Vascular occlusion: causes, symptoms and treatment

When carrying out diagnosis and treatment, it is necessary to establish the location of the damage, the degree of stenosis and its causes. Therefore, patients are prescribed a wide diagnostic program, as well as treatment methods - today they are varied and effectively eliminate the problem.

Most often, the disease affects extracranial vessels, but pathology of intracranial arteries also occurs. This condition is responsible for half of the clinical cases of cerebral ischemia and about 30% of strokes. There are complete and incomplete obstruction (blockage) of the vascular lumen, which lead to disruption of the blood supply.

Normally, the common carotid arteries arise: the left one from the aortic arch, and the right one from the brachiocephalic trunk. They are directed vertically and are located on either side of the cervical spine. Next, it divides into the external and internal carotid arteries. The branches of the arteries supply blood to the intracranial parts, parts of the face, and organs of the head and neck.

Causes

Vascular occlusions are associated with a state of vascular insufficiency. The occlusion process occurs:

as a result of injuries, if the artery is compressed.
due to the fact that the lumen is blocked by a thrombus or embolus.

The formation of blood clots is promoted by a chronic disease - vascular atherosclerosis. As atheromatous plaques grow and increase in diameter, they interfere with normal blood flow. Atherosclerotic plaque leads to blood clotting and blood clot formation. Occlusion is caused by separated plaque fragments that move freely along the vascular bed. In addition, as a result of atherosclerosis, the walls of blood vessels lose their elasticity, become thinner and stratify under blood pressure, which causes the formation of aneurysms. Thrombosis or embolism is likely to occur in the area of the vessel where the dilatation has appeared.

Diagnostic program for the disease

First of all, a timely start to the diagnostic search is necessary. It is better to rule out the disease and continue to live peacefully than to postpone a visit to the doctor “for later.” For symptoms that cause concern, professional medical attention is necessary. The doctor begins making a diagnosis by interviewing the patient and general clinical examinations. If there are neurological symptoms, reflexes, sensitivity, motor activity, muscle and analyzer function are assessed. The following instrumental methods are used:

Ultrasound of the arteries of the head and neck with Doppler sonography - triplex scanning. A safe, fast and inexpensive method that allows you to exclude or confirm the diagnosis;
Functional tests during ultrasound examination;
Computed tomography angiography - visualization of blood flow through vessels using a contrast agent;
Magnetic resonance imaging of the brain.

To diagnose atherosclerosis, a laboratory method is used - the patient donates blood for a lipid profile. Also, it is necessary to evaluate the blood coagulation system and its coagulation properties. It is mandatory to measure pulse and blood pressure. To identify systemic vasculitis, specific laboratory tests and immunological studies are used.

MRI and CT are the “gold standard” in the diagnosis of ischemic disorders, including stroke. Depending on the location and extent of the lesion, treatment is prescribed.

Occlusion of cardiac vessels

A dangerous condition is considered to be acute occlusion of the coronary arteries, which supply blood to the heart muscle. This occurs as a result of atherosclerosis of the coronary arteries and coronary heart disease. If, during the chronic course of the disease, a person experiences angina pectoris, then the acute form is fraught with a heart attack and even death of the patient. Typical signs of cardiac vascular occlusion are chest pain that lasts more than 10 minutes and does not go away with rest or after taking nitroglycerin. In this case, the concept of acute coronary syndrome is used: a patient with such symptoms should be immediately hospitalized.

The danger lies in the fact that a person initially ignores the symptoms of coronary artery disease or simply does not feel them without taking any measures. Vascular occlusion is characterized by suddenness and unexpectedness, so at the first signs of developing coronary artery disease, consult a doctor immediately.

What else causes stenosis?

More rare cases are associated with a specific pathology. Narrowing of the arterial vessel is observed with a disease of the connective tissue that forms the stroma of the artery. This is called fibromuscular dysplasia - the vessels cease to maintain tone and collapse, stopping blood flow. Stenosis can accompany some inflammatory diseases of the vascular wall - arteritis, systemic vasculitis, Takayasu's disease, Horton's disease. There are rare pathologies, for example moyamoya disease, in which there is a slow progressive narrowing of the lumen of the arteries.

Stenosis can occur after an injury - a strong blow, a concussion. After some traumatic brain injuries, a special hematoma is observed - subintimal, which has the appropriate localization. A blood clot that forms due to increased blood clotting and rare types of anemia can block the lumen. There is antiphospholipid syndrome, in which young patients experience heart attacks and strokes precisely because of increased coagulation. Blood clots form when heart rhythm disturbances occur while taking certain medications.

