Ministry of Health of Ukraine Ukrainian Medical Dental Academy

Methodical instructions for independent work for students during training to practical (seminar) classes and in class

Academic discipline Surgical dentistry

Module № 5

Lesson topic № 1 Anatomy of the temporomandibular joint (TMJ). Modern methods of diagnosing TMJ diseases. Arthroscopy, its possibilities in the diagnosis and treatment of TMJ diseases. Dislocations of the mandible: etiology, clinic, diagnosis, treatment. Curation of the patient in the clinic of maxillofacial surgery. Writing an academic medical history.

Course V

Faculty Stomatological

Poltava 2020 1. Relevance of the topic.

Knowledge of the anatomical structure of the temporomandibular joint (TMJ) and the characteristics of modern diagnostic methods for assessing their pathologies. The etiology, clinical diagnosis and treatment of mandibular dislocations allows you to choose a timely and effective way to treat this pathology, avoid mistakes and complications, allows the dentist to diagnose TMJ and prescribe optimal treatment. Academic history in which the student is able to use knowledge , obtained in the study of basic and applied sciences, obtained demonstrate practical skills.

2. Specific target: 2 .1.Analyze to know statistics, diseases TMJ.; 2.2. Explain the methods of diagnosing diseases TMJ; 2.3. To offer to examine patients with diseases of TMJ; 2.4. Classify diseases TMJ; 2.5. Interpret theoretical and clinical studies of diseases TMJ; 2.6. Draw diagrams, graphs 2.7. Analyze the treatment plan for patients with diseases TMJ; 2.8. Make a plan for the treatment of patients with diseases TMJ;

3. Basic knowledge, skills, abilities necessary for studying the topic (interdisciplinary integration).

Names of previous Acquired skills disciplines

Anatomy To study the anatomical and topographic structure of the temporomandibular joint.

2. Physiology Know the spatial ratio of the components of the temporomandibular joint.

3. Biophysics Determine the functional load on the joint.

4. Surgical dentistry To make methods of treatment of patients with TMJ.

4. Tasks for independent work in preparation for class and in class. 4.1 The list of the basic terms, parameters, characteristics which the student should master at preparation for employment:

Term Definition

TMJ temporomandibular joint

Congruence Correspondence of an articular surface to each other

Incongruence Mismatch of the articular surface to each other 4.2. Theoretical questions for the lesson: 1. Classification of the temporomandibular joint by type of structure. 2. Classification of the temporomandibular joint by periods of postnatal development of the TMJ. 3. Features of the structure of the TMJ in the age aspect. 4. The effect of masticatory muscle contractions on movements in the joint. 5. Innervation and blood supply of the TMJ. 6. Biomechanics of the TMJ depending on the type of bite. 4.3. Practical work (tasks) performed in class: 1. By demonstrating stands with different types of joints in animals: predators, rodents, primates with an explanation of the prevalence of certain movements of the mandible in students formed an idea of the structure and movements of the TMJ. 2. Students on the human skull indicate the ratio of the articular head to the articular fossa, the location of the articular tubercle and other bone formations that are part of the TMJ.

Topic content:

