Theme 1. Physical rehabilitation in
chronic inflammatory processes in the maxillo-facial
area.
2. Physical rehabilitation with neuritis of the facial and trigeminal nerves.
Therapeutic exercise if pyo-inflammatory processes in the maxillo –
facial area
Methods of medical gymnastics
classes with the stomatological patients
have a number of features, due to the
clinical manifestation of disease. First of all, it concerns methods of
special exercises using . They perform in front of a mirror, as a visual control
facilitates proper development of the
exercises and help at the monitoring of the
movements’amplitude . To features of medical gymnastics classes include
the need for repeated recurrence of special exercises during the day
independently.
Correct selection and reasonable
inclusion to the medical gymnastics
complex of special exercises should be
guided by the following information about the features of mimic muscles.
of damaged
bone.
Muscle Action
Frontal muscle:extends the eye fissure,raises the brow, forms the folds on the
forehead
Muscles that the eyebrow wrinkles: knit brows,forms
the vertical folds on the bridge of the nose
Muscle, which lowers the inter-brows interval: lower
the inter-brows interval ,forms the vertical folds on the bridge of the
nose
Individual method is most efficiently during the TE
classes with the stomatological patients.
In the TE study in addition to typical medical
equipment should be a mirror with individual tables and screens for special
exercises, mehano-therapeutic devices and accomodations for additional action on organs and tissues
of the maxillo-facial region. For the mechanical therapy the rubber cross-bars, corks , wooden wedges,
spoons of Limberg, pressing sets,
espander of Balon ,plates of Jadernaja,which are fluctuated , anf other
accomodations and apparatus are used .
However, to the estoration
of chewing and mimic muscles function
we can not be limited of only one
mechanical therapy using. Its is a kind of passive exercise,so it doesn’t not allowed reprodese all variety of movements in the
temporo-mandibular joint .
Muscle Action
Circular muscle of eye: lowers the brow,closes the
eyelid and eye ,smooth out the horizontal forehead’s folds,provides the
epiphora
Muscle that lifts the corner of mouth:
Raises the angle of mouth, stretches it to aside
Zygomatic muscle:
lifts and delayed the top of the mouth angle
aside, bares the upper teeth, creates the
noso-labial fold, expresses the laughter
Muscle that raises the upper lip:
raises the upper lip, expands the
nostrils, creates the naso-labial fold, bares the upper teeth
Muscle of laughter:
stretches angle of mouth aside, bares the
teeth , expressing the laughter
Buccal muscle:
blows the cheeck, taking part in blowing air out,
stretched outside the mouth angle, presses the inner surface of cheeks to the
teeth
Muscle, which lowers the mouth angle
:
Lowers and stretches toward the mouth angle, aligns
the naso-labial fold
Circular muscle of mouth:
compresses the lips,
closes the mouth, obtains the lips forward, folded its inside (whistle,
kiss)
Muscle, which lowers down and draws aside the lower
lip:
Down and delayed toward lower lip, bares the lower teeth , open mouth
Chin’s muscle:
raises the lower lip, close the mouth,
take part in whistle
of joint,
carried out at the active (voluntary) exercise.
Mechanical therapy is indicated mainly during
the elimination of residual effects - at post-immobilizaion contractures,
fibrotic ankylosis, rigidity of joints, astringent scars, paresis, paralysis
and other states.
Indications to the TE
appointment in stomatology: violation of chewing function, speech and
mimic, resulting from trauma, inflammatory diseases or congenital defects.
Terms of the early TE use ,usually coincide with the
finishing of the diseas’s acute period .
Contraindications: bad general condition of the
patient, body temperature above 38 ° C, acute inflammation, increased of ESR, septic condition, pain that is
aggravated at the performing of special
exercises; risk of secondary bleeding in connection with the foreign body near the vessels,
insufficient immobilization of damaged bone dragments.
Inflammatory
diseases of maxillo-facial area (phlegmon, abscess, periostitis, odontogenic
osteomyelitis) are the only progressive inflammatory process at different
stages of its course, which gradually affects the different anatomical areas.
