Theme 1. Physical
rehabilitation at fractures of the jaws and facial bones of the skeleton.
2. Physical rehabilitation in diseases and contracture temporo-mandibular joints.
Fractures of the jaws belong to the common injuries (
over 15% of all bodies fractures ). From all facial bones of
the skull the most frequent take place
the mandibular fractures (more than 85%
of cases), fractures of the maxilla ,in
combining with other injuries facial bones’ middle zone
,are approximately in the 10% of cases.
Law’s damage is accompanied of physiological equilibrium mimic muscle disorders,disorganizing of brathing functions , swallowing, chewing and speech. As a result of the pituitary-adrenal system reaction ,at the jaw’s fractures ,arising the hemo-dynamic , thermo-regulation changes and other physiological processes, which lead to poor general condition of patients .
Damage of maxillo-facial area has some features, due not only anatomic and physiological importance located I this place vital value organs, but also emotional and mental changes, that often occure due to distortion of the face. Functional violation of eating, speech defects and changes of external respiration at the jaw’s fractures lead to the capacity lowering and the patient’s mental condition is worsening.
However, the tissues of the maxillofacial area have the increased capacity for regeneration and high level of resistance to infection due to good blood supply and innervation. Therefore, even in large face damages at the right treatment usually have the happy final.
Complex treatment of patients with the jaw’s fractures provides timely and reliable fixing of bone fragments, medicamental and dietary treatment, use of functional therapy methods (TE , mechanical therapy, massage, etc.).
A very important factor, which affects on the TE methods on the classes at the jaws’ fractures , is the mode of bone’s fragments consolidation.
Relatively , two basic methods for fixing of jaws’ fragments we can distinguish: orthopedic or conservative, and surgery (osteo-synthesis). In some cases the combined –conservative-surgical methods of jaws’ fragments consolidation are used . For example, at maxilla fractures , put the teeth thewire splints with wire loops on the jaws (conservative method) and make rapid fixation (suspension) fragment of maxilla fragments to the immobile zygomatic appendixes of frontal bone. In last years for the fixation of mandibular fragments the plastic splints on teeth are used ; thir splints are quickly hardening.
Regardless of the method of permanent fixation of mandibular fragments , the most early terms the functional therapy is appointed. It should be accaunt that forced limitation of physical activity, prolonged jaws’ immobilisation , the possibility of damage’s at the fracture soft tissues scarring ,may lead to serious complications such as mandible’s contracture, temporal-ankylosis of mandibular joint , pneumonia, etc..
Therefore, the TE use for the prevention of complications, accelerated consolidation of bone fragments, the most frequent restoration of jaws’ functions and period of patient’s disability reducing , is the important element of complex treatment. Successful completion of these tasks is depevd greatly of well-timed of the functional treatment and whether it properly is perfomed.
Basic requirements for the TE methods on the occupations at the jaws’ fractures is necessity keep the immobilizing conditions of primary bone’s callus formation (first period of the TE application ). Just breach hopestion of bone’s fragments fixation is the cause of various complications and increasing of the treatment terms. To avoid complications, to create the most favorable conditions for the blending of fractures is possible only when the rest (immobilization) and functional loading (TE ) is used correctly .
The final aim of jaws’s fractures treatment is not only in restoring of the anatomical continuity and damaged bones’form, but also full-fledged normalization, as soon as possible, functions of chewing.
Methods of medical gymnastics at the jaws’ fractures depends on the periods of bone’s healing, accepting in traumatology, immobilization features (one-moment or 2-moment jaws’ splintage, osteo-sythesis) and patient’s clinical condition .
Each lesson should include medical gymnastics of general-strengthenining and breathing exercises in the following sequence and dosage, to ensure the overall effect on the body and achieve of improvements in thetissues’ local processes in damaged pllaces. Character of general-strengthening and breathing exercise depends on the movement mode and functional stateof respiratory and cardio-vascular system of patient.
The use of special exercises to mimic and chewing muscle depends of the immobilixtion method .
When the conservative (orthopedic) treatment, which applies almost 80% of patients with jaws’ fractures, bone fragments are fixed in two main ways: 2-jaws stretching and immobilization with the help of aluminum wire and hooktraction rubber, plastic and kaps aparatus, 1-jaw splintage, using into-oral splints, with offensive hooks, and devices of various designs.
At the surgical (operative) treatment, the osteosynthesis of a damaged jaw’s fragments is perfomed with a special wire, knitting needles,suturing apparatus and other devices, which are not limited the temporo-mandibular joint function.
At 2-3-day after immobilization a medical gymnastics is appointed afrer the method of the first period of occupations. Temporary contraindications to the use of TE should be considered: a) bad general condition of the patient , b) fever more than
Tasks of the TE in the first periodi of occupation:
- Improving the general patient’s condition ;
- Promoting of bone fragments’ consolidation and postoperative wound healing (at the osteo-synthesis);
- Prevention of complications associated with hypodynamia and immobilization of temporo-mandibular joint;
- Facilitate the restoration of coordinated muscles’ work ,which take part in acts of swallowing, chewing and speech.
Solving of these problems is provided by the appropriate selection exercise: the general - developing and breathing exercises, that would strengthen the activity of the respiratory and circulatory functions adequately to the organism’s functional possibility are included. Because of bones fragments fixation’s disruption fears are not allowed to make the dramatic inclinations of trunk ,jumps , heads’turning and so on.
During the first 3-.4 days of patient’s treatment with the fractures of maxilla and mandible the half-bed(ward) and then free regimens are appointed . Starting position for general-development and breathing exercises - lying or sitting on the bed. Young patients with good general state, in most cases can do the exercises standing.
In appointing the special exercises in the first lesson period should bear in mind thatin the case of double -jaws’ splintage, the exercises for the chewing muscles are not used, because of the inability to open the mouth and the risk of bone fragments’ displacement . You can send impulses to reducing of chewing muscles contraction at the closing teeth and slow tempo (interval 1-2 sec.) without much effort.
Due to the increased chewing muscles tonus on the side of the fracture and increasing its influence of it under the immobilization’s influence, should contribute of fully mimic muscles relaxation . For this purpose, widely used the exercises to mimic muscles ,tongue and neck , that help to improve tissues blood and lymph circulation in the area of fracture . All exercisesare conducted in the position , sitting in front of a mirror.
If there is no acute inflammatory processes in the damage’s area , on the 7-8-day, you can proceed to massage of face and and neck. Applying the techniques of stroking, rubbing and kneading in the direction of the face’s middle line upward to the ear and temporal pits. Then massage the front and. side of the neck. The final part of massage is the stroking .
