Buttresses of the lower and upper jaw, contracture, types, causes and methods of treatment

Function of buttresses

Buttresses are thickened areas of bone tissue on the facial parts.

They perform the following important functions:

1. Load balancing during chewing movements. In this case, not only the teeth and alveolar parts of both jaws take on the pressure, but part of it is redistributed to the zygomatic region. This reduces the impact on the teeth. They are less susceptible to destruction and last longer.
2. Reducing the intensity of jolts and shaking that occurs when a person walks. Due to the upright posture that has developed in the process of evolutionary development, the head and brain, in particular, constantly experience shocks when walking and running. Some of them are cushioned by the spinal column and the peculiarities of the membranes of the brain. Some are hidden precisely by the structure of the skull, that is, by the presence of buttresses.
3. It is also necessary to soften shocks when a person plays sports.

Important: In case of accidents, skull buttresses help reduce concussive forces that are destructive to the human brain.

Photos and videos in this article will demonstrate the operation of buttresses and the distribution of force load across the bones of the skull.

Buttresses and structural features of the skull

Bone thickenings or buttresses of the jaws alternate with thinner bony sections. These weak points are very vulnerable to physical impacts, shocks, and pressure. Most often, these places become holes in the bones, which serve for the passage of nerve fibers and blood vessels.

Upper jaw buttresses

Buttresses of the upper jaw, features of their location

The maxillary thickenings consist of four formations.

Table No. 1. Maxillary buttresses and their functions:

Name of thickening	Location	Functions
Frontonasal thickening	It starts from the alveolus in which the fang is located, rises higher along the frontal process of the upper jaw, and reaches the nasal zone of the frontal bone. These right and left thickenings have additional reinforcement due to bone ridges. They are located transversely and are superciliary arches.	The purpose of these buttresses is to reduce the pressure that is generated during the operation of the fangs.
Alveolar-zygomatic thickening	Originates from the alveolar eminences of the first and second painters. Moves upward and to the side with the help of the zygomaticalveolar ridge. It reaches the cheekbone bone, where the excess load is redistributed. With the bone it is directed back to the zygomatic process of the temporal bone. Up, onto the zygomatic process, which belongs to the frontal bone. Inwardly, towards the zygomatic process and the infraorbital zone of the upper jaw, approaching the frontonasal buttress. Externally, this buttress is the most pronounced on the relief of the human skull.	The task is to distribute the load that occurs during the operation of chewing teeth, which is directed upward, backward and inside the jaw.
Pterygopalatine thickening	It extends upward from the alveolar tuberosity and maxillary tuberosity. There it is strengthened by the pterygoid process belonging to the sphenoid bone, as well as by the plate of the palatine bone.	The task of this buttress is to redistribute the force arising from the painters upward and forward.
Palatal thickening	Formed using the maxillary palatine processes. And the plates of the palatine bone, which connect the alveolar arches on both sides, located horizontally.	The function of this buttress is to alleviate the pressure generated in the transverse plane that occurs during chewing of food.

Important: all buttresses are formed as a person grows; in newborns they are less pronounced than in adults.

Mandibular buttresses

Location of thickenings on the lower jaw

There are two main buttresses:

1. Alveolar thickening. It starts from the lower border of the alveoli and moves upward to the gingival margin.
2. Ascending thickening. It runs along the entire body of the lower jaw, reaching the condylar process. Thus, providing basic support to the entire lower jaw.

The buttresses of the lower jaw are located along the following paths, according to the course of tension arising during chewing food and movements:

• in directions from the coronoid and condylar processes to the alveolar zone;
• between the apices of the processes in an arcuate manner along the notch;
• between the mental tubercles on the right and left;
• in the interval from the mandibular angle to the peak of the coronoid process;
• fan-shaped lines of thickening follow from the retromolar recess.

We can say that the formation of thickenings is a response of the bone structure to the occurrence of overload of bone tissue.

Important: there are buttresses not only on the outer surface of the skull, but also on the inner, this provides protection from fractures and cracks under force.

