931. All of the following formations strengthen the joint from the outside, EXCEPT:
1. joint capsule;
2. awl - mandibular ligament;
3. temporomandibular ligament;
4. sphenoid-mandibular ligament;
5. pterygomandibular ligament.
932. The TMJ ligaments include all of the following, EXCEPT:
1. sphenotemporal;
2. disconandibular;
3. sphenomandibular;
4. temporomandibular ligament;
5. stylomandibular ligament.
933. Which of the following muscles is MOST likely to attach directly to the elements of the joint?
1. temporal;
2. digastric;
3. genioglossus;
4. external pterygoid;
5. internal pterygoid.
934. The muscles that provide movement in the temporomandibular joint include:
1. temporal, trapezoid;
2. actually chewing, buccal;
3. internal pterygoid, rhomboid;
4. external pterygoid, actually chewing;
5. tensor tympani muscle, temporalis.
935. The main source of innervation of the temporomandibular joint is:
1. buccal nerve;
2. facial nerve;
3. drum string;
4. greater auricular nerve;
5. auriculotemporal nerve.
936.The temporomandibular joint is MOST likely incongruent because:
1. due to the nature of movements in the joint;
2. there is no constant position of the head in the joint;
3. the size of the articular head does not correspond to the size of the articular fossa;
4. the surfaces are covered not with hyaline, but with connective tissue cartilage;
5. due to the anatomical and topographic relationships of surrounding organs.
937. Extra-articular diseases of the temporomandibular joint include:
1. bruxism;
2. arthritis;
3. arthrosis;
4. joint abnormalities;
5. osteoarthritis.
938. One of the following diseases of the temporomandibular joint is MOST likely to be extra-articular:
1. TMJ arthritis;
2. arthrosis of the TMJ;
3. temporomandibular joint ankylosis;
4. TMJ osteoarthritis;
5. contracture of the lower jaw.
939. Post-injection contracture of the masticatory muscles is MOST likely to be of the following nature:
1. cicatricial;
2. myogenic;
3. arthrogenic;
4. neurogenic;
5. inflammatory.
940. Contracture of the masticatory muscles with difficulty in the eruption of the lower teeth of the “wisdom” muscles is MOST likely of the following nature:
A) scar;
A) myogenic;
B) arthrogenic;
C) neurogenic;
D) inflammatory.
941. Contracture of the masticatory muscles in the syndrome of painful dysfunction of the TMJ is MOST likely of the following nature:
1. cicatricial;
2. myogenic;
3. arthrogenic;
4. neurogenic;
5. inflammatory.
942. Contracture of the masticatory muscles with recurrent dislocation of the TMJ disc is MOST likely of the following nature:
1. scar;
2. myogenic;
3. arthrogenic;
4. neurogenic;
5. inflammatory.
943. Contracture of the lower jaw can be associated with dysfunction of any of the following muscles, EXCEPT:
1. chewable;
2. temporal;
3. zygomatic;
4. actually chewing;
5. internal pterygoid muscle.
944. A 45-year-old woman complains of restriction and pain when opening her mouth. 2 days ago, a molar tooth on the left lower jaw was removed. External examination without any features. The socket of an extracted tooth is in the stage of epithelialization.
What was MOST likely to be the cause of this complication?
1. needle injury to a nerve;
2. injury to the internal pterygoid muscle with a blunt needle;
3. injury to the periosteum due to a needle cut;
4. injury to the external pterygoid muscle with a blunt needle;
5. injection of a large amount of anesthetic under the periosteum.
945. A 37-year-old man, on the 3rd day after the removal of the 3.8 tooth, complained of painful, limited mouth opening. There are no signs of inflammation at the site of injection and administration of anesthetic. The socket is in the stage of epithelialization.
Which of the following complications is MOST likely to have developed in the patient?
1. temporomandibular joint ankylosis;
2. paresis of the facial nerve;
3. scar contracture;
4. neuritis of the inferior alveolar nerve;
5. post-injection contracture.
946. A 34-year-old man complains of limited mouth opening. The history includes a gunshot wound to the right half of the face 2 years ago. The patient is aggressive and overexcited. On examination: rough scars in the temporal and buccal areas on the right. Mouth opening is limited to 1 cm. Movements in the area of the temporomandibular joints are almost undetectable.
Which of the following preliminary diagnoses is MOST likely?
