LIMITATIONS OF ORAL OPENING
Plan
I – Introduction:
II – Positive diagnosis:
III. Lockjaw:
1°Definition
2° Physiopathology
3. Etiology
3.1. General causes
3.1.1. Tetanus
3.1.2. Other general causes:
3.2. Local causes
4°. Characteristics of trismus of local causes:
5° Evolution
6° Treatment
IV. Permanent jaw constrictions
1°Definition
2°Constriction due to bone alteration = Temporomandibular ankylosis
2.1. Etiologies
2.1. 1. joint trauma:
2.1.2 Extra-articular trauma:
2.1.3) Infections:
2.2. Pathological Anatomy
2.3. Clinic
2.4. Diagnosis:
2.5. Treatment
3. Constriction due to alteration of the soft parts
3.1. Mucosal lesions:
- Skin lesions:
3.3. Muscle injuries
3.4. Treatment
I – Introduction :
Limitation of mouth opening (LOB) results in a decrease in the amplitude of
the mouth opening. It can be reversible and it is trismus or fixed constituting a
permanent constriction of the jaws.
When faced with acute LOB, the practitioner must consider many etiological diagnoses. Indeed, acute LOB can result from pathological processes at the level of the temporomandibular joint, the surrounding extra-articular tissues or even general pathologies.
II – Positive diagnosis : is made from several elements:
1 – examination of the patient
a- interrogation:
age, addresses, profession It is necessary to specify: *the date and mode of onset *record the medical and surgical history *the mode of development *associated signs: pain, dysphagia, muscle contracture, etc. b-clinical examination: The mouth opening must be assessed using a caliper measured between the upper and lower inter-incisal point. The normal mouth opening must be greater than or equal to 47±7mm. We speak of limitation of the OB when it is less than 30mm
- The clinical examination should include the rest of the face, ATM, muscles, salivary glands, lymph node chains.
- A neurological exploration of V and VII must also be carried out.
- Thorough examination of the entire oral cavity
- ENT examination to explore deep structures
c- additional examinations:
Panoramic X-ray, CT, MRI, Schuller
Nasofibroscopy: examination of the cavum, oropharynx
Sometimes biopsy
III. TRISMUS :
1°Definition
Lockjaw is the temporary constriction of the jaws.
It manifests itself by the more or less great, temporary difficulty in opening the mouth.
This constriction, often painful, is a symptom that can accompany a local, loco-regional or general condition.
Trismus is thus qualified according to the amplitude of opening:
– mild from 35 to 20 mm
– moderate from 10 to 20 mm
severe if the amplitude is less than 10 mm.
2° Physiopathology
The constriction of the elevator muscles responds to a reflex during neighboring affections.
Shopart-Stokes law: “When there is inflammation near a muscle, it contracts reflexively”
3°Etiology
3.1. general causes
3.1.1. Tetanus
It is a toxic infection caused by a gram + bacterium, Nicolaier bacillus or Clostridium tetani. Following a skin-mucosal lesion (deep or superficial), the toxins of this germ will selectively attach to the nervous tissue. This nervous excitation will be the cause of characteristic generalized painful muscle contractures (tonic, paroxysmal, painful), appearing on average 6 to 12 days after the injury.
Trismus is sometimes the first sign of this condition, hence the role of the dental surgeon.
Other contractures appear in the facial muscles and the patient presents the face of sardonic laughter.
If treatment is not instituted, the contracture, after a few hours or days, extends to the muscles of the neck and spine at the same time as more significant infectious signs appear which can end in a fatal outcome.
You should always look for:
- tetanus vaccination (which must be repeated every 10 years)
- Concept of wound, surgery or dental care
Treatment:
Hospitalization in a medical intensive care unit
- anti-tetanus serum (specific gamma globulins)
- muscle relaxants
3.1.2. other general causes:
-Poisoning:
Neuroleptics, barbiturates, Strychnine (accidental ingestion of mole poison, drug addiction, etc.).
- Multiple sclerosis
- Ethylism
- Epilepsy
- Central nerve damage
- Tetany crisis due to hypocalcemia
-Rabies : transmitted by the saliva of contaminated animals (dog or canine bites) and is due to an RNA virus.
Meningitis: In a case of meningitis, trismus is associated with a meningeal syndrome and fever. This picture may also be associated with cutaneous signs, a deficit syndrome or even damage to the cranial nerves, directing the diagnosis towards the causative germ.
3.2. Local causes
3.2.1.infectious :
Are the most frequent. In this case, trismus is the response to a nearby infection: Cellulitis, osteitis, stomatitis, pericoronitis, skin infection (furuncle), muscle infection (myositis), arthritis….
3.2.2. Traumatic:
Mandibular, maxillary, facial fracture.
Iatrogenic surgical procedures…
3.2.3. Tumor:
Benign tumors
Malignant tumors: articular, muscular, deep structures (cavum++)
3.2.4..DAM
4. Characteristics of trismus of local causes:
a) trismus of local cause mainly accompanies acute phase conditions,
it may persist and become chronic with the condition, or disappear.
If it does not go away, trismus becomes a muscle disease and no longer trismus.
b) the trismus is all the more severe as the affection is posterior
5° Evolution
Lockjaw usually disappears when the cause disappears.
In some chronic accidents, despite the disappearance of the cause, an organic lesion of the elevator muscles sets in (myositis).
6°Diagnosis
The diagnosis is etiological:
- Local cause: 95% of cases
- General cause: *sardonic laughter tetanus
*bite rage
*drug poisoning
Differential diagnosis:
Conditions that do not meet the definition of trismus should be ruled out.
Eliminate temporary ailments, permanent ankylosis and constrictions, ATM dislocations, etc.
