Odontogenic sinusitis: classification, etiology, pathogenesis, clinical manifestations, diagnosis and treatment.
Odontogenic maxillary sinus inflammation ( sinusitis ).
Etiology . According to etiology distinguish the following types of sinusitis : odontogenic , rynohenni , rynoodontohenni , allerhichni , posttraumatic . Odontogenic maxillary sinus inflammation ( sinusitis ) is a disease of the mucous membrane lining it.
Inflammation of the maxillary sinus caused by normal oral microflora involved in the development of acute, acute and chronic periodontitis located in other odontogenic foci. Odontogenic maxillary sinusitis or sinus infection often occurs as a result of infection foci of acute or chronic inflammation in the premolars and molars of the upper jaw ( periodontitis, abscess, osteomyelitis, suppuration radicular cysts , perforation of the maxillary sinus inflammation in retynovanyh teeth – fangs, a second molar . Often maxillary sinus inflammation may be associated with the removal of teeth, especially traumatic. such cases are damaged alveoli walls , the bottom of the maxillary sinus, pushed her roots and growth of granulation bilyaverhivkovi with curettage. in close proximity to the roots of the maxillary sinus molars and premolars in treatment may be pushing through the crown of the tooth root gangrenous content hitting filling material , which also causes its inflammation . Odontogenic sinusitis is more common in adults. in children, it is rare, it is because baby teeth are not in contact with the maxillary sinus.
Pathogenesis . Of great importance in the development of odontogenic inflammation of the maxillary sinuses are features of its anatomical structure . Often there is the proximity of roots to its bottom when only a thin layer of bone separates them or direct them to fit sinus mucosa . In addition to these reasons , the importance of inflammation in the pathogenesis of maxillary sinus is the state of defense reactions that determines the nature of the process.
Log into bosom located in the nasal cavity on the side of the wall. The entire sinus cavity is lined with mucous membrane , which together with other anatomical structures perform drainage function. Normally , a person in the paranasal sinuses produces mucus that absorbs bacteria and particles of solids removed from the sinuses into the nasal cavity . This process ensured that the mucous membrane incorporates cells, the so-called ciliary epithelium. These cells provide a constant movement of fluid from the sinuses out. And opening that connects the sinus with the nasal cavity , located in the upper maxillary sinus is the normal outflow of mucus need a good working mechanism of mucus . On the other hand the very opening of the maxillary sinuses are covered with mucous membrane as in case of swelling of the latter, the opening narrowed sharply , which greatly hinders the outflow of mucus. In a healthy person , these processes are working well and the reasons for the occurrence of sinusitis had not. But the presence of an acute inflammatory process that occurs in the lining of the nasal cavity , swelling of the nasal mucosa covers the hole and maxillary sinus. The mucous membrane swells and clearance, leading from the sinuses into the nasal cavity gradually closed. In these conditions, the maxillary sinus start change: not in the bosom incoming air, thus – oxygen that is essential for normal mucosa , increases the pressure that is causing pain to the patient , in the bosom of continuing formation of mucus , which, as a result of breach outflow , stagnates in the sinus and gradually becomes inflammatory . Mucus this nature is called exudate. It is a perfect breeding ground for new and development of existing bacteria and viruses. They produce so-called toxins – waste products that are soaked in the blood in the body causing symptoms such as malaise, headache, loss of appetite , fever , and others. Gradually, the mucus becomes manure, which is viscous consistency , very bad evakuyovuyetsya of the sinuses, even during normal operation spivustya . It is seen that the mucous membrane swells dramatically , while as spivustya not work. Because the bacteria continues and again and again they produce toxins – manure is much greater. Gradually, he can fill the entire lap . If this point is not made adequate treatment, purulent discharge may break into surrounding structures . First of all responsive tissues of the eye – there is gradually increasing swelling of eyelids, they blush, can be marked protrusion of the eyeball forward – exophthalmos. Purulent process may destroy the maxillary sinus wall and penetrate into the bone tissue . Developed osteyit maxilla – osteomyelitis. Nowadays, thanks to the development of medicine, these conditions are rare, and if timely treatment is not present danger .
Spivustya maxillary sinus.