2. myogenic contracture of the lower jaw;
3. neurogenic contracture of the lower jaw;
4. cicatricial contracture of the lower jaw;
5. arthrogenic contracture of the lower jaw.
947. On the 3rd day after the removal of the 3.8 tooth, a 28-year-old man complained of limited mouth opening. When examining the patient: the socket of the extracted tooth is in the stage of epithelialization, restriction of mouth opening of the 2nd degree, there are no signs of inflammation.
Which of the following reasons for the development of this complication is MOST likely?
1. nerve injury from a needle;
2. injury to the periosteum due to a needle cut;
3. injection of a large amount of anesthetic under the periosteum;
4. injury to the external pterygoid muscle with a blunt needle;
5. injury to the internal pterygoid muscle with a blunt needle.
948. On the 3rd day after the removal of the 3.8 tooth, a 28-year-old man complained of limited mouth opening. When examining the patient: the socket of the extracted tooth is in the stage of epithelialization, restriction of mouth opening of the 2nd degree, there are no signs of inflammation.
1. mechanotherapy;
2. novocaine blockades;
3. antibacterial therapy;
949. A 34-year-old man complains of limited mouth opening. The history includes a gunshot wound to the right half of the face 3 years ago. The patient is aggressive and overexcited. On examination: rough scars in the temporal and buccal areas on the right. Mouth opening is limited to 1 cm. Movements in the area of the temporomandibular joints are almost undetectable.
Which of the following treatments is MOST appropriate?
1. surgical;
4. intramuscular injections of the vitreous body;
950. On the 3rd day after the removal of the 3.8 tooth, a 28-year-old man complained of limited mouth opening. When examining the patient: the socket of the extracted tooth is in the stage of epithelialization, restriction of mouth opening of the 2nd degree, there are no signs of inflammation.
What is the MOST likely treatment strategy in this situation?
1. physical therapy;
2. novocaine blockades;
3. antibacterial therapy;
4. desensitizing therapy;
5. oral baths with an antiseptic solution.
951. A 37-year-old man, on the 3rd day after the removal of the 3.8 tooth, complained of painful, limited mouth opening. There are no signs of inflammation at the site of injection and administration of anesthetic.
Which of the following is MOST appropriate?
1. mechanotherapy;
2. aloe injections intramuscularly;
3. phonophoresis with hydrocortisone ointment;
4. injections of antibiotics intramuscularly;
5. electrophoresis with a 5% solution of potassium iodide.
952. A 42-year-old man complains of limited mouth opening. In the medical history, anesthesia was administered six months ago, during which severe, unbearable pain appeared and did not subside for 2 weeks. A painful necrotic ulcer appeared. On examination: Mouth opening is limited to 1 cm. Movements in the area of the temporomandibular joints are almost undetectable.
What caused the complications of local anesthesia?
1. emphysema;
2. paresis of the facial nerve;
3. post-injection hematoma;
4. incorrect pain relief technique;
5. erroneous administration of calcium chloride solution.
953. A 42-year-old man complains of limited mouth opening. In the anamnesis, six months ago, for the purpose of removing a molar tooth in the upper jaw, tuberal anesthesia was performed, during which severe, unbearable pain appeared. There was swelling on this side of the face and pain that continued for 2 weeks despite treatment. Mouth opening is limited to 1 cm. Movements in the area of the temporomandibular joints are almost undetectable.
Which of the following complications of anesthesia performed by a doctor is MOST likely?
1. temporomandibular joint ankylosis;
2. paresis of the facial nerve;
3. necrosis of soft tissues;
4. post-injection reflex contracture;
5. post-injection inflammatory contracture.
954. Special exercises for the masticatory muscles are indicated for all of the following diseases, EXCEPT:
1. post-injection contracture of the masticatory muscles;
2. peripharyngeal phlegmon (after opening the lesion);
3. painful dysfunction of the TMJ;
4. bone ankylosis of the TMJ (before surgery);
5. cicatricial contracture of the parotid-masticatory area (after surgery).
955. Pathological fusion of the articular surfaces of the temporomandibular joint is:
1. Arthritis of the TMJ;
2. Arthrosis of the TMJ;
3. Ankylosis of the TMJ;
4. Osteoarthritis of the TMJ;
5. Contracture of the lower jaw.
956. There are all of the following ankylosis of the temporomandibular joint, EXCEPT:
1. full;
2. bone;
3. partial;
Mandibular contracture is a contraction of the jaws caused by pathological changes and disturbances in the elastic properties of the soft tissues of the maxillofacial area, functionally associated with the temporomandibular joint.