6° Treatment
The treatment is etiological.
The cause of trismus must be eliminated or treated.
If it becomes chronic, myositis must be treated.
IV. PERMANENT CONSTRICTIONS OF THE JAWS
1°Definition
It is a complete or incomplete abolition of lowering of the mandible, therefore it is a partial or total impossibility of opening the oral cavity.
Constriction is an irreversible lesion (unlike trismus which is temporary).
It may be due to bone damage or soft tissue damage, or a combination of both etiologies at the same time.
2°Constriction due to bone alteration = Temporomandibular ankylosis
These ankyloses will be characterized by the welding of the mandibular and temporal condyles.
2.1. Etiology
2.1. 1. joint trauma:
- Capital fractures of the mandibular condyle are often complicated by ankylosis.
- TMJ trauma with or without foreign body penetration.
2.1.2 Extra-articular trauma :
- Low condylar fractures, especially when bilateral and when treated with prolonged bimaxillary blocking, can be complicated by ankylosis.
- Fracture of the zygoma and injury to all the muscles that insert into it.
Fracture of the coronal-malar region.
2.1.3) Infections :
- Arthritis of general causes: which can be rheumatic or specific.
- Neighborhood infections that can spread to the ATM (suppurative otitis, osteitis of the tympanic bone, osteitis of the BM or upper jaw, osteomyelitis of the upper jaw).
2.2.Pathological Anatomy:
The destruction of the articular surfaces will bring the two condylar and temporal bones into contact, which will fuse together, forming a callus whose volume and size varies from one subject to another.
This bony bridge connecting the base of the skull to the mandible is called a CRANIOMANDIBULAR SYNOSTOSIS.
2.3.Clinic
a)In adults:
Whether it is unilateral or bilateral, we have the same symptoms:
- More or less complete inability to open the oral cavity.
- The endo-oral examination, which is very difficult, still allows us to see a mouth in a very poor state (cavities, tartar, gingival and periodontal infection and foul breath).
- These patients are very prone to stomatitis due to the increase in the virulence of oral germs (due to a change in living conditions with constant closing of the mouth).
- Palpation at the level of the ATM will reveal the presence of craniomandibular synostosis and very slight movement when the ankylosis is partial.
b) In children :
It is very difficult to locate the onset of the disease.
It has a different appearance depending on whether it is unilateral or bilateral:
- Unilateral ankylosis: (affects only one joint). We have:
- Facial asymmetry
- The chin is deviated to the diseased side
- Palpation reveals the presence of a callus at the level of the affected ATM and very slight condylar movement at the level of the healthy joint.
- Bilateral ankylosis: damage to both joints.
The child has a characteristic appearance:
- Face finished in a lower point
- Bird profile (pathognomonic) due to inferior micrognathia and superior proalveolism.
- Palpation shows the presence of bone callus at both joints.
2.4. Diagnosis :
The diagnosis is easily made clinically, and confirmed by radiographic examinations.
-the low face incidence allows you to see the width of the callus;
-other radiological examinations: profile view, maxillary defilement which show the length and condition of the BM and also the condition of the joints + Panoramic, scanner and tomography, MRI, Electromyography.
NB
The Cone Beam certainly has its place in the preoperative assessment of ankylosis , replacing the CT scan, particularly in children due to its less irradiating nature.
MRI will give more precise images than CT scan in the case of fibrous ankylosis, but will be of no use in the case of bony ankylosis.
2.5. Treatment
a) prophylactic treatment:
- Consists, especially during general or local infectious accidents, in avoiding joint damage. Therefore, treatment of the infection by antibiotic therapy, drainage of purulent collections located near the ATMs.
- When children fall, be particularly concerned about ATMs.
- In the event of a fracture of the condylar region, to avoid temporomandibular ankylosis, it will be necessary to maintain a balance between blocking and mobilization when treating this fracture. It is sufficient to release the patient for a few minutes per week for the duration of the treatment, and not to continue the contention beyond one month.
b) curative treatment = surgical treatment
The aim of the treatment is to recreate a new joint or pseudo-joint which can only be achieved by creating a pseudoarthrosis in the region that underwent an osteotomy (which can be low or high).
Noticed :
Adult ankyloses pose 2 problems:
-free mandibular movements
-restore masticatory function while respecting occlusion and mandibular kinetics.
In children, deformities must be treated and surgical treatment must be combined with functional rehabilitation.
3. Constriction due to alteration of the soft parts
They are characterized by the presence of retractile scars or bands that prevent mandibular lowering.
These flanges can be inserted only at the level of the mandible or form a craniomandibular bridge.
These are skin, mucous membrane and muscle lesions.
3.1. mucosal lesions :
These are mainly the region of the inner face of the cheek and the retromolar region; a scar band can follow:
- traumatic injuries,
- to the absorption of caustic liquid,
- to submucosal oral fibrosis (chewed betel leaves),
- but most often due to the absence of repair after surgical excision of a malignant tumor,
- Skin lesions:
These are the most important ones.
These are all losses of substances following serious illnesses (syphilitic gumma, tuberculosis, malignant tumor, noma) or following major traumas which heal slowly leading to progressive retractile sclerosis, sequelae of serious burns, exceptionally dermatological conditions such as congenital epidermolysis bullosa or xeroderma-pigmentosum.
3.3. Muscle injuries
It is the lesions of the masseter which are at the origin of permanent constriction.
Myosclerosis has multiple origins, post-infectious (tuberculosis, etc.), post-traumatic but also iatrogenic (radiotherapy).
Post-traumatic ossifying myositis : rare, localized, occurring after trauma or a local inflammatory episode;
3.4. Processing
Excision of the bands and retractile scars followed by skin-mucosal grafts.
END
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.