Contracture of the lower jaw: causes, symptoms, diagnosis, treatment. Post-injection contracture of the lower jaw (experimental clinical study) Ibragimov Zakarya Ibragimovich Contracture of the muscles of the temporomandibular joint symptoms

TMJ contracture - this is a restriction of movements of the n / h or reduction of the jaws to complete immobility. The disease can be of various etiologies.

Inflammatory contracture (trismus) occurs with direct and reflex irritation of the apparatus associated with the innervation of the masticatory muscles (pain irritation). Post-infectious contractures are accompanied by damage to the nerves or muscles. They occur when the technique of conduction anesthesia is violated after inflammatory processes in the tissues adjacent to the n / h (abscesses, phlegmon, pericoronitis, etc.).

There are three degrees of inflammatory contracture. At the first degree, the opening of the mouth is slightly limited and possibly within 3–4 cm between the cutting surfaces of the upper and lower central teeth; in the second - there is a restriction of mouth opening within 1 - 1.5 cm; at the third - the mouth opens less than 1 cm.

Treatment inflammatory contracture is reduced to the elimination of the inflammatory process. If it is impossible to access the opening of the purulent focus in the oral cavity, it is necessary to remove the spasm of the masticatory muscles by blocking the motor branches of the third branch of the trigeminal nerve according to Bershe-Dubov. With the duration of the inflammatory process with the reduction of the jaws for more than 2 weeks, physiotherapy and therapeutic exercises are indicated.

Scar contracture occurs due to cicatricial changes in the tissues surrounding the n / h. This occurs with ulcerative-necrotic processes in the oral cavity (noma, complications after scarlet fever, typhoid, cardiovascular decompensation), chronic specific processes (syphilis, tuberculosis, actinomycosis), thermal and chemical burns, trauma (including after surgery for the removal of benign and malignant tumors). Cicatricial contractures occur in patients after an erroneous injection of irritating solutions instead of an anesthetic (hydrogen peroxide, formalin, calcium chloride, ammonia, etc.). Wound healing by secondary intention leads to the formation of scar tissue, represented by collagen fibers, which practically does not stretch. This leads to deformation of tissues and organs. There are dermatogenic, desmogenic (connective tissue), myogenic, mucosogenic and bone contractures.

Clinic characterized by the reduction of the jaws of varying degrees. Dermatogenic and mucosogenic scars, as well as scars that replace a through defect, are determined visually, deep ones - by palpation. The movements of the articular heads are preserved (small rocking and lateral movements n/h).

Treatment cicatricial contractures depends on the localization of deformed tissues, the extent of the lesion, the duration of the disease and can be conservative with the use of paraffin, pyrogenal, lidase, repidase, hydrocortisone, vacuum therapy, ultrasound, helium-neon laser, etc. The main goal of conservative treatment is to prevent the development of hyalinosis of collagen fibers. These treatments are effective for fresh, "young" scars no more than 12 months old. In other cases, surgical treatment is indicated. Surgical intervention consists in dissecting the scars, excising the scar tissue and replacing it with another tissue.

Various plasty methods are used: counter triangular flaps, a pedunculated flap, free tissue grafting (skin, subcutaneous tissue, fascia, etc.), using a Filatov stalk, a flap using microvascular anastomoses (with deep scars).

To prevent the recurrence of cicatricial contractures after surgical interventions, it is necessary to carry out therapeutic exercises, including mechanotherapy.

Ankylosis of the TMJ

Ankylosis - reduction of the jaws, characterized by a significant limitation or complete absence of movements in the TMJ, associated with persistent fibrous or bone adhesions inside the joint with the glenoid cavity of the temporal bone, and often the tissues surrounding the articulation.

The disease develops mainly in childhood and adolescence. It can be caused by trauma, postpartum traumatic injuries, inflammatory processes near the condylar process (otitis, mastoiditis, osteomyelitis of the n / h branch).

As a result of the pathological process (arthritis, trauma), the soft tissues of the articular surfaces of the articulation are damaged, the cartilaginous surfaces become cloudy. The meniscus splits into fibers. The joint capsule shrinks. The synovial membrane is reborn. The cartilage gradually disappears. Both articular surfaces turn into dense scarred connective tissue (fibrous ankylosis), which then ossifies, i.e. bone ankylosis occurs.

Clinic. Fibrous ankylosis develops during the period of complete formation of the facial skeleton. In this case, there is no deformation of the h/h. In the initial stage of the disease, mouth opening is limited. The amplitude of movements n / h is gradually reduced. In a later stage, these movements can only be preserved in a horizontal direction. On palpation, the articular heads are more or less mobile.

Fibrous ankylosis is radiographically characterized by uneven width of the joint space, the latter is difficult to trace in places due to the formation of fibrous adhesions.

Ankylosis can be unilateral and bilateral, as well as complete or partial. With partial bone ankylosis, the remnants of the articular cartilage and areas of the surface of the articular head are preserved, with complete ankylosis, immobility develops. The deformity of the lower part of the face is caused by intra-articular bone fusions and often fusions of the condylar process of the lower part of the face with the zygomatic arch, filling the space from the upper part of the branch, the semilunar notch, including the coronoid process, causing significant deformity. The severity of jaw deformity depends on the time of occurrence of ankylosis. With unilateral ankylosis, a shift of the midline of the face towards the affected side is observed, flattening of the tissues along the body of the n/h on the undamaged side and bulging on the side of the lesion due to shortening of the branch and body of the n/h are determined. On palpation of the articular heads, movements in the affected joint are not determined, and in the joint of the opposite side are limited. There are multiple tooth decay, abundant dental deposits with gingivitis phenomena; crossbite. With bilateral ankylosis, the retraction of the submental part of the lower part of the head is sharply expressed due to shortening of the base of the body and its branches on both sides. The anterior section of the military h, as it were, hangs over the lower one. The bite is broken. Often, the anterior lower teeth are in contact with the oral cavity. Their dystopia is observed (fan-shaped arrangement of the frontal teeth). Premolars and molars are displaced to the lingual side, the root of the tongue is displaced backwards, speech is slurred, there is a violation of the rhythm and depth of breathing, sleep is accompanied by severe snoring. Eating is difficult. Sanitation of the oral cavity is not possible.

Radiologically, with complete bone ankylosis, shortening of the branch and condylar process of the n / h is noted, the latter is expanded, in the form of bone growth it connects to the articular cavity of the temporal bone. The joint gap is not defined. The angle of the jaw is deformed, a spur is formed on it. If the coronoid process is involved in the process, then it forms a single bone mass with the articular process. With incomplete bone ankylosis, a gap with a partially preserved shape of the articular head is detected over a greater or lesser extent of the joint.