Causes of contractures of the lower jaw
There are unstable and persistent contractures.
Unstable contractures in most cases are the result of weakening of the masticatory muscles after prolonged wearing of splints with intermaxillary rubber traction (used in the treatment of jaw fractures), as well as inflammatory processes in the soft tissues surrounding the lower jaw.
Persistent contractures of the lower jaw are caused by the development of scar deformities in the tissues of the maxillofacial area after gunshot wounds of the face, transport trauma of the facial skeleton, fractures of the coronoid process of the lower jaw and zygomatic arch, burns and inflammatory processes in the perimaxillary area. Contracture can be a complication after conduction anesthesia during dental treatment or tooth extraction.
Cicatricial changes in the oral mucosa can occur as a result of ulcerative necrotic stomatitis, gummous syphilis, noma, burns, and trauma. Significant limitation of mouth opening is associated with scars located between the upper and lower fornix of the vestibule of the oral cavity, as well as on the mucous membrane in the area of the anterior edge of the jaw branch.
Symptoms of contracture of the lower jaw
With contracture of the lower jaw, speech and eating are impaired. The teeth, especially the front ones, take on a fan-shaped position. Deformation of the upper and lower jaws is often observed. If the contracture occurs during the period of growth of the facial skeleton, then the lower jaw is somewhat behind in development, but its deformation is not so significant.
Treatment methods for contracture of the lower jaw
Elimination of contracture of the lower jaw is achieved by surgical treatment using methods of mechanotherapy, therapeutic exercises and physiotherapy in the postoperative period.
Surgical intervention consists of excision of scars or longitudinal dissection with closure of the wound surface with tissue adjacent to the defect or taken from other parts of the body.
In the early stages after surgery, physical therapy and mechanotherapy are prescribed. In case of contracture caused by cicatricial deformations of the skin and subcutaneous tissue, the resulting defect after excision of the scars is covered with triangular flaps transferred from the surrounding tissues, or tongue-shaped flaps on a pedicle, borrowed from the adjacent submandibular region, neck, etc.
For extensive soft tissue defects resulting from scar excision, which require a large amount of plastic material, Filatov stem tissue is used. Superficial scars of the mucous membrane in the area of the corner of the mouth and cheeks are eliminated by longitudinal dissection and movement of the opposite ones; triangular flaps of the mucous membrane and submucosal layer, cut on both sides of the defect.
Treatment of contractures should be pathogenetic. If the contracture is of central origin, the patient is sent to the neurological department of the hospital to eliminate the main etiological factor (spastic trismus, hysteria). In the case of inflammatory-painful trismus, the source of inflammation is first eliminated (remove the causative tooth, open the phlegmon or abscess), and then antibiotics, physiotherapy and mechanotherapy are carried out. Contractures caused by cicatricial adhesions, adhesions of the coronoid process, the anterior edge of the ramus or cheek are eliminated by excision, dissection or plastic surgery with counter triangular flaps, etc., securing success with subsequent active mechanotherapy.
When choosing a surgical method, one must take into account the localization and extent of scar or bone adhesions, the presence of scar changes in the skin and muscle tissue, paralysis of the facial nerve (traumatic or other origin), the degree of exhaustion of the patient, etc. All other things being equal, a guideline in choosing an operation criteria can be used for scar contracture.
In the case of bone fusions between the lower jaw, the zygomatic arch and the bone or upper jaw.
To keep transplanted patients in oral cavity skin grafts use a special therapeutic splint made of AKR-7 with a support platform for a stent insert according to M. P. Barchukov.
A skin graft, sutured and pressed (with a forming medical splint) to the wound surface in the oral cavity, usually survives by primary intention. However, scarring occurs underneath, which reduces the range of movements of the lower jaw and can contribute to one degree or another to the recurrence of contracture. Secondary (postoperative) scarring can also occur due to partial necrosis of the edges of the skin flap.
Therefore, after surgery, in order to prevent wrinkling of the skin flap and scarring under it, it is necessary Firstly, leave the therapeutic splint (together with the stens insert) in the mouth for 2-3 weeks, removing it daily for oral hygiene. Then a removable denture is made (M. P. Barchukov, 1965).