The narrowing may be due to congenital structural features of the vessels - they can be tortuous and hypoplastic. Vascular pathology accompanies systemic diseases, diabetes, obesity and metabolic disorders.

Peripheral vascular occlusion

Large arteries of the extremities, more often the lower ones, are susceptible to vascular occlusion. Occlusions are an unpleasant consequence of vascular diseases of the legs. At the same time, the threat of an acute occlusive process in this area is dangerous due to the development of tissue necrosis, which leads to amputation of the affected limb. Characteristic signs of thromboangiitis obliterans, atherosclerosis of leg vessels and other common pathologies are:

pain in the legs that does not go away with rest;
pallor of the skin of the extremities;
coldness in the legs;
tingling sensation, numbness in the limb;
impairment of motor functions of the limb.

If these symptoms appear, it is recommended to immediately examine and treat the vessels of the extremities: the slightest delay can result in the development of gangrene. In the early stages of the development of the disease, treatment of obliterating atherosclerosis of the lower extremities and other pathologies of sclerotic origin is carried out using conservative methods, whereas in an advanced form it is difficult to fight the disease.

Occlusive processes occur in the arteries of the kidneys, resulting in the development of renovascular hypertension and kidney dysfunction. The aorta is also affected, since it is the largest vessel. Read about the consequences of aortic atherosclerosis by clicking on the link.

What manifestations are accompanied by the pathology?

The clinical manifestations of the disease depend on where the problem is located. Also, the nature of the onset of the disease, which can be sudden or gradual, plays an important role. It is worth remembering that in the first stages of the disease, compensatory mechanisms always turn on. For example, if the blood flow is partially disrupted, a system of collaterals develops, which will provide alternative routes for blood supply to the brain. The lack of oxygen supply is also compensated - the pulse and breathing become more frequent, intracellular processes change. For short-term conditions this is enough, but for serious pathologies it is not. In such cases, symptoms of the condition develop. Naturally, with an abrupt onset and significant stenosis, compensatory forces do not work and the clinical picture has a pronounced character, which indicates a stroke.

One of the first alarm signals is transient cerebral ischemia. These are short-term episodes of circulatory disturbance that can be compensated by collateral blood flow. The condition can be recognized by decreased sensitivity and motor activity, as well as visual disturbances. Patients usually complain of a feeling of numbness in the upper limb, half of the face, and loss of visual fields. Decreased muscle strength in the arm or forearm. The patient feels the movement of dark spots in front of the eyes, as well as a decrease in visual acuity. In some cases, the section of the artery that supplies the retina is affected. In some localizations, corresponding disorders occur - difficulty speaking, hearing, swallowing, facial asymmetry, severe pain. More common symptoms are dizziness, feeling unwell, weakness, and convulsions.

If stenosis develops gradually, the clinical picture also develops slowly. In some cases, it is so nonspecific that it is difficult to recognize the disease. For a long time, both the patient and the doctor may mistakenly believe that the cause of poor health is fatigue or increased stress. Also, the symptoms of occlusion overlap with the symptoms of a tumor process and dementia. This is indicated by increased irritability, depressive disorders, sudden changes in mood, increased drowsiness, decreased memory and mental abilities.

Nonspecific symptoms require a high level of responsibility from the patient and the doctor, since high-quality diagnosis is necessary. The diagnosis determines how correct the treatment of the pathology and the result will be.

Occlusion of blood vessels supplying blood to the brain

Occlusive processes in the arteries supplying the brain are fraught with dangerous consequences. Impairment of cerebral blood supply is fraught with the development of a stroke or ischemic cerebral infarction, and this often ends in the patient’s death, paralysis or dementia. A common cause of this is carotid artery occlusion. It is accompanied by loss of consciousness, nausea and vomiting, impaired coordination, speech and vision, weakness and numbness of the limbs. A harbinger of strokes are transient (cerebral) ischemic attacks, which we described in detail earlier.

Forecast and preventive recommendations

If the arterial lumen is blocked by half, the disease may occur without obvious signs. With such a picture, the risk of developing apoplexy is 10% of all cases within five years. A 75% vascular blockage leads to a 6% stroke rate in the first year. Complete thrombosis of the canal leads to inevitable neurological damage in 40% of incidents. Preventive surgical intervention with or without prosthetics makes it possible to reduce these risks to a minimum.