Anatomy of the maxillary sinus
Relationship bottom of the maxillary sinus and maxillary teeth
Pathological Anatomy. Depending on the clinical features distinguish acute , chronic and worsening of chronic odontogenic sinusitis . GN Marchenko ( 1966) points to the existence of two forms of odontogenic inflammation of the maxillary sinus – open and closed . In the first version maxillary sinus communicates with the oral cavity , and the second – no.
Microscopic changes in the mucosa of the maxillary sinus inflammation varied.
Morphological changes in the maxillary sinus is largely dependent on the pathogenesis of inflammation. If you break the bottom cavity of infection from peryapikalnyh lesions, foreign body ingestion observed changes in the limited area of the mucosa. With the development of the disease due to acute osteomyelitis, suppuration of radicular cysts in the process involved the entire sinus mucosa . There are acute sinusitis and serous to purulent . The nature of pathological changes Asimov M. (1977 ) identifies catarrhal, purulent , polypous and purulent sinusitis polypous form . Acute sinusitis is marked edema, congestion of the mucous membrane of the sinus , which thickens , reducing the volume of the cavity and often closing or narrowing the hole in the nasal cavity. Originally mucosa expressed catarrh , and then overlaid in places infiltruyetsya epithelial lymphocytes and polinuklearamy , sometimes it is flaky . Submucosal layer swells , vessels it extended around them formed infiltrates and focal hemorrhage. In some parts of the submucosal layer formed cracks of various sizes ( pseudocyst ). Mucous glands are enlarged, are released secret that fills the cavity. Catarrh in 2-3 days varies purulent when inflammatory changes in the mucosa are more pronounced ( increase of redness , swelling ). Infiltration of the mucosa intense – due kruhloklitynnyh elements with a predominance of polymorphonuclear leukocytes, microabscesses formed individual . Observed inflammatory changes in the periosteum and bone.
Chronic inflammation of the maxillary sinus morphology may be limited and diffuse , and nonpolyposis polypous . With limited nonpolyposis form of chronic inflammation of the maxillary sinus observed slight hyperplasia and thinning of the epithelial layer. The walls of the blood vessels in some areas loosened , others thick . Submucosal base increased by fuksynofilnoyi of loose fibrous tissue , which occasionally appear collagen fibers . In diffuse nonpolyposis chronic inflammation observed a significant thickening of the mucosa, causing narrowing of the cavity. Thickened epithelial layer on its surface shows a significant number of deep crypts with the release of mucus. Some parts are marked desquamation of the epithelium , the formation of erosions, ulcers and necrosis. When polypous chronic inflammation on the surface of the walls of the cavity seen various sizes overemphasizing that is polypous – granulation growths , in some cases in a limited area of the maxillary sinus (limited polypous form) , others – in all of its walls (diffuse polypous form). The lumen cavity filled with muco- purulent or purulent content , and at some period of the disease – holesteatomnymy masses.
Submucosal basis of the maxillary sinus infiltrated by lymphocytes , macrophages , lymphoid , plasma and round cells. The vessels are dilated, in many parts of the wall of garnetted , some observed vascular sclerosis membranes.
In the bone cavity walls in chronic process marked bone tumors and its alteration . In odontogenic sinusitis maxillary sinus is the transformation of ciliated epithelium in polypous growths in multicore squamous epithelium .
Normal sinus . sick sinus
Clinical picture. In acute inflammation of the maxillary sinus patients complain of pain in infraorbital , buccal areas or the entire half of the face are gradually increasing, feeling of heaviness , nasal congestion respective half . Pain radiating along the branches of the trigeminal nerve in the frontal , temporal, occipital region , the teeth of the upper jaw. Less severe pain in the morning, picking up – in the evening. Often there pain in molars and premolars , their sensitivity iakushuvanni . Pain may vary depending on the amount of fluid in the sinus and its outflow. After the appearance of the nose serous or sero- purulent discharge pain decreases. The patient lies half of the nose under the affected side. The voice becomes nasal tone. Obstructed nasal breathing or constant with little relief. Are marked complaints of malaise, fatigue , headache , weakness , loss of appetite.