Material and methods

From 2008 to 2014 in the reconstruction of the upper jaw, we used a fibular autograft for the reconstruction of total defects (5 cases) and a radial autograft for the reconstruction of subtotal defects (10 cases). When using a radial skin-bone autograft in the subsequent placement of dental implants, there is a need to recreate the second cortical-spongy layer of the alveolar process on the lingual side, which can be achieved using parietal or mandibular free autoblocks.

With VRGN, relatively small defects of the alveolar process of the frontal part of the upper jaw are noted; more often the problem is the elimination of the defect of the palatal plate. Bone reconstruction requires the alveolar process, represented by genetically modified bone tissue in the projection of the bone cleft. A palatal bone defect does not require repair, since functional loss does not occur in the absence of reconstruction of the bone component. It should be noted that with complete clefts the main problem is communication with the nasal cavity. To eliminate defects of the upper jaw, we have developed a technique for using a free split chin graft and transplanting a fasciocutaneous graft [Application: 2010118686/14, 05/12/2010. Patent No. 2435537 ](4 cases).

In cases where the patient's health condition did not allow microsurgical transplantation, we installed Zygomatic system implants and fixed prosthetics (6 cases).

After a clinical assessment, instrumental diagnostic methods were used to study the pathology of the integrity of the jaw/s: OPTG, TRG, CT (with angiocontrast and soft modes).

If a tumor was present, the extent of resection was assessed and the optimal graft was selected according to the developed algorithm. If the X-ray picture of the tumor was detected, a biopsy was performed and, when the diagnosis was verified, resection of part or all of the jaw was performed. For jaw defects, after clinical and instrumental analyses, treatment planning began.

Preoperative planning was carried out using 3D visualization programs that made it possible to simulate the sizes, shapes, and position of the revascularized autografts relative to the bone structures, taking into account the positioning of the condylar processes of the mandible in the temporal fossae (anterior-superior position in the articular cavities) according to CT studies and the formation of anatomical buttresses for the upper jaw. A special feature of the programs is the absence of distortions in the individual dimensions of the patient’s skull.

We used fibular and radial autografts, since only they allow us to perform 3D modeling of the bone component congruent with the defect in the maxillary defect. Subsequently, when using a radial graft, the technique of transplanting free cortical-cancellous grafts was used to thicken the alveolar process for further dental implantation. Thus, a comprehensive and step-by-step reconstruction of the jaw defect was carried out to create conditions for restoring chewing function with fixed and conditionally removable orthopedic structures, which is important for any jaw defects.

After engraftment and activation of the dental implants, the subcutaneous fat pad of the fibular and radial flaps and the removal of excess skin pad were removed.

Orthopedic rehabilitation consisted of choosing the design of the prosthesis and precise adherence to the accuracy of taking impressions to transfer the complex relief of soft tissues and the position of the implants onto precise plaster models. The usual occlusion and central relationship of the jaws were recorded for the subsequent selection of prosthetic tactics for patients with reconstructed upper jaws. Plaster models were installed into the articulator using a facebow. The existing occlusion and centric relation were assessed. Depending on the type of defect, we selected the desired position of the lower jaw to create optimal chewing function and aesthetic results.

Particular attention was paid to the creation of a prosthetic bed for a future orthopedic design supported by dental implants. In these clinical situations, there is no attached keratinized mucous membrane around the implants in the oral cavity, which makes it difficult to accurately transfer the relief of the soft tissues of the prosthetic bed to create adapted non-removable orthopedic structures.

After the manufacture and fixation of temporary crowns on the implants, the presence of tumor-like growths of the mucous membrane around the installed orthopedic superstructures, which were histologically described as polyps, was noted. Patients complained of bleeding and discomfort around the installed crowns. Attempts to change the eruption profile of structures from implant shafts did not produce a positive result.

We used a method of simultaneous surgical correction of the subcutaneous fat area of ​​autografts with the installation of provisional structures supported by dental implants. In a number of cases, we used a removable compression acrylic plate on the gum formers, which held the surgically created profile until permanent prosthetics or installation of provisional fixed and conditionally removable structures.

After 3 months, we made permanent orthopedic fixed or conditionally removable structures.

For the manufacture of orthopedic structures, we used cobalt-chrome alloy, titanium and zirconium dioxide.

