Limitation of mouth opening.
Dr Benharrats k
Plan :
Introduction
Trismus: LOB of a transient nature:
-Definitions
-Etiological diagnosis
-Differential DGC
-Positive diagnosis
-Evolution
-Treatment
Permanent constriction of the jaws: LOB of a definitive nature:
1/Joint bone constriction = Temporomandibular ankylosis:
-Definition.
-Etiological diagnosis.
-Anatomopathological forms
-Differential diagnosis.
-Positive diagnosis.
-Treatment.
-Complications and sequelae.
2/Extra-articular bone constriction:
3/Skin, mucosa or muscle constriction:
Conclusion.
Introduction:
Mouth opening limitations (LOB) that can be described as transient (trismus) or permanent are warning symptoms that frequently lead patients to consult their dentist.
A systematic approach including patient questioning and a careful clinical examination must be conducted in order to determine the cause and thus allow the implementation of appropriate therapies.
I/ Trismus:
Definition:
Trismus is a transient symptom characterized by a more or less complete inability to open the mouth. The constriction is acute or subacute and of short duration, typically less than two months. It is due to a muscular or joint dysfunction.
“Transient, recent and transient limitation of opening”.
Trismus is thus qualified according to the amplitude of opening:
Light: 35 to 20mm. Moderate: 10 to 20mm. Tight: ≤ 10mm.
Etiological diagnosis:
1/Local causes:
1-1/Inflammatory and infectious cause:
*Dental causes: Dental, periodontal or pericoronary infection. Perimaxillary cellulitis. More rarely osteitis.
*Non-dental causes:
-Mucous membranes: stomatitis, gingivitis
-Salivary: submandibulitis, parotitis, etc.
-Articular: temporomandibular arthritis.
– Specific infection: cervicofacial actinomycosis, tuberculosis, etc.
*ENT origin:
-Peritonsillar phlegmon
– Lateropharyngeal adenophlegmon.
1-2/ Traumatic causes:
– Fracture of the mandible ATM coronal BM/angle.
– Fracture of the zygomatic or zygomato-malar arch.
– Trauma to the masticatory muscles: Contusion or wound Hematoma.
* postoperative infectious complications or that of fractures of the angle of the mandible after extraction of impacted wisdom teeth.
* Local regional anesthesia at the spine of Spix.
1-3/ Tumor causes:
-Benign inflammatory tumors.
-Invasion of the muscle by a malignant tumor.
1-4/ ATM pathology:
-DAM.
-Inflammatory or degenerative rheumatological conditions.
2/ General causes:
2-1/ Infectious causes:
*Tetanus: This is a Clostridium tetani toxi-infection, it is the first etiology to consider when faced with trismus given its severity (mortality 20 to 50%). Trismus generally precedes (48 hours) a generalized contracture.
*Malaria: It is an infectious disease caused by a parasite of the Plasmodium genus transmitted via a mosquito bite, LOB can be a symptom of the disease or a sequelae of treatment (quinine).
*Acute meningitis:
Trismus + General signs.
Lumbar puncture establishes the diagnosis.
Rabies: meningoencephalomyelitis:
Convulsions + generalized contractures, hypersialorrhea.
2-2/ Toxic and drug causes:
-Neuroleptics: Haldol®, Majeptil®, Terfluzine®
-Antihistamines
-Strychnine poisoning: Toxic dose = 20 mg in adults.
2-3/ Neurological causes:
– Vaccine or epidemic encephalitis.
-Brain lesions of the bulboprotuberant region.
-Certain forms of Parkinson’s disease.
2-4/ Metabolic or deficiency trismus
*Hypoglycemia,
*Vit B1 deficiency.
Differential diagnosis:
*Permanent construction of the maxillae:
Fixed, acquired state. Abnormal consolidation process. Does not yield under general anesthesia.
*Temporomandibular dislocation:
Closed mouth, Laterodeviation, emptiness of the dislocated condylar region.
*Pithiatism: Stimulate the gag reflex.
Positive diagnosis:
Circumstances of discovery.
Questioning.
Clinical examination.
General examination.
Paraclinical examinations: a panoramic scan provides an initial idea of the dental, joint and bone condition.
-As a second option, the following are performed:
A CT scan
A nasal fibroscopy.
An MRI.
Treatment:
1/ symptomatic:
*Infiltrations:
Loco-regional anesthesia of the temporo-masseteric nerve.
Extra-oral anesthesia of the inferior alveolar nerve.
General anesthesia confirms the diagnosis and allows treatment.
*Medical treatment: -Muscle relaxants.
-Injection of botulinum toxin into a spasmed muscle.
*Physiotherapy:
Based on maxillofacial rehabilitation and mechanotherapy.
2/ Etiological:
*Traumatic cause: Analgesic, ATB. Reduction + contention of fracture sites.
And functional treatment.
*Infectious cause: ATB + local treatment.
*General causes:
Tetanus seroprophylaxis.
Preventive measures in the event of an animal bite.
Evolution:
– Healing is complete when the cause is treated. – In the absence of treatment, it evolves into permanent constriction.
– The prognosis remains favorable when the etiology is local, it will be reserved when it is general.
II/ Permanent constrictions of the jaws (CPDM):
Definitions:
They are defined as the partial or total but permanent inability to open the mouth. They are the consequence of the hindrance to mandibular lowering, due to bone fusion (temporomandibular ankylosis or extra-articular bone constriction), or soft tissues (muscle or skin scar lesion).
This limitation is less than 30 mm measured between the incisors. It is said to be complete when the opening is less than 5 mm.