Characteristic violation of smell – from lowering to the full loss.
Overall condition caot be broken, varying degrees of severity of intoxication symptoms : weakness , fatigue, fever, poor sleep and so on. Often there is a rise in temperature to 37,5-39,0 ° C. With the subsiding of acute inflammation in the maxillary sinus had been declining , and sometimes normalization of body temperature,
The external examination revealed swelling (edema ) in the buccal and infraorbital areas , in some patients, changes can not be. Palpation and percussion of the anterior wall of the body of maxilla , zygomatic bone painful. Regional lymph nodes on the affected side are enlarged, painful. In the vestibule oral marked redness , edema of the mucosa. Percussion 2-3 teeth ( molars and premolars ) painful. On examination of the oral cavity can be found odontogenic focus of acute inflammation ( periodontitis, alveolitis, abscess, osteomyelitis).
In the nasal cavity from the corresponding observed by edema and hyperemia of the mucosa, increase in the average or lower shell and mucus (clear ) or pus (yellow , green, foul-smelling ) from nasal passage , especially when tilting the head down and forward, this symptom caot be if very stuffy nose because of the obstructed sinus outflow .
Smearing middle nasal passage and the middle turbinate 1% solution dicain with one drop of 0.1% solution of epinephrine provides a discharge from the sinus , while the existing outflow strengthen it.
Chronic sinusitis often develops as a result of previous acute process in the maxillary sinus. Patients report headaches , discharge from the respective halves of the nose , sometimes complain of pain and a feeling of heaviness in the occipital region . Some patients are asymptomatic chronic inflammation and pain complaints no .
Due to the accumulation of inflammatory exudate in their arms appear pain, fullness , discharge from putrefactive odor from one half of the nose. The general condition is satisfactory. Fever is not observed, but may occur during exacerbation of the process. However, in some patients, sometimes accompanied by chronic inflammation of the evening rise in body temperature to 37,2-37,5 ° C. Patients report decreased performance , fatigue, weakness, lethargy.
When viewed face configuration is not changed. Palpation of the anterior surface of the body of the upper jaw painless. The mucosa of the upper vault vestibule of mouth swollen, cyanotic . Rhinoscopy shows that the mucous membrane of the nasal cavity in color is not changed, but the hypertrophied within the lower and middle turbinate . In some patients in the middle meatus is visible thick muco- purulent discharge or purulent crusts and sometimes explosively determined polypous sprawl .
Clinical disease of the maxillary sinus in the presence of traffic through different dental alveoli calm occurrence . Patients complain of putrefactive odor , the passage of air from the mouth and nose when entering the liquid food from the mouth to the nose. The introduction of the probe through the alveoli of the tooth can be set polypous growths that bleed easily , sero -purulent discharge from the sinus.
CT scan with sinusitis
Diagnosis . The basis for diagnosis of acute sinusitis is a clinical picture of the disease , the survey data and the results of the review. On radiographs in acute sinusitis observed the eclipse of varying intensity . Dental x-rays can specify the source of odontogenic infection , often it is located in the area peryapikalniy premolars or molars , at least – canines.
Chronic inflammation of the maxillary sinus diagnosed on the basis of complaints , anamnesis, clinical symptoms. However, due to the poverty of clinical symptoms often leading X-ray data. On plain film extra nasal cavities visible darkening of the maxillary sinus.
After diagnostic puncture and research punctate very important input radiographic mass, which allows to establish the nature of the disease, its localization and prevalence . Puncture of the maxillary sinus performed through the lower nostril . The easiest sinus wall is pierced in the dome lower nasal passage at the place of attachment of the lower shell at 2.0-2.5 inches back from its front end. When purulent sinusitis conduct diagnostic puncture to detect the presence of purulent exudate in the sinus.
Spend as vnutrishnorotovi images , allowing to specify the presence peryapikalnyh lesions. Diagnosis help of computed tomography ( more informative method) sinuses .
Differential diagnosis . Acute sinusitis should be differentiated from acute pulpitis, periodontitis, trigeminal neuralgia . Most composite differential diagnosis of neuralgia . In the branches of the trigeminal nerve neuralgia pain attacks are limited zone of innervation of one of the branches of the trigeminal nerve, marked by points or areas of pain , impaired sensitivity of the skin or oral mucosa under ” Kurkov zones .”