Treatment should start with conservative measures. In the initial stage of the disease, physiotherapeutic methods (phonophoresis, ultrasound), absorbable drugs (potassium iodide solution, lidase, hyaluronidase, hydrocortisone, etc.) should be used. Sometimes the patient is injected into the joint with 25 mg of hydrocortisone 2 times a week, a total of 5 injections. Under the influence of hydrocortisone, fibrous adhesions inside the joint dissolve (especially young ones).

With insufficient effect of therapy, it is possible to carry out forced opening of the mouth (redress) in combination with the indicated methods of treatment and mechanotherapy.

Treatment of bone and persistent forms of fibrous ankylosis is surgical. It is aimed at restoring the function of the mandible and eliminating the deformity by creating a false joint, restoring the size, anatomical shape of the mandible and bite. The most rational place for osteotomy is the border between the upper and middle thirds of the n/h branch, i.e. above the low hole. When performing only a linear osteotomy, relapses often occur. As a result of the delayed formation of the end bone plate on the osteotomized surfaces, the fusion of these surfaces occurs.

To avoid fusion of bone fragments, interposition with various tissues and materials is used, a wide range is created between bone fragments by their skeletonization; use the method of early and effective mechanotherapy of the jaws, preferably with special devices. These methods are used very rarely, since the creation of only a false joint does not eliminate the deformation of the jaws.

The most effective use as a graft is an autologous bone (rib, iliac crest, etc.), formalized, frozen, lyophilized, (gamma) irradiated bones. However, the use of autografts is associated with additional trauma, and the use of allogeneic grafts requires the presence of special laboratories and tissue banks. In recent years, implants made of carbon composites (carbon synthetic foam, Ostek material) and metals that are indifferent to body tissues (titanium, tantalum and other biomaterials) have been developed and successfully used.

Very promising is the use of endoprostheses made of biostable materials (polymethylmethocrylate - PMMA), which allow individualizing the selection and manufacture of implants.

Sjögren's disease and syndrome

Disease and syndrome of Gougereau - Sjögren are characterized by a combination of signs of insufficiency of the external secretion glands: lacrimal, salivary, sweat, sebaceous, etc.

Etiology and pathogenesis diseases and syndromes are little studied. It is believed that infection, endocrine disorders, dysfunctions of the autonomic nervous system, and immune status play a role in the development of the process. A syndrome should be distinguished when dysfunctions of all external secretion glands occur in systemic lupus erythematosus, systemic scleroderma, rheumatoid arthritis and other autoimmune diseases, and Sjögren's disease, in which the same clinical picture develops against the background of autoimmune disorders.

clinical picture. Pathological manifestations are diverse, which is determined by a combination of s/f changes with damage to other organs and tissues (digestion, eyes, endocrine glands, joints, connective tissues, etc.). This diversity also depends on the stage of the process (initial, clinically pronounced, late) and the activity of the course.

Patients complain of dry mouth, recurrent inflammation of the parotid glands, general weakness, fatigue. Sometimes, dryness of the SO eyes, photophobia, a feeling of sand in the eyes are noted first, then an increase in the parotid glands and rarely - up / h. At the same time, the patient sometimes says that he is registered with a rheumatologist about joint disease, lupus erythematosus or scleroderma.

During the examination, the parotid glands during the period of remission are often enlarged, dense, tuberous, painless. Both paired glands are usually affected. Sometimes increased l / y. The swelling of the glands periodically decreases or increases. An increase in the parotid glands is accompanied by a deterioration in general well-being. The exacerbation is severe, with high body temperature, severe pain, mucopurulent discharge from the duct. Changes in oral mucosa are characteristic of xerostomia. After the exacerbation subsides, which often happens on the one hand, the glands remain dense, bumpy.

With sialography, cavities of various sizes with fuzzy contours are determined in the gland, the image of the parenchyma is not detected. The small ducts of the gland are intermittent, not everywhere. The parotid and sub/h ducts have uneven contours. A characteristic feature is the fuzziness of the contours of the ducts, due to the penetration of a contrast agent into the interstitial tissue.

According to the results of the examination, it can be concluded that chronic sialadenitis in Sjogren's disease and syndrome often proceeds as parenchymal.

Diagnostics. Damage to the salivary glands in Sjögren's disease and syndrome is confirmed by the patient's examination data (identification of signs of eye damage, digestive disorders, etc.).

In some patients with "dry" syndrome, the functions of the sweat and sebaceous glands are disturbed, the skin becomes dry, flaky. Sometimes hyposecretion of the uterine and vaginal glands is possible, leading to CO dryness, colpitis. All patients showed an increase in ESR, sometimes leukocytosis. In the study of protein fractions of blood, hypergammaglobulinemia is detected.

Chronic sialadenitis in Sjögren's disease and syndrome should be differentiated from a tumor, chronic parenchymal and interstitial parotitis, and chronic sialodochitis.

Treatment disease and syndrome should be carried out in a rheumatological clinic. The rheumatologist prescribes basic therapy indicated for the autoimmune process, depending on its activity - cytostatic, steroid and anti-inflammatory drugs (prednisolone, plaquenil, brufen, sapicylates, metindol, etc.). Restorative therapy (multivitamins, retabolil, sodium nucleinate, etc.) is indicated for all patients.

In the treatment of chronic parotitis and xerostomia in Sjögren's disease and syndrome, local effects on the s/f and oral cavity mucosa are used: dimexide, novocaine blockade, physical methods, etc.

Prevention and prognosis. Preventive measures include general and personal hygiene. Dispensary observation and periodic administration of a complex of drug therapy ensure a favorable course of the process, it is possible to achieve a long-term remission of the disease, and patients remain able-bodied.

Under the contractures of the jaws, it is customary to understand the complete or partial persistent reduction of the jaws, due to powerful cicatricial growths located both in the soft tissues of the perimaxillary region and between the lower and upper jaws. Therefore, the fight against contractures should consist mainly in the destruction of these scars.

Contractures that have arisen as a result of cicatricial reduction of the jaws, we define as cicatricial. In some cases, scars can turn into bone lesions. We attribute such a persistent reduction of the jaws to bone contractures. Persistent contractures most often occur after gunshot wounds, noma, typhus, ulcerative stomatitis and other inflammatory processes, with a significantly larger number of cicatricial contractures, a smaller number of bone contractures. Scars can capture both the mucous membrane with a submucosal layer, and the skin with subcutaneous tissue.