II-1/Temporomandibular ankylosis ( Permanent joint constriction) :
Definition:
It corresponds to the disappearance of normal joint structures which are replaced by bone tissue (bone fusion) or by fibrous tissue (fibrous fusion) and which lead to the welding of the jaw to the skull.
Etiological diagnosis:
*Trauma:
-Condylar fractures.
-Prolonged intermaxillary blockage.
-Obstetric during childbirth.
-Undiagnosed fractures.
*Infections:
-General: Septicemic, gonococcal arthritis, scarlet fever, typhoid
-Local: Otitis media, mastoiditis, parotitis,,,,
*Inflammatory and degenerative diseases:
Rheumatoid arthritis, ankylosing spondylitis, juvenile chronic polyarthritis.
Anatomo-pathological forms:
– Partial ankylosis: Part of the joint appears to be intact.
– Total ankylosis: The joint is replaced by a bone block of considerable thickness.
Positive diagnosis:
Clinical:
In adults: Once growth is complete, these are essentially functional disorders.
Reason for consultation: limitation of mouth opening
The interview must specify: trauma or infection. Date and method of installation.
Inspection: asymmetries, deformations and scars.
Mouth opening limited to less than 35mm.
Palpation:
Unilateral form:
-On the ankylosed side: A painless bony mass with absence of movements.
-On the healthy side: Atrophied masticatory muscles, mucosa and teeth are altered.
+ deviation of the interincisal point and the chin on the affected side.
Bilateral form:
-Bilateral pretragal bone wedge. -Difficult intraoral examination.
In children:
Unilateral form:
-Facial asymmetry
-Deviation of the chin towards the side of the ankylosis.
-Flattening of the cheek on the healthy side.
– the occlusal plane is generally oblique, rising towards the ankylosed side.
– Short ascending branch.
Bilateral form:
-Atrophy of the lower jaw.
– Bird profile.
– No latero deviation.
– Hypogenesis. Occlusion of CLII
– Propulsion and diduction are abolished.
– Altered dentition.
Imaging:
According to the incidence (dental panoramic, TLR, CT, MRI,,,):
-Bone block. – Disappearance of the interarticular line
-Insufficient height of the ascending branch
-Pre-angular notch and hypertrophy of the coronal.
– Image of osteolysis (rheumatic origin).
– The existence of intra or peri-articular fibrous tissue.
Differential diagnosis:
*Trismus.
*Permanent constriction of extra-articular origin.
*JACOB’s disease.
*Constrictions related to ossification of the masticatory muscles.
*Arthrogryposis multiplex congenita.
* temporomandibular dislocation.
Treatment:
*objectives:
In adulthood:
– Frees mandibular movements while avoiding relapse.
– Restores masticatory function.
During childhood:
– TRT of deformities which combines surgery and functional rehabilitation.
*Prophylactic treatment:
-Avoid joint damage in the event of general or local infectious accidents.
-Look for condylar fractures after any mandibular trauma.
-Never immobilize the joint in children in the event of a condylar fracture.
*Curative treatment:
Age of intervention: Early intervention
Technique: surgical.
Anesthesia: general implies the need for tracheal intubation.
Approach: pre-auricular, passing in front or on the edge of the tragus.
Removal of ankylosis: by resection of the bone and/or fibrous block,
1/ Arthroplasty.
2/ Condylectomy and resection of a large block.
3/ Creation of a new joint cavity to prevent recurrence and preserve
physiology by: – Interposition. – Endoprosthesis. – Osteocartilaginous grafts
Functional rehabilitation:
Begins immediately after the joint intervention. It is a physiotherapy controlled by the practitioner.
Objectives:
-Soften the peri-articular elements.
-Maintain the range of motion.
-Restore the balance of muscle strength.
Methods:
Prefabricated apparatus. DELAIRE and MERCIER method
Open mouth block.
Molar wedge.
Periodontal TRT. Caries TRT and Correction of occlusion and malpositions (ODF).
Prediction:
– Fibrous ankylosis: good
– Complete bone: dark => risk of recurrence
Evolution and complications: in the absence of treatment:
Local complications:
-Hypogenesis of the maxilla.
-Denture particularly affected if the disease is old.
-Mouth and pharynx impossible to explore.
General complications:
-Severely hampered feeding.
-Digestive disorders.
-Disturbed phonation.
-Ventilation function may be impaired.
-Psychological disorders.
II-2/ Extra-articular bone constriction:
Etiology:
Traumatic lesions:
– Fracture of the zygomatic process. – Fracture of the malar process. – Fracture of the coronoid process.
-JACOB’s disease: Hypertrophy of the coronoid process associated or not with hypertrophy of the malar .
Diagnosis:
Based on history, clinical examination, X-ray.
Treatment:
Repositioning of fractured elements.
JACOB’s disease: resection of the coronoid.
II-3/ Skin, muscle or mucosal constriction:
-No bone lesion, the TMJ is healthy.
-Limitation of mouth opening can be created by progressive retractile cicatricial sclerosis
. -Normal tissues are partly replaced by retractile fibrous tissue.
Skin, mucosal and muscle covering plane.
Scar blocks affecting all planes.
Treatment:
1/Etiological: Treatment of infectious lesions.
2/Restoration of superficial skin and/or endo-oral mucosal planes.
Limitation of mouth opening
Conclusion:
Trismus remains a symptom that is quite revealing of many pathologies, it is first of all necessary to take it into account and to look for the etiology, but it is also a question of preventing its installation by early and adequate management.
The permanent constriction has as its main origin the temporomandibular ankylosis which can be prevented in the dental office thanks to early and adequate management of infectious and traumatic lesions.
Limitation of mouth opening
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.