Chronic sinusitis maxillary sinus and should be differentiated from peryapikalnoyi cysts, malignant tumors of the upper jaw.
When peryapikalniy bone of the upper jaw sinus wall deformation occurs , they often thinning and resorption . Determined by palpation or parchment crunching bone defect and fluctuations . Assist differential diagnosis radiography and puncture.
Malignant tumors of the upper jaw can occur from the mucous membrane of the maxillary sinus. Similar symptoms of malignant tumors of the maxillary sinus and sinusitis are pain , nasal congestion , purulent discharge from it. In contrast, inflammation in malignant tumors constant pain , bloody nasal discharge , smelly . In the study of the deformation of the walls of the cavity are established , the presence of bladder growths in the nasal cavity.
On radiographs , except for violations of transparency sinus marked resorption of its walls. Proper diagnosis allows you to set cytological or pathological studies.
In recent years, an increasing number of cases of allergic lesions of the maxillary sinus , from which it is necessary to differentiate odontogenic sinusitis. It is necessary to clarify details and medical history to determine the existence of allergic reactions ( angioedema , urticaria , eczema , etc.). .
Treatment. Treatment of inflammation of the maxillary sinus is to eliminate peryapikalnoho inflammatory foci , which is a cause of disease of the maxillary sinus. Perform puncture with washing antiseptic solutions rivanola , Frc , dioksidina , introduction to chlorhexidine and sinus antibiotics, enzymes. Wash it through dental alveoli . In the nasal cavity should be instilled sudynnozvuzhuyuchi agents ( 3-5% solution of ephedrine hydrochloride halazolinu , naftizina , Sanorin et al. ) For anemia of the mucous membrane and the creation of outflow from the sinus through the natural opening nose. Assign physiotherapy : UHF, diathermy , radiation of helium -neon laser.
Assign analginum, Amidopyrine , phenacetin , aspirin 0.25-0.5 g 2-3 times a day , desensitizing means – ( diphenhydramine, suprastin , tavegil, loratydyn , ketotifen , diazolin et al. ). Depending on the functional state of the organism and the clinical features of the disease are shown treated sulfonamides , antibiotics, zahalnoukriplyuyucha and stimulating therapy. Started early and properly conducted treatment, usually with good results – comes complete recovery .
Chronic sinusitis short period and limited pathological changes in the sinus tooth removed – the source of infection, sinus puncture is carried out by washing it and the introduction of drugs and complex treatment measures recommended in acute process. After this conservative treatment may occur recovery. Chronic inflammation of the maxillary sinus often requires radical surgery – on the Caldwell – Luc . In this operation, remove abnormal tissue from the maxillary sinus and wide spivustya do it with inferior way. The operation is performed under conductive ( tuberalna , infraorbitalna , incisive , palatine anesthesia ), infiltration anesthesia 1-2% solution of novocaine, lidocaine or trimecaine and Application anesthesia in the lower nasal passage and inferior turbinate dicain 3% solution with epinephrine , local potentiated anesthesia endotracheal anesthesia. Carry on the upper section slepinnyu prysinka mouth of lateral incisor to the second molar. Detach muco- oxide flap and using rugine expose the anterior surface of the body of the maxilla . Using a drill , trepan , bone cutter form bone window in sinus and remove abnormal tissue from it : thickened and altered mucosa , polyps, granulation, foreign bodies .
In the nasal wall of the maxillary sinus in the lower nasal passage make the hole size 1,5 x1 , 5 cm , forming extensive spivustya with the nasal cavity . Maxillary sinus is filled swab dipped yodoformnoyu fluid through the end of which spivustya derive the nasal cavity . The wound in the nasal cavity sewn tightly , imposing catgut sutures. If you break the bottom of the maxillary sinus and the presence of perforations make the incision through the mucous membrane of the outer wall of the dental alveoli are removed before entering the granulation lap and carefully – abnormal tissue of perforations in the bottom of the maxillary sinus.