The temporomandibular joint is one of the most active human joints. The movements of the lower jaw occur almost constantly - during the function of chewing, speech, etc. The formation of TMJ in phylogeny is inextricably linked with human activities, the nature of nutrition, ie depends on the characteristics of the movements of the mandible. Predators in the TMJ have only vertical movements that allow them to tear off food, so it has a hinged structure. The heads of the mandible are located deep in the pits and completely fill them. The joint of primates has an intra-articular disk, the head of the mandible does not completely occupy the fossa, due to which the movements in the joint are complicated and perform a combined action. Human TMJ is more perfect, has a variety of movements, but it is less durable. Its structure is attributed to diarthritic or synovial joints, it consists of a complex of formations that provide movements of the lower jaw. This complex includes bone and cartilaginous structures of the articular surfaces, ligaments and muscles. Bone structures include: the head of the mandible, the articular fossa and the articular tubercle of the temporal bone. The articular fossa of the temporal bone has the shape of an ellipse and is convex in the anterior part (articular tubercle) and concave - in the distal part. The articular tubercle is a dense bone formation that provides the perception of masticatory load. In the posterior (concave) part is the head of the articular sprout at rest. It occupies the same place when the teeth are in the central occlusion. The articular process of the mandible ends with an elliptical head. By structure, it has mainly a spongy fabric, bordered by a thin layer of compact substance. On its anterior surface there is a pterygoid fossa - the place of attachment of the lower bundle of the lateral pterygoid muscle. The dimensions of the articular fossa and the head of the articular process differ from each other, their incongruence and the possibility of different positions of the head in the fossa - depending on the condition of other components of the tissue complex that provide movement in the joint. The articular surfaces of the articular head and the articular cavity have a fibro-cartilaginous coating, which is generally represented by collagen fibers. During embryonic development, connective tissue structures are formed from the mesenchyme, which form a disc, capsule and wedge-mandibular ligament. In the same period 2 floors of a joint cavity are formed. Between the head of the articular process and the articular fossa is an articular disc of biconcave oval shape. The lower part repeats the shape of the head, the upper - the articular fossa. The presence of the disc avoids incongruence of bone formations of the joint, as well as its lower surface forms a hole for the rotation of the articular head. The disc consists of dense fibrous connective tissue with inclusions of cartilage cells. Its posterior part extends into the connective tissue bilaminar zone, which connects the posterior part of the fossa and the posterior part of the articular plane of the head. The joint is divided by a disk into two floors. The volume of the upper floor is 1.2 ml, the lower - 0.9 ml. All these structures are surrounded by a joint capsule, which is a connective tissue shell. The top of the capsule is attached to the temporal bone, below - to the neck of the articular process. The connection of the capsule with the disc is strengthened by intra-articular ligaments, which are attached to the disc and the bone structures of the articular fossa and the head of the articular process. The capsule and posterior disc compartments form parallel axes that macroscopically merge with the disc. These are the so-called inspiratory protrusions, which consist of two parts: the posterior - between the disc and the capsule and the anterior, which protrudes from the capsule and is intertwined with ligaments and muscles. The fibers of these protrusions form folds, and their bone attachments allow you to control the movements of the disk. The anterior disc edge of the anterior disc layer is the site of attachment of the capsular disc head to the masticatory muscle. A layer of this muscle (20-30 mm long and 10 mm thick) goes up and back and attaches to this protrusion. The connecting part of the specified beam is attached in the center of a mandibular fossa on the outside. The capsule of the joint, which descends from the posterior third of the temporalis muscle, is attached to the middle and anterior parts of the protrusion. The fibers of the temporalis muscle go down, back and obliquely from the scales of the temporal bone, and the capsular disc part of the lateral pterygoid muscle passes into the tendon part of the anterior head of this muscle. So not only the lateral pterygoid muscle, but also the actual masticatory and temporal muscles are related to the movements of the disc. From the upper surface of the disc to the articular fossa are elastic bundles of ligaments, and from the bottom - a thick fibrous connective tissue. The upper elastic ligaments rotate the disc back when moving it forward, and the lower, rough, help keep it from moving forward. The disk is suspended from the sides to the poles of the head and separated from the capsule. The structure of the joint capsule is represented by two layers: outer (fibrous) and inner (epithelial). In the posterior part of the joint between the capsule and the posterior pole of the disc is a loose connective tissue called the "dyspnea cushion", or bilaminar area. The inner layer of the capsule and the bilaminar area are the site of production of synovial fluid, which reduces surface friction during movement and is an immunobiological environment that protects the joint from infection. The joint capsule is strengthened by extra-articular ligaments that counteract its stretching. These connections include: temporomandibular, maxillary and maxillary-maxillary. The ligaments are formed by inelastic connective tissue, so in the case of overstretching, they do not restore the original size. The blood supply to the TMJ comes from the external carotid artery basin through the superficial temporal, deep auricular, anterior tympanic, middle arteries, dura mater, and pterygoid artery. Anastomoses between arteries are weakly expressed. The most pronounced vascular network on the periphery of the disc, in the bilaminar zone and the capsule of the joint, from where the vessels penetrate to the periosteum of the head. The venous network is well expressed, widely anastomoses with the veins of the middle ear, external auditory canal, ear canals and veins of the pterygoid venous plexus. The venous network forms broad plexuses around and within the capsule. The outflow of venous blood is carried out in the pool of the facial vein. In addition to the cartilaginous