Causes and types of contractures in dentistry. Post-injection contracture of the lower jaw (experimental clinical study) Zakaria Ibragimov Ibragimov

The main factors leading to the occurrence of extra-articular mandibular contractures are: incorrect primary processing wounds, prolonged intermaxillary fixation of jaw fragments and belated use of physiotherapy exercises. At the same time, scars appear between the bone fragments of the jaw and soft tissues, limiting movement. mandible. Depending on which tissues are affected (skin, oral mucosa, or muscles), contractures are dermatogenic, multigenic, or mixed.

In addition, damage to the joint (arthrogenic contracture), which is difficult to treat conservatively and leads to ankylosis, can serve as the cause of contracture. Finally, there are neurogenic contractures (with damage to the nerve trunks), psychogenic, inflammatory, which quickly disappear after the elimination of the inflammatory infiltrate. Contractures may be due to the presence foreign bodies in the area of the muscle.

Extra-articular contractures are associated with cicatricial changes in the region of the muscle group that lifts the lower jaw and soft tissues of the oral cavity. They are divided into temporo-coronary, zygomatic-coronary, zygomatic-jaw and intermaxillary. The first two groups of cicatricial contractures (temporo-coronal and zygomatic-coronal) require surgical intervention. Cheekbones and intermaxillary contractures are eliminated by functional methods of treatment - physiotherapy exercises.

B. N. Bynin divides extra-articular contractures of the jaws into two main groups - cicatricial and reflex-muscular. The former are associated with scarring of soft tissues, which mechanically impede the movements of the lower jaw, and therefore can be called mechanical. The latter arise reflexively due to the effect of the stimulus on the receptor apparatus, leading to muscle hypertension. Such a division of extra-articular contractures of gunshot origin is of clinical importance for the purposes of diagnosis and treatment, since the prevention and treatment of these contractures are different. Extra-articular contractures according to the degree of mouth opening are divided into severe (mouth opening up to 1 cm), moderate(1-2 cm) and light (up to 3 cm).

In some cases, muscle hypertension turns into a persistent contracture with pathological manifestations in the muscle in the form of its cicatricial change. This process is characterized by rigidity of the masticatory muscles that lift the lower jaw. With persistent muscle contractures, conservative (mechano- and physiotherapy) or surgical treatment can be used. The latter is recommended for persistent pathological changes in the region of the temporal muscle and consists in resection of the coronoid process or cutting off the masticatory and medial pterygoid muscles from the place of their attachment to the lower jaw in case of their cicatricial change.

Mechanotherapy for jaw contractures

The simplest means of mechanical opening of the mouth are corks, wooden and rubber wedges, screw-threaded cones, which are inserted between the teeth for more or less long time(2-3 hours). However, these remedies are crude, non-physiological and often result in periodontal damage to individual teeth and dental occlusion. The best results are achieved with devices based on the principle of active and passive movements of the jaw, caused by elastic traction or springy processes. For the first time such an apparatus was proposed by Darcissac. The device was used for ankylosis of the temporomandibular joint after the operation to create a false joint. Impressions for the manufacture of the apparatus are taken on the operating table after osteotomy, when the patient's mouth opens wide. The inconvenience of this apparatus lies in the fact that its manufacture is possible only by the impression of the jaw. With limited opening of the mouth, the removal of the impression is extremely difficult.

Recently, a number of new standard devices have been proposed, based on the use of active and passive movements of the lower jaw (A. A. Limberg, I. M. Oksman) (Fig. 243). The advantage of these devices is that they are standard (no need to take impressions of the jaw) and can be used when severe forms jaw contractures. They transmit pressure to the entire dentition and, most importantly, allow you to perform active-passive exercises (opening and closing the jaws). Mechanotherapy should be carried out after physiotherapeutic procedures (sollux, ultraviolet irradiation, thermal mouth baths, paraffin therapy, electrophoresis, etc.). Good results are given by electric baths of the entire facial area, followed by mechanotherapy. Mechanotherapy can also be used for microstomy to stretch scars and restore the mobility of soft tissues of the oral region, for which special devices with elastic traction are used. Most of these deformities, however, require surgical intervention (excision of scars and plastic surgery of soft tissues) followed by the use of physiotherapy exercises.

Speech therapy exercises for developing contractures of the jaws. For the prevention of contractures, it is useful to combine maxillofacial gymnastics with speech therapy exercises. This method can also be used to treat contractures in the initial stage. It includes a series of exercises for the muscles of the face, walls oral cavity and language, taking part in the design of sound, the act of chewing and swallowing.