Classes of medical gymnastics in the first days continues to average 10-15 minutes, and at the finish of the first period - up to 20-25 minutes. During the day, patients should be 3-4 times independently perform the individual tasks from medical gymnastics, which consists of complex of special exercises (5-7) with the individual dosing. Multiple of special exercises promotes the faster resorption of edema andincresing the tissue’s regeneration in locus of damage.
At 1-jaw splinting methods and osteosynthesis in the first period of the TE application ,the patient is already on 2-3-day can open and close your mouth, do the lateral moves of mandible , make chewing movements.
Thus, 1-jaw’s splintage and osteosynthesis allow assign the exercises for chewing muscles after the pain decreasing, which creates better conditions for anatomical and functional restoration, than at the 2-jaws’ immobilization.
Duration of the medical gymnastics’ application first period , take about two weeks.
Delivr the training scheme of classes’ first period (duration - 12-14 days) using of medical gymnastics for patients with fractures of tmaxilla and mandible.
Scheme of medical gymnastics classes at the fractures of maxilla and nandible ( the first period of the Te application )
Initial part (2 - 5 min)
IP (Initial position) - sitting or standing.
Exercises for upper extremities and humeral belt, dynamic breathing exercises. Turn torso to the parties, swinging movements alternately right and left hand, dynamic breathing exercises. Turn torso to the parties, swinging movements alternately left and right legs in different directions. Turns ,inclinations and circular head movements . The performance’s tempo – slow or medium. Amplitude of extremities’ movements is not full. Avoid sudden movements of the head and torso.
The main part (10 -12 min)
The final part (2-3 min)
IP - sitting or standing. Exercises to relax the muscles of the upper extremities and humeral belt and mimic muscles in the connection with the deep breath. Tempo- slow, watch for the complete muscles’ relaxation of patient .
Approximate complex for class of medical gymnastics by the method of the first period of the TE application .
IP - the basic stand.
1. Hand on the sides, breaths through the nose, slowly lowering hands down – rxpiration on the three accounts; 4-6 times. Tempo – slow’ expiration through the closed lips.
2. Arms ahead , palms - upwards, crossing movements of direct arms (20-30 sec.). Average tempo, respiration isn’t delaying
3. Hands behind of head, breaths through the nose, turn to the right, arms to the sides – expiration . The same in the other direction, 6-8 times. Arms are not lowering, breathing- freely. Tempo - slow .
The main part
IP - sitting in front of a mirror.
1. ircular head movements in each direction (30-40 sec.). Tempo – slow , no delay the breath.
2. Imitation a smile, cheeks inflated by one, 10-15 times.
Tension of muscles 2- 3 sec., 3 - 5 sec. - rest. Breathing - freely.
3. Knitting of eyebrows, its lifting p (imitation of surprise) stretching of the lips in tube and mouth angles’drawing out to the sides, 10-12 times. Tempo-slow .
4. Head turning head to sides, inclinations forward and back, 6-8 times. Tempo - slow . 5. Simultaneously and alternately eyes’screwing up with the cheeks’ blowing up and drawing in (20-30 sec.). Muscles tension (3-4 sec.), rest (2-3 sec.).
6. Pulses’ sending to the chewing muscles contraction (30-40 sec.). Tempo of contraction - 2 sec., breathing - freely.
7. Mixing in the mouth of water ‘s gulp with the blowing cheeks (20-30 sec.), gradually increasing of movement’s speed.
8. Movement of the tongue in the oral cavity with simultaneous nominations of head forward and returning to the I.P.(20-30 sec.). Slow and average tempo.
IP - The basic stand.
1. Walking in place, lifting knees high and wide with the sweeping arms’ movements (30-40 sec.). Average tempo, wach for the carriage.
2. Turn torso to side with the free movements in the lowering relaxed arms, 6-8 times. Slow tempo.
3. Lifting of arms upwards - breath through the nose into 2 accounts, lowering arms down – exhalation out on 4 accounts 5-6 times. Slow tempo. .
In addition to daily classes of medical gymnastics gymnastics in the TE study , patient independently should do for 5 times per day such complex of special exercises:
1. Cheeks’ stroking in the direction from the external auditory duct to the corners of mouth (30-40 sec.).
2. Simultaneously cheeks’ blowing and turns (40-60 sec.).
3. Pulling away of the mouth corners to the sides and lips’ and drawing in tubes (40-50 sec.).
4. Massage with the tongue of gums and hard palate (20-30 sec.).
5. Rhythmic static contraction of chewing muscles with the closing teeth (20-30 sec).
6. Fast mixing of air at the relaxed cheecks’ muscles closedand mouth , head inclinated forward (30-40 sec.).
Duration of the first period of the TE application for patients with the uncomplicated jaws’ fractures is in the middle-age – 2-3 weeks. At this time, the formation of primary osteoid callus is finished.
Further development of bones’ tissue regeneration process is associated with the seepage of primary callus of calcium phosphate. transform it into a full bone.
Since the beginning of the 3 week immobilization, the inter-jaws fixation is weakened ,or removable splint, at 2-jaws splintage is imposed, so you can use active exercises for chewing muscles, involved in movements of the mandible, to prepare it to work.In this time the second period of the TE using is beginning
In this period the training methods are slightly different: to the complex are included exercises exercises for chewing muscles. Exercises to be done very carefully, slowly with low amplitude, not prove to pain.
Mechanical therapy and passive movements of the mandible at jaw’s splintage in this period does not apply.
At the 1-jaw splintage recommend more vigorous and active exercise for the chewing muscles ,second nature, but limited use the passive movements and elements of mechanical therapy.
Duration of medical gymnastics in the 2 period increased to 20-30 minutes instead of general- development and special exercises. Improves overall intensity of physical loading: increasing the number of exercises’ repetitions, tempo and amplitude of movements, often the I.P. are changing.
The main task of TE in the 2 period : - fighting with the development of contractures and hard mobility in the temporal-mandibular joint and patient’s preparation to leavinng hospital for home. This increases the general duration of functional loading by increasing of individual tasks from medical gymnastics repetitions (from 7 to 12 during the day). To individual tasks along with special exercises we recommend including of 3-4 general - developing exercises for large muscle groups.
After the immobilizations removing, transferred to the 3, rehabilitation period of fractures treatment ,that coincides, usually, with the patient leaving of hospital and sending it to the clinic to complete the treatment. At this stage of treatment should be the complete medical of patients.