With contractures caused by cicatricial changes in the oral mucosa with a submucosal layer, after excision of scars, most often located in the buccal pockets and transitional folds, such an extensive defect remains that it cannot be replaced by moving local tissues and one has to resort to free skin grafting.

Excised scars should always be all over, and often they stretch from the corner of the mouth to the front edge of the ascending branch.

The main, most difficult task is the fixation of the skin graft after surgery in the oral cavity. The existing methods for this are described by us in the section “Skin Transplantation”. The negative side of free skin grafting to replace the oral mucosa with deep scars is the strong wrinkling of the flap and the difficulty of fixing it in the mouth. In addition, the flap is devoid of fat, which is of great importance for the cheeks.

Hussenbauer (Hussenbauer) first proposed in 1887 to carve out ribbon-like flaps on the cheeks, with the base in front of the ear and, after excision of the scars, wrap the flaps (with bilateral contracture) in the mouth and hem them there to the mucosa.

Rotter cut out a transverse flap on the inner surface of the shoulder and brought it with his hand to the cheek, where he made a vertical through incision in front of the masticatory muscle, through which he pulled the flap and sutured it to the edges of the mucosa after dissecting the scars.

Such operations also include the method proposed in 1920 by N. V. Almazova. The advantages of this method, which we have described in the Cheek Restoration section, are that, if necessary, the mucosa and skin can be restored with one flap. However, it must be taken into account that after excision of extensive scars of the mucous membrane and skin that caused contracture, it is difficult to replace the resulting defect by the above methods due to the lack of plastic material. In addition, with all these methods, additional scars appear on the face.

In these cases, the best and most easily performed method for eliminating contractures is an operation using the Filatov stem. The operation for through lesions of the buccal region with the help of a stem is divided into three stages:

1) the formation of the Filatov stem;
2) through dissection of scars, their excision and closing of the resulting wound surface with a stalk;
3) restoration of both layers of the cheek with a stem.

The operation is carried out as follows. The Filatov stem is prepared on the stomach and transferred to the hand. After 2-3 weeks, the scars are dissected through a through incision from the corner of the mouth to the ascending branch, which ensures full opening of the mouth. After dissection of the scars, wound surfaces are formed along the dissection line and a through defect of the cheek, which is detected when the mouth is opened. The exposed surfaces of the edges of the defect are closed by stitching the mucosa with the skin. Later, the stem stem is separated from the abdomen and the end of the stem is cut into two halves over a length of 3-4 cm. These halves of the end of the stem are sutured to the edges of the cheek defect in the area of the angle between the jaws (Fig. 370). After engraftment, the stem is cut off by hand and cut along its entire length along its upper and lower ribs. Then, the edges of the cheek defect are stratified and the stem is sewn along the entire length of the cheek to form the inner and outer layers of the cheek.

In some cases, despite the complete dissection of the cheek scars, the mouth either does not open at all, or opens partially. The reason is that, in addition to the cheek, scars can spread upward along the branch of the lower jaw and serve as an adhesion between the coronoid process on one side and the zygomatic bone and arch on the other. Sometimes such cicatricial adhesions turn into bone (Fig. 371). In such cases, after the dissection of the cheek through the incision, it is necessary to penetrate the raspator along the anterior edge of the branch up to the base of the coronoid process, detach the periosteum and resect it.

If the contracture is caused by a cicatricial change in all layers of the cheek only, which does not reach the angle between the jaws, its elimination is greatly simplified.

The leg of the stem is sewn into healthy skin on the cheek behind the scars. When the stem takes root, it is cut off by hand, cut along the upper and lower edges, all the scar tissues of the cheek are excised, and the stem is sewn to the edges of the formed defect, and the inner side is sutured to the mucous membrane, and the outer side to the skin (Fig. 372).

Bone adhesions can form between the alveolar processes of the lower and upper jaws. In these cases, adhesions after dissection of soft tissues over them have to be dissected with a chisel, and their edges are compared with wire cutters (Fig. 373, a, b) and the mucous membrane is sewn over them. If bone adhesions connect the branch with the tubercle of the upper jaw, then in order to eliminate them, it is necessary to resect the anterior edge of the lower jaw branch.

Very rarely, there are cases when, even after resection of the anterior branch of the branch, the mouth does not open. This happens when the branch along the entire width is soldered to the upper jaw. Under such conditions, in order to open the mouth, it is necessary to make an osteotomy of the branch immediately under the adhesion site (see "Ankylosis of the jaw"). After surgery for jaw contracture, it is necessary to carefully carry out active and passive therapeutic exercises for 3-4 months, even with good mouth opening, in order to prevent relapse. The patient should open his mouth as much as possible 3-4 times a day for 10-15 minutes. At the same time, it is necessary to open the mouth to failure with a mouth expander, a wooden screw or plugs, i.e., apply all types of mechanotherapy. You can also resort to special devices, for example, the apparatus of Darcissac (Fig. 374), Weinstein, Akhmedov.

Here are photos of patients operated on for persistent contractures of the lower jaw. On fig. 375 shows a patient in whom, with flat scars of the mucous membrane and unchanged skin, the scars were excised and replaced with free skin flaps.

On fig. 376 depicts a patient who had bone fusion (see Fig. 371.6) of the coronoid process with the zygomatic bone. The operation was performed from the side of the oral cavity with an incision along the anterior edge of the lower jaw branch. The coronoid process was resected through this incision.

The patient, whose scars were located in the anterior part of the cheek in the region of the corner of the mouth, was operated on with a good outcome using a double flap according to A. E. Rauer (Fig. 377).

The main factors leading to the occurrence of extra-articular mandibular contractures are: incorrect initial treatment of wounds, prolonged intermaxillary fixation of jaw fragments and belated use of physiotherapy exercises. In this case, scars appear between the bone fragments of the jaw and soft tissues, limiting the movements of the lower jaw. Depending on which tissues are affected (skin, oral mucosa, or muscles), contractures are dermatogenic, multigenic, or mixed.

In addition, contracture can be caused by 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 may be due to the presence of foreign bodies in the muscle area.

Extra-articular contractures are associated with cicatricial changes in the region of the muscle group that lifts the lower jaw and soft tissues of the oral cavity. They are divided into temporo-coronary, zygomatic-coronary, zygomatic-jaw and intermaxillary. The first two groups of cicatricial contractures (temporo-coronal and zygomatic-coronal) require surgical intervention. Cheekbones and intermaxillary contractures are eliminated by functional methods of treatment - physiotherapy exercises.