Rice. 243. Apparatus for mechanotherapy with contractures of the jaws.

a - according to Limberg; b - according to Darcissac; c - according to Oksman; d - according to Ezhkin; e — apparatus for mechanotherapy with the angle of the mouth.

The exercises are selected so that each subsequent one includes the previous one and consolidates it. The first exercise - the formation of the sound "a" - consists in a very slow opening of the mouth with a consistently increasing load or tension until the mouth opens to the limit and pain is felt. This is followed by a slow raising of the lower jaw with a gradual decrease in volitional load until the teeth close. These movements mobilize groups of chewing muscles that take part in the movements of the lower jaw in the vertical direction during the formation of the sound "a" and the act of chewing. The rest of the exercises consist in repeating the previous one and designing other sounds - mobilizing the facial and chewing muscles to design the sounds "s", "y", "e". The patient consistently does each of these exercises 5-6 times per session at intervals of several seconds. The necessary conditions- the sequence of application of exercises and bringing them to the onset of pain. The pain disappears after the effort is removed. Exercises are performed in front of a mirror after being shown by a speech therapist.

The contracture of the mandible must be pathogenetic. If contracture of the lower jaw of central origin, the patient is sent to neurological department hospitals to eliminate the main etiological factor (spastic trismus, hysteria).

In the case of its inflammatory origin, the source of inflammation is first eliminated (the causative tooth is removed, the phlegmon or abscess is opened), and then antibiotic, physio- and mechanotherapy is carried out. It is desirable to carry out the latter using the devices of A. M. Nikandrov and R. A. Dostal (1984) or D. V. Chernov (1991), in which the source of pressure on the dental arches is air, that is, a pneumatic drive, which in the collapsed state has a thickness of 2-3 mm. D. V. Chernov recommends bringing the working pressure in the tube inserted into the patient's oral cavity within 1.5-2 kg / cm 2 as with conservative treatment cicatricial-muscular contracture, and in its inflammatory etiology.

Mandibular contractures caused by bone or bone-fibrous extensive adhesions, adhesions of the coronoid process, the anterior edge of the branch or cheek, are eliminated by excision, dissection of these adhesions, and due to the presence of narrow cicatricial constrictions in the retromolar region - by the plastic method with counter triangular flaps.

After the operation, in order to prevent wrinkling of the skin flap and scarring under it, it is necessary, firstly, to leave a medical splint in the mouth (together with a wall liner) for 2-3 weeks, removing it daily for the toilet of the oral cavity. Then make removable prosthesis. Secondly, in postoperative period it is necessary to carry out a number of measures to prevent the recurrence of contracture and strengthen the functional effect of the operation. These include active and passive mechanotherapy, starting from the 8-10th day after the operation (preferably under the guidance of a methodologist).

For mechanotherapy, you can use standard devices and individual devices that are made in a dental laboratory. This is discussed in more detail below.

Physiotherapeutic procedures are recommended (irradiation with Bucca rays, ionogalvanization, diathermy), which help prevent the formation of rough postoperative scars, as well as injections of lidase with a tendency to cicatricial tightening of the jaws.

After discharge from the hospital, it is necessary to continue mechanotherapy for 6 months - until the final formation of connective tissue in the area of the former wound surfaces. Periodically, in parallel with mechanotherapy, it is necessary to conduct a course of physiotherapy.

At discharge, it is necessary to provide the patient with the simplest devices - means for passive mechanotherapy (plastic screws and wedges, rubber spacers, etc.).

Excision of fibrous adhesions, osteotomy and arthroplasty at the level of the base of the condylar process using a deep-epidermal skin flap

The same operation at the level of the lower edge of the zygomatic arch with excision of the bone-scar conglomerate and modeling of the head of the lower jaw, interposition of the deep-epidermal skin flap

Dissection and excision of soft tissue scars from the oral cavity; resection of the coronoid process, elimination of bone adhesions (with a chisel, drill, Luer cutters); epidermization of the wound with a split skin flap

Dissection and excision of cicatricial and bone adhesions through external access, resection of the coronoid process. In the absence of scars on the skin - surgery through intraoral access with a mandatory transplantation of a split skin flap

Excision of the entire conglomerate of scars and bone adhesions through intraoral access to ensure a wide opening of the mouth; transplantation of a split skin flap. Ligation of the external carotid artery prior to surgery

Dissection and excision of bony and fibrous adhesions of the cheek to ensure wide opening of the mouth and closure of the resulting defect with a Filatov stalk transplanted to the cheek in advance or elimination of the cheek defect with a skin arterialized flap

Good results in the treatment of the above methods were noted in 70.4% of patients: their mouth opening between the front teeth of the upper and lower jaws ranged from 3-4.5 cm, and in some individuals it reached 5 cm. In 19.2% of people, the opening of the mouth was up to 2.8 cm , and in 10.4% - only up to 2 cm. In the latter case, a second operation had to be performed.