In this regard, therapeutic tactics must be combined and include surgery,
medication and general-strengthening treatment.
Medical gymnastic is appointed in early terms for the the general
strengthening of the organism and prevent the formation of jaws’contractures. In the first days of the 1 period, after surgical
dissection of inflammatory foci and
anti-inflammatory treatment, while calming down the pain and
normalization of body temperature (sub-febrile temperature is not a
contraindication) using the breathing
and general-strengthening exercises . Exercises to mimic and
chewing muscles in this period should be performed with caution to avoid
dissemination of the inflammatory process, in the slow tempo, with a minimum amplitude.
In the second period, when the
inflammation dies, disappears or reduced pain and swelling, the special
exercises are used without any limitations. Improving the tissue’s trophism ,contributing the
intensification of reparative processes, its decrease the prabability of
complications. This period is recommended to
perform the active exercises as maximal
possible amplitude of motion in the temporo-mandibular joint and passive
exercises (using fingers, rubber plugs, etc.). It is many times a day to
repeat the exercises, for clear and energetc its performance. In therapeutic
procedures of medical gymnastics exercises it’s necessary use the exercises with mechanical traction,
mouth dilatators, massage and physiotherapy.
Medical gymnastics is appointed after surgical
dissection of the inflammatory foci and the calming down of the acute
inflammatory process, reducing pain and improving the general patient’s
condition , typically on the 2 - 3 days
after surgery. Sub-febrile temperature and increased ESR are not a
contraindication to the medical gymnastics appointment.
The task of medical gymnastics in the
1 (introductory) period classes: 1) general tonic effect on the body of the
patient, 2) increase of local blood
circulation to improve of resorption hydratation processes in the
post-operative wound, 3) prevention of destructive-atrophic processes in
the peri-joint tissues, jaws’contractures and ankylosises.
Methods of medical gymnastics classes in this period
involves the use of: a) general-development exercises for muscles of arms and
feet, back and abdominal press, performed at a slow tempo in the initial position
lying and sitting;
b) respiratory static and dynamic exercises with
prolonged exhalation phase ( inflated of rubber toys);
c) special exercises to mimic and chewing muscles
(avoiding the pain increase), repeating
its series on (each exercise 5-10 times). Mouth opening and closing
may be accompanied by head movements (bending, turning, circular
movements), avoiding of dizziness or
autonomic disorders associated with the vestibular analyzer irritation (table . 1).
"
During the review of postoperative wound , the surgeon advised the patient to perform the
maximum possible amplitude of movements in the temporo-mandibular joint .
Methods of medical gymnastics classes
in the second (main) period, which begins after the release of wound drainage
and cover it with a layer of granulation, the expansion of physical activity
the patient and the wide-spread use of special exercises. Recommended walks in the fresh air (to avoid refrigerated),
gradually increasing the intensity of physical activity in the early
improvement of general condition of the patient.
All exercises performed without limitations of the
maximum motion amplitude many times during the day. However, active movements of the mandible may use wedges, rubber corks
and other accomodations for maximum mouth opening.
At residual effects, as a violation of chewing and mimic
muscles function, limitation of movements in the temporo-mandibular joint , the medical gymnastics classes continue to
the complete functional recovery.
At the perfomimg of special exercises using the loading and response. The massage, heat and mechanical therapy ate indicated.
Research
Methodology and data evaluation reography in patients with
traumatic neuritis of the facial nerve
When patients with traumatic neuritis n. facialis
present pain, accompanied by spasm of blood vessels, it is clearly recorded on rheogram.
This is particularly evident when comparing rheogram soft tissue taken from
symmetrical areas face. Thus on the affected side showed a significant, compared with a healthy
half, reduced amplitude (Fig. 17).
When analyzing rheogram lots of soft facial
tissue, where no large arterial
branches, the amplitude of the output
rheogram even healthier
side small and contour rheogram often
has a large number of additional
waves that invariably affects the degree of
objectivity of the results.