While suturing a wound in the mouth conducting plastic closure of perforations . This should take into account the width of the alveolar process in place perforation , length of it ( in one – two teeth) , the presence of scarring of the mucous membranes. Plastic closure of perforations is made by vykroyuvannya trapezoidal flap of the vestibule mouth. Concluding flap for defect location , pay attention to the possibility of tension. In such cases, it is carried out by extending the horizontal section of the periosteum at the base of the flap . When perforations at the site of the alveolar process , which has a number of teeth cut out and should be widely vidseparovuvaty muco- oxide flap of vestibule of mouth and bridge flap in hard palate .
Punched a hole within a tooth should be close yazykopodibnym flap , a cut from the mucosa of the hard palate . Flap Dimensions : width must match the distance between your teeth , length – three values of width. Flap invest in the region of the alveolar process defect and fix knotted catgut sutures. Yodoformnoyu wound closed with gauze and put on protective plate made in advance .
With significant amounts perforations , scarring of the mucous membranes in his circle of conduct defect closure by vykroyuvannya yazykopodibnoho muco- oxide flap of the vestibule of mouth – from the alveolar ridge to the vault, move it to the area of the defect and fix catgut sutures.
The day after radical surgery for maxillary sinus removed yodoformnyy tampon. Performs toilet protective plate and wounds. The 7 Day 8 off of joints ( in one ) , and others – for further ligation of 9 – 10th day . The protective plate should be worn 14-16 days, but sometimes up to 3 weeks.
In the postoperative maxillary sinus wash (1 to 3.4 times ) from 5- 6th day , while taking in the plastic and perforations – not earlier than 9-10 days after surgery.
When properly performed surgical treatment of complications happen. In the postoperative period may experience paresthesia or hyperesthesia branches of infraorbital nerve on the side of operation ( from several weeks to 1-2 months.) . In some patients, these effects are not abolished and developed infraorbital nerve neuritis , mainly upper alveolar nerves. Sometimes there is a recurrence of inflammation , due to the lack of coupling of the maxillary sinus with nasal cavity , narrowing or scar closing it. This requires re-operation for maxillary sinus.
Complications . Acute odontogenic sinusitis may be complicated by the proliferation of inflammation in the infratemporal and pterygopalatine fossa in fiber orbital frontal and ethmoid sinuses. Possible and these rare but ominous complication as cavernous sinus thrombosis , sepsis , meningitis, and mediastinitis.
Weather Acute sinusitis maxillary sinus in a timely and proper treatment are mostly favorable. Only with a late start and wrong , and lowered immunological resistance of the patient , the inflammatory process becomes chronic .
These complications , especially eye socket cellulitis , phlebitis , thrombophlebitis facial veins and sinuses of the dura mater may cause fatal results. Acute chronic sinusitis can cause inflammation switch to other paranasal sinuses . Chronic sinusitis is a violation of immunological reactivity and leads to the development of infectious immune deficiency syndrome .
In the surgical treatment of chronic sinusitis favorable prognosis .
Prevention of odontogenic inflammation of the maxillary sinus is dental health – treatment of dental caries and its complications, timely surgery ( removal of teeth and roots , opening pidokisnyh lesions ). It is necessary to remove the upper jaw teeth retynovani , which is a source of ignition. When you remove the maxillary molars premolars should pay attention to the value of the roots of the teeth and the bottom of the maxillary sinus , exclude trauma intervention for removal of teeth.
OROANTRALNI links.
One of the complications are quite common in surgical practice , arise directly from operations remove molars of the upper jaw – a perforation of the maxillary sinus. Within 7-10 days oroantralne combination called spivustyam after epithelialization occurs last fistula .
Maxillary sinus or sinus maksylyarnyy – the largest of the paranasal sinuses, and the tops of the roots of molars are located very close to the bottom wall ( bottom ) of the sinus. Perforation bottom sinus maxilaris, often occurs when the root of the tooth being removed , ” sent ” into the sinus and mucous membrane lining the sinus , just covering them. If the extirpation of the tooth in such a place without any difficulty and without a fracture of the roots (so -called ” common deletion “) – only get perforated in its purest form. However, if removal is difficult and fraktura root , then when you try to extract a fragment of a high probability ” push it into the maxillary sinus.