Secondly, in the postoperative period it is necessary to implement a number of measures to prevent 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, you can use standard devices and individual devices that are made in a dental laboratory. This is discussed in more detail below. Physiotherapeutic procedures (irradiation with Bucca rays, ionogalvanization, diathermy) are recommended to help prevent the formation of rough postoperative scars, as well as injections of lidase if there is a tendency to cicatricial contraction of the jaws.
After discharge from the hospital, mechanotherapy must be continued for 6 months.- until the final formation of connective tissue in the area of former wound surfaces. Periodically, in parallel with mechanotherapy, it is necessary to conduct a course of physiotherapy. Upon discharge, it is necessary to provide the patient with the simplest devices - means for passive mechanotherapy (plastic screws and wedges, rubber spacers, etc.).
Good results when treated with the methods described above were noted in 70,4 % patients: their mouth opening between the front teeth of the upper and lower jaws ranged from 3-4.5 cm, and in some individuals it reached 5 cm. In 19.2% of people, the mouth opening was up to 2.8 cm, and in 10 .4%—only up to 2 cm. In the latter case, a repeat operation had to be done.
The causes of recurrence of contractures are insufficient excision of scars during surgery, the use (for epidermization of the wound) of a thin epidermal flap of A.S. rather than a split one.
Yatsenko - Tiersh; necrosis of part of the transplanted skin flap; insufficiently active mechanotherapy, ignoring the possibilities of physiotherapeutic prevention of the occurrence and treatment of scar tissue after surgery.
Relapses of contractures occur more often in children, especially in those operated on not under anesthesia or potentized anesthesia, but under ordinary local anesthesia, when the surgeon is unable to perform the operation according to all the rules. In addition, children do not follow mechanical and physical therapy prescriptions. Therefore, in children, it is especially important to correctly perform the operation itself and prescribe rough food after it (crackers, bagels, candies, apples, carrots, nuts, etc.).
Other articles
Diseases of the temporomandibular joint. Methods of orthopedic treatment and prevention. Part 3.
Study of joint noise. Joint noises occur when there is a violation of the synchronization of movements of the disc and the head of each joint, joints on both sides, when they are excessively mobile, as well as when the articular surfaces are deformed.
Surgical interventions for temporomandibular joint ankylosis. Measures to prevent relapse of ankylosis during surgery using the P.P. method. Lvov.
Bone spines and protrusions remaining in the cut gap, especially in the posterior and internal parts of the wound, contribute to the formation of bone tissue and relapse of ankylosis. Therefore, having completed the reduction of the jaw, the surgeon, using straight cutters driven by a bone processing apparatus, must smooth the edges of the bone wound on the lower (reduced) and upper fragments of the jaw branch and model its head.
The author uses an interosseous backfill from the connective tissue base of V.P. Filatov’s stalked flap, which has the above-mentioned qualities and, in addition, eliminates the retraction of soft tissue behind the jaw branch (after it is moved forward).
Ankylosis of the TMJ. Treatment of temporomandibular joint ankylosis. Operation according to the method of V.I. Znamensky
The operation according to the method of V.I. Znamensky consists in the fact that after separation from the scars and osteotomy (the jaw branch is moved to the correct position, and then it is secured with an allogeneic cartilage graft, which is sutured along the posterior edge of the branch.
The main factors leading to the occurrence of extra-articular mandibular contractures are: improper primary treatment of wounds, prolonged intermaxillary fixation of jaw fragments and delayed use of physical therapy. In this case, scars appear between the bone fragments of the jaw and the soft tissues, limiting the movements of the lower jaw. Depending on which tissues are affected (skin, oral mucosa, or muscles), contractures can be dermatogenic, mogenic, or mixed.
In addition, the cause of contracture can be damage to the joint (arthrogenic contracture), which is difficult to treat conservatively and leads to ankylosis. Finally, there are neurogenic contractures (with damage to the nerve trunks), psychogenic, inflammatory, which quickly disappear after the elimination of the inflammatory infiltrate. Contractures can be caused by the presence of foreign bodies in the muscle area.
Extra-articular contractures are associated with scar changes in the area of the muscle group that lifts the mandible and the soft tissues of the oral cavity. They are divided into temporo-coronoid, zygomatic-coronal, zygomatic-maxillary and intermaxillary. The first two groups of scar contractures (temporo-coronoid and zygomatic-coronal) require surgical intervention. Zygomaticomaxillary and intermaxillary contractures are eliminated by functional methods of treatment - physical therapy.