On the eve of patient’s leaving of a hospital , the patient let know in need to continue the restoration treatment to full normalization of temporal mandibular joint function.
Methods of the TE occupations at the jaws’ fractures in 3 period - using of special exercise. . Apply the active, active and passive and active with the resistance exercises for the chewing muscles are used. Its are perfomed in the average tempo with the maximal amplitude, emphasizing the open mouth, mandible’s movements to the side and forward. According to the indications, the mechanical therapy and massage can be assigned .
In the first days of treatment in the policlinic , with the patient’s participation, the program of functional loading is produced. After the patient is learning it , he go in for TE at home, attending the policlinic once a week for the to determining of the home classes effectiveness and making of correctives to the program.
One of the gravest violations of the chewing function apparatus is the contracture temporal-mandibular joint . Pathologic changes in soft tissues surrounding joints, resulting from trauma or inflammatory processes , long hypo-dynamia at the 2-jaws’ splintage, and later specialized in treatment too. Often the contracture caused by scar changes in the temporal-mandibular joint that in further leads to its total immobility (ankylosis).
After the the degree of mouth opening distinguish some kinds of extra-joints contractures: hard - opening of mouth to
For patients with contracture is using the surgical, orthopedic, and complex methods of treatment (required complementary appointment of TE as a means of functional therapy ). Indications for TE appointment at contracture of temporal – mandibular joint:
a) Reduction of acute manifestations of the process that was causing the contracture;. b) operations (lancing of the abscess or phlegmon, removal of scars or plastic colliding triangular chunks of skin, coronary appendix resection or amputation of the mandible’s chewing muscle , etc.)
c) mandible’s redressation , which is bloodless forcibly restoring of joint mobility;
d) Operational repositon with the aim to section scar, adhesions and muscle for transform of hard mobile mandible’s fragments in the mobile and then the applaing of wire 1-jaw splint .
TE application prevent the contracture reccurence and improve the functional efficiency of operations or orthopedic treatment.
Surgical intervention, which is the radical removing of scar tissue and replaceof the the skin defects (with a help of Filatov’s sterm or other ways to skin plastic), creates the objective conditions for the functions of temporal-mandibular joint restoration.
Effectiveness of surgical treatment depends on the active attitude of the patient to medical gymnastics classes. Early and energetic multiple implementaion of special exercices in the postoperative period is crucial for sustaining a positive functional outcome of the operation.
Immediately after the operation (1 period of the TE application ) not more than 2 -3 h rubber pad, between large molar teeth to the maximum possible opening of the mouth, with the repetition of this procedure over the same interval of rest should enter.
If there is swelling and postoperative pain syndrom (usually in the first 2-3 days), assign the respiratory exercises and simple movements for small muscles groups of extremities in the slow tempo.
Already on the 4-5-days, patient transferred from the bed regimen on the half-bed (ward) or freemode . Medical gymnastics classes include breathing and general-development exercises for all muscle groups in an amount that causes no acceleration of pulse more than 20-30% compared to the rest condition .
If there are no contraindications, using the exercises to mimic and chewing muscles. At the time of course the rubber pad removed, then inserted , according to the above recommendations.
Special series of exercises, performed on 5-10 to repetitions at a slow tempo with intervals of rest 1-2 min. Opening of mouth, jaw’s nomination forward, side and circulator moves it in the first days of classes do carefully with a small amplitude of motions, avoiding the pain and fatigue resulting in chewing muscles. Exercises’ complex for self-use patient has to repeat every day at least 8-10 times.
Active and passive mechanical therapy with the Darssiaka, Limberha, Oxman, Solomon and others apparatus using , may. start with a 6-8-th days after the operation. Effectiveness of mechanical therapy increases after heat physiotherapy and massage procedures.
In the second period, theTE using ie after removal of stitches (usually on the 10-12 days after operation), increases the duration and intensity of general-development (general - hardening), and special breathing exercises, which connects with massage heat- and mechanical therapy.
Scheme of medical gymnastics occupations at the scars’ contracture of the mandible in the 2 period the TE using
Initial part (3-5 min)
IP - sitting or standing. Exercises for coordination and attention. General-development exercises for major muscle groups. Average tempo, amplitude of theextremities’motions is complete.
The main part (10-15 min)
IP - sitting in front of a mirror. Exercises for muscles of the neck (turns, circular movements and head inclinations ) in connection with exercises for mimic muscle . Stroking of buccal and temporal area, active mouth opening , movements of mandible in the sagittal and frontal planes.
IP - standing. General-development gymnastic exercises with sticks, dumb-bells, etc.. Exercises to mimic muscles to relax faster the chewing muscles. Rotate of general-development exercises with special in ratio of 2: 3.
Final part(2-3 min)
IP - sitting or standing. Practice relaxing of upper exremities, humeral belt and mimic muscles. Deep breathing and reprimanding of sounds "fu". Slow tempo; achievement of complete muscles’ relaxation.
After each class of medical gymnastics it is necessary to control the dynamics of mandibular joint functions’ restoration.
In addition to the medical gymnastics training, the patients designate the special set of exercises for inepending multiple perfoming during the day. It should be explained to the patient that the restoration of mandible movements in the complite volume is possible only at the systematic functional loading of temporal –nmandibular joint.
Approximate complex of special exercises for the independent conducting (the second period of the TE ).
1. slow opening and closing of the mouth (20 - 30 times). .
2. Mouth opening mouth with the simultaneous extension of head and putting tongue out (20-30 times).
3. Circular moves of mandible , alternately left and right , with the closing lips ( 10-15 times in each direction).
4. The nomination of the mandible forward - first with closed lips, then with open mouth (20 - 30 times).
5. The lateral movement of mandible with a change of tempo -from slow to fast (15-20 times in each side).
6. Imitation of yawning with simultaneous extension of head and a deep breath. Extended expitation through lips ,drawning in pipe, at the lowered on chest head (10-12 times in a slow tempo).
7. Fast mouth opening and closing ,with the pronunciation of sounds "pa-pa-pa" (20-30 times).
Perform series of exercises, that are repeated several times with rest intervals from 35 to 45 sec.. In brackets indicate the number of movements in this series . Exercises should not cause the pain feelings in the field of temporal-mandibular joint.
In the 3 of the TE using the main task is to restore fvolume of motion in the temporal- mandibular joint. With this aim increase the number of special exercises and increase the load, including to the classes the exercises on resistance to mouth opening and closing , with lateral movement mandible . Every special exercise is repeated 30-40 times on average and a fast tempo.
