in the masticatory muscles, in the fascia (parotid-temporal), in nerve fibers of traumatic or inflammatory origin.
Coarse fibrous and bony fissures of the anterior margin of the mandibular branch or its coronoid process with the zygomatic arch or the tubercle of the upper jaw can occur after gunshot and non-acute lesions of the temporal, malar and buccal areas, and after mistaken injection of solutions (alcohol, formalin, acids, hydrogen peroxide etc.), causing necrosis of soft tissues around the jaw at the injection site. After necrosis, normal tissues are replaced by cicatricial.
Contractures on the soil of prolonged adynamia of the head of the lower jaw with intermaxillary fastening of the fragments of the lower jaw can be supplemented by the formation of scars in the thickness of the cheeks or lips, if simultaneously with a fracture of the jaw soft tissue of the face has been damaged.
The neurogenic contracture of the lower jaw can develop on the basis of reflex-painful contraction of the masticatory muscles (caused by pericoronitis, osteomyelitis, needle trauma during anesthesia), spastic paralysis and hysteria.
Symptoms of contracture of the lower jaw
With contracture of the mandible, there is always a more or less pronounced reduction of the jaws. If it is based on acute inflammation of the masticatory muscles (trismus on the soil of myositis), attempts at forcible breeding of the jaws cause pain.
With persistent cicatricial and bone fusion, the reduction of the jaws can be particularly significant, but the attempt to dilute them in this case is not accompanied by acute painful sensations. Palpatory, in this case, it is sometimes possible to identify rough cicatrices in the whole vestibule of the mouth or in the retromolar region, in the region of the malar bone, the coronoid process.
In cases where a trauma or inflammatory process has occurred in an adult, the outwardly noticeable rough asymmetry of the face, as well as changes in the shape of the branch, condylar process, angle and body of the mandible is not noted. If the disease has developed in childhood or adolescence, then by the time of the examination (in an adult), the doctor can detect (clinically and radiographically) gross anatomical disorders: underdevelopment of the jaw's branch and body, displacement of her chin to the sore side,
Where does it hurt?
What do need to examine?
Treatment of contracture of the lower jaw
Treatment of contractures of the lower jaw must be pathogenetic. If the contracture of the lower jaw of the central origin, the patient is sent to the neurological department of the hospital to eliminate the main etiological factor (spasmodic trismus, hysteria).
In the case of its inflammatory origin, first eliminate the source of inflammation (remove the causative tooth, open the phlegmon or abscess), and then carry out antibiotic, physio-and mechanotherapy. The latter is desirable to be carried out by the apparatuses of AM Nikandrov and RA Dostal (1984) or DV Chernov (1991), in which the source of pressure on the dental arches is air, that is, the pneumatic drive, which in the collapsed state has a thickness in 2-3 mm. DV Chernov recommended to bring the working pressure in a tube introduced into the cavity of the patient's mouth within 1.5-2 kg / cm 2 as in the conservative treatment of cicatricial contracture of muscle and in inflammatory its etiology.
Contractures of the mandible caused by bone or osteo-fibrous extensive spikes, fusions of the coronoid process, the anterior margin of the branch or cheek, are eliminated by excision, dissection of these adhesions, and due to the presence of narrow cicatrices in the retro-molar area - by the method of plastic colliding triangular rags.
After the operation to prevent wrinkling of the skin flap and scarring underneath it, it is first necessary to leave a medical tire (together with the stent liner) in the mouth for 2-3 weeks, daily extracting it to hold the toilet of the oral cavity. Then make a removable denture. Secondly, in the postoperative period it is necessary to carry out a number of measures that prevent the recurrence of contracture and strengthen the functional effect of the operation. These include active and passive mechanotherapy, starting from 8-10 days after surgery (preferably - under the guidance of a methodologist).
For mechanotherapy, it is possible to use standard apparatuses and individual devices that are manufactured in a dental laboratory. This is discussed in more detail below.
Recommended physiotherapy procedures (beech irradiation Bukki, iono-galvanization, diathermy), which contribute to the prevention of the formation of gross postoperative scars, as well as injections of lidase with a tendency to cicatricial cramping of the jaws.
After discharge from the hospital, it is necessary to continue mechanotherapy for 6 months - until the final formation of connective tissue in the area of the former wound surfaces. Periodically, in parallel with mechanotherapy, it is necessary to conduct a course of physiotherapy.
When discharging, it is necessary to equip the patient with the simplest devices - the means for passive mechanotherapy (plastic screws and wedges, rubber spacers, etc.).
Excision of fibrous adhesions, osteotomy and arthroplasty at the level of the base of the condylar process with the use of de-epidermis cutaneous flap
The same operation at the level of the lower edge of the zygomatic arch with excision of the bone-scarring conglomerate and modeling of the head of the lower jaw, the interposition of the skin de-epidermis flap
Dissection and excision of soft tissue scars from the oral cavity; resection of the coronoid process, elimination of bone adhesions (chisel, drill, Luer's clippers); epidermisation of the wound with a split skin graft
Dissection and excision of cicatricial and bone fusion through external access, resection of the coronoid process. In the absence of scarring on the skin - surgery through intraoral access with mandatory transplantation of a split skin flap
Excision of the entire conglomerate of scars and bone adhesions through intraoral access to ensure wide opening of the mouth; transplantation of a split skin graft. Before surgery, the external carotid artery is bandaged
Dissection and excision of bone and fibrous adhesions of the cheek to ensure wide opening of the mouth and closure of the formed defect in advance with a Filatov stem on the cheek or elimination of a cheek defect with a skin arterialized graft
Good results in treatment with the methods described above were noted in 70.4% of patients: their mouth opening between the anterior teeth of the upper and lower jaws varied within 3-4.5 cm, and in individuals reached 5 cm. In 19.2% of the person, the opening of the mouth was up to 2.8 cm , and in 10.4% - only up to 2 cm. In the latter case, we had to do a second operation.
The reasons for the recurrence of contractures of the lower jaw are: insufficient excision of scars during surgery, the use (not for the epidermis of the wound) of a thin epidermal flap AS Yatsenko-Tiersh; necrosis of part of the transplanted skin flap; insufficiently active mechanotherapy, ignoring the possibilities of physiotherapeutic prevention of the onset and treatment of scarring after surgery.
Relapses of mandibular contractures occur more often in children, especially those who have not under anesthesia or potentiated analgesia, but under the usual local anesthesia, when the surgeon fails to perform the surgery according to all the rules. In addition, children do not perform appointments for mechano- and physiotherapy. Therefore, the correct operation of the operation itself is especially important for children and the appointment after it of rough writing (crackers, bagels, candies, apples, carrots, nuts, etc.).