First principle: Do not panic .
The second principle : Check the symptoms of perforation of the maxillary sinus :
1. Ask the patient to inflate the cheeks. When perforation he caot or it will be difficult to do so.
2. Maybe nosebleed from one nostril ( on the side of removal)
3. The patient may mark ingress of air into the mouth during nasal breathing with the mouth closed .
4. Note the change of voice resonance – ” snuffle “.
5. Perhaps the “naso-oral discharge” ( hitting nasal discharge in the mouth ).
If all these symtomy marked – so you do perforation .
X-ray examination should be carried out .
a) Good intraoral image ;
b) Oktsypito – mental X-ray at an angle of 15 degrees ;
c) Panoramic X-ray ;
Any of these images would be enough to see the perforations on the radiograph. And if you remove it without any difficulty , that there was no fracture of the root apex and you are not pushed through a piece of the maxillary sinus , then the picture will only see the integrity of the sinus floor . In other words, the bone defect , coupled with extractive tooth.
If the perforation is not difficult finding a foreign body in the maxillary sinus , the closure of the perforation operation is carried out , ie the closure of the defect.
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Keep in mind that simply tightening the edges seam holes does not lead to anything good. For full closure spivustya need to mobilize mucous oxide flap .
Principle that must be cut to the bone through the mucosa and periosteum , vidseparovuvatysya should muco- oxide flap , ie not only lining vidseparovuvaty . If only vidseparuyete lining – so the cut is not held to the bone , in which case it may be bleeding. Excess mucus tension can cause it to rupture and subsequent long healing wound .
Surgical technique
The most important points of operation:
1. Basis of muco- oxide flap should be wide in order to ensure good blood supply ;
2. Flap should be vidseparovanyy of bone;
3. Palatine and vestibular wall socket rezekovani should be at least 3-5 mm. their height (you can use bayonet forceps ) , sharp bone edges should be smoothed ;
4. To increase the mobility of periosteum flap be cut from the proximal to the distal edge of the flap , but the mucous membrane should be cut . Thereby achieve increased mobility of the flap and move it without any tension in the palatine side.
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5. Tweezers capture edge flap and gently move it into the sky towards the contact with the edge of the palatal mucosal surface of the alveolar process . Tension of the flap should not be.
6. Spend irrigation wells , for example, 0.2% chlorhexidine , move the flap into the sky and put side seams.
7. Usually impose two vertical mattress sutures to close the wound, and then – the usual nodal joints on vertical sections of the mucosa.
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8. Suture material – Nylon, silk or Vicryl “№ 3”
9. Do not use catgut . It swells and holds the wound edges , and caot properly compare the wound edges .
10. Sutures are placed on the palatal surface of the alveolar process . The underlying bone support them.
Postoperative period.
Purpose : antibiotics, mouthwash (0.2% chlorhexidine 5-6 times a day), nasal drops .
User patient : ” Do not create pressure in the nasal cavity : not syakaty not cough with your mouth closed , do not inflate the cheeks …”
After 5-6 days you can remove sutures.
This is a simple operation that applies in the absence of the roots of the tooth being removed , the maxillary sinus. If the X-ray you have determined that a foreign body is located in the sinus , you can try to use “saction”, ie vacuum suction to pull the top piece of the sinus , but usually it is difficult. Anesthesia in outpatient cases haymorotomiyi to do infiltration and tuberalnu . If you manipulate in the maxillary sinus , it is wise to put some time in sinus swab moistened with lidocaine. By the way , using this pad can gently remove the root of the sinuses , just swab should be turned around. If the perforation is not very large , it is possible to restrict the filing yodoformnoho tampon per well . Never tamponuyte hole – so you are 100% build fistulas. If you turned up , not zatamponuvaly hole , the clot with great certainty organized and close the hole. It is ofteecessary to close the fistula maxillary sinus is not the first day, and after three weeks . In the maxillary sinus is a lot of polyps, they are also perfectly swab away .
If you caot remove the foreign body , the prescribed antibiotic and send patient to the hospital for surgery on Caldwel-Luc.
Diseases of the temporomandibular joint.