Individual tasks the patients perform 10-15 times per day, with the mechanical therapy using. In the break between the classes the chewing gum’s using is recommended .
Shown description of individual tasks for independent conducting of special exercises (the 3period of the TE using ).
1. Open and close mouth in a slow and average tempo (20-30 times).
2. Open mouth with the fingers, which are enclosing the mandible (20-30 times).
3. The lateral mandible’s movements at the half - open mouth and closed your teeth with the fingers or fists, pressed from the cheeks to the mandible (20 - 30 times).
4. Circular moves of mandible ,alternately left and right, changing the tempo and amplitude of movements (10-15 times in both directions).
5. Mouth opening with oral extenders , imposed from both sides between the teeth (5-10 times for 1-2 min). During the rest - stroking and grinding of tissues around the joint.
6. The nomination of the jaw with a closed mouth and closed chewing surfaces of teeth (20-30 times).
7. Maximum extension of the head and opening mouth with the fingers, located between the dental series (20-30 times).
8. Rinsing of the mouth with warm water (40 - 60 sec.) for the relaxing of muscles and fatigue removing
Before performing an individual task , the patients should be explained that only persistent classes of TE for a long time can provide the effective functional results.
For orthopedic treatment of mandible’s contractures the scars stretching and restore movements are reached with the help of the mechano-therapeutic apparatus , blades, screws made of wood or plastic, elastic rubber bands of different thickness and etc..
Active-passive mechanial therapy performs 15 - 20 minutes 3-4 times daily. However, mechanic training only complements the medical gymnastics’ classes, as the majority of movements with the use of machines and devices iare conducting in the same plane and limited of the mandible’s lowering . The restoration of complete function of the temporal-mandibular joint ,requires of various mandible’s movements ( to the sides , front- back, circular , etc.), that are possible only the conducting of special exercises for chewing muscles.
physical culture at the JAWS’ dislocations
Some teaching methods therapeutic exercises with dental patients have some features due to clinical manifestation of disease. First of all it concerns the method of application specific exercises. They perform in front of a mirror as a visual control facilitates proper development exercises and allows you to monitor the amplitude of movement. The special features include therapeutic exercises classes also need multiple repetition of specific exercises for the day itself.
The proper selection and reasonable inclusion complex gymnastics, special exercises should be guided by information about the facial muscles.
Solo is the most rational method during gymnastics classes with dental patients.
In a classroom therapeutic exercises than typical equipment to be mirrors of individual tables and screens for specific exercises mechanotherapeutic apparatus and devices for additional actions by organs and tissues in maxillo-facial area. For mechanotherapy used rubber spacers, stoppers, wooden wedges, spoon Limberg, wavering, zhomov devices Balloon Expanders, boards that heartwood ranges and other appliances and devices. However, functional recovery of facial and chewing muscles can not be limited to using only one mechanotherapy. It is a kind of passive exercise, does not allow to reproduce the variety of movements in the temporomandibular joint, carried out with the active (volitional) exercise.
Mechanotherapy shown mostly during the elimination of residual effects - when pos-timmobilization contracture, fibrous ankylosis, stiffness of joints, pulling scars, paresis, paralysis and other selected states.
Indications for the appointment of physiotherapists in dentistry: dysfunction of mastication, speech and facial expressions, resulting from injuries, inflammatory diseases or birth defects.
Timing of application of physical therapy is usually coincide with the end of the acute period of the disease.
Contraindications: general grave condition of the patient, the body temperature above 38 ° C, acute inflammation, incrased ESR, septic condition, pain that increases the performance of specific exercises, the risk of secondary bleeding due to the finding of a foreign body near vessels, insufficient immobilization fragments of damaged bone.
Among all the damage the facial skeleton mandibular fractures account for more than 70%.
Timely application of exercise therapy eliminates adverse effects hypokinesia, prevents the development of complications associated with prolonged immobilization of jaw (chewing muscles atrophy, scarring facial soft tissues, contracture TMJ etc.).
Methods based physiotherapist considering periods of callus formation, features immobilization (splinting odnoschelepne or bucket, osteo-synthesis) and the clinical condition of the patient. The first (introductory) period usually begins classes on 2-3rd day after the imposition of a permanent patient immobilization and lasts until initial signs of callus formation. The duration of this period for fractures of the mandible 3.4 weeks., The optimal time mizhschelepnoyi fixing fragments up to 5 weeks.
The task of the physiotherapist in the first period classes: improving the patient's general condition, stimulation of reparative processes in the damaged bone and soft tissues of the maxillofacial region, prevention of complications associated with immobilization and hypokinesia of TMJ.
Methods medical gymnastics classes provides individual selection bracing, respiratory and special exercises against motor mode, the patient adequately. Typically, the first 3-4 days of treatment for patients with jaw fractures recommended half-bed (ward), and future - free driving mode.
Bracing and breathing exercises prescribed at a dosage that provides amplification of cardio-respiratory system, proper functionality of the patient. Initial conditions for the exercises, lying or sitting in bed, in good general condition of most of the exercises can be done standing.
When the special exercises should not be allowed landslides mapped bone fragments as violation immobilization causes of complications and longer fracture. Therefore, when 2-jaws splinting take place, the exercises for masticatory muscles in the first period of classes do not apply. Allowed only prudent assumption impulses to the reduction of masticatory muscles during tooth of closed ranks. In this period also recommended restorative exercise-related sudden torso, head rotation, jumping, etc., due to the risk of violation of fixing the damaged bone fragments.
At 1-jaw splinting or fixation with osteosynthesis between jaws , patients already at 2-3-day permit careful moves the lower jaw in various directions.
This term is widely used exercises for facial muscles, tongue and neck muscles that improve local blood circulation and reduce the tone of masticatory muscles. Exercises for facial muscles do sitting in front of a mirror.
Duration of employment therapeutic exercises for 10-15 minutes. In addition, patients should be several times a day to perform self 5.10 special exercises.
In patients with single mandibular fractures (for smooth flow of the healing process) by an average of 8-9th day after dvohschelepnoho splinting permitted to shoot rubber rings on the meal. This fact allows the active movement of the mandible in of closed lips, avoiding pain in the temporo-mandibular joint. The patient was advised at every meal to perform a series of exercises, consisting of 4-5 movements of the mandible (opening and closing the mouth, lateral and circular motion of the jaw), repeating 5-10 times each of them.