As a rule, after the integration of implants and placement of gum formers at the prosthetic stage, we were faced with the need to modernize the prosthetic elements of the implantation system for specific clinical cases.

The gum formers were needed to be longer and predominantly conical in shape. The cylindrical shape of the gum former created parallel walls of the crater of the mucous membrane, which caused rapid collapse of the walls during the placement of the impression coping and caused severe discomfort to patients during manipulations. We attribute this to the presence of excess connective tissue layer, which is located on the autograft bone.

It is important to note that immediately after corrective operations on the skin-fat part of the flaps, orthopedic compression plates were fixed to prevent further growth of the soft tissue component.

Patients were monitored every seven days and appropriate compression plate adjustments were made.

Depending on the chosen permanent structure, a set of further orthopedic manipulations was carried out to make prostheses.

The results were recorded using a Canon D 60 camera, 100 mm lens, and MR-100 ring flash.

Description of clinical observations

Patient U. , 18 years old, was admitted to the clinic on April 1, 2008 with a diagnosis of osteoblastoma of the upper jaw, a condition after subtotal resection of the upper jaw on the left. From the anamnesis: a neoplasm was discovered and removed in early childhood at the Federal State Institution Central Research Institute of Infectious Diseases and Maxillofacial Surgery. The patient was sent to the clinic of the Russian Scientific Center for Surgery named after. acad. B.V. Petrovsky.

Status localis: the configuration of the face in front and profile is changed, the upper lip is retracted on the left. On palpation, a defect in the alveolar process of the upper jaw on the left is noted.

Mouth opening is not limited, there is a through defect in the alveolar process of the upper jaw with teeth 21-28, the patient wears an obturating denture, the denture teeth are in the bite.

Bite according to the second class according to Angyu.

On OPTG and CT: there is a defect of the zygomatic tubercle, alveolar process on the left, absence of the spine of the upper jaw, the base of the pyriform foramen on the left, defect of the tubercle of the upper jaw on the left. An impacted 28th tooth is noted in the remains of the pterygomaxillary articulation.

Treatment tactics: since the defect of the upper jaw was subtotal and through, a radial skin-bone graft on a vascular pedicle was used. When transplanting a radial cortico-periosteal-skin graft, a zygomatic-maxillary buttress was formed using a free split graft from the branch of the mandible on the right. The second stage involved the formation of the alveolar process using parietal grafts.

Rice. 1. Appearance of the patient, existing defect of the upper jaw, bite, obturating prosthesis, CT scan

The patient was noted to have no nasal lining, and to anatomically restore aeration, before transplanting a microsurgical graft, the nasal lining was formed with local tissues.

Rice. 2. Stages of planning the bone and soft tissue components of the graft

Rice. 3. Stages of surgery

Rice. 4. Computed tomography of the patient after surgery and condition on the third day

Rice. 5. Scintigram after surgery

In the postoperative period, there was a divergence of the sutures and a reduction in the volume of the flap, and therefore a protective mouth guard was made to protect the soft tissue component of the flap from food getting into the graft. Kappa also pressed the flap into the defect area to allow healing by secondary intention.

Rice. 6. Postoperative mouth guard

2 months later, the patient, being a cycling athlete, fell from the “saddle” and received a fracture of the upper limb at the site of collection of the radial skin-cortical-periosteal graft on the vascular pedicle. Therefore, the patient underwent osteosynthesis with the Ilizarov apparatus.

Rice. 7. Condition after osteosynthesis of the upper limb on the left, condition in the oral cavity

Rice. 8. 3D reconstruction of the alveolar process using parietal grafts, CT scans after the second operation

After 5 months, we installed three dental implants in the area of ​​the reconstructed alveolar process using parietal bone autografts. Thanks to this technique for reconstructing the alveolar process, it was possible to obtain adequate bone thickness and height for placing dental implants.

Rice. 9. Implantation in the area of ​​3D reconstruction with parietal blocks

After 5 months, we opened the implants and applied a method of one-stage surgical correction of the subcutaneous fat pad of the autograft with the installation of elongated gum formers in dental implants, which simplified the formation of soft tissues during surgery.