and soft tissue components of the TMJ, a large number of muscles are attached to the mandible, which are directly involved in the implementation of its functions. The lateral pterygoid muscle consists of two muscles. Its upper part starts from the subtemporal surface of the large wing of the main bone and the subtemporal ridge and, going horizontally and outwards, is attached to the capsule and the anterior edge of the articular disc. The lower head starts from the outer plate of the pterygoid process of the cuneiform bone and partially from the hump of the upper jaw and is attached to the lower jaw in the pterygoid fossa. The function of this muscle is to press the lower jaw to the upper. Muscle contraction occurs strictly under the control of the central nervous system. TMJ innervates independent nerve branches, the main source of which is the auricular- temporal nerve, but also in the innervation involved branches of the facial, posterior deep temporal, as well as the third branch of the trigeminal nerve. The latter innervate the inner, outer and posterior surfaces of the joint capsule. Movements in the TMJ are performed by contraction of the muscles that are attached to the mandible, their innervation is a motor portion of the third branch of the trigeminal nerve. Motor nerves, innervating certain muscles have appropriate names. The localization of the motor and sensory nuclei in the gasser node and the exit through the oval hole of the sensory and motor branches of the trigeminal nerve emphasize their close relationship. Hence, the role of information from periodontal tissues for the normal functioning of the mandible and TMJ becomes clear. According to NA Rabukhina (1966) distinguish three types of TMJ: Moderately concave joint, which is characterized by a medium convexity of the articular surface of the head and articular tubercle; the average width and depth of the articular cavity and a slight inclination of the neck of the articular process forward relative to the horizontal plane. Superficial, planar joint, characterized by a flattened head, low flat articular tubercle, shallow articular fossa and almost vertical structure of the neck of the articular process. The convex-concave joint is characterized, which is characterized by a deep and narrow joint cavity, high and convex articular tubercle, a large angle of inclination of the head of the articular process to the neck with a convex articular surface of the head. The first type of joint, which corresponds to the orthognathic occlusion, is an example of the most harmonious ratio of TMJ elements and provides a combination of articulated and sliding movements. In the second type of joint, sliding movements predominate, and articulated ones are minimized. At the same time at such structure the cartilage which usually covers only a back slope of a hump, covers all hump with an exit to its front edge. The third type of joint is characterized by a predominance of articulated movements. TMJ undergoes age and involutional changes in the process of human life and development. Yu.A. Petrosov (1982, 1985) conducted a dynamic observation of the histostructure of the TMJ in the age aspect and identified 4 periods of postnatal development: from birth to 2-3 years - the period of anatomical formation of the joint as an organ; adolescence (up to 12-14 years) - the period when the anatomical formation of the joint relative to its function ends; period of active activity - from 14 to 50 years; elderly and senile - from 50 years to old age. Of course, the TMJ is an organ of the whole organism, as well as all its components, undergoes periods of formation, formation and involutionary changes, performing one of the most important functions of the movements of the mandible. Already after the birth of a child there are coordinated movements of the temporomandibular complex during sucking, swallowing, screaming. When teething, when a child gets the opportunity to chew food, language development, the nature of the movements of the lower jaw is complicated. According to the mechanics of the TMJ - a complex joint. When the mouth is opened, all joint systems function consistently. First - the upper front part: the head and ligaments with the disk. There is a rotation of the head around the transverse axis, which ends in the lower floor of the joint. Then the disc-head complex moves down to the top of the articular tubercle, ie the movement is carried out and ends in the upper floor of the joint. Rotational movements occur in the lower floor, the depression is the lower surface of the disk, and the axis of rotation goes across through the center of the articular head. The upper pole of the head during rotation moves ventrally; during rotation changes its position and the disk - begins to move along the posterior surface of the articular tubercle. This is not a straight path, but a curved one, and its axis lies in the center of the articular tubercle at the end of the opening of the mouth. At the specified shift at first the lower fibrous bunches of a sheaf, then - elastic top, causing sensory activity of the receptors located between them are irritated and stretched. The CNS reflex is transmitted to the muscle fibers that stabilize the position of the head. This mechanism protects and stabilizes the joint. At transition from physiological rest to occlusion only small rotation of a joint head is noted. During chewing, the movements in the joints are much more complicated, because there are working and balancing sides of the lower jaw. At lateral movements on the working party there is no rotation, and on balancing there is a tubercular rotation, but not around cross, and around a direct vertical axis which goes from the center of a hump from balancing sorona to the center of a head of the working party. At the same time before the first tooth contact the maximum development of muscle strength is registered. When dental contact occurs, the muscles are excited and the joint is unloaded. In 60% of normal people during chewing the first dental contact occurs on the side opposite to chewing. Therefore, the physiological load of the joints never exceeds the possible limits. Thus, TMJ is a very complex anatomical formation, in the formation of which bone and soft tissue structures take part. The movements of the lower jaw are carried out by the muscles when moving the components of the joint, which are coordinated by the CNS, which receives information from the receptor apparatus of the capsule, ligament and periodontium. Arthroscopy is primarily used to accurately diagnose joint problems. This procedure, usually associated with injuries to the knee and shoulder, it allows you to give an accurate examination and diagnosis of damaged ligaments and joints, surfaces, and other connecting structures. Definition of arthroscopy - a detailed examination of the ligaments on the