The reasons for recurrence of contractures of the lower jaw are: insufficient excision of scars during surgery, the use (for epidermization of the wound) of a thin, not split, epidermal flap of A. S. Yatsenko-Tiersh; necrosis of a part of the transplanted skin flap; insufficiently active mechanotherapy, ignoring the possibilities of physiotherapeutic prevention of the occurrence and treatment of cicatricial constrictions after surgery.

Relapses of contractures of the lower jaw often occur in children, especially in those operated not under anesthesia or potentiated anesthesia, but under normal anesthesia. local anesthesia when the surgeon fails to perform the operation according to all the rules. In addition, children do not fulfill prescriptions for mechano- and physiotherapy. Therefore, it is especially important for children correct execution the operation itself and the appointment of coarse food after it (crackers, bagels, candies, apples, carrots, nuts, etc.).

Mandibular contractures are characterized by the reduction of the jaws due to pathological changes in the soft tissues in the face. In most cases, this pathology is an acquired disease.

Contracture classification and causes

This pathology occurs due to traumatic and inflammatory changes in the joints. subcutaneous tissue, skin itself, nerve fibers, masticatory muscles, parotid-temporal fixation. Depending on the severity of the course and manifestations of the disease, several types of contractures of the lower jaw are distinguished. These include temporary (unstable) and persistent pathological processes, as well as congenital and acquired during the patient's life.

unstable

Contractures of a temporary nature are expressed in the weakness of the masticatory muscles. Most often they appear as complications due to prolonged fixation of the jaw (for example, after wearing splints) or as a consequence of the inflammatory process in the tissues of the jaw.

Persistent

Persistent pathologies are caused by deformation of the lower part of the face due to scarring of soft tissues or inflammatory processes. For example, after receiving a gunshot wound to the face, trauma to the bones of the skull, fractures, burns, as well as inflammation of the maxillary tissues.

The appearance of cicatricial contracture of the lower jaw is often associated with diseases such as ulcerative stomatitis, syphilis, ulcerative necrotic gingivitis.

As a result of changes in soft tissues, the mobility of the lower part of the face develops, which leads to a significant deterioration in the quality of life of the patient, up to a serious deformation of the facial skeleton, especially if scars form in several perimaxillary areas at once.

Contracture after anesthesia may occur due to a violation of the technique of the procedure. In this case, the disease belongs to a number of inflammatory.

There are three degrees of mandibular contracture:

First, the opening of the patient's mouth is slightly limited. Distance between surfaces central teeth upper and lower jaw - 3-4 cm.
The second is the restriction of mouth opening within 1-1.5 cm.
Third - the mouth opens no more than 1 cm.

Congenital and acquired pathologies

Congenital changes in the tissues of the jaw and bones of the skeleton are quite rare. Acquired pathologies of a permanent and temporary nature, arising from the weakening of the facial masticatory muscles, deserve much more attention. In some patients, the development of contracture of the lower jaw is due to spasticity (tension) of the muscles against the background of hysterical conditions. In such cases, a person experiences temporary paralysis of the face, associated with muscle tension in the lower part of the face.

Characteristic symptoms

As a result of mandibular contracture, the patient may experience some of the following symptoms:

How are contractures treated?

To eliminate mandibular pathologies, a surgical method is used to restore the elasticity of facial tissues, as well as the motor functions of deformed muscles.

The operation is performed under general anesthesia by excision of the scar tissue or a longitudinal incision of the scar, followed by its replacement with healthy tissue taken from areas adjacent to the scar or other parts of the patient's body.

Small scars are successfully eliminated using the Limberg method (use of triangular flaps).

For the treatment of mandibular contracture caused by the formation of flat scars, a full tissue is produced. The wounds formed as a result of excision are closed with thin skin flaps taken from the surface of the patient's body.