Rice. 17. Reducing the pulse
amplitude oscillations blood and smooth dykrotycheskymy wave on rheogram facial
soft tissues in traumatic neuritis of the facial nerve:
and - the healthy half face, b - half face of injury n. facialis [AA
Prohonchukov, NK Loginov, NA Zhizhina, 1980]
5.7. Research Methodology and Evaluation thermometric indicators of skin
projection of acupuncture points (AP) maxillofacial region
Over time, more and more widely used in medicine method finds local
thermography and thermometry used to control the dynamics of different
pathological processes. The method proved to be positive in its various
versions, demonstrating its reliability and a positive correlation with clinical
parameters and enables both reliably and accurately assess a situation
neuromuscular system and the degree of vegetative-vascular changes.
Research carried out at room temperature in the morning after a 15-minute
adaptation of the patient. The study begins with the establishment of the
absolute temperature of skin projection vnemerediannoy acupuncture point RS3.
This point of reference is the area in the maxillofacial region - area skin
surface with a relatively constant parameter of interest to us. Temperature was
also measured in the projection of skin 8 acupuncture points located in the
maxillofacial region affected and healthy half face strictly symmetrical. BP were
chosen based on their location in the area of innervation of the
facial nerve: the upper branch - V1, TR23; secondary branches - E1, E3, IG-18; inferior
branches - E5, extrameridian points RS18 and GI18. Also accounted for and
belonging to the classical meridian points of the body that come in an
interesting area for us, and the greatest stability in maintaining their
parameters, compared with the surrounding acupuncture points. Their location
was determined in accordance with the description of EL Macheret, IZ Samasyuk
(1986), Havana Luvsan (1991), IA Pohodenky-Chudakov, AP Chudakov (2004), Chen
Jing (1990).
To determine the temperature recommended Elektrotermometriya TPEM-1, which has
a gradation of 0,1 ˚ C. Moreover, in addition to the absolute temperature
at these points should fix the rate of temperature asymmetry (temperature
gradient) in the homologous points of healthy and affected half of the face.
The results are recorded in the register map (Table 3). Study of thermal
behavior to determine the dynamics of the disease and the effectiveness of the
medical and rehabilitation measures recommended in time (before treatment,
during the course of treatment measures and after its completion).
5.7.1. Localization and topographical anatomy of acupoints used to assess
thermometric indicators maxillofacial region for traumatic neuritis of the
facial nerve
In Eastern traditional medicine made the distance between acupuncture points
expressed in tsunyah (1 tsun - 1.5-
Localization in the maxillofacial region acupoints used to assess thermometric
indicators for traumatic neuritis of the facial nerve, is shown in Figure 18.
Of reference zone maxillofacial region:
RC3 (Yin-tang) - "sealed palace."
Location: in the center distance between the beginning of the eyebrows, above
the bridge of the nose.
Topographic anatomy: frontal artery and frontal nerve (the first branch of the
trigeminal nerve).
Point to determine the patient sitting.
Acupuncture points located in the upper branch
n. facialis:
V1 (ching-min) - "ching - eyes min - light."
Location: inwards from the inner corner of the eye by
Topographic anatomy: internal medial ligament century, the final branch of the
maxillary artery end nerve block, branches frontal, lacrimal and
nosoresnichnoho nerves (branches of the optic nerve).
Point defined in the sitting position, the patient's eyes closed.
TR23 (si-Chu-kun) - "Silk Bamboo."
Location: in deepening the outer end of the eyebrow.
Topographical Anatomy: circular muscle of the eye surface temporal artery,
optic nerve (I branch of the trigeminal nerve).
Point to determine the patient sitting.