According to the WHO International Classification of Diseases (1978) joint diseases are a group of diseases of musculoskeletal system and connective tissue , which include arthropathy and other joint damage .
Among the diseases of the temporomandibular joint most common are:
1. Infectious Arthritis : purulent ; specific – rheumatoid , Feltham syndrome , juvenile chronic arthritis – a disease Shtallya .
2. Osteoarthritis .
3. Ankylosis .
4. Contracture .
5. Pain dysfunction syndrome .
6. Traumatic and other lesions.
7. Dislocations of the mandible.
TMJ includes the joint head of the mandible, mandibular fossa , articular tubercle of the temporal bone and articular disc. All these elements are found in the joint capsule .
Articular disc has a biconcave shape insulates the joint head of the lower jaw holes and edges adherent to the capsule , resulting in the joint cavity is divided into upper and lower sections.
Articular capsule has two layers : outer – and inner fibrous – Synovial the latter synovialnuyu produces fluid that causes the reduction of friction when sliding joint surfaces .
Joint elements interconnected vnutrishnokapsulyarnymy and pozakapsulyarnymy bonds.
Movement joint at the expense of the chewing muscles, but it caot ignore the function of the muscles of the tongue and facial muscles. Blood supply of the temporomandibular joint by branches of the external carotid artery.
Innervuyetsya TMJ mainly branches of ear – temporal nerve , and with great ear , small occipital , vagus nerve .
TMJ is combined in nomupoyednuyutsya almost two joints (right and left), symmetric with respect to each other , are closely inter-related and those that are only kinematic system. In physiologically normal joint possible combination of two types of motion – hinge (lower section ) and reciprocating (upper section ).
Combination of motion allows for a relatively small shifts within the joint to achieve significant amplitude displacement of the mandible between the cutting edges of the upper central incisors and lower jaws.
There are large individual differences in the functionality of the temporomandibular joint , depending on the anatomical structure of the individual elements of the joint . Normally there are three types of temporomandibular joint :
1. Flattened joint. Articular fossa shallow but wide. The head of the mandible flattened . Articular tubercle is low. This type of joint is responsible direct bite in it is dominated by reciprocating motion.
2. Moderately convex – concave joint. Articular fossa is well defined . The head of the mandible convex . Articular tubercle is also well expressed. This type of joint is responsible ortohnatychnyy bite. In this joint is equally well expressed as reciprocating and articulated movements.
3. Strongly convex – concave joint. Articular fossa is deep but narrow. The head of the mandible convex . Articular tubercle high, its steep rear slope . This type of joint is responsible profound riztseve overlap. It is dominated by articulated motions.
Individual differences in functionality temporomandibular joints due not only anatomical structure of some of its elements , but also as zuboschelepnoho system, masticatory muscle tone , height occlusion. If you change the function of joints subject to change face shape , and, conversely , changes in the anatomical shape of the face resulting in changes in the function of the joint . This causes difficulty in patohnezu different in origin and nature of the lesions temporomandibular joint.
Diagnosis of diseases of the temporomandibular joint, determine the nature of the anatomical and functional abnormalities based on general clinical data – patient complaints , anamnesis, objective examination – inspection , palpation, assessment of dentition overall (condition of teeth, dentures, bite , etc. ). When examining a patient with complaints of violation or pain in the joints should examine the state of the joint space , shape and size of the articular heads, their correlation with the glenoid cavity and the articular tubercle. When you open your mouth defined trajectory, synchronicity , amplitude and fluidity of the articular heads, and the nature of displacement of the mandible. Conduct special studies ( radiography, mastykatsiohrafiya , audiometry , etc. ). Radiologically examined two joints ( for comparison) , preferably in the open and closed mouth. This method includes Plain radiography , CT scan at a depth of 2-2.5 cm in profile shots , while frontal projections – at a depth of 11-13 cm, contrast radiography , renthenokinotomohrafiyu , рентгенотелекінематографію .
Plain X-ray method to determine a gross destructive changes in the joint. Tomography has greater resolution because it provides an isolated joint image without shadow layers.
When infectious diseases ( specific and nonspecific ) requires laboratory studies of peripheral blood protein fractions , consulting rheumatologist , dermatologist , etc. .