inside. The procedure is performed by inserting a specially designed device with a light source into the joint through a small incision. This instrument is called an arthroscope. The arthroscopy procedure is primarily related to the diagnosis process. However, when it is used for surgery, it is already called arthroscopic surgery. Purpose: arthroscopy is used primarily by doctors who specialize in the treatment of diseases of bones and connective tissues (orthopedics). Previously, arthroscopy was used only for athletes with their numerous injuries and injuries, but now arthroscopy is a common procedure performed by orthopedists to treat patients of all ages. This procedure is commonly used to diagnose knee and shoulder disease, however elbows, thighs, wrists, and ankles can also be examined with an arthroscope. Most arthroscopic procedures are performed in conventional surgery centers, where the patient comes immediately before surgery. A few hours after the procedure, the patient is allowed to return home, although usually only accompanied by relatives. Depending on the type of anesthesia used, the patient should not eat for several hours before the procedure. Before the procedure, the anesthesiologist usually asks if the patient is allergic to local or general anesthetics. Air obstruction is always possible in any patient undergoing general anesthesia. Because of this, an oxygen mask and a suction device must be available. The patient's heart rate should always be checked if any cardiac abnormalities occur during arthroscopy. An arthroscope is a tool used to directly examine a joint. It contains magnifying lenses covered with fiber, which send concentrated light to the joint. The camera attached to the arthroscopy allows the surgeon to clearly see the joint from the inside. This image is transmitted to the computer monitor in real time. This video technology is very important for documenting arthroscopic procedures. For example, if the surgeon decides after the examination that the usual surgical approach should be used, such as opening the joint (arthrotomy), a good photo report will assist the surgeon in the work. The procedure requires the surgeon to make several small incisions on the skin to the joint. Through one or two holes insert 2 hollow needles attached to the tube. The joint is inflated with a harmless saline solution to expand it and ensure a clear image. Often, after a recent joint injury, the natural fluid of the ligaments and joints can envelop the joint itself, making internal examination of the joint difficult to achieve. In this case, a constant flow of saline is required. This stream of saline can flow through one tube of the arthroscope and be sucked through the other tube. Before an arthroscopy is performed, the surgeon must perform a complete medical evaluation. Importantly, for the accuracy of this diagnostic procedure, a medical evaluation may reveal other problems with the joints and ligaments, proving the need for the procedure itself. This is always an important preliminary step, because the pain can often come from the joint, and its source comes from a completely different organ. The doctor and his assistants should do everything possible to prevent contamination from the instruments used in arthroscopy: chambers, thin cords and tubes. General or local anesthesia can be used during arthroscopy. Local anesthesia is commonly used because it reduces the risk of pulmonary and cardiac complications and allows the patient to recover faster. The local anesthetic can be administered in small amounts to different sites and combined skin tissues. In other cases, the anesthetic is injected into the spinal cord or the main nerve of the damaged cavity. This process is called "blocking" because it blocks all sensations below the main nerve trunk. For example, a hip block relieves pain in the leg from the thigh to the foot. Many patients find it comfortable when the skin, muscles, and other tissues around the joint become numb due to the anesthetic, but some patients are also given a sedative if they are concerned about the procedure. It is important for the patient to remain conscious during the arthroscopic examination. General anesthesia, in which the patient is unconscious, can be used if the procedure is very complicated or painful. For example, people who have "relatively tense" joints and ligaments need general anesthesia, although other problems may occur after surgery, but they are less dangerous. Care after surgery. The patient does not stay long in the recovery ward after arthroscopy. Most patients can go home about an hour after the procedure. Painkillers can be taken for a few days after the procedure, however, many patients rarely resort to strong drugs and use conventional painkillers. After the surgical procedure, the patient should be aware of signs of infection that include redness, warmth, excessive pain, and swelling. The risk of infection increases if the incisions start to get wet too early after the procedure. Therefore it is necessary to cover a sore spot with a film or a plastic bag, at water procedures after arthroscopy. The use of crutches is a common practice after arthroscopy, then the patient gradually switches to normal walking. In general, a physiotherapist-controlled recovery program should be followed shortly after arthroscopy to help the patient restore mobility and strength to the affected joint. The scope of complications is low compared to the high number of arthroscopic procedures performed annually. Possible complications include infection, tumor, joint tissue damage, blood clots in the legs (thrombophlebitis), hematomas, blood clots that move into the lungs, and mild damage to the nerve tissue around the joint. The purpose of arthroscopy is fatigue to diagnose the cause of pain in the joints and ligaments, as well as the problem of dysfunction of these parts of the body. For example, arthroscopy can be a useful tool in finding a hole in the knee joint or finding a torn shoulder ligament. Arthroscopic examination is often accompanied by arthroscopic surgery, which is performed to get rid of a problem in the joint or ligament. The end result is fatigue to reduce pain, improve joint mobility, and thus improve the quality of the patient's daily actions. Materials for self-control : Test tasks 1. A 58-year-old patient complains of clicking in the TMJ while eating. Periodically, when the mouth is wide open, the lower jaw occupies a position in which closing the mouth is impossible. By pressing your fingers on the coronal processes of the lower jaw, the latter easily falls into place. What diagnosis can be assumed? Answer options: A. Subluxation of the lower jaw. B. Acute dislocation of the lower jaw. C. Anterior dislocation. D . Posterior dislocation. E . The usual dislocation of the lower jaw . Correct answer : The usual dislocation of the lower jaw.