After completion of the surgical stage, the alginate impression was removed from the upper jaw and a compression plate was made using cold polymerization at a pressure of 3 atmospheres from acrylic plastic.

The patient was advised to wear the plate constantly, removing it only for hygiene procedures. Inspection and correction of the plate fit were carried out every seven days for a month.

Thus, we were able to form a stable mucosal contour around the gingival formers.

The next stage was the production of a conditionally removable prosthesis supported on a beam structure on implants.

Rice. 10. Correction of the subcutaneous fat area of ​​the autograft

Considering the fact that microsurgical elimination of the jaw defect and reconstruction of the alveolar process was carried out by transplantation of free parietal cortical autografts, the further stage of orthopedic rehabilitation is practically no different from classical prosthetics for patients with an extended terminal defect of the dentition.

In order to be able to produce a conditionally removable beam-type prosthesis supported by implants, it was necessary to produce an accurate plaster model that displayed the entire relief of the prosthetic bed and accurately reproduced the position of the implants. To do this, we took primary impressions of the upper jaw using Clip-transfers for implants. The primary plaster model gave us the opportunity to make a custom impression tray with prepared transfer checks for precise transfer of the position of the implants.

Having made an accurate working model of the upper jaw and a model of the antagonists, we installed them in the articulator according to the average parameters. Registration of the central ratio was carried out using an occlusal hard wax plate with refinement on ALUWAX (soft wax with the addition of aluminum filings for long-term heat retention and elasticity).

Rice. 11. Impressions and plaster models

After analyzing the relationship of the plaster models in the articulator, we manufactured a beam frame supported by three implants. The beam frame was made by vacuum casting from cobalt-chrome alloy. To achieve a passive fit of the frame, we used adapters for external connection with the implants.

We fixed titanium ball locks into the cast part of the frame. Then a model of the upper jaw was made from a fire-resistant mass for modeling and casting the mating part of the prosthesis itself.

Rice. 12. Beam frame and mating part of the prosthesis

Taking into account the possibility of changing the relief of the soft tissue component of the autograft, the frame of the response part was modeled in such a way that it was possible to change the acrylic base part, changing the fit of the prosthesis to the bed.

After fitting the beam and frame in the oral cavity, we manufactured the base part of the conditionally removable denture with the installation of acrylic artificial teeth, using the method of cold polymerization of plastic under a pressure of 3 atmospheres and a temperature of 50 degrees Celsius. We took into account all possible characteristics of the patient at rest and when smiling, creating the most natural appearance of the entire orthopedic restoration.

The final fixation of the prosthesis was carried out in a certain sequence:

1. Cleaning and disinfection of all components of the prosthetic restoration.
2. Removing the gum formers, irrigating the internal shafts of the implants with a solution of 3% hydrogen peroxide and 0.05% chlorhexidine solution, installing adapters on the external connection.
3. Installation of the beam structure on three implants, tightening the fixing screws with a force of 30 N/cm2.
4. Fixing the actual removable denture on the beam frame, checking the occlusion, teaching the patient about hygienic measures.

Rice. 13. Fixation of the prosthesis in the oral cavity

Contracture of the lower jaw

Important: all contractures must be differentiated from trismus, strong clenching of the jaws during an epileptic seizure, so the diagnosis must be made by a doctor.

Contracture is a phenomenon when a person can only close his jaw with pathological features. They are explained by changes in the elasticity of the soft tissues of the jaw, disruption of the functioning of the temporomandibular joint ligaments. Disorders occur due to a traumatic factor or disease.

Contractures are accompanied by painful sensations for the patient when working the jaws. You should consult a doctor as soon as a person feels the first sensations of pain and restrictions in the functioning of the jaws.

Self-medication for this disease is not effective, but also dangerous. After all, it is better to devote the time spent to qualified treatment; in such conditions, the cost of delay is too high.