When double fractures of the mandible occurring without complications mizhschelepnu fixation shot on eating for 3-4 days later compared with single fractures.
Therapeutic exercises for fractures of the jaw bones (the first period of 2-jaws splinting)
Sitting or standing
Exercises for the muscles of shoulder girdle and upper limb dynamic breathing exercises. Turns body to the side, alternate movements underneath the lower limbs in different directions. Rotate, skew and circular movements of the head 2-3min.
Air slow or medium. Amplitude motions limbs are not in full. Avoid sudden movements of the head and torso
Sitting in front of a mirror
Exercises for facial muscles, muscles of speech, combined with breathing through the nose. Exercises in sending impulses to the actual reduction in masticatory muscles of closed teeth. Exercises for the muscles of the neck and upper extremities 8-10min.
Air doing exercises for facial muscles slow, each exercise is repeated 5-10 times. Follow in the absence of pain at a voltage of masticatory muscles
Sitting or standing
Exercises in relaxation of muscles of shoulder girdle, upper extremities and facial muscles, combined with deep breathing 2-3min.
Air slow, watch full muscle relaxation. Measure the degree of opening of the mouth
Functional load should also be conducted with great care and supported the appointment of an appropriate diet.
When osteosynthesis of the mandible at 3-5-day ill be carried out sparing movements in temporo-mandibular joint. Even at 7-8 day at smooth fracture healing movement in the joint performed with full amplitude.
The task of the physiotherapist in the second period classes: prevent the hard moving of temporomandibular joint and prepare the patient for discharge from hospital; For this purpose, increasing the duration of therapeutic exercises classes by appointment larger number of bracing and specific exercises. Functional load TMJ increase by assigning of individual tasks, consisting of several special exercises performed by patients themselves 7-10 times during the day.
When dvohschelepnomu mechanotherapy splinting and passive movements of the mandible is not used because it can lead to the formation of a false joint.
After immobilization (before the formation of complete bone) go to the third period of treatment of fractures. This stage of completing the restorative treatment that provides full medical rehabilitation of the patient and his return to work. A wide selection of special exercises for the masticatory muscles (active, active-and passive resistance, the use of mechanotherapy) carried out with the maximum amplitude of movements (even against moderate pain), can remove existing restrictions on the function of temporomandibular joint.
ORTHOPEDIC TREATMENT of temporo-mandibular joints pathology.
Diseases of the temporo-mandibular joints occupy a special place because of the difficulty in diagnosis and treatment is extremely diverse and sometimes complex clinical picture.
No single classification of diseases of the joint. Various forms of pathology of the body that are observed in the clinic, often do not fit in the traditional diagnosis of "arthritis" and "arthrosis." There prefabricated concept to describe diseases temporomandibular jaw joint unclear etiology "arthropathy", "functional mioartropatiya", "deforming arthropathy", "myofascial syndrome joint dysfunction," "joint neuralgia," "pathological syndrome bite" and others., However, the introduction of such terms is not conducive to the improvement of diagnosis.
The literature and clinical observations suggest that the etiology and pathogenesis of temporomandibular joints are important occlusive disorders, pathological processes in the dentition and masticatory muscles, psycho-emotional and endocrine disorders, infectious diseases, injuries (bruises, fractures, etc.). . It should be noted mutual conditionality of all these etiological moments.
Y.A. Petrosov (1996) proposed a working classification, according to which functional disorders and diseases of the TMJ are divided into 5 groups.
1) Disfunktsyonalne joint state:
a) neuromuscular dysfunctional syndrome;
b) occlusive syndrome-articulation;
c) habitual dislocation of joint (jaw meniscus).
a) acute infectious (specific, nonspecific);
b) acute traumatic;
c) chronic rheumatism, rheumatic and infectious-allergic.
a) postinfection (neoartrosis);
b) posttraumatic (deformation) osteoarthritis
c) myohenic osteoarthrosis;
d) metabolic arthrosis;
e) Ankylosis (fibrous and bone).
4) The combined form.
5) Neoplasm (benign and malignant).
Methods for evaluation of patients with diseases of the temporo-mandibular joint.
Survey. Should detail the symptoms, trying to figure out what came first, such as pain or clicking in the joint. This is important because when subluxation and habitual dislocations often appears first click, and then joins a pain, but with arthritis and arthrosis appears first, usually pain, and then click in the joint. Clarifies the nature of pain and the location (point, diffuse, irradiyuyucha). Spot or strictly local pain typical of habitual dislocation and subluxation, dysfunctional syndromes and osteoarthritis. Spills more often in acute and subacute arthritis, myositis and other inflammatory processes around the joint. Irradiyuyucha pain occurs during compression of the auditory nerve twigs ear-temporal, trigeminal neuralgia, pulpitis. The examination is necessary to determine whether the patient is lockjaw, gnashing of teeth, muscle fatigue, feeling constant chewing and grinding food. These symptoms can occur when parafunctions. Such patients should be further examined by a psychiatrist.
Physical examination. For the diagnosis and treatment of diseases of the temporal-mandibular joint conduct functional analysis of dentition, including the assessment of occlusion and occlusal contacts dentition, occlusal height measurement lower person articular noise analysis, palpation of the joint, masticatory muscle pain points person, x-ray jaws, teeth and joints in central occlusion, physiological rest of the mandible and the maximum opening of the mouth as well as electromyography and arthrography. Conduct analysis of movements of the mandible.
Review. The survey begins with a review of the face, where its define the proportions, symmetry, pay attention to the muscles, branches of the jaw. This is followed by intraoral examination, which primarily assess occlusion, the characteristics of resistance to diseases of the joints which are:
1. maximum multiple contacts dentition in the center, front and side occluded;
2. smooth sliding dentition during the transition from one to another occlusion without horizontal pushes on the teeth;
3. no decrease or overstatement inter-alveolar height;
4. absence of lateral displacement of the mandible during its transition from the physiological rest position in central occlusion and minimal distal offset this;
5. lack of soft tissue injuries of the oral cavity teeth.
Palpation of the joints hold the skin in front of tragus ear, placing your index finger on the projection of the articular heads, or little finger through the anterior wall of the external auditory canal at stulenni jaws in central occlusion and during movement of the mandible. At the same time determine the severity and time of articular noise. Palpation reveals tenderness of masticatory muscles, compression, compression asymmetry of teeth in the central occlusion.
Radiographic methods. Among the various methods of radiography of temporo-mandibular joints most widely used methods Shyullera,
In prosthetic dentistry tomograms or zonography removed at close order jaws at the central occlusion, as well as physiological rest mandible.