2. The patient went to the dentist with complaints of inability to close her mouth, difficulty speaking. Objectively: the oral cavity is half open, saliva flows from it, the central line is shifted to the right. In front of the "tragus" of the ear - a hollow, and under the zygomatic arch - protrusion due to the head of the lower jaw into the temporal fossa. Make a diagnosis. Answer options: A. Unilateral posterior dislocation of the lower jaw on the left. B. Unilateral anterior dislocation of the lower jaw on the right. C. Unilateral posterior dislocation of the lower jaw on the right. D . Unilateral anterior dislocation of the lower jaw on the left. E. Bilateral anterior dislocation. Correct answer : D . Unilateral anterior dislocation of the lower jaw on the left.

3. During the operation to remove 4.6 teeth, the doctor did not fix the lower jaw with his left hand. Tooth dislocation was performed with great effort. During removal, the patient felt pain in the left auditory canal, the jaw shifted to the left. Attempting to close his mouth became impossible. What complication did the patient have? Answer options: A. Bilateral dislocation of the TMJ. B. Fracture of the articular process of the mandible. C. Unilateral dislocation of the TMJ. D . Fracture of the mandibular branch. E. Fracture of the angle of the mandible. Correct answer : C. Unilateral dislocation of the TMJ.

4. A patient with complaints of inability to close his mouth was taken to the Department of Maxillofacial Surgery. The condition arose when biting an apple. On examination: the patient's face expresses fright, mouth wide open, chin shifted to the left, there is a leakage of saliva. At a palpation through an external auditory pass movements of the right articular head are absent. What diagnosis can be assumed? Answer options: A. Fracture of the articular process of the mandible. B. Dislocation of the left temporomandibular joint. C. Dislocation of the right temporomandibular joint. D . Bilateral dislocation of the temporomandibular joint. E. Pain dysfunction of the temporomandibular joint. Correct answer : C. Dislocation of the right temporomandibular joint.