B. N. Bynin divides extra-articular contractures of the jaws into two main groups - cicatricial and reflex-muscular. The former are associated with scarring of soft tissues, which mechanically impede the movements of the lower jaw, and therefore can be called mechanical. The latter arise reflexively due to the effect of the stimulus on the receptor apparatus, leading to muscle hypertension. Such a division of extra-articular contractures of gunshot origin is of clinical importance for the purposes of diagnosis and treatment, since the prevention and treatment of these contractures are different. According to the degree of mouth opening, extra-articular contractures are divided into severe (mouth opening up to 1 cm), moderate (by 1-2 cm) and light (up to 3 cm).

In some cases, muscle hypertension turns into a persistent contracture with pathological manifestations in the muscle in the form of its cicatricial change. This process is characterized by rigidity of the masticatory muscles that lift the lower jaw. With persistent muscle contractures, conservative (mechano- and physiotherapy) or surgical treatment can be used. The latter is recommended for persistent pathological changes in the temporal muscle and consists in 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 their cicatricial change.

Mechanotherapy for jaw contractures

The simplest means of mechanical opening of the mouth are corks, 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 result in periodontal damage to individual teeth and dental occlusion. The best results are achieved with devices based on the principle of active and passive movements of the jaw, caused by elastic traction or springy processes. For the first time such an apparatus was proposed by Darcissac. The device was used for ankylosis of the temporomandibular joint after the operation to create a false joint. Impressions for the manufacture of the apparatus are taken on the operating table after osteotomy, when the patient's mouth opens wide. The inconvenience of this apparatus lies in the fact that its manufacture is possible only by the impression of the jaw. With limited opening of the mouth, the removal of the 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 casts of the jaw) and can be used in severe forms of jaw contractures. They transmit 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 mouth baths, paraffin therapy, electrophoresis, etc.). Good results are given by electric baths of the entire facial area, followed by mechanotherapy. Mechanotherapy can also be used for microstomy to stretch scars and restore the mobility of soft tissues of the oral region, for which special devices with elastic traction are used. Most of these deformities, however, require surgical intervention (excision of scars and plastic surgery of soft tissues) followed by the use of physiotherapy exercises.

Speech therapy exercises for developing contractures of the jaws. For the prevention of contractures, it is useful to combine maxillofacial gymnastics with speech therapy exercises. This method can also be used to treat contractures in the initial stage. It includes a series of exercises for the muscles of the face, the walls of the oral cavity and the tongue, which are involved in the formation of sound, the act of chewing and swallowing.

Rice. 243. Apparatus for mechanotherapy with contractures of the jaws.

a - according to Limberg; b - according to Darcissac; c - according to Oksman; d - according to Ezhkin; e — apparatus for mechanotherapy with the angle of the mouth.

The exercises are selected so that each subsequent one includes the previous one and consolidates it. The first exercise - the formation of the sound "a" - consists in a very slow opening of the mouth with a consistently increasing load or tension until the mouth opens to the limit and pain is felt. This is followed by a slow raising of the lower jaw with a gradual decrease in volitional load until the teeth close. These movements mobilize groups of chewing 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 rest of the exercises consist in repeating the previous one and designing other sounds - mobilizing the facial and chewing muscles to design the sounds "s", "y", "e". The patient consistently does each of these exercises 5-6 times per session at intervals of several seconds. Necessary conditions - the sequence of application of exercises and bringing them to the appearance of pain. The pain disappears after the effort is removed. Exercises are performed in front of a mirror after being shown by a speech therapist.

Contracture of the temporomandibular joint is the reduction of the jaws of various etiologies, up to the complete immobility of the lower jaw.

Inflammatory contracture (trismus) occurs with direct and reflex irritation of the apparatus associated with the innervation of the masticatory muscles (pain irritation from the focus of inflammation).

There are three degrees of inflammatory contracture. At the first degree, the opening of the mouth is slightly limited and possibly within 3-4 cm between the cutting surfaces of the upper and lower central teeth; in the second case, there is a restriction of mouth opening within 1-1.5 cm; at the third - the mouth opens less than 1 cm.

Treatment of inflammatory contracture is reduced to the elimination of the inflammatory process. If access to the opening of the purulent focus in the oral cavity is impossible, it is necessary to remove the spasm of the masticatory muscles by blocking the motor branches of the third branch of the trigeminal nerve according to Bershe-Dubov. With the duration of the inflammatory process with the reduction of the jaws for more than 2 weeks, physiotherapy and therapeutic exercises are indicated.

Cicatricial contracture occurs due to cicatricial changes in the tissues surrounding the lower jaw. This happens when

ulcerative-necrotic processes in the oral cavity (noma, complications after scarlet fever, typhoid, cardiovascular decompensation), chronic specific processes (syphilis, tuberculosis, actinomycosis), thermal and chemical burns, trauma (including after surgery for the removal of benign and malignant tumors). Wound healing by secondary intention leads to the formation of scar tissue, represented by collagen fibers, which practically does not stretch. This leads to deformation of tissues and organs.

There are dermatogenic, desmogenic (connective tissue), myogenic, mucosogenic and bone contractures.

The clinical picture is characterized by reduction of jaws I, II, III degree. Dermatogenic and mucosogenic scars, as well as scars that replace a through defect, are determined visually, deep ones - by palpation. The movements of the articular heads are preserved (small rocking and lateral movements of the lower jaw).

Treatment of cicatricial contractures can be conservative, using paraffin, pyrogenal, tissue therapy according to V.P. Filatov, lidase, repidase, hydrocortisone, vacuum therapy, ultrasound, helium-neon laser, etc. The main goal of conservative treatment is to prevent development hyalinosis of collagen fibers. These treatments are effective for fresh, "young" scars no more than 12 months old. In other cases, surgical treatment is indicated. Surgical intervention consists in dissecting the scars, excising the scar tissue and replacing it with another tissue.

To prevent the recurrence of cicatricial contractures after surgical interventions, it is necessary to carry out therapeutic exercises, including mechanotherapy.