B. N. Bynin divides extra-articular contractures of the jaws into two main groups - cicatricial and reflex-muscular. The first are associated with scarring of soft tissues, which mechanically impedes the movements of the lower jaw, and therefore can be called mechanical. The latter arise reflexively due to the influence of an irritant on the receptor apparatus, leading to muscle hypertension. This division of extra-articular contractures of gunshot origin is of clinical importance for the purposes of diagnosis and treatment, since the prevention and therapy of these contractures are different. Extra-articular contractures according to the degree of mouth opening are divided into severe (mouth opening up to 1 cm), moderate (1-2 cm) and mild (up to 3 cm).
In some cases, muscle hypertension turns into persistent contracture with pathological manifestations in the muscle in the form of scarring. This process is characterized by rigidity of the masticatory muscles that elevate the mandible. For persistent muscle contractures, conservative (mechanical and physical therapy) or surgical treatment can be used. The latter is recommended for persistent pathological changes in the area of the temporal muscle and consists of resection of the coronoid process or cutting off the masseter and medial pterygoid muscles from the place of their attachment to the lower jaw in case of cicatricial changes.
Mechanotherapy for jaw contractures
The simplest means of mechanical opening of the mouth are plugs, wooden and rubber wedges, cones with screw threads, which are inserted between the teeth for a more or less long time (2-3 hours). However, these remedies are crude, non-physiological and often lead to damage to the periodontium of individual teeth and disruption of dental occlusion. The best results are achieved with the help of devices built on the principle of active and passive movements of the jaw caused by elastic traction or spring processes. For the first time such a device was proposed by Darcissac. The device was used for ankylosis of the temporomandibular joint after surgery to create a false joint. Impressions for making the device are taken on the operating table after the osteotomy, when the patient’s mouth opens wide. The inconvenience of this device is that its production is possible only from an impression of the jaw. With limited mouth opening, taking an impression is extremely difficult.
Recently, a number of new standard devices have been proposed, based on the use of active and passive movements of the lower jaw (A. A. Limberg, I. M. Oksman) (Fig. 243). The advantage of these devices is that they are standard (no need to take impressions of the jaw) and can be used for severe forms of jaw contractures. They transfer pressure to the entire dentition and, most importantly, allow you to perform active-passive exercises (opening and closing the jaws). Mechanotherapy should be carried out after physiotherapeutic procedures (sollux, ultraviolet irradiation, thermal oral baths, paraffin therapy, electrophoresis, etc.). Electron baths of the entire facial area followed by mechanotherapy give good results. Mechanotherapy can also be used for microstomy to stretch scars and restore mobility of soft tissues of the perioral area, for which special devices with elastic traction are used. Most of these deformities require, however, surgical intervention (excision of scars and plastic surgery of soft tissues) followed by the use of physical therapy.
Speech therapy exercises for developing jaw contractures. To prevent contractures, it is useful to combine maxillofacial gymnastics with speech therapy exercises. This method can also be used to treat contractures in the early stages. It includes a series of exercises for the muscles of the face, the walls of the oral cavity and the tongue, which take part in the production of sound, the act of chewing and swallowing.
Rice. 243. Devices for mechanotherapy for jaw contractures.
a - according to Limberg; b - according to Darcissac; c - according to Oksman; g - according to Ezhkin; d — device for mechanotherapy at the corner of the mouth.
The exercises are selected so that each subsequent one includes the previous one and reinforces it. The first exercise - making the sound "a" - consists of very slowly opening the mouth with successively increasing load or tension until the mouth opens to the limit and pain is felt. This is followed by a slow lifting of the lower jaw with a gradual decrease in the volitional load until the teeth are closed. These movements mobilize groups of masticatory muscles that take part in the movements of the lower jaw in the vertical direction during the formation of the sound “a” and the act of chewing. The remaining exercises consist of repeating the previous one and forming other sounds - mobilizing facial and chewing muscles to form the sounds “y”, “u”, “e”. The patient consistently performs each of these exercises 5-6 times per session at intervals of several seconds. Necessary conditions are the sequence of application of exercises and bringing them to the point of pain. The pain disappears after the effort is removed. The exercises are performed in front of a mirror after being shown by a speech therapist.