5. A 48-year-old patient complained of inability to close her mouth, discharge, and inability to swallow saliva. Objectively: the mouth is open, the chin is pushed forward and lowered, the attempt to close the mouth causes or exacerbates pain in the temporomandibular joints. The face is elongated, the buccal areas are tense, compacted. Speech is incomprehensible, chewing is impossible, soft tissues sink in front of the earlobes, bone thickening is palpated under the chin arch (right and left). What is the condition of the above clinical picture? Answer options: A. Bilateral anterior mandibular dislocation. B. Unilateral anterior dislocation of the mandible. C. Bilateral posterior dislocation of the mandible. D . Fracture articular heads of the mandible. E. Bilateral fracture of the mandible in the area of the corners. Correct answer : A. Bilateral anterior mandibular dislocation.

6. A 35-year-old woman, on the second day after tooth extraction, complained of pain in the parotid and masticatory area, feeling that there was no contact between the teeth of the upper and lower jaw on the right. During the examination: the chin is shifted to the left, the mouth is half open, the lips are closed, the bite is broken. Restriction of lateral movements of the lower jaw. In front of the tragus of the right ear is a depression of soft tissues. What research is most informative in this violation? Answer options: A. Symptom of load. B. Ultrasound. C. X-ray of the TMJ. D . Radiography of the lower jaw E. Bimanual research. Correct answer : C. X-ray of the TMJ.

7. The patient, 20 years old, went to the doctor with complaints about the impossibility of lower jaw movements, difficulty speaking and eating. The condition is associated with trauma caused by biting an apple. At inspection the half-open mouth is noted, the bite is opened at the expense of single contacts of distal mounds of the last molars of jaws, salivation, speech is illegible, articular heads of a lower jaw in front of tracts are palpated. What diagnosis will the doctor make for the patient? Answer options: A. Fibrous ankylosis of the temporomandibular joint. B. Exacerbation of osteoarthritis of the temporomandibular joint. C. Acute anterior bilateral dislocation of the mandible. D . Traumatic bilateral fracture of the articular processes of the mandible. E. Fracture of the articular processes of the mandible. Correct answer : C. Acute anterior bilateral dislocation of the mandible.

8. A 45-year-old patient complains of inability to close her teeth. Difficulty eating, salivation. When examining the chin is shifted to the left and forward. The bite is open. He can't close his mouth. This condition arose after the accident. Which diagnosis is most likely? Answer options: A . Anterior right mandibular dislocation. B . Bilateral anterior dislocation of the mandible. C . Posterior right dislocation of the mandible. D . Traumatic fracture of the right articular process of the mandible. E . Traumatic fracture of the left articular process of the mandible. Correct answer : A. Anterior right mandibular dislocation.