Introduction

Chapter 1. Literature review 8

1.1 Local anesthesia in dentistry 8

1.2. Complications during local anesthesia 16

1.2.1. Some terminological aspects 26

1.3. The role of topographic and anatomical substantiation in anesthesia in dentistry 30

Chapter 2 Materials and methods 37

2.1 Characteristics of the anatomical material and methods of layered macropreparation 37

2.2 Materials and methods of experimental research 41

2.3 Characterization of clinical material 42

2.3.1 Clinical methods 43

2.3.2 Radiation methods 45

2.3.3 Patient management 47

Chapter 3 Results of own research 51

3.1 Topographic anatomy of the pterygo-maxillary space during anesthesia of the third branch of the trigeminal nerve 51

3.2 Results of the pilot study 69

3.3 Modified method of mandibular anesthesia 88

Chapter 4 Diagnosis and treatment of patients with post-injection contracture of the lower jaw 89

Chapter 5. Discussion of own research results and conclusion 107

References 124

Introduction to work

Relevance of the topic. Local anesthesia in dentistry can now be considered as a separate discipline of dentistry. As experience shows, anesthesia has been and remains one of the most important problems, both in general dentistry and in its private sections. Back in 1981, on the initiative of Professor V.F. Rudko at the All-Union Congress of Dentists adopted a comprehensive scientific program "Development, improvement and implementation in practice of methods for combating pain in the treatment of dental diseases" .

Local anesthesia has been, is and will be the main method of anesthesia in dental practice. Gone are the days when a doctor at a dental appointment was not able to offer the patient adequate pain relief. However, having solved some problems, practicing dentists got completely different ones. The huge supply market in the dental anesthesiology market has created certain difficulties in the implementation of adequate pain relief.

A special place among them is occupied by complications of an iatrogenic nature.
Analyzing the complications, we can conclude that they are based on
insufficient professional training, formal, sometimes negligent
attitude towards patients. Wide scope and improved quality of delivery
dental care, further development and implementation in practice
rehabilitation of dental patients put before

dental clinic new tasks for a comprehensive in-depth examination of tissues and organs of the oral cavity, maxillofacial region and the general condition of the body. Every year, new methods of diagnostics and treatment are introduced into dental practice. In dental science, an important direction is the search for new methods of diagnosis and treatment. But, despite the improvement in the diagnosis and treatment of teeth, mistakes are still made that lead to various complications.

In recent years, local anesthesia in dentistry has become widespread. And in this regard, the number of patients with various complications after local anesthesia has sharply increased. The widespread use of local anesthesia during various dental procedures has led to a sharp increase in the number of patients with post-injection contractures of the lower jaw.

Postinjection contracture of the lower jaw is characterized by a pronounced persistent restriction of mouth opening. Today, the problem of sharp violations of the movements of the lower jaw that occurs during conduction anesthesia of the lower jaw remains relevant. Usually this complication occurs in patients who underwent conduction anesthesia of the third branch of the trigeminal nerve. As a rule, almost all patients have a history of poor pain relief and repeated attempts at anesthesia.

These questions are practically not disclosed in the literature. There are different hypotheses and only a few authors address them.

The ignorance of this problem in the literature, different approaches to the treatment of emerging complications during local anesthesia, emphasize the relevance of the work.

There is no consensus on the mechanism of occurrence of extra-articular post-injection contracture of the mandible, which additionally introduces confusion into the treatment tactics of such patients.

Knowledge of the mechanism of occurrence of post-injection contractures of the lower jaw will help timely prevention and proper treatment of emerging complications.

PURPOSE OF THE STUDY: Improving the effectiveness of local anesthesia in dental patients through the prevention and timely treatment of local complications, based on the identification

the mechanism of their development with the help of anatomical and experimental studies.

To achieve this goal, the following tasks were solved:

1. Determine the relationship between the injection needle and the structures of the pterygo-maxillary space during conduction anesthesia of the third branch of the trigeminal nerve and, based on topographic and anatomical studies, identify anatomical structures that are subject to injury.

2. Clarify the reaction of muscle tissue to the introduction of various
solutions of anesthetics in the experiment.

3. Determine the mechanism for the development of post-injection contracture
mandible after anesthesia of the third branch of the trigeminal nerve on
based on the data obtained during the anatomical and experimental
research.

4. Modify the technique of mandibular anesthesia for
prevention of post-injection contracture of the lower jaw.

5. Develop an algorithm for diagnostic measures carried out
patients with post-injection contracture of the lower jaw at the stage
diagnosis.

6. Develop a method for treating patients with post-injection
contracture of the mandible, based on the identified mechanism
development of this complication of local anesthesia.

SCIENTIFIC NOVELTY

For the first time, the nature of trauma to the tissues of the pterygo-maxillary space with a needle during conduction types of anesthesia of the third branch of the trigeminal nerve was studied, which was expressed in their mechanical damage with the formation of hemorrhages, hematomas, or the introduction of an anesthetic into the thickness of the muscle tissue. It has been established that at

the introduction of an anesthetic into the muscle, necrosis occurs in the area of its introduction, which is associated with the presence of a vasoconstrictor in the composition of the drug.

For the first time, a mechanism for the development of post-injection
contractures of the lower jaw due to mechanical
injury to the tissues of the pterygo-maxillary space

an injection needle, in case of violation of the technique of anesthesia, with the formation of hemorrhages, hematomas and / or the introduction of an anesthetic with a vasoconstrictor into the muscle, which leads to the formation of an adhesive process with subsequent formation of a scar in the tissues of the pterygo-maxillary space and is manifested by a sharp violation of the range of motion of the lower jaw.

For the first time, a modified method for conducting

mandibular anesthesia, which ensures the prevention of possible complications, and based on the features of the anatomical structure of the area of anesthesia, which minimizes trauma to the tissues of the pterygo-maxillary space.

For the first time, an algorithm of diagnostic measures has been developed, based on clinical and radiological research methods, which provides the diagnosis of post-injection contracture of the lower jaw.

For the first time, a complex method for the treatment of patients with post-injection contracture of the lower jaw has been developed, depending on the period of seeking medical help and the severity of changes in the tissues of the pterygo-maxillary space.

PRACTICAL SIGNIFICANCE An algorithm for diagnosing post-injection contracture of the lower jaw has been developed, which allows timely detection of this complication of local anesthesia, based on clinical and radiological data and mandatory differential diagnosis. For practical application, a method has been developed for the treatment of patients with

post-injection contracture of the lower jaw, depending on the period of seeking medical help and the severity of changes in the tissues of the pterygo-jaw space.

Based on the determination of the mechanism of occurrence of post-injection contracture of the lower jaw during conduction anesthesia of the third branch of the trigeminal nerve, a modified method of mandibular anesthesia was developed, which ensures minimal trauma to the tissues of the pterygo-jaw space.

MAIN PROVISIONS FOR DEFENSE

Post-injection contracture of the lower jaw is a complication of local anesthesia that occurs when the technique for conducting conduction types of anesthesia of the third branch of the trigeminal nerve is violated.