Graphic methods. Drawing methods function dentition include recording movements of the mandible, miography, based (mehanohraphy, electromyography), arthrography.
Medical treatment of temporo-mandibular joints should be integrated. After a detailed analysis of clinical and research findings begins with the definition of the plan and features of the patient. Complex therapeutic measures may include:
5. orthopedic treatment
6. orthodontic treatment before prosthetic
8. physiotherapy and hydrotherapy at the joints contractures
2000 is the lower jaw movements per day. Hard mouth opening observed at the inflammatory contractures: abscess of pterygoid-mandibular space, hard eruption 8 lower teeth, broken jaw, fractured of zygomatic bone, with trismus masticatory muscles (tetanus, hysteria, cerebro-vascular accident), because such patients come to neurologists, otolaryngologists, psychiatrists and infectious disease.
With existing species approach to joint most cosmetic section is for Rauerom. This section has a length of
Ankylosis of temporomandibular joints - fibrous or bone fusion of the articular surfaces and the associated partial or complete lack of mobility in the joint.
Etiology: infectious, traumatic and others.;
For morphological substatom process: bone, fibrous;
Localization process: one-sided, two-sided;
The degree of prevalence of adhesions: incomplete, or partial, full, or extended;
By the nature of accompanying changes facial bones: from microhenia, without microhenia.
Etiology. The cause of ankylosis are acute joint, septic arthritis, osteomyelitis joint head of the mandible, articular fractures germ.
Pat. Anatomy. Bone fusion of articular surfaces - bony ankylosis. Cicatricial adhesions between the articulated surfaces - fibrous ankylosis. Unlike children, which often develop bone Ankylosis (in childhood articular surfaces covered with periosteum and have no cartilage cover) in adults more often defined fibrous fusion of the joint.
Unilateral Ankylosis are more common than bilateral. Development of ankylosis in children involving violations of growth affected half of the mandible, leading to deformation of the face. In adults, these deformations do not occur or are less pronounced. The earlier the patient developed a pathological process in the joint, the more pronounced deformation of the whole mandible, especially in a sick way.
Clinical picture. The main features of symptomatic ankylosis is stable partial or complete restriction mouth opening and full nature of horizontal movements in the affected joints. There is a mouth opening within 0.5 -
When unilateral bone ankylosis chin and nose shifted in a sick way, conch on the affected side is lower than in healthy. The affected side shortened and looks more convex and healthy zmischayuchys in a sick way, sinks and flattened.
For bilateral ankylosis, developed in childhood, N / underdeveloped jaw on both sides, chin shifted backwards / bird face / movement in the joint sharply limited, preventing the examination and treatment of the oral cavity, pharynx. Often there are disorders of speech, breath and mind, reducing power.
In fibrous ankylosis unlike bone pain frequently observed.
The main features of the initial manifestations of fibrous ankylosis are: slight crackling in the joint, masticatory fatigue "muscles and zatrudnene mouth opening in the morning. These symptoms occur against a background of rheumatic process, which is already available in other joints as well as phenomena revmakardytu in the acute stage.
Typically, TMJ struck on both sides, just as rheumatism affects even large joints. Body temperature grade, accelerated ESR, leukocytosis observed. In acute rheumatic process can be marked to show the flushing of the skin, hrypuhlist, sharp pain in the joint, limited mouth opening. Limited movement in the joint contributes to further development of ankylosis. The diagnosis is proposed with regard to etiological factors and the dynamics of the disease, on the basis of clinical and radiological examination.
Surveying the area of the joints, you need to pay attention to skin scarring / be injured due to otitis media operations, mastoidytu / purulent discharge from the external auditory canal, the position of the chin, the form n / jaw.
Characteristic features of partial bone ankylosis is the lack of joint space on some areas of the head and neck thickness articular sprout reduction clippings l / jaw. At full bone ankylosis synovium no. On the face of marked joint bone fusion n / jaw with the temporal and zygomatic bone, branch l / jaw shortened, on the back edge of the angle of the jaw features a "spur" in front of the angle - notching.
Unlike kutkovoho fibrous ankylosis in the joint space is preserved, but a smaller width and clearly marked, "zauvalovana." Blanking l /jaw deformed, head and neck joint petiole slightly thickened.
Bone ankylosis that emerged in childhood, accompanied microhenia. Pathogenesis of underdevelopment l / jaw about the same and is closely connected with congenital or acquired changes in the articular heads l / jaw. Only in some rare cases mikroheniya caused by inborn formation of the jaw and can be attributed to a group of congenital malformations of the jaws. Underdevelopment n / jaw in such patients is always combined with impaired bone formation, which lie at the same time the lower jaw, often temporal bone, as well as partial or complete absence of the ear. The reason mikroheniyi in such cases is the retention of embryonic differentiation mezenoymy of underdevelopment elements TMJ, which provides mandible’s bone.
Conclusion of communication mikroheniyi with that or other pathology TMJ / congenital or acquired / is consistent with data on the characteristics of growth and morphogenesis n / jaw. Growth l / jaw bone is provided superimposition of bone in the area of fibro-cartilage covering the articular head. After 16-18 years, when cambial elements fibro-hryaschevoho coating heads replaced by bone growth l / jaw in length stops and various lesions or joint injury underdevelopment l / jaw is not accompanied.
Ankylosis be distinguished from inflammatory contraction of masticatory muscles, in which are inflammatory tissue changes, and increased tenderness of lymph nodes, as well as tumors, fractures and fractures of the articular sprout without displacement of fragments.
Treatment: with fibrous ankylosis used "bloodless" method of breaking fibrous adhesions - "redresatsiya" which is as follows. In soft tissues surrounding the joint, and the joint is injected 1% solution trimecaine. Then in the region of molars set gag, which gradually extend the jaw. gap fibroznyk adhesions feel sick, catching "crackling" in the joint. then you must enter drug or steroid lidasa to prevent the formation of yet more adhesions. If this method does not work, then perform operation excision of adhesions in the joint with removal rozrushenoho and deformed disk. Once opened his mouth freely between moramy put spacer rather than tires with aggressive loops - rubber ring. 7-10 days spacer and rubber traction remove and appoint active gymnastics. hydrocortisone injected into the joint cavity through 1 ml. 05.03 per course injections. intervals between injections - 2-3 days. Following the treatment stiffness in the joint passes, fades, or disappears altogether crunch.