To prevent the closure of vascular walls, it is recommended to get rid of bad habits, balance your diet, and monitor weight gain. The lipid composition of the blood is determined by regular testing. If necessary, therapeutic recommendations help adjust the composition of the blood solution. If cardiac abnormalities are present, supportive treatment should be provided promptly. In case of congenital diseases of the cardiovascular system, it is also recommended to undergo regular examination as prescribed by a cardiologist.

Lower extremity lesions

Such vascular damage can be included in a separate section, since according to medical statistics, in approximately half of all known cases, occlusion of the femoral artery and popliteal artery is recorded.

The symptoms of such occlusion have been studied and described in detail, and in the English-language medical literature there is even a rule of “five R” - characteristic manifestations, if at least one of them occurs, emergency diagnostics and treatment are required:

Pain - pain - diffuse, extensive area below the affected area, intensifying and not relieved by changing the position of the leg.

Pulselessness is the disappearance of the pulse in characteristic places close to the arteries. Doctors use a similar symptom to more accurately determine the location of occlusion.

Pallor – pallor, the color of the skin below the affected area initially turns pale, then spots of cyanosis appear. The temperature of such areas is rapidly decreasing.

Paresthesia - paresthesia, a feeling of numbness, tingling, "pins and needles" - are sure signs of vascular damage. Sensitivity to touch disappears, complete numbness may occur with the disappearance of painful sensations.

Paralysis – paralysis of a limb, impairment of its motor function – a manifestation of extensive ischemia of the area.

Failure to take measures in a timely manner (over 4–6 hours) can lead to irreversible necrotic changes in tissues and the development of a gangrenous process. Occlusion of the arteries of the extremities is one of the main causes of disability and leg amputation, especially in men over 60 years of age.

Tests and diagnostics

It is recommended to consult a doctor at the first manifestations of the disease. After examination, collecting anamnesis and assessing the manifestations of clinical symptoms, they begin diagnostics, which includes:

CT arteriography;
Doppler ultrasound;
cerebral angiography;
MR angiography;
coagulogram;
MRI of the brain.

Only after a comprehensive examination is appropriate treatment prescribed, which is selected individually for each patient.

Conclusions:

It is necessary to use modern anatomical dental chairs and instruments to provide competent dental care, as well as gentle methods of tooth extraction.
Occlusal disharmony of the dentition is of great importance for the development of postural imbalance and systemic pathobiomechanical changes in the musculoskeletal system.
It is necessary to work together between a dentist and an osteopath/kinesiologist in the treatment of diseases of the dentofacial system and the prevention of complications.
The use of craniosacral osteopathic treatment methods and/or kinesiological effects can have a beneficial effect on the relief of attacks, as well as the complete cure of the pathology of the temporomandibular joint in patients who have suffered from pain in this area for many years.
During dental and orthodontic procedures, it is recommended to use the complex of kinesiological anti-stress therapy developed in our Clinic.

This is desirable because physical and mental stress, appearing even at the stage of discomfort, can be aggravated when pain occurs and, unfortunately, during treatment. The degree of its (stress) severity decreases after treatment, but does not completely go away on its own.

Come to the Karaulov Clinic and we will help you!

Pathogenesis

When the blood thickens, there is an accumulation of fibrin in its composition, which leads to thrombus formation . Venous formations are characterized by constancy - they are located in one area and clog the vessels of the extremities, leading to necrosis and gangrene . Arterial formations are characterized by migration; they often break away from the original source and disrupt the blood supply to large organs, provoking the development of stroke , heart attack and other dangerous conditions.

Dental stress.

Temporomandibular joint syndrome may include pain in and around the joint, as well as in the ear, above and behind the ear, along one side of the head or neck, there may be decreased hearing, congestion and tinnitus, dizziness, feeling burning or discomfort in the throat, tongue, entire nose, along one side of the nose, impaired vision, bite, muscle balance, trismus, increased tooth wear, increased mobility of the TMJ, increased sensitivity of the oral mucosa and its dryness, herpes of the oral mucosa, external auditory canal , faces.

“Trauma” is a certain force that always causes stress, with disruption of the physiological functions of organs and tissues of the human body, resulting from external influence. It can be physical and/or mental. Its size can vary from microtrauma to macrotrauma. Unfortunately, a visit to a dentist or orthodontist can be considered as a combined injury of varying severity.