Injury to the structures of the pterygo-maxillary space with the formation of hemorrhages and hematomas and / or the introduction of an anesthetic into the thickness of the muscle tissue create conditions for the development of an adhesive process in the tissues of this area, which leads to the formation of a scar and the development of an extra-articular post-injection contracture of the lower jaw, manifested by a pronounced persistent volume limitation mouth opening.

Treatment methods for patients with post-injection contractures of the lower jaw depend on the timing of the start of therapeutic measures and the severity of changes in the tissues of the pterygo-jaw space.

Local anesthesia in dentistry

The problem of pain and the fight against it during medical interventions is as old as the whole history of mankind. To eliminate or relieve the pain that occurs during various manipulations, doctors have tried since the early days of medicine. So, Hippocrates used for this purpose mandrake (a plant of the Mediterranean coast), in ancient India and China, opium and Indian hemp were used. He used other, often quite witty, tricks. So, some dentists had an assistant who pinched the patient during tooth extraction. One kind of pain suppressed, as it were, another pain.

Archaic methods aside, we can say that the fight against pain was crowned with real success after the first attempts to use anesthesia with nitrous oxide and ether. M.A. Gubin et al. writes: “The rapid development of natural science predetermined the discovery and production of pure oxygen and nitrous oxide. In fairness, it should be noted that the ether was first discovered in 1200 by R. Momeus. At the same time, V. Kordtsi synthesized ether from alcohol and sulfuric acid. In 1680, E. Boyle once again "discovered" the ether. Gradually, ether and nitrous oxide begin to be introduced into medical practice in one form or another. But more often these experiments went unnoticed and did not have a significant impact on the development of surgery and medicine in general. It is known that the first experience of using ether anesthesia belongs to W. Crawford, who in January 1842 used it during a tooth extraction operation. However, this was announced only in 1849. For the first time, ether for anesthesia during a tooth extraction was used by the dentist Morton (August 1 and September 30, 1846). The first public demonstration of ether anesthesia was also held by Morton on October 16, 1846. The first tooth extraction operation under ether anesthesia was carried out by I. Robertson and F. Butt in 1846, and then this type of anesthesia began to be irresistibly introduced in almost all European clinics of any importance.

P.Yu. Stolyarenko writes: “The beginning of the era of local anesthesia is associated with the production of pure cocaine (from the leaves of the Erythulon Coca shrub) in the laboratory of the chemist Vetre and his student A. Nishanna. Soon there were reports of the anesthetic effect of this drug on the mucous membranes (Shtroff, 1862; Gazo, 1879; Fauvel, 1877, etc.). The possibility of a comprehensive study of the physiological action and clinical use of cocaine was largely prompted by the invention of A. Wood and G. Pravacele (1855) of the syringe and F. Rind (1848) of a hollow needle. Further, the discovery of the analgesic effect of cocaine by V.K. Anrep (1880) and A. Kollyar (1884), as well as the establishment of the possibility of injecting with a hollow needle, previously proposed by A. Wood (1853), provided the conditions for local and regional anesthesia. W.Halstead (1884) used cocaine to block nerve trunks during tooth extraction. Oberst (1888) laid the foundation for conductive local anesthesia (quoted in Farr, 1923)" .

As you know, drugs that can temporarily eliminate the sensitivity of receptors and block conduction through the peripheral nervous afferent apparatus at the site of their application, without turning off or disturbing consciousness and thinking, are called local anesthetics, or local anesthetics.

The study of the chemical structure of cocaine showed that it is an ester of methylecgonine and a benzene group. On this basis, about 60 modern local anesthetics were synthesized, including novocaine, dicaine, sovkaine, lidocaine, and later trimecaine, pyromecaine, rihlocaine, marcaine, etc. .

The experience of the first decades of the use of local anesthesia was of exceptionally outstanding value, convincing practicing surgeons of the possibility of performing operations without pain. The revealed disadvantages of cocaine anesthesia further stimulated the search for ways to optimize methods of local anesthesia. Since the end of the 19th century, new local anesthetic drugs have been introduced into dental practice - these are eikain, holocaine, amenin, orthofoin, anezol, stowain and others.

The name of the chemist Alfred Eingorn (1856-1917) is associated with a new era in local anesthesia. In 1904 he synthesized a fundamentally new anesthetic of the ether series - procaine, which began to be produced under the name - novocaine. The main merit of the introduction of novocaine into clinical practice belongs to the famous German surgeon Heinrich Braun. It was found that novocaine provides a temporary local anesthetic effect and is less toxic than cocaine, does not cause drug dependence. The onset of the novocaine era began, displacing cocaine from medical practice. Local anesthesia techniques developed during the second quarter of the 19th century using cocaine (intrapulpal, intraseptal injections, various types of infiltration anesthesia) have found wide application when using novocaine.

Gubin et al.: “World and, for the most part, European experience of local anesthesia in dental practice was accumulated in the works of famous scientists of that time. The work of Guido Fischer had an exceptionally great influence on the development and popularization of methods of local anesthesia in dentistry. For the period from 1912 to 1955. his major work "Die Locale Anasthesie in der Zahnheilkimde" was reprinted seven times and received great recognition in many countries of the world, including Russia.

It is also important that in the first quarter of the 20th century, interest in local anesthesia steadily increased and was no longer limited to an analysis of the experience of using it in surgical branches of medicine.

“Research has been carried out in the field of physiology and pharmacology of pain in connection with analgesia; the tasks of anesthesia were argued; the diagnostic significance of local anesthesia was assessed; a comparative analysis of anesthesia methods was carried out; studied the effect of novocaine anesthesia on peripheral blood; anatomical substantiation of methods of local anesthesia was given; studied the features of wound healing after operations under local anesthesia; improved techniques of local anesthesia; components of the applied anesthetics were evaluated and complications were analyzed;”. .

Despite the ongoing search for methods and means of pain relief, local anesthesia using novocaine in dentistry during the second quarter of the 20th century gradually became fundamental. The works of this time mainly reflect the accumulated experience in anesthesia of the main branches of the trigeminal nerve in dental surgery, taking into account topographic-anatomical and experimental studies.

Along with S.N. Weisblat, the author of numerous journal articles on local anesthesia in dentistry (more than 30 of them) and who had extensive personal experience, in the 30s and 40s of the 20th century, other authors actively developed issues of local anesthesia in dentistry.