Picture. 18. Localization in the
maxillo-facial
region acupoints used to assess thermometric indicators for traumatic neuritis
of the facial nerve:
black dots labeled SC in the projection of skin which produce local
thermometry, namely 1 - RS3 (Yin-tang), 2 - V1 (ching-min), 3 - TR23
(si-Chu-kun)
4 - E1 (Cheng Qi), 5 - E3 (Ju Liao - nose), 6 - IG18 (Quan Liao), 7 - E5
(Da-Ying), 8 - RC18 (Jia-Chen-Jiang or Hei- Liao, Xia Di Tsan), 9 - GI18 (fu-tu
- neck), white dots marked BP used to determine the correct location of
acupuncture points used in the study of local thermometry: 5th - VG26
(jen-chung), 5b - E2 (si-bei), 8a - E4 (di-Tsan), 8b - VC24 (Chen, Jian)
Acupuncture points located in the middle branch
n. facialis:
E1 (Cheng Qi) - "reservoir of tears."
Location: under the pupil in the middle of the lower edge of the orbit (the
point is usually determined by the pupil - under the middle, at right
directional view patient).
Topographical anatomy: circular muscle of the eye, podhlaznichnaya artery
infraorbital nerve.
Point defined in the sitting position, the patient must look ahead.
E3 (Ju Liao - nose) - the "big hole".
Location: in the nasolabial crease at the intersection of a vertical line from
the center of the pupil with a horizontal line through the point VG26
(jen-chung) and a vertical line from point E2 (si-bye).
Topographic anatomy: square muscle of the upper lip, jaw foreign branching
artery, a branch of the facial nerve schechnaya, nizhnehlaznichnoho nerve.
Point defined in the sitting position, the patient's eyes should be focused
straight ahead.
Acupuncture points necessary to properly determine the localization E3:
VG26 (jen-chung) - "middle man."
Location: under the nasal septum in the upper third of the vertical furrows
upper lip.
Topographical Anatomy: circular muscle of the mouth, upper lip artery, II
branch of the trigeminal nerve, a branch of the facial nerve schechnaya.
Point defined in the patient supine.
E2 (CLI-by) - "four-light."
Location: vertically below the pupil to 1 tsun and below the E1 (Cheng Qi)
Topographical Anatomy: circular muscle of the eye, podhlaznichnaya artery,
facial nerve nizhnehlaznichnoho nerve podhlaznichnoe hole.
Point defined in the sitting position, the patient must look ahead.
IG18 (Quan Liao) - "Trench zygomatic bone."
Location: in a hollow in the bottom of the zygomatic bone, vertically below the
outer corner of the eye level point TR23 (si-Chu-kun).
Topographic anatomy: the upper part of the chewing muscles, the transverse
artery of the person who departs from the superficial temporal artery,
zygomatic branch of the facial nerve, II and III branches of the trigeminal
nerve.
Point to determine the patient sitting or supine.
Acupuncture points located in the lower branches
n. facialis:
E5 (da, etc.) - "great reception".
Location: anterior to the angle of the mandible on 11/3 tsunya, somewhat out of
place, which is determined throbbing arteries (corresponds to level of the
third artist of the mandible).
Topographical Anatomy: insertion of masticatory muscles, the outer jaw artery,
the lower branch of the facial nerve, III branch of the trigeminal nerve, the
great auricular nerve.
Point defined in the sitting position, the patient's mouth closed.
RC18 (Jia-Chen-Jiang or Hei-Liao, Xia Di Tsan).
Location: on the lower jaw, where the mandibular hole at the intersection of
the vertical which passes out of the corner of his mouth at
Point defined in the sitting position, the patient's mouth closed.
Acupuncture points necessary for the proper determination of localization RS18:
E4 (di-Tsan) - "breadbasket of the earth."
Location: out of the corner of the mouth to
of the pupil.
Topographical Anatomy: circular muscle of mouth, II and III branches of the
trigeminal nerve, a branch of the facial nerve schechnaya, deep muscle is the
outer jaw artery.
Point defined in the sitting position, the patient's eyes should be focused
straight ahead.
VC24 (Chen, Jian).
Location: in the center of the chin-labial folds.
Topographic anatomy: bones of the lower jaw, circular muscle of mouth, artery
lower lip, chin nerve, which departs from the III branch of the trigeminal
nerve.