In cases where the removal of the scar leads to large-scale loss of soft tissues, leading to the exposure of the masticatory muscles of the patient's face, the Filatov method is used to compensate for the lost areas. This is a plastic method, which consists in transplanting a rolled up flap of the patient's skin, excised together with subcutaneous tissue (Filatov's stalk). This method is often used for deformities caused by deep scar formations in the tissues of the skin, subcutaneous tissue, muscles and mucous membranes of the oral cavity.

In cases of surgical removal of the deformation of the lower jaw caused by the formation of scars in the area of the masticatory muscles, they are cut off from the lower jaw. In the presence of multiple scars formed in the adjacent tissues, in some cases it is impossible to achieve the result of self-opening of the patient's mouth. In such situations, the surgeon introduces a special screw dilator. The muscle cut off at the time of the operation grows to the branch of the lower jaw in a new place. The success of restoring lost muscle functions in the future depends on correctly selected methods of rehabilitation and the quality of performance of the therapeutic exercises prescribed by the rehabilitation specialist.

Inflammatory contracture of the lower jaw is treated by eliminating the source of the infectious process. In the postoperative period, mandatory rehabilitation measures are carried out, including mechanical and physiotherapy, as well as therapeutic exercises.

The value of gymnastics

In terms of restoring lost jaw functions, physiotherapy exercises are given priority not only in the early postoperative period, but also in the treatment of contractures caused by injuries and diseases. The final result of the operation performed by the surgeon largely depends on the quality rehabilitation measures, correctly selected therapeutic exercises for the development of jaw muscles.

You can perform exercises on your own in front of a mirror or in a group of patients suffering from similar disorders, under the guidance and supervision of an instructor.

A set of exercises for recovery

Gymnastics, as a rule, consists of several sequentially performed parts:

An introductory or preparatory part, consisting of general hygiene exercises performed for about ten minutes.
The special part of the lesson includes exercises, selected individually for each patient in accordance with clinical picture diseases. A special set of exercises, depending on the nature of the course of the postoperative period, is introduced already on the eighth day after surgery, in severe cases - on the twelfth day after surgery and more. late dates.
The final stage, like the introductory part, consists of general exercises.

A special set of exercises may consist of movements such as:

Movement of the lower jaw and head in different directions.
Mimic movements performed for recovery, such as exercises for the cheeks and lips (puffing out the cheeks, stretching the lips in the form of a smile or a tube, performing a grin and other movements).

Prevention measures

As a rule, the prognosis of the result of operations to eliminate the causes of contracture is favorable. However, in order to prevent relapses, doctors recommend continuing rehabilitation after discharge from the hospital, in particular, undergoing treatment on special devices for six months after discharge from the hospital (mechanotherapy), perform the prescribed therapeutic exercises undergo a second course of physiotherapy.

If all indications are met, the likelihood of recurrence is significantly reduced, and the final result of the operation improves in more than 50% of cases.

Usually, the pathological process does not resume, except in cases of incomplete removal of scar tissue.

Most often, young patients who were operated on under local anesthesia, which does not completely eliminate the cause of the contracture, are subject to the resumption of contracture of the lower jaw. In some cases, children who evade compliance with the prescribed rehabilitation measures are subject to relapse. In the treatment of such pathologies in children, it is important to perform the operation with high quality the first time, after which it is immediately recommended to the patient to take rough food (hard fruits, raw vegetables, crackers, nuts or hard candies), which contributes to the development of jaw muscles.

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Contracture of the mandible

Contracture of the mandible is a contraction of the jaws due to pathological changes and violations of the elastic properties of soft tissues maxillofacial area functionally associated with the temporomandibular joint.

Classification

By the nature of the course and etiology:

.unstable contractures;

.persistent contractures. There are also:

.congenital;

.acquired. Etiology and pathogenesis

Congenital contractures are extremely rare, acquired contractures are more important. Unstable contractures are mostly the result of weakening of the masticatory muscles after prolonged wearing of splints with intermaxillary rubber traction, as well as inflammatory processes in the soft tissues surrounding the lower jaw. Contracture occurs in connection with spastic paralysis due to hysteria. Persistent contractures of the lower jaw are caused by the development of cicatricial deformities in the tissues of the maxillofacial region after gunshot wounds to the face, transport injury of the facial skeleton, fractures of the coronoid process of the lower jaw and zygomatic arch, burns and inflammation of the perimaxillary region. Cicatricial changes in the oral mucosa Moiyr occur as a result of ulcerative necrotic stomatitis, gummous syphilis, skin, burns, trauma.