Types of contractures

Contractures of the lower jaw occur in various situations; their type depends on the source:

1. Unstable contracture is formed due to weakening of the muscles involved in chewing actions. This occurs after wearing special splints that are used to treat fractures. The reason is long-term inactivity of the muscular system of the joint. Also, unstable changes occur due to inflammation in the tissues around the lower jaw.
2. Persistent contracture is formed due to the formation of scars and similar changes in the maxillofacial area, due to: a gunshot wound, a traffic accident, a fracture of the coronoid process, the zygomatic arch, due to a burn or inflammation of the tissues near the jaw. The cause of scar formation can be an oral disease - stomatitis. Diseases of the muscles involved in chewing - myositis - can also cause contracture. The neurological factor influences the formation of contracture, so hysterical states and paralysis contribute to excessively strong contraction of the jaws with subsequent injury to the perimaxillary tissues.

So, depending on the source of scar formation, the type of contracture depends:

• dermatogenic – if the scar is on the surface of the skin;
• mucosogenic – when scar tissue is concentrated in the mucous membrane;
• myogenic – if the cause is a scar in the muscle.

With complex injuries and damage, a mixture of several types of contractures is possible.

Important: contracture can occur as a complication after certain types of anesthesia during treatment and tooth extraction.

Signs of contracture of the lower jaw

If a person suffers from this disease, the following symptoms will be observed:

• a person’s speech is disrupted and distorted;
• difficulty eating;
• the line of the dentition is transformed, taking on the shape of a fan;
• an open bite is formed;
• when opening the mouth, the jaw moves towards the source of the disease, the patient is not able to move the jaw towards the absence of damage;
• If a child suffers from contracture and the formation of the jaw bones has not yet completed, the lower jaw may lag behind the upper jaw in development.

Microsurgical operations of maxillofacial surgery

Microsurgery is a universal method used in almost all surgical disciplines to eliminate a defect in a particular tissue. In the human body, there are more than 400 donor sites with an axial type of blood supply, from which taking tissue does not cause any harm to the further blood supply of the entire organ. In the reconstruction of the jaws, the main place is played by the property of the flap with the presence of such a quantity and quality of bone that will make it possible to recreate the anatomical integrity of hard tissues and in the future the possibility of use for dental implantation and prosthetics .
For total and subtotal defects of the mandible, a fibular skin-bone flap . The fibula has sufficiently large supporting properties, having a fairly large amount of cortical component, and can be easily modeled to recreate anatomical contours. An iliac or otherwise inguinal skin-bone flap is optimal for reconstructing small defects of the lower jaw; in the latter cases, it is sometimes possible to use a free iliac bone.

For total and subtotal defects of the upper jaw, radial skin-bone and fibular skin-bone flaps are optimal. In cases where the defect covers the zygomaticomaxillary buttress in combination with a defect in the alveolar process, it is possible to fill the bone defect with corticocancellous parietal grafts and mandibular grafts taken from the ramus and mental region with free grafts of mesenchymal origin, which is optimal for reconstruction of the middle zone faces.

Of course, the dominant algorithm remains aimed at engrafting the flap on a vascular pedicle. If you have to choose between convenience for subsequent dental implantation in the form of the presence of a cortical plate of the bone component of the autograft in the area of ​​the recreated alveolar process for subsequent implantation and this somehow reduces the reliability of the vascular anastomosis, it is necessary to choose the reliability of engraftment. Disputes often arise between implant surgeons and reconstructive surgeons about how the iliac bone should be positioned in the defect area, but experience shows that there can be no compromises, since in case of thrombosis of the vascular anastomosis, the entire flap is lost. It is also necessary to understand that the location of the spongy component in the area of ​​the alveolar process does not interfere with subsequent implantation, since a new one is formed within 6 months.

To return and normalize chewing function and the ability to eat, it is necessary to have:

• 1. Lips and complex of swallowing organs.
• 2. Presence of jaws.
• 3. The presence of teeth and a bite that provides adequate chewing.
• 4. Presence of buttresses.
• 5. Stabilization of the TMJ.
• 6. Synchronicity of the masticatory muscles.
• 7. Mental balance of the patient.