Recovering branches n / jaw by the method Titova / I962 / carried submaxillary access with free bone grafting autorebrom and the creation of a new joint at scales of the temporal bone. After clearing the remnants of scars and branches crossing coronary petiole N / y falls down and mixed doperedu to establish ortohnatychnoho bite. During the zygomatic arch tunnel is created where injected bone graft from the patient's rib cartilage from the ends up to the scales of the temporal bone at the level or in front of the articular tubercle. By the angle of the jaw is fixed the other end of the graft. To keep the jaw in position, apply pozarotove pulling within 10-12 days.
"Harness" by V.S.Yovchevym arthroplasty (1963) also used to extend the branches n / jaw with the formation of joint. This after excision scars, lowering and shifting n / ni forward osteotomy performed coronary stem. Autorebro fixed to the angle of the jaw, and by the end of his second stitched osteotamovanyy coronal germ peak which then serves as the head of the joint. To the rear edge of the newly formed branch record fragment allohenic cartilage.
In cases where bilateral ankylosis SNSCH joints combined with lower mikrohnatieyu and open bite, N.A.Plotny-ing / I966 / offered two options arthroplasty using canned dried allotranplantatu the branches l / jaw with articular head.
In passive bony growths, when articular and coronal shoots form a single bone conglomerate transverse osteotomy is made in the upper third of the branches. Bone is removed by an array rolling. With spherical cutters shaped articular hollow semioval shape, and the front it - articular tubercle. Thread n / jaw drops down, mixed doperedu, the teeth of the upper and lower jaws are fixed in position ortohnatychnoho bite. On the outer surface of the branches removed lefting compact layer to expose the spongy substance. The inner surface of lyophilized graft branches n / jaw also removed a compact disc. The resulting defect in the upper third of the jaw replaced with a graft so that its articular head were located created in the hollow joints. Thread with articular head graft is fixed to the residual branches patient using wire suture. Tendons medial alary and proper chewing muscles attached to the rear edge of the branches l / jaw.
In cases where ankylosis due to interpenetration of only joint heads held kondylectomiya, just as in the first embodiment, is formed perceiving bed for lyophilized allograft, jaw moves in the correct position and then you nakistkova and mandible’s fixation.
H.P.Myhaylyk, Yu.Y.Bernadskyy / I979 / proposed a new original way SNSCH plastic joint with ankylosis and mikroheniyi. Its essence is to increase the height of the branches, shifting n / u down and forvard, as well as creating new SNSCH joint. This no bone grafting or replanting cartilage is not required, which is an important advantage of the method. With this method performed osteotomy at the base of coronary sprout, remove excess bone conglomerate in the area semilunar notch and articulate stem.l / jaw drops down and doperedu. Osteotomoized coronal germ upper-back fixed to the edge of the branch, he is a new articular sprout.
N / jaw drops
down and doperedu. Osteotomo-ized coronal germ upper-back fixed to the edge of
the branch, he is a new articular sprout. Clinical experience removing SNSCH
joint ankylosis and microheniai using of autolohic coronar sprout and
xenogeneic sclero-corneal membrane allowed the authors to conclude whether
widespread use of this method.
Dislocation (luxatio) bone - is damaged when one of the bones of movable joints comes from the joint capsule and, coming to his natural position remains in the tissues surrounding the joint. The cause dislocation in most cases a mechanical violence, and to break the joint capsule, communications and distribution connection ends of the bones need more strength.
Dislocations are congenital and acquired. Among acquired dislocations isolated traumatic and pathologic and separately isolated habitual dislocations.
By degrees violation distinguish complete dislocation, the joint surfaces of both bones forming the joint completely lose connection with one another, and partial dislocation (subluxation) when the articular surface displaced bones are partly conjugated.
Dislocations involving damage to the skin in the area of joint (wound penetrating into its cavity), called the open, while maintaining the integrity of the skin is closed dislocation.
Traumatic dislocation usually occurs from excessive or unusual for this joint motion by impact or pressure on the joint. This dislocation may be accompanied by compression and even rupture of blood vessels and nerves. Dislocations, still, there are less than other traumatic injuries, such as broken bones, bruises and sprains, dislocations often exposed joints of the limbs as the most moving and the most exposed external influences. Cases dislocations often occur while taking heavy work, after falling from a height, for this reason they are more common in men than in women (according to the Kiev hospital for 274 men had 63 women) in middle-aged persons more often than in children and seniors. In traumatic external violence, sprains occur (but very rarely) even spontaneously during strong muscular contraction, such as seizures during epilepsy. By involuntary dislocations can be classified and pathological dislocations observed in lesions of the joint and the surrounding parts (hydrops joint, tubercular, funhozni, carious processes, etc.). Congenital dislocations are observed (luxationes congenitae) mainly in the hip joint, the reason they - or the wrong anatomical development, or various disease processes at the very beginning of life.
Looking for the character of dislocations, changes in the joint seem different. When deviations from external violence is always a gap joint capsule, bone dislocated end, based on the joint, tearing the tissue surrounding the joint, causing sometimes severe bleeding, and it happens that the gap tissue is complete and the end of the bone protrudes outward. Affected tissues become inflamed bone that is in them, causing cellular elements in severe irritation, stimulates the vital functions, and as a result - around the bones gradually formed a real voloknyste - connective tissue. Prolonged dislocation of the bone grows around like a new joint capsule of fibrous tissue, which then is doing more solid so that the bone becomes able to move, finding resistance in it, in the end vyvyhnenoyi bones in the head, there are also significant changes, and formed the so-called "false joint. " Rapid reduction of dislocation and restore normal joint is presented in the form above conditions, a matter of critical importance.
Dislocations that systematically repeated in the same joint, called commonplace. This generally occurs due to errors that assumption in the treatment of first on account of traumatic dislocation (inept conducted no specialist reduction, lack of immobilization after reduction, started too early jaw movements) as well as in connection with a late appeal to the doctor when vpravyty joint is difficult to be found, but this is rare. Dislocation, accompanied by significant damage connection joint can become familiar even with proper treatment. In all these cases, after the first dislocation remains insufficient connection obligatory joint staff, which leads to repeat dislocations, rarely from the most minor reasons.
Common symptoms of dislocation of the mandible following:
change in the form of joint;
significant complications and even complete inability active movement;
swelling around the joint parts, sometimes bruising.
Affected joint is certainly thicker and wider than healthy, it prominent recess and performances where for healthy joints do not.