Clinical picture

With contracture of the lower jaw, speech and eating are disturbed. The teeth, especially the front teeth, take a fan-shaped position. Often there is a deformation of the upper and lower jaw. If the contracture occurred during the growth of the facial skeleton, then the lower jaw is somewhat behind in development. With unilateral contracture, at the time of opening the mouth, there is a displacement of the lower jaw to the diseased side, and with lateral movements, it does not move to the healthy side.

Treatment

Elimination of the reduction of the jaws, restoration of the mobility of the elasticity of the soft tissues of the facial skeleton with contracture of the lower jaw is achieved surgical treatment using in the postoperative period the methods of mechanotherapy, therapeutic exercises and physiotherapy, Surgical intervention should be performed under general care. In this case, excision of scars or longitudinal dissection is performed with closing of the wound surface with tissues adjacent to the defect or taken from other parts of the body. Small constriction scars can be eliminated using Limberg triangular flaps. AT early dates after the operation, it is advisable to actively use physiotherapy exercises and mechanotherapy.

Prevention

Timely treatment of diseases that can lead to contracture of the lower jaw. To prevent the formation of rough, tightening scars, the use of therapeutic exercises as a method of prevention.

The role of physiotherapy exercises

Therapeutic exercises are of decisive importance not only in the postoperative period, but also in the prevention of the development of jaw contracture after traumatic injuries and diseases.

The success of the operation depends on the activity of conducting therapeutic exercises.

Remedial gymnastics classes are usually held in front of a mirror, individually or in a group under the guidance of a methodologist.

A session of therapeutic gymnastics is usually built according to the following plan: an introductory lesson in which several preparatory exercises of a general hygiene nature are given (8-10 minutes), special exercises that are selected according to the period and clinical course postoperative period: on the 8-12th day, on the 12-22nd day after the operation; the final part, consisting of general hygiene exercises.

Special exercises: movements of the lower jaw and head in various directions. Exercises should be given to the mimic muscles of the face, since in some lesions the function of these muscles suffers. To train facial muscles, exercises for the lips and cheeks are offered: puff out the cheeks, stretch the lips (whistling), stretching the lips to the sides, baring the teeth, etc.

To obtain a stable result after treatment in the postoperative period, when the patient is discharged, he should be given a home assignment to consolidate the results obtained.

Under the contractures of the jaws, it is customary to understand the complete or partial persistent reduction of the jaws, due to powerful cicatricial growths located both in soft tissues maxillary region, and between the lower and upper jaws. Therefore, the fight against contractures should consist mainly in the destruction of these scars.

Contractures that have arisen as a result of cicatricial reduction of the jaws, we define as cicatricial. In some cases, scars can turn into bone lesions. We attribute such a persistent reduction of the jaws to bone contractures. Persistent contractures most often occur after gunshot injuries, nomas, typhus, ulcerative stomatitis and other inflammatory processes, with a significantly larger number of cicatricial contractures, a smaller number of bone. Scars can capture both the mucous membrane with a submucosal layer, and the skin with subcutaneous tissue.

With contractures caused by cicatricial changes in the oral mucosa with a submucosal layer, after excision of scars, most often located in the buccal pockets and transitional folds, such an extensive defect remains that it cannot be replaced by moving local tissues and one has to resort to free skin grafting.

Excised scars should always be all over, and often they stretch from the corner of the mouth to the front edge of the ascending branch.

The main, most difficult task is the fixation of the skin graft after surgery in the oral cavity. The existing methods for this are described by us in the section “Skin Transplantation”. The negative side of free skin grafting to replace the oral mucosa with deep scars is the strong wrinkling of the flap and the difficulty of fixing it in the mouth. In addition, the flap is devoid of fat, which is of great importance for the cheeks.

Hussenbauer (Hussenbauer) first proposed in 1887 to carve out ribbon-like flaps on the cheeks, with the base in front of the ear and, after excision of the scars, wrap the flaps (with bilateral contracture) in the mouth and hem them there to the mucosa.

Rotter (Rotter) cut out a transverse flap on the inner surface of the shoulder and brought it with his hand to the cheek, where he made a vertical through incision in front of the masticatory muscle, through which he pulled the flap and sutured it to the edges of the mucosa after dissecting the scars.