In the literature, we did not find a specific algorithm or approaches aimed at returning such vital abilities as sucking and swallowing, chewing and normalization of speech function. To normalize the patient's nutrition, the presence of lips is necessary, otherwise salivation occurs, followed by maceration of the skin and the inability to receive and send food into the esophagus. Patients with defects of the soft tissues of the perioral area constantly suffer from gastritis, inflammation of the oropharynx, since the vacuum property of food evacuation into the esophagus is reduced, many adapt to swallow with an open mouth, throwing their head back; in the latter, the absorption of carbohydrates is impaired, since saliva takes part in cleansing the oral cavity from food residues, plaque and bacteria, thanks to its buffering properties, it neutralizes the negative effects of strong acids and alkalis within the buffer capacity, provides the supply of ions necessary for the remineralization of teeth, and has antibacterial, antifungal and antiviral properties. Claude Bernard proved that we recognize the functions of an organ by identifying the consequences of its absence. From the point of view of the functional return of the ability to eat, the second place in our algorithm is the presence of jaws. To eliminate defects in part or the entire jaw, we use preoperative planning.

Preoperative planning of the jaws is carried out using 3D visualization programs that allow modeling the sizes and shapes of autografts, taking into account the positioning of the condylar processes of the lower jaw in the temporal fossae (in the anterior-superior position in the articular cavities) according to CT scans. Despite the fact that we perform reconstruction in the previous bite, most often we have to deal with an already remodeled TMJ and a broken bite. Therefore, planning is necessary taking into account the subsequent achievement of centric occlusion in the centric relation. A functional study of occlusion consists of comparing central occlusion (CO-occlusion in which there is maximum contact between the teeth of the upper and lower jaw) and the central ratio (CO-condition in which the heads of the lower jaw occupy an anterior-superior position in the articular sockets). If there is a significant difference, a description of the differences is required. Thus, a significant difference between these conditions is more common with asymmetric deformations and with Angle class II deformities. Determining the CA is important for correctly drawing up an operational plan.

When planning the elimination of maxillary defects, we take into account the need to restore the buttresses, as well as the air supply of the upper jaw. Buttresses are the most important component for supporting the alveolar process, otherwise mobility of the upper jaw occurs after prosthetics.

Although restoration of the lost maxillary cavity and mucous lining is not possible, restoration of anatomical proximity is necessary, therefore filling the zygomaticomaxillary buttress with ilium is incorrect. It is optimal to use free split mandibular or parietal auto-bone blocks in shape in combination with bone with vascular nutrition. In the future, perhaps with the development of technologies for the use of stem cells, we will learn to restore the true mucous lining of the maxillary or paranasal sinuses.

In the reconstruction of the upper jaw, we use a fibular autograft for the reconstruction of total defects and a radial one for subtotal defects. When a radial skin-bone flap is subsequently used to place dental implants, it becomes necessary to reconstruct the second cortical-spongy layer of the alveolar process on the lingual side, which can be done using parietal or mandibular free autoblocks.

In maxillofacial microsurgery , when it is necessary to recreate bone curves, in the choice of grafts with bone, we are limited to iliac, fibular, and radial flaps, since only the latter allow 3D modeling of the bone component congruent with the defect.

of one-stage reconstruction after resection still remains open in the country . It is necessary to understand that if the reconstruction is not performed simultaneously with the resection of the jaw and even a temporary titanium structure is not applied to maintain the bite, remodeling of the temporomandibular joint occurs, both from the healthy and from the pathological side, and a violation of the trophism of the masticatory muscles. In these cases, before placing dental implants and before prosthetics of the implant, orthodontic fixation of the bite is performed in the form of braces and mini-implants, as well as muscle relaxation of the masticatory muscles on the part of the healthy jaw using Botex therapy or myotronic.

HISTORY OF THE PROBLEM

In our opinion, microsurgical autotransplantation for the purpose of jaw reconstruction has gone through several stages in its development:

Stage 1 – high-quality autograft collection, minimal modeling, and transfer to the recipient area. The main objective of this stage was to ensure graft engraftment (from 1978 to 1990).

Stage 2 included better modeling of autografts using conventional radiographs and wax templates. The main task of this stage was to restore facial aesthetics. The impaired function of the lower jaw was restored after a series of additional corrective operations and removable dental prosthetics (from 1990-1995). Stage 3 - computer modeling of the lower jaw and restoration of chewing function using prosthetics using dental implants. The main goal of this stage is to restore facial aesthetics and chewing function of the lower jaw without the use of additional corrective surgeries (from 1995 to 2011). Stage 4 - restoration of not only an ideal bite and stabilization of the TMJ, but also elimination of the imbalance of the masticatory muscles (in fact, this article opens the 4th stage in the history of maxillofacial microsurgery).