Situations in which imbalance in the temporomandibular joint may occur.

Acute injury.

Long dental procedures performed with the mouth open
Tooth extraction or tonsillectomy

Chronic injury

Poor quality rehabilitation treatment
Treatment by an orthodontist
Loss of teeth

Other reasons

Psychogenic factors
Contact sports, whiplash injuries
Untracked Factors

Explanation

A long time spent in the dental chair, during the dentist’s manipulations, when the patient lies with his mouth wide open, with his head thrown back and neck straightened, without the use of a mouth dilator, can be traumatic, because This is not a physiological position of the temporomandibular joint with overextension of the masticatory muscles. The location of the head restraints has a serious influence, as they limit the physiological movement of the occipital bone due to the protective tension of the posterior neck muscles.

Extraction of molars is especially traumatic. When removing a lower tooth, inward traction is used to separate the lower jaw and the temporomandibular fossa of the opposite side. When extracting the upper tooth, the picture is somewhat different, but can lead to a similar result.

It must be taken into account that the patient comes to the dentist with existing chewing pattern disorders. Such deviations from the norm are characteristic of every person and the intervention of a dentist can aggravate them. The localization of pain is most often unilateral, but in some cases it occurs symmetrically on both sides.

With TMJ dysfunction, chewing food causes severe, excruciating pain. This leads to a situation where patients switch to liquid food until they completely abandon it.

Emotional disturbances noteworthy:

- feeling of fear, anxiety,

- feeling of hopelessness, melancholy,

- irritability.

— sleep disorders: difficulty falling asleep, short-term intermittent, restless sleep, frequent awakenings, disturbing dreams.

- feeling tired, tired in the morning

— sensory-vegetative manifestations: hypersalivation, increased sensitivity of teeth to cold, dry mouth

- increased sensitivity to shock, heat, pressure,

- phonophobia, photophobia.

Diet for occlusion

To restore the elasticity of the vascular wall, strengthen it and reduce the severity of occlusion, it is recommended to adhere to certain dietary rules. In case of occlusion, it is recommended to adhere to a special cholesterol-lowering diet, which includes:

Legumes . Beans and legumes are sources of protein, iron, folic acid and contain absolutely no fatty acids.
Whole grains (wheat bread, buckwheat, oatmeal and brown rice).
Cabbage (all types, especially broccoli). Prevents salt deposition, normalizes the lipid spectrum of cholesterol, enriches the body with vitamins K and C.
Asparagus . Helps lower blood pressure and reduce cholesterol in the blood.
Persimmon . Rich in fiber and has a pronounced antioxidant effect.
Spinach . Allows you to reduce blood pressure in hypertensive patients.
Turmeric . It has an anti-atherosclerotic effect, reduces the volume of cholesterol plaques, and reduces the severity of the inflammatory process.

Basic principles of nutrition

In case of deep vein thrombosis of the lower extremities, it is necessary to eat a balanced, varied diet. The diet should consist of fruits, vegetables, whole grain cereals, lean meat, and natural dairy products. All dishes must be baked or steamed. It is necessary to completely exclude fatty, fried, salty, and sweet sodas from the diet. You also need to minimize your consumption of sugar and flour products. This will help not only reduce the load on the cardiovascular system, but also strengthen the entire body.

General information

Vascular occlusion is a blockage (more often of arteries than veins), which is characterized by a pronounced decrease in the speed and quality of blood flow. Occlusion can cause necrosis and, as a result, lead to death.
The pathology is quite common and can affect the organs of visual perception, the central nervous system, limbs and great vessels. sepsis and peritonitis develop . Abdominal ischemic syndrome develops against the background of a lack of adequate blood circulation in the digestive tract. The pathology is associated with occlusion of the unpaired visceral branches of the abdominal aorta - the celiac trunk and mesenteric arteries (superior, inferior). Abdominal toad can develop under the influence of both internal ( thrombosis ) and external factors (traumatic occlusion).

What is an occlusive dressing?

This method of sealing the lesion is used for wounds that require maintaining sterile conditions and protection from the external environment.

Applying an occlusive dressing to the knee joint requires certain skills and technique:

cover the wound surface with sterile gauze;
Place the top of the scarf on the thigh area and wrap it around the waist;
bend the bandage at the base by 2 cm;
cross the ends under the thigh, tie knots on the thigh;
Throw the top over the knot formed and then pass it under the knot.