Arthritis.
Arthritis (synonym – osteoarthritis ) – inflammation in the TMJ . More common in people young and middle age. Among the causes of arthritis may include: local infection ( periodontitis , gingivitis , stomatitis , otitis , tonsillitis , osteomyelitis of the jaws , and others .) , Inflammatory infections (ARI , influenza , pneumonia , dysentery , tuberculosis , syphilis , etc. .) , Allergic diseases , traumatic effects , etc. of inflammatory processes in the TMJ paraallerhichni contributing factors ( hypothermia , overheating , etc. .) , changes in the endocrine and nervous systems , the presence of foci of chronic infection ( particularly in the mouth ), and others . Infection in the joint and pin penetrates hematogenous routes.
Depending on what the causative factor is the cause of the disease are distinguished : non-infectious ( metabolic- dystrophic ) infections – specific (tuberculous , syphilitic , gonorrheal , aktinomikotychnyy etc. .) And nonspecific (after otitis or osteomyelitis, rheumatism, etc. kollagenozah . ), posttraumatic ( occurring in chronic microtrauma , acute trauma , surgery on the jaw after tooth extraction because of the wide mouth opening, joint during a single overload during vidkusuvannya large piece of apple or at rozkusuvanni solid food ). In clinical flow arthritis distinguish acute and chronic. Secondary arthritis – an inflammation of TMJ as a result of another disease or injury.
Osteoarthritis
Osteoarthritis (synonym – osteoarthritis ) – a dystrophic diseases of TMJ , which is based on degeneration of articular cartilage that leads to its thinning and razvoloknennya , exposure of the underlying bone and bone growth .
Degenerative processes in the joint develop as a result of imbalance between the load on the TMJ and its physiological endurance fabrics. The normal load of chewing muscles develop evenly distributed on the two joints , all teeth and periodontium . Therefore, overloading the joints occurs. With the loss of teeth, especially molars and premolars , which has a strong burden on the articular surface , and the head of the mandible moves deeper into the joint hole. There is an overload TMJ . It is more common in elderly and senile age due to tooth loss , misuse or lack of dental prosthetics dentures, involutive changes in tissues. Osteoarthritis occurs in patients with dentition defects , in violation of interdigitation ( pathological occlusion ), systemic lupus erythematosus , metabolic disorders and diseases that lead to the emergence of pathological osteoporosis. Osteoarthritis may be primary (with loss of teeth , etc.) and secondary (the result of some disease or injury) . Depending on the clinical arthritis distinguished: sclerosing ( going sclerosis cortical plates of bone articular surfaces ) and deforming (characterized by severe and destructive (or) hyperplastic changes in bone joint elements ). When deforming arthrosis may appear abnormal bony growths on the surface of the bone – ekzofity ( osteophytes ).
DYSFUNCTION painful temporomandibular joints .
Pain TMJ dysfunction syndrome ( TMJ pain ) has synonyms: Kostena syndrome , pain disfunktsionalnyy TMJ syndrome , myofascial pain disfunktsionalnyy syndrome, TMJ , kraniomandibulyarna dysfunction , dysfunction of the lower jaw, musculo- articular TMJ , TMJ mioartropatiya et al.
J. Costen ( 1934) described a syndrome that is observed in edentulous patients and in patients with a deep bite . Symptom characterized by the following: dull pain in the joints , headache , dizziness , pain in the cervical spine , neck and behind the ear, which is aggravated by the end of the day, clicking in the joint while eating , hearing loss , tinnitus , burning throat and nose. Described symptom complex was later named Kostena syndrome . This syndrome later added some other symptoms: paresthesia, xerostomia, hlossodyniyu , feeling of pressure in the ears, ear pain , and others.
J. Costen ( 1936) believed that the symptoms associated with hearing loss , tinnitus and other emerging due to the pressure head of the mandible to the auditory tube . Reducing occlusion leads to a pressure head of the mandible to the articular fossa arches separating the joint cavity from the dura mater and therefore there is a dull pain in the spine , and pain in the tongue and the temporal region observed as a result of pressure head at ear – temporal nerve and Drum string.