Such operations also include the method proposed in 1920 by N. V. Almazova. The advantages of this method, which we have described in the Cheek Restoration section, are that, if necessary, the mucosa and skin can be restored with one flap. However, it must be taken into account that after excision of extensive scars of the mucosa and skin that caused contracture, it is difficult to replace the resulting defect by the above methods due to the lack of plastic material. In addition, with all these methods, additional scars appear on the face.

In these cases, the best and most easily performed method for eliminating contractures is an operation using the Filatov stem. The operation for through lesions of the buccal region with the help of a stem is divided into three stages:

1) the formation of the Filatov stem;
2) through dissection of scars, their excision and closing of the resulting wound surface with a stalk;
3) restoration of both layers of the cheek with a stem.

The operation is carried out as follows. The Filatov stem is prepared on the stomach and transferred to the hand. After 2-3 weeks, the scars are dissected through a through incision from the corner of the mouth to the ascending branch, which ensures full opening of the mouth. After dissection of the scars, wound surfaces are formed along the dissection line and a through defect of the cheek, which is detected when the mouth is opened. The exposed surfaces of the edges of the defect are closed by stitching the mucosa with the skin. Later, the stem stem is separated from the abdomen and the end of the stem is cut into two halves over a length of 3-4 cm. These halves of the end of the stem are sutured to the edges of the cheek defect in the area of the angle between the jaws (Fig. 370). After engraftment, the stem is cut off by hand and cut along its entire length along its upper and lower ribs. Then, the edges of the cheek defect are stratified and the stem is sewn along the entire length of the cheek to form the inner and outer layers of the cheek.

In some cases, despite the complete dissection of the cheek scars, the mouth either does not open at all, or opens partially. The reason is that, in addition to the cheek, scars can spread upward along the branch of the lower jaw and serve as an adhesion between the coronoid process on one side and the zygomatic bone and arch on the other. Sometimes such cicatricial adhesions turn into bone (Fig. 371). In such cases, after the dissection of the cheek through the incision, it is necessary to penetrate the raspator along the anterior edge of the branch up to the base of the coronoid process, detach the periosteum and resect it.

If the contracture is caused by a cicatricial change in all layers of the cheek only, which does not reach the angle between the jaws, its elimination is greatly simplified.

The leg of the stem is sewn into healthy skin on the cheek behind the scars. When the stem takes root, it is cut off by hand, cut along the upper and lower edges, all the scar tissues of the cheek are excised, and the stem is sewn to the edges of the formed defect, and inside it is sewn with the mucous membrane, and the outer one with the skin (Fig. 372).

Bone adhesions can form between the alveolar processes of the lower and upper jaws. In these cases, adhesions after dissection of soft tissues over them have to be dissected with a chisel, and their edges are compared with wire cutters (Fig. 373, a, b) and the mucous membrane is sewn over them. If bone adhesions connect the branch with the tubercle of the upper jaw, then in order to eliminate them, it is necessary to resect the anterior edge of the lower jaw branch.

Very rarely, there are cases when, even after resection of the anterior branch of the branch, the mouth does not open. This happens when the branch along the entire width is soldered to the upper jaw. Under such conditions, in order to open the mouth, it is necessary to make an osteotomy of the branch immediately under the adhesion site (see "Ankylosis of the jaw"). After surgery for jaw contracture, it is necessary to carefully carry out active and passive therapeutic exercises for 3-4 months, even with good mouth opening, in order to prevent relapse. The patient should open his mouth as much as possible 3-4 times a day for 10-15 minutes. At the same time, it is necessary to open the mouth to failure with a mouth expander, a wooden screw or plugs, i.e., apply all types of mechanotherapy. You can also resort to special devices, for example, the apparatus of Darcissac (Fig. 374), Weinstein, Akhmedov.

Here are photos of patients operated on for persistent contractures of the lower jaw. On fig. 375 shows a patient in whom, with flat scars of the mucous membrane and unchanged skin, the scars were excised and replaced with free skin flaps.

On fig. 376 depicts a patient who had a bone fusion (see Fig. 371.6) of the coronoid process with the zygomatic bone. The operation was performed from the side of the oral cavity with an incision along the anterior edge of the lower jaw branch. The coronoid process was resected through this incision.

A patient with scars located in anterior section cheeks in the corner of the mouth, operated with a good outcome using a double flap according to A. E. Rauer (Fig. 377).