Fundamentals of occlusion and biomechanics of the jaws: a new look at old concepts

A deep understanding of the basics of occlusion and biomechanics of the jaws is one of the most important and necessary components for providing comprehensive patient rehabilitation in dental practice. Knowledge of the principles of differential diagnosis of pain, planning of future iatrogenic intervention, as well as algorithms for the treatment of prosthetic disorders provides the doctor with all the necessary tools for further normalization of the patient’s dental status.

An orthopedic doctor simply cannot do without understanding how significant the concept of occlusion is not only in pathology, but also in a state of stable and adequate function. The formation of appropriate occlusal schemes is based on the redistribution of acting forces, because, in fact, it is precisely because of the excess of such indicators that diseases, pathologies and dysfunctions of the elements of the dentofacial apparatus arise.

Occlusal disorders can manifest themselves in the form of various structural damage to the dental status, such as pathological abrasion, fractures, and premature wear of restorative structures. In addition to the latter, functional pathologies are characterized by tooth mobility, loss of volume of soft and hard tissues, muscle pain, as well as pain and noise in the joints (the so-called clattering), limitation and impairment of movements of the lower jaw, remodeling changes in bone tissue in the structure of the temporomandibular joint . In such cases, patients form so-called parafunctional habits, the presence of which he himself does not know. Clinically, signs of such are manifested by excessive wear of one’s own teeth and various types of restorative structures present in the oral cavity.

There are different opinions regarding the relationship between the state of occlusion and disorders of the temporomandibular composition. According to the most extensive literature reviews, such associations are rather weakly expressed, as evidenced by the fact that when correcting occlusal relationships, it is not always possible to prevent the development and progression of joint pathologies. Based on the available data, the following conclusions can be drawn: only the absence of traumatic occlusal injuries, which are manifested by the action of excessively high parafunctional forces exceeding the adaptive capabilities of the body, ensures complete prevention of the occurrence of pathologies and dysfunctions, or the presence of such in the acceptable adaptation range. This conclusion is evidence-based, regardless of how ideal or non-ideal the occlusal schemes of each individual patient are. On the other hand, with prolonged exposure to excessive occlusal forces, the development of corresponding dysfunctions and diseases occurs regardless of the characteristics of a particular occlusal scheme. The corresponding pathological types of occlusion only further aggravate the course of related prosthetic diseases.

From the above it follows that if the doctor is fully familiar with the specifics of occlusal movements in a particular patient, and also understands their impact on the condition of soft and hard tissues, muscles and joints, then he can ensure the formation of such occlusal patterns that would be the most stable and least traumatic for each specific patient. In other words, understanding the basics of occlusion helps doctors not only plan future interventions, but also predict the functional rehabilitation of prosthetically compromised patients. The main connecting link between the pathology of the temporomandibular joint, the state of occlusion and the functional disorder of the dentofacial apparatus is the repeated action of excessive occlusal load, which goes beyond the adaptive range of the body. Based on this, the author considers it wrong to separate the dynamics of the application of force on human tissue from disorders and diseases developing in the same tissues - after all, in fact, these processes are of an indirect cause-and-effect nature.

The question is different: what is the true connection between the existing parafunction, the state of occlusion and functional deviations of the dentofacial apparatus. In order to understand how the jaw functions and where occlusion begins, you need to repeat in detail the anatomy of the masticatory muscles, the temporomandibular joint, and, of course, the teeth, taking into account the functional parameters of each of the above-mentioned components. After analyzing the anatomy, you should focus on how the relationship between the upper and lower jaws is generally formed, taking into account the occurrence of static and dynamic contacts between the surfaces of antagonist teeth. After this, the data obtained during the analysis can be implemented into a plan for future iatrogenic intervention aimed at eliminating structural disorders of the dentition and aesthetic problems, while ensuring not only the functional comfort of the dentofacial apparatus, but also the stability of the achieved results of complex rehabilitation.

In the course of analyzing the features of anatomy and intermaxillary relationships, doctors should look for key parameters of each of these components, on the basis of which they will subsequently make a decision regarding one or another possible treatment plan.