It is known that local anesthetics - dikain (tetracaine), anestezin, novocaine (procaine), lidocaine (xycaine), trimeca-pyromecaine, marcaine (bupivacaine), mepivacaine (carbocaine), etc. can cause various side effects, often associated with low latitude therapeutic action, the phenomenon of intolerance; a number of drugs in this group (novocaine, lidocaine, trimecaine) do not always cause an analgesic effect of sufficient depth and duration.

Characteristics of the anatomical material and methods of layered macropreparation

A sharp increase in the number of patients with extra-articular post-injection contracture of the lower jaw in recent years, as well as the lack of consensus in the literature regarding the mechanism of occurrence and development of this complication during anesthesia, made us think about the implementation of an anatomical and experimental study.

We carried out anatomical studies both to study the trajectory of the injection needle during anesthesia of the third branch of the trigeminal nerve with an analysis of the nature of tissue damage, and to study the features of the topographic anatomy of the anesthesia area.

Anatomical studies aimed at studying the damaging effect of anatomical formations with an injection needle during anesthesia of the third branch of the trigeminal nerve have not been identified in the available literature.

In addition, in this study, we studied the features of the topographic and anatomical structure of the pterygo-maxillary space for the possible disclosure of the mechanism for the development of contracture of the lower jaw after conduction anesthesia of the third branch of the trigeminal nerve.

Knowledge of the mechanism of contracture development will contribute to the timely prevention and proper treatment of the complication that has arisen.

The topographic and anatomical study was carried out at the Department of Operative Surgery and Topographic Anatomy of the Moscow Medical Academy. THEM. Sechenov (head of the department prof. Nikolaev A.V.) and in the pathoanatomical department of the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky (head Prof. Titova G.P.).

The work was introduced in two directions: the first - the study of the anatomy of the deep region of the face in the area of anesthesia; the second is to study the trajectory of the movement of the injection needle during various types of anesthesia of the third branch of the trigeminal nerve by the intraoral method and the nature of damage to the tissues of the pterygo-maxillary space in this case. For these purposes, injections were made according to the type of mandibular and torusal anesthesia with a contrast agent. A 1% alcohol solution of brilliant green was used as a contrast agent.

To visualize the tissues of the pterygo-maxillary space, semi-coronary with anterior, collar-shaped and intraoral incisions were used.

In the first part of the study, the study of topographic anatomy in the field of anesthesia was carried out. For this, a unilateral semi-coronary approach was used: an incision was made in the skin and temporal-parietal fascia to the level of the temporal fascia in the temporal region and the aponeurotic helmet was dissected in the projection of the coronal suture. The temporoparietal fascia, as well as the nerve fibers and vessels passing within it, were retracted along with the skin flap. Blunt detachment in this area was performed down to a point about 2 cm above the zygomatic arch, where the line of attachment of the two sheets of the temporal fascia is located. The superficial temporal adipose tissue was isolated, its thickness was determined, and streaks of the contrast agent were detected. Further, the incision was continued through a deep sheet of the temporal fascia, the temporal process of the buccal fat lump (Bish's lump) was found, and contrast agent streaks were detected. The periosteum of the zygomatic arch was dissected and taken forward as a single flap with a superficial sheet of the deep temporal fascia, the temporo-parietal fascia containing the neurovascular apparatus and skin.

Next, the zygomatic arch was resected for a visual overview of the course of the temporal muscle and its attachment to the lower jaw. The chewing muscle was dissected and taken aside. Then, an osteotomy of the mandible was performed in the area of the angle and body of the mandible and thus gained access to the pterygo-mandibular space.

In the second part of the beginning of our study, anesthesia was performed according to the type of mandibular and torusal anesthesia, with a contrast agent. Further, using the intraoral access, we studied the nature of tissue damage in different variants of the needle insertion.

With intraoral access, the mucous membrane in the injection area was cut in layers, passed through a thin layer of the buccal muscle and fatty tissue. Then, in a blunt way, they went deep into the pterygo-maxillary space, into its fatty tissue. The continuation of adipose tissue in the temporal pterygoid space was isolated, and its thickness was determined. Anatomical formations and tissues of the pterygo-maxillary space were isolated and dissected, which were stained with a contrast agent. The difficulty of intraoral access was that it was impossible to administer anesthesia and observe the course of the needle at the same time.

In order to visually trace the course of the needle during one or another type of anesthesia of the third branch of the trigeminal nerve, collar-like access was used. This access was provided by an incision along the lines of the clavicles, subcutaneously reaching the edge of the lower jaw. At the same time, the muscles of the lower floor of the diaphragm of the mouth, the maxillary-hyoid and geniohyoid, then the medial pterygoid muscle were exfoliated and thus reached the pterygo-maxillary space, where it was possible to visualize the zone of passage of the needle during anesthesia.

Topographic anatomy of the pterygo-maxillary space during anesthesia of the third branch of the trigeminal nerve

Thus, on the basis of our study, it was found that when conducting conduction types of anesthesia of the lower alveolar nerve, it is possible to injure various anatomical formations: the tendon of the temporal muscle, the medial pterygoid muscle, the sphenomandibular ligament, the neurovascular bundle entering the canal of the lower jaw, the pterygoid venous plexus, maxillary artery, etc., which can contribute to the formation of a hematoma in the pterygo-maxillary space. These data can be regarded as one of the factors of a possible mechanism for the development of extra-articular post-injection contracture of the mandible.

It can also be assumed that another of the possible factors in the mechanism of contracture development may be a consequence of the introduction of an anesthetic solution into the thickness of the medial pterygoid muscle, especially if the technique of anesthesia is violated. We observed cases of needle penetration into the thickness of the muscle in our study.

As you know, modern anesthetics used in dental practice contain vasoconstrictors in fairly high concentrations. According to the literature and in our anatomical study, we have shown that the medial pterygoid muscle has an abundant blood supply and a dense network of anastomoses.

With the introduction of an anesthetic with vasoconstrictors into the thickness of the muscle, the vessels can spasm. causing a site of necrosis in the injection zone of the "heart attack" type.

What is the role of an anesthetic injected into a muscle, can an anesthetic with a vasoconstrictor cause necrosis of the striated muscle?

These are the questions we asked ourselves while conducting an experimental study on rats. In the literature, there are reports of necrosis of the area of the medial pterygoid muscle with an accidental injection of an anesthetic into the muscle.

Modern anesthetics contain a vasoconstrictor (epinephrine, norepinephrine, etc. at a dosage of 1:100,000 and 1:200,000), which prolongs the action of the anesthetic along with administration. This effect occurs as a result of vasospasm in the area of drug administration, which, in turn, can cause necrosis in the area where the anesthetic solution is deposited.