Point defined in the patient supine.
GI18 (fu-tu - neck) - "lateral protrusion."
Location: outside from the upper edge of the thyroid cartilage in the center
projection sternum-clavicular-mastoid muscle.
Topographical Anatomy: sternoclavicular-mastoid muscle, beneath which are
optional and vagus nerves; external jugular artery, internal jugular artery,
cervical cutaneous nerves.
Point to determine the patient sitting.
5.8. Method of determining the index BRCHVSN - assessing pain
sensitivity disorders and neuro-vascular disorders
for traumatic neuritis of the facial nerve
Violation of facial muscles in traumatic neuritis of the facial nerve often
accompanied by painful symptoms, disorder sensitivity and cardiovascular
disorders. And if the function of facial muscles, can be objectively measured
by electromyography and functional tests, the pain and frustration of
sensitivity and neuro-vascular disorders, to date no clear quantitative
expression. Given the above, we propose to quantify the characteristics of the
considered complex symptoms of facial nerve neuritis index (BRCHVSN) and about
its description and method of determination.
1. Installing spontaneous and reactive pain:
2. subjectively (based on survey);
3. objectively (palpation).
4. Test to ascertaining changes in sensitivity carried out using blunt needles
compared with the healthy half of the face.
5. Injection of conjunctival hyperemia and symmetry skin buccal region set
visually.
6. Swelling of the oral mucosa,
identify areas of congestion and areas poblednenyya carried out using dental
mirrors, tweezers, a spatula and a light source (lamp dental unit, operating
lamp, oroskop, frontal reflector Simanovsky).
Index for pain, sensitivity disorders and neuro-vascular disorders in neuritis
n. facialis set in three stages.
The first stage - performing clinical examination.
The second stage - Coding of survey results in the table with eight centers in
accordance with the following codes:
Code number 1 2 3 4 5 6 7 8
Code
0 - no pathological changes;
1 - spontaneous and reactive pain localized in the chin;
2 - spontaneous and reactive localized pain in the arches;
3 - meaning light sensitivity disorder in the BTE region;
4 - meaning light sensitivity disorder on the face;
5 - determined by unilateral injection of the conjunctiva;
6 - defined asymmetrical coloring of the skin in the cheeks;
7 - swelling of the mucous membrane of the mouth;
8 - congested areas of the oral mucosa alternating with zones poblednenyya.
The third stage - calculate the index using the formula:
Index BRCHVSN = Σ / n (6)
where Σ - the sum of the coefficients, n - number of codes is equal to 8.
Study BRCHVSN index to determine the path of reconstruction cardiovascular
changes and establish the degree of the effectiveness of treatment and
rehabilitation is recommended in dynamics (before treatment, during the course
of treatment measures and after its completion).
Exercise therapy in neuritis of the facial nerve.
Neuritis of the facial nerve (NLN) is manifested peripheral paresis or
paralysis of the facial muscles corresponding half of the face, followed by its
asymmetry.
Indications for gymnastics at NLN:
1. Neuritis infectious and vascular origin.
2. After surgical removal of the tumor and compression of the nerve.
3. After a complete rehabilitation of acute purulent process in the middle ear,
causing the NLN.
4. NLN as a result of surgery on epitympanitu (rare).
Task gymnastics at NLN:
1. Improved regional blood flow (face, neck).
2. Restore function of facial muscles.
3. Prevention of contractures and friendly movements.
4. Restoring the correct pronunciation.
5. Reduction in severe violations of facial nerve lesions that are poorly
treatable to Hide defects of the face.
Periods of recovery
Early basic restorative
In NP 02.12 days 20-40 days 2-3 months
In LW 30-40 days 3-4 months 2-3 years
Early period.
Use the treatment position, massage, medical gymnastics.