9. A 58-year-old patient complains of clicking in the TMJ while eating. Yesterday, the patient ate an apple, opened her mouth wide, and her lower jaw was in a position where it was impossible to close her mouth. By pressing your fingers on the coronal processes of the lower jaw, the latter easily falls into place. What diagnosis can be assumed? Answer options: A . Subluxation of the lower jaw. B . Acute dislocation of the lower jaw. C . The usual dislocation of the lower jaw. D . Anterior dislocation. E . Posterior dislocation. Correct answer : C . The usual dislocation of the lower jaw.

10. The patient went to the dentist with complaints of inability to close her mouth, difficulty speaking. Objectively: the oral cavity is half open, saliva flows from it, the central line is shifted to the right. In front of the earlobe - a hollow, and under the zygomatic arch - a protrusion due to the displacement of the head of the mandible in the temporal fossa. Make a diagnosis. Answer options: A . Unilateral anterior dislocation of the lower jaw on the left. B . Unilateral posterior dislocation of the left lower jaw. C . Unilateral anterior dislocation of the lower jaw on the right. D . Unilateral posterior dislocation of the lower jaw on the right. E . Bilateral anterior dislocation. Correct answer : A . Unilateral anterior dislocation of the lower jaw on the left.

Situational tasks

Task 1. The patient, 67 years old, opened his mouth very wide while yawning, but could not close it. He believes that he injured his jaw because "something in his ear cracked." Examination revealed that the lower jaw was pushed forward, the mouth was half open and did not close. Make a diagnosis? Answer options: A. Posterior dislocation. B. Bilateral fracture of the articular process. C. Dislocation of the anterior bilateral mandible D. Lateral dislocation of the mandible. E. Bilateral fracture of the mandible Right answer: C. Dislocation of the anterior bilateral mandible Solution algorithm: To establish the diagnosis, you should pay attention to the data of objective examination (the lower jaw is pushed forward, the mouth is half open and does not close), so the correct answer is C.

Task 2. A patient with unilateral dislocation of the right temporomandibular joint was taken to the Department of Maxillofacial Surgery. What type of local anesthesia is indicated for relaxation of the masticatory muscles during joint repositioning? Answer options: A. Extraorbital mandibular anesthesia, mandibular tract. B. Torus anesthesia. S. By Bershe-Dubov, subconscious way. D. Extraoral mandibular anesthesia, maxillary pathway. E. Intraoral mandibular anesthesia. Right answer: S. By Bershe-Dubov, subconscious way. Solution algorithm: To fix the mandible, you need to relax the masticatory muscles by excluding from the function of the motor branches of the mandibular nerve (III branch of the trigeminal nerve). This is possible during Bershe-Dubov anesthesia.

Task 3. A patient, 40 years old, complains of a clatter in the projection of the right TMJ, which occurs in the final phase of mouth opening. Joint sounds appeared after prosthetics. The opening of the mouth is free, on a straight path, the amplitude of the opening is 5 cm. What is the most probable diagnosis? Answer options: A. Posterior dislocation of the articular disc. B. Dislocation of the lower jaw. C. Perforation of the meniscus. D. Anterior dislocation of the articular disc. E. Subluxation of the lower jaw. Right answer: E. Subluxation of the lower jaw.