We have developed an algorithm for treating patients with jaw defects: 1. Preoperative 3D planning and production of stereolithographic and bite templates. Planning taking into account subsequent dental implantation and prosthetics. Selecting the optimal flap. 2. Restoration of buttresses, if possible, and the anatomical contours of the alveolar process of the jaws using free and pedunculated bone grafts. 3. Remodeling of the TMJ when eliminating subtotal defects of the lower jaw. 4. Dental implantation and prosthetics.

Microsurgical operation: resection of the lower jaw affected by the tumor with simultaneous reconstruction with a fibular graft on a vascular pedicle

1. Resection of the lower jaw affected by the tumor within healthy tissues
2. Stage of control of resection according to the preoperative template
3. Harvesting the fibula on a vascular pedicle	Read also:  Dentist's recommendations after cleaning teeth from tartar
4. Stage of modeling the harvested transplant using the author's device Karayan A.S. and Nazaryan D.N.
5. Control of the simulated transplant on the preoperative template
6. Fixation of the graft on the vascular pedicle to the remaining healthy fragments of the lower jaw
7. Microsurgical stage: under a microscope, the vessels from the lower leg and the external carotid artery, jugular vein are sutured, after suturing the vessels, the clips are removed and the tissue taken from the leg is filled with blood, i.e. the flap becomes alive, but on the jaw.
8. Control of blood supply - the final stage of microscopic surgery		Watch the video
9. The patient’s appearance before and after the operation will be practically unchanged; thanks to one-stage reconstruction, after 6 months the person will be completely rehabilitated

In the scientific and clinical department of maxillofacial and plastic surgery of the Federal State Budgetary Institution NCCO FMBA of Russia under the leadership of Professor Karayan A.S. and Ph.D. Nazaryan D.N. Unique surgeries are performed to eliminate jaw defects. Such operations are performed only in 3 medical centers in Russia.

Treatment

Foci of inflammation can be stopped with local injections

Treatment of contractures is based on treating the underlying cause of the disease.

Table No. 2. Causes of jaw reduction disorders and treatment methods:

Reason for violation	Treatment method
Neurological disorders	Treatment and relief of symptoms of epilepsy, treatment of spastic paralysis and hysterical conditions.
Inflammatory conditions	Elimination of the source of inflammation - tooth extraction, opening of phlegmon or abscess. For inflammatory contractures, local injection of anti-inflammatory drugs into the perimaxillary tissue is used. The final part is antibiotic therapy.
Bone changes	Surgical treatment, resection of adhesions and adhesions are performed.
Scar formations	Excision of scars and insertion of triangular flaps.

Carrying out the operation

For a person who has contracture of the lower jaw, surgical treatment is the main way to get rid of the disease if it arose due to scar formation. It is also necessary to carry out postoperative measures - mechanotherapy, therapeutic exercises, physiotherapy.

The essence of the intervention is dissection of scar formations. In this case, it is often necessary to close the wound surface. For this purpose, flaps from surrounding tissues or from the submandibular area and neck are used.

If the defect is significant and a too large piece of tissue is required, then a Filatov stem is used for replacement. If, after an injury, superficial scars have formed on the cheeks and corners of the mouth, they are eliminated using longitudinal dissection and joining the edges of the tissue prepared on the sides of the defective area.

In rare cases, when contracture occurs due to bone degenerative processes, operations are performed on the affected bone formations.

Physiotherapy

Physiotherapy is an important part of recovery

In simple cases, physiotherapy and gymnastics can be used as the main treatment method.

As physiotherapeutic support after the implementation of the main method of treatment, the following is used:

• paraffin therapy - using heated paraffin to apply to the site of the disease;
• Ultrasound therapy – application of an ultrasound source to the diseased area;
• the use of lidase and hyaluronidase, they can be used as a means for subcutaneous administration, for electrophoresis, for applications.