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 Ė facialarea

Methods of medical gymnastics classes withthe stomatological patients have a number of features, due to theclinical 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 developmentof the exercises andhelp at the†† monitoring ofthemovementsíamplitude . 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 themedical gymnastics complex ofspecial 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,raisesthe 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 accomodationsfor additional action on organs and tissues of the maxillo-facial region. For the mechanical therapythe rubber cross-bars, corks , wooden wedges, spoons ofLimberg, pressing sets, espander of Balon ,plates of Jadernaja,which are fluctuated , anf other accomodations and apparatus are used .However, tothe estoration ofchewing and mimic muscles function wecan not be limited of only one mechanical therapy using. Its is a kind of passive exercise,so itdoesnít not allowed reprodeseall 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 foreheadís folds,provides the epiphora
Muscle that lifts the corner ofmouth:
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 thenoso-labial fold, expresses the laughter

Muscle that raises the upperlip:
r
aises 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, baresthe lower teeth , open mouth

Chinísmuscle:
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 TEappointment 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 diseasís acute period .
Contraindications: bad general condition of the patient, body temperature above 38 į C, acute inflammation, increasedof ESR, septic condition, pain that is aggravated at the performing ofspecial exercises; risk of secondary bleeding in connection withthe 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 gymnasticis
appointed in early terms for the the general strengthening of the organism and prevent the formation of jawsícontractures. In the first days of the 1 period, after surgical dissection of inflammatory foci andanti-inflammatory treatment, while calming down the pain and normalization of body temperature (sub-febrile temperature is not a contraindication) using the breathingand 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 theslow 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 tissueís trophism ,contributing the intensification of reparative processes, its decrease the prabability of complications. This period is recommended to perform the active exercises asmaximal 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 itís 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 patientís 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 oflocal blood circulation to improve of resorption hydratation processesin thepost-operative wound, 3) prevention of destructive-atrophic processes in the peri-joint tissues, jawsícontractures 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 openingand closingmay be accompanied by head movements (bending, turning, circular movements), avoidingof dizziness or autonomic disorders associated with the vestibular analyzerirritation (table . 1).









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During the review of postoperative wound , thesurgeon 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 usingthe 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.

 

–ŤŮ. 17.

 

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 - 1.5-3 cm) - individual proportional segments for each person, are in direct proportion to its growth. It is believed that 1 tsun individual patient is transverse size nail phalanx of the thumb, respectively, the transverse size nail phalanges II and III fingers together equal to 1.5 tsunya; I, III and IV - 2 tsunyam, and all four fingers (II, III, IV, V) - 3 tsunyam.
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 0.3 cm
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.

–ŤŮ. 18.

 

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) 1 cm, which corresponds podhlaznichnoe hole.
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 1 cm (point E4 (di-Tsan)), and the horizontal line that passes through the chin-labial furrow - level point VC24 ( Cheng-Jian).
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 1 cm on the vertical line
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 exercisesí 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)