Task 4. The 29-year-old patient opened her mouth wide while yawning and was unable to close it. On examination - the mouth is open, saliva flows from it. The patient is confused and helpless. X-ray examination of the TMJ determines the location of the articular heads of the mandible in front of the articular tubercles of the temporal bones. 1. Make a diagnosis. 2. Make a treatment plan. Solution algorithm: 1. Acute anterior bilateral mandibular dislocation. 2. Correction of dislocation should be performed by inserting the doctor's fingers into the patient's mouth and placing them on the coronal processes that protrude under the mucous membrane. With a downward and backward effort, strain the dislocated jaw. Task 5. The patient, 52 years old, complained of pain in the TMJ on both sides, clicking and moving the lower jaw when opening and closing the mouth in different directions. From the anamnesis it is known that the pain arose against the background of clicking, which has existed for a long time. The appearance of pain was caused by limited mobility in the joint, limited mouth opening. Of the diseases noted frequent SARS, bilateral chronic mumps. The configuration of the face has not changed. Palpation determines the mobility of the articular heads, which is combined with movement in different directions of the mandible. In the oral cavity: orthognathic occlusion , mild gingivitis. The patient has been using partial removable dentures for 8 years. At X-ray inspection - articular tubercles are expressed on height, and articular hollows - on depth. The articular cleft is noticeably dilated, with the mouth open the articular heads are located in front of the articular tubercles of the temporal bones. 1. Make a diagnosis. 2. Make a treatment plan. Solution algorithm: 1. Clinical and radiological examination: clicking in the TMJ, excessive mobility of the lower jaw, opening and closing of the mouth occurs abruptly, when opening the mouth the articular heads of the lower jaw are in front of the articular tubercles, and with closed jaws lower jaw. 2. When deciding on the choice of treatment, it is necessary to assess the anatomical features of the TMJ. At normally expressed on height of articular tubercles and sufficient depth of articular depressions treatment is appointed conservative, and at weakly expressed - surgical. literature Basic: 1.Malanchuk VO Surgical dentistry and maxillofacial surgery / V.O. Malanchuk - Kyiv 2011. Vol.2.- 478-482 p. 2. Timofeev OO Guide to maxillofacial surgery and surgical dentistry: a textbook. [5th ed., Revised. and add.] - K .: Chervona Ruta-Tours, 2012. - 1048 p: ill. 3. Kharkov LV, Yakovenko LV, Chekhova IL Surgical dentistry and maxillofacial surgery of childhood. –K., 495 p. Additional: 1. Cherkashin SI Diseases of the temporomandibular joint: clinic, diagnosis, treatment / S.I. Cherkashin // Ternopil. TSMU - "Ukrmedkniga". - 2014. - 147 p. 2.Avetikov DS A comprehensive approach to the choice of methods of examination of patients with painful dysfunction of the temporomandibular joint as a condition for effective treatment / DS Avetikov, OS Ivanitskaya, OV Rybalov // Actual problems of modern medicine: Bulletin of the Ukrainian Medical Dental Academy. - 2013. - № 2 (42). - P. 15 - 17. 3. Moskalenko PO Visualization of sounds that give the components of the TMJ, as an additional method of diagnosing its diseases / PO Moskalenko, OI Yatsenko // Actual problems of modern medicine: Bulletin of the Ukrainian Medical Dental Academy. - 2009. - Volume 9. -№ 3 (27) .– P. 89 - 93. 4. Yatsenko OI Clinical and radiological characteristics of the compression-pain symptom of the temporomandibular joint /O.I. Yatsenko, OV Рибалов, О.С. Ivanytska, P.I. Yatsenko // Bulletin of problems of biology and medicine. - 2015. - № 2 (1). - P. 363 - 366. 5. Lunkova Yu.S. Peculiarities of topographic-anatomical and morphological changes of TMJ elements in patients with unilateral and bilateral dislocation of the articular disc according to MRI studies / US Lunkova, Yu.V. Stupina, VM Novikov // Ukrainian Dental Almanac. - 2016. - № 3 (Vol. 2). - P. 46 - 60. 6.. Mirza AI The role of complex treatment of dental patients with pain syndrome of the temporomandibular joint dysfunction / AI Mirza, E.Yu. Mozolyuk // Problems of ecology and medicine. - 2011. - № 15 (3–4). - P. 113 - 115. Electronic resources: 1 [http://www.krasotaimedicina.ru/diseases/zabolevanija_stomatology/TMJ- ankylosis], 2015. 2. [http://bone-surgery.ru/view/ankilozy_visochno-nizhnechelyustnogo_sustava/], 2013. 3. [http://intranet.tdmu.edu.ua/data/kafedra/internal/stomat_ter_dit/classes_stud/ru], 2014. 4. International Classification of Diseases ICD-10. // http : // www . mkbl 0. com 5. barrmathiars williams [email protected] 2018 6. http://www.scienceeducation.ru/ru/article/view?id=25125. 7. https: // science education.ru / ru / article / view? Id = 25336 prepared by Steblovskiy D.V.