To this end, we conducted an experiment on 24 white laboratory rats. Anesthetics were injected into the striated muscle of the right leg of rats. Anesthesia came in 3-4 minutes, manifesting itself in the form of turning off the leg from the act of walking. In the first series of experiments, when the very fact of a possible damaging effect of an anesthetic with a vasoconstrictor on muscle tissue was determined, we obtained the following results.

3 hours after the injection of 0.9 ml of lidocaine with adrenaline histologically revealed signs of intermuscular and intramuscular edema with dissociation and fragmentation of muscle fibers. At the same time, the transverse striation of the fiber was lost, but the pyknotic nuclei remained. With special MSB staining of sections, signs of damage to muscle fibers are more clearly visible from focal contracture contractions to necrobiotic ones with a complete absence of visualization of the transverse striation of the fiber and coagulation necrosis of individual muscle fibers (Fig. 26 a, b). Between the bundles of muscle fibers in the layers of connective tissue are full-blooded arteries and veins, as well as nerve trunks. Focal perivascular hemorrhages spread between individual muscle fibers. The perimysium and endomysium were absent in the edematous connective tissue.

3 days after the injection of lidocaine 0.9 ml with adrenaline, histologically in the muscle tissue, large fields of completed necrosis of the striated muscles are visible with signs of demarcation inflammation in the form of migration of segmented leukocytes into necrotic tissues (Fig. 27 a). Along with the migration of leukocytes through the intermuscular spaces, the penetration of fibroblasts and monocytes occurs with the separation of muscle fibers into fragments with partial or complete replacement by their young multicellular connective tissue. In the subfascial connective tissue there is diffuse lymphoid, histiocytic infiltration. Veins and small arterial vessels are moderately plethoric and with focal perivascular hemorrhages. Among the dense inflammatory infiltrate of the perimysium, there are small and larger nerve trunks with signs of intraneural edema (Fig. 75 b).

Histologically, 3 hours after intramuscular injection of 0.9 ml of Ultracain Ds forte, muscle tissue showed signs of edema, vascular plethora with focal perivascular and intramuscular hemorrhages. Muscle fibers throughout with diffuse necrobiotic changes due to contracture contractions of the sarcoplasm, complete erasure of transverse striation and diffuse fuchsinophilia while maintaining the nuclei of the muscle fiber. These changes characterize incomplete necrosis, when the nuclei are preserved, and the cytoplasm is subject to severe dystrophic changes, leading not only to a violation of the contractile function of the fiber, but also to its necrosis.

Diagnosis and treatment of patients with post-injection contracture of the lower jaw

In the title of the topic of the dissertation research, the circle of patients is already defined - patients with complications after conduction anesthesia in the lower jaw. As part of our study, patients who had problems with the normal functioning of the masticatory function were examined after anesthesia of the third branch of the trigeminal nerve. Unfortunately, there was no shortage of patients. All the examined patients were united by one thing: a visit to the dentist, unsuccessful anesthesia on the first attempt, repeated, sometimes repeated attempts to anaesthetize, and as a result, the appearance of a restriction in opening the mouth after a few days.

At the same time, almost all patients noted that anesthesia was carried out with modern anesthetic solutions using carpool technology. Now at the dental appointment, mass anesthesia with carpules with a high content of vasoconstrictor is common. Most of the patients, on the 2nd-3rd day of the appearance of mouth opening restriction, before coming to us, repeatedly turned to those specialists who performed dental procedures on them with complaints of mouth opening restriction. However, only 5 patients were prescribed therapeutic measures for this reason (Table 5).

Of the 36 patients observed at TsNIIS, 31 did not receive any recommendations from the attending physicians regarding the complication that had arisen and were assured that this was a temporary phenomenon that would pass on its own, within a few days. Physiotherapeutic procedures were prescribed to 5 patients by attending physicians.

In patients with post-injection contractures of the mandible, the main symptom is limited mouth opening. This symptom can also occur in other diseases and be also the leading one, therefore, in all patients with complaints of limited mouth opening, differential diagnosis was carried out with a number of diseases. These diseases include: 1. inflammatory processes in the cellular spaces of the maxillofacial region (maxillary-lingual groove, peripharyngeal, pterygo-maxillary, masseteric region and infratemporal and pterygopalatine fossae); 2.oncological diseases; 3. pathology of the temporomandibular joint (TMJ).

Differential diagnosis was mainly based on the clinical method of examination. When clarifying complaints and anamnesis of the disease, the features of the course of the disease, which led to the appearance of a restriction in opening the mouth (fever, swelling of the soft tissues of the face, pain and its irradiation, etc.), were clarified in detail. To exclude inflammation in the cellular spaces of the maxillofacial region, they were examined and palpated. During palpation, special attention was paid to the identification of painful points, the presence of edema, infiltrates and enlarged lymph nodes in the maxillary tissues. The absence of clinical signs characteristic of the inflammatory process made it possible to exclude this type of pathology as the cause of the existing limitation of mouth opening.

Due to the fact that in oncological diseases of the floor of the mouth and the root of the tongue, one of the symptoms is the limitation of the movement of the lower jaw, it was necessary to examine the tissues of these localizations to detect the presence of ulcers or mucosal lesions.

To exclude pathology from the side of the TMJ, in addition to clinical research methods, X-ray methods were necessarily used. X-ray methods allowed us not only to assess the state of the bone elements of the articulation at rest and with the maximum volume of mouth opening, but also to identify the presence of ossifications in the pterygo-jaw space or bone adhesions of the upper and lower jaws, which can occur with post-injection extra-articular contracture of the lower jaw. In addition to purely X-ray methods, we also used radiation methods of research (MRI, ultrasound). However, we can state that these research methods could not supplement the information obtained with the X-ray method, and after several studies we abandoned them.

Thus, after a detailed clinical and radiological examination of patients and differential diagnosis, a diagnosis of post-injection extra-articular contracture of the lower jaw was established.

Depending on the severity of changes in the pterygo-maxillary space, detected radiographically, two variants of the course of the disease can be distinguished:

1. Contracture, in which radiologically there are no areas of ossification in the pterygo-maxillary space in the area of anesthesia.

2. Contracture, in which areas of ossification are clearly visible in the pterygo-maxillary space in the area of anesthesia.

The treatment of patients with extra-articular post-injection contracture of the lower jaw was based on the above division of patients into 2 groups, depending on the radiographic changes in the tissues of the pterygo-jaw space.