1. Treatment provision:
- Sleep on the side (on the affected side);
- During the day 3-4 times sitting head bent in the opposite direction, keeping
her hand with resistance to the elbow. This pull muscles with a healthy side to
side damage (bottom-up) trying to restore the symmetry of the face;
-
Leucoplaster tension on your good side on the sore using special helmet mask;
- Tying handkerchief;
2. Massage.
Begin with neckline neck. The patient sits
in front of a mirror. Masseur
must see everything completely face the
patient. All massage techniques
(stroking, rubbing, kneading light, vibration) conducted carefully, without significant displacement of the facial skin.
Reducation (refer muscles).
3. Therapeutic exercises I.
- Dosed tension
and relaxation of muscles healthy
side (skulovoyi, laughter, circular muscle
of the eye, etc.)
- Napuzhennya and
relaxation of the muscles that
form the facial images (smile,
laugh, attention, grief). These
exercises are only a preparatory
stage for the main period.
Special exercises for facial muscles:
1. Raise your
eyebrows upwards.
2. Move eyebrows together.
3. Close eyes
(the stages of exercises’ performing:
see down; close eyes;
keep the eyebrow with fingers on the
side of INJURIOUS, keep an
eye on closed during I min., Open
and close eyes
3 times).
4. Smile with closed mouth.
2. Move
the eyebrows together.
3. Close your
eyes (the stages of the exercise:
look down, close
your eyes, holding the eyelid
with your fingers on the side of the injury, keep your eyes closed
for a minute, open and close your eyes 3 times).
4. Smile with
your mouth closed.
5. Screw up eyes.
6. Lower your
head down, take a breath and
while exhaling "snort".
7. Whistle.
8. Expand nostrils.
9. Lift the upper
lip, the upper teeth show.
10. Omit the lower
lip, the lower teeth show.
11. Smile with an
open mouth.
12. Redeem a match.
13. A mouthful of water, and rinse your
mouth shut, not pouring water.
14. Inflate cheeks.
15. Move air
from one mouth to
the other half.
16. Lower down
the corners of his mouth with a
closed mouth.
17. Protruding tongue and make it narrow.
18. Move the tongue
forward - back with
open mouth.
19. Move your
tongue right - left with an open mouth.
20. Outstretched lips "tube".
21. Fingers do the circle, watching him eyes.
22. Involved cheek with a closed mouth.
23. Lower the upper lip to the bottom.
24. When closed mouth to drive to the tip of the tongue Gums right-left,
pressing the tongue with various efforts.
Main (late) period (II)
Characterized by spontaneous recovery of muscle function, which is combined
with active treatment, special physical exercises and other methods gymnastics.
- Treatment of VP increased to 4-6 hours (in some cases up to 8-10 hours).
Increasing the degree of tension Plasters, reaching hypercorrection (due overstratching and weakening of healthy muscle
tone. Healthy muscles there by converted from enemies into "allies"
sick muscles).
- Massage II. A variety of techniques based on the topography of the
pathological process. Thus, the muscles that are inervated and branches n.
facialis, massaged the usual way. This light to medium stroking, rubbing,
vibration of the points. The basic massage is carried out from the middle of
the mouth and thus performs a dual role: regulation of muscle (small) and the
actual massage, stimulating blood flow, trophic paretic muscles and others.
The massage 5.11 minutes for 2-3 weeks. If no effect, LH continue and massage
stop for 8 - 10 days. A second course - 20 treatments.
- LH III.
LH plays an important role in the recovery period. All exercises are divided
into several groups: 1) differentiated strain of individual paretic muscles
(frontal, brow, zigomatic, muscle laughing, square muscle of the upper lip,
chin triangular, circular muscle of the mouth), 2) dose intensity (relaxation )
of all these muscles with the growing
strength and vice versa, and 3) awareness of exclusion muscles to form
different facial images, situations, smile, laughter, grief, bewilderment, and
4) dosed muscle tension during the pronunciation of sounds. All exercises
before a mirror featuring instructor and independently (2-3 times a day).
Residual period (after 3 months).
Objectives are the same: increase muscle activity to play the maximum symmetry
between the healthy and the sick side of the face (in this period, the most
frequently occurring contractions of facial muscles)