Distinguish anterior and posterior dislocation of the mandible. Often occurs anterior dislocation, when the head of the mandible moves doperedu and slips on the front slope of the articular tubercle. Very rarely arises posterior dislocation. Anterior dislocation of the mandible can result from excessive mouth opening (when yawning, during tooth extraction, when a doctor does not support the lower jaw) injury inflicted in the area of the chin down, gnaving of nuts. Distinguish unilateral, bilateral, and habitual dislocation of the mandible.
When habitual dislocation patients themselves easily replaced into it by moving the lower jaw.
In front duplex dislocation in patients with pain appear in the joints; mouth is closed, slurred speech, chewing during the eating is impossible. On examination, the patient's original appearance: mouth open, chin forward put forward, the front teeth do not merge, mouth saliva flowing. Cheeks flattened, stretched, no lateral movement of the mandible. Palpation of the front of the tragus ear felt retraction (no head, which is easily detectable in normal), and under the zygomatic arch, the anterior protrusion determined (displaced head).
In unilateral dislocation mouth ajar patient and seemed skewed.
In complex cases, when together with dislocation is a fracture or blow with strong swelling or strained muscles, etc., determine the dislocation can not be easy. The key in recognizing signs of fracture dislocation is crackling, ie noise generated by friction against each other over the perelomanyh bones and abnormal, easy mobility of fractured back bone and limitation of movement and persistent preserve those provisions, even unnatural, in the case of dislocation.
Treatment of acute dislocations should be in their immediate reposition certainly experienced person. Reduction is easier if there is a partial dislocation (subluxatio). Particularly severe reduction in complication of bone fracture or hit soft tissues develop connections between bones. When reposition bones usually applied contra-pulling. Big fingers of both hands, wrapping with small layer of gauze or bandage should be put on the large lower molars patient's fingers are placed from outside under the lower jaw. Thumb to press down on the lower molars, while other fingers to move the lower jaw forward and upward. Then, after click dramatically move your thumbs on the front teeth to prevent them biting dental patient.
To date, experimental method of treatment proposed dvohbichnoyi anesthesia on Bershe. Needle intoduced perpendicular integument under the lower edge of the zygomatic bone, departing to the front of the tragus of ear shells to two centimeters. Needle promoted horizontally to the midline at a depth of 2 -
After surgery early application of physical therapy is crucial for sustained functional outcome.
Special exercises for the masticatory muscles prescribed for 3 to 4 days after surgery (first period), repeating each exercise 5-10 times at a slow pace with intervals for rest (1-2 minutes). Avoid increasing pain and prevent fatigue of masticatory muscles. The complex of these exercises the patient takes at least 8-10 times a day. Application of Mechano through various devices and appliances can begin at 6-8th day after the operation, combining it with heat treatments and massage.
After removing the stitches postoperative increase the duration and intensity of the functional load on temporomandibular joints (the second period). Open mouth, lateral, and circular movements of the mandible perform with maximum amplitude until the pain in the joint. In class therapeutic exercises include a large number of bracing and breathing exercises.
In addition to training medical gymnastics patients continue to perform their own set of special exercises.
Approximate range of special exercises for self-fulfillment sick
1. Slow painless opening and closing the mouth (20-30 times).
2. Open mouth with simultaneous extension of the head and sticking Language (15-20 times).
3. The circular movements of the mandible alternately in the right and left sides of closed lips while (10-15 times).
4. Movement of the lower jaw back and forth at the beginning of closed dental rows, then - at the maximum open mouth (15-20 times).
5. Lateral movements of the mandible with a gradual increase in the rate and amplitude of the open and closed mouth (15-20 times).
6. Imitation zivanyya with simultaneous extension of the head and a deep breath. Lower chin to your chest, make prolonged exhalation through a narrow cleft lip (8-10), the pace is slow.
7. Quick opening your mouth with pronunciation labial "dad-pa" (20-25 times).
Restoring full range of motion in the joints and prepare the patient for employment is a major challenge in the third (final) period physiotherapist. Technique classes in this period supplemented appointment of special exercises with the resistance movement of the mandible in different directions, using passive exercises with the fingers of the patient or mechano-therapy appliances and devices. At the same time seeking to achieve full (physiological) range of motion in the joint.
It is important to control the amount of daily opening mouth.
Massage and thermal procedures preceding the lesson therapeutic exercises, improve efficiency Rehabilitation.
Pri \ 'orthopedic treatment method contractures mandible application of active and passive devices mehanoterapevtycheskyh, wedges, screws, wood or plastic, elastic rubber bands of varying thickness and other devices can effectively stretch scars and breed jaw. However, be aware that when mechanotherapy usually all motions made in only one plane (lowering and raising of the jaw). To restore full function joint is necessary and other movements (side, front-nezadnye, circles, etc.), which are possible only when the active exercises for the masticatory muscles. In this regard, studies using mechanotherapeutic apparatus and appliances necessary supplemented by a set of special exercises.
Contracture mandible accompanied by a sharp restriction of mobility in temporomandibular joint nyzhnechelyustnom due to pathological changes in the surrounding soft tissues it.
Causes of contractures can be traumatic or inflammatory processes lasted adynamia arthroplasty in dvuhchelyustnom splinting, gunshot and not shooting damage parotid region and oolasty neck.
Treatment of contractures should be pathogenic and complex. Evidence for the purpose of medical physical culture in contracture temporomandibular joint is mandible’s: subsiding acute events that caused the occurrence of contracture; surgery (incision of abscess or cellulitis, scar excision, etc.); redressation (bloodless forcible restoration of mobility) mandible . The use of therapeutic physical training can prevent recurrence of contracture and improved functional effect of surgery.
In I period when there is marked tissue swelling and pain within 2-3 days prescribed respiratory and restorative exercises for small muscle groups performed at a slow pace, at the 4-5-day (in the absence of contraindications!) - Exercises for mymyc and chewing muscles against bracing and breathing exercises. Special exercises should be done at a slow pace in series of 5-10 repetitions with rest intervals of 2.1 min. Complex special exercises, sets forth the individual characteristics of the patient, it is recommended to perform at least 10-12 times a day. Active and passive mechanotherapy can start with the 8-10th day after surgery.
In the second period, ie 10-12th day after the operation, increase the duration and intensity of training, combining them with massage, heat therapy and hydrotherapy. The main task of this period is to restore full range of motion in the temporo-mandibular joint. To address its increasing number of special exercises and increase the load by applying resistance when opening and closing the mouth. Every special exercises repeated 30-40 times in the middle and fast pace. Individual tasks patients perform 15-20 times a day - this pledge receiving high functional results.