In this article, the author will refer to the concept of dental treatment planning, which takes into account changes in the facial profile during iatrogenic interventions, developed by Frank Spear. With significant destruction of the tooth structure, the main occlusal landmarks are simply lost, and the pathology goes beyond the boundaries of possible dental-alveolar compensation. Consequently, the clinician’s task is also to restore the supporting occlusal points of the intermaxillary relationship, and then, based on their stability, carry out further prosthetic rehabilitation. When implementing an approach to treatment taking into account changes in the facial profile, it is possible to ensure successful prosthetic reconstruction of the bite, based precisely on the position of the supporting occlusal landmarks.

Pankey rules and the concept of optimal occlusion

Dr. LD Pankey, being a pioneer and developer of comprehensive approaches to dentition restoration, proposed a specific concept that helps critically evaluate occlusion both during systemic dental rehabilitation and during everyday dental care:

When the condyle of the jaw is completely in the glenoid fossa, all the posterior teeth exhibit equal and uniform contact, while the anterior teeth only lightly touch the opposing teeth.
When the jaws are clenched, neither the teeth nor the lower jaw move.
When the mandible moves in any direction, none of the back teeth contact faster or more strongly than the teeth in the anterior region.

Having analyzed these features, we can take a fresh look at the specifics of the anatomy of the dentofacial apparatus.

Anatomy of the temporomandibular joint

In Photo 1 you can see that the condyle of the mandible is in very close contact with the biconcave disc of the joint. These elements of the joint are located inside the capsule, which is protected behind by retrodiscal ligaments, and below, by means of capsular ligaments, is attached to the neck of the condylar process. Anteriorly, the superior portion of the lateral pterygoid muscle attaches to both the disc and the neck of the condylar process, while the inferior portion of the muscle attaches only to the neck of the condyle. Behind the joint is the external auditory canal. Anterior and superior to the condyle is the eminence, and directly above it is the glenoid fossa. The articular surfaces are covered by fibrocartilage, which is a smooth structure, and is supported by synovial fluid. The latter lubricates the surfaces of the joint, providing them with nutrients and oxygen, as well as ensuring the removal of possible debris. In the structure of the capsule, the number of blood tissues is very limited, or they may be completely absent.

Photo 1. Classic diagram of the anatomy of the temporomandibular joint.

When analyzing a joint, it is necessary to note the most important relationships of its individual components. First, there is the close condyle/disc/fossa connection. Essentially, they are in as much contact as possible, allowing the joint to withstand the necessary loads. On the other hand, this form of connection of the elements ensures the anatomical and functional integrity of this organ during dynamic movements of the lower jaw. In certain articular pathologies, this relationship is disrupted, which leads to permanent functional changes. It is obvious that the variation in the size, volume and shape of the temporomandibular joint is quite significant, and these differ greatly from person to person. Historically, we have assumed that the dimensions of the condylar process are relatively stable. However, recent research has established that the size of this anatomical structure can change and adapt over time and depending on the prevailing circumstances. A striking example is the increase in condyle size when using night guards. Due to the protrusion of the mandible to maintain patency of the upper airway, the condyle also remodels, increasing in size. Thus, it is obvious that this bone structure can not only adapt to functional conditions, but also change its shape, increasing in its geometric parameters. Consequently, the previously determined dimensional stability is very, very relative. As the first occlusal guideline, the doctor can use the position of the condyle during the registration of the centric relation, which is the most desirable. Firstly, the central ratio is a parameter that, with adequate execution technique, can be quite accurately and easily recorded. In addition, this position of the structures is repeatable, and it can be restored even if the position of the teeth changes or the contact between them is disrupted. A stable joint in this position has the ability to withstand significant loads, and the lateral pterygoid muscle can remain in a passive state even with strong clenching of the jaws (photo 2, 3).

Photo 2. Muscles that lift the mandible on the right side.

Photo 3. Muscles that lift the mandible on the left side.

Anatomy of the masticatory muscles

The function of raising the lower jaw is provided by three masticatory muscles. With parafunctional habits, such as bruxism, these masticatory muscles can develop significant force acting on all structures of the dentofacial apparatus. The masticatory muscle starts from the zygomatic arch and is attached to the lower edge of the lower jaw. The force vector of this muscle is directed upward and forward. The cross-sectional thickness of the masticatory muscles justifies the fact why they can develop the most significant strength indicators, located anterior to the temporomandibular joint. The temporalis muscle begins in the area of the temporal fossa and the deep part of the temporalis fascia. It is directed medial to the zygomatic bone and forms a tendon that is attached to the coronoid process of the mandible, and also passes into the region of the retromolar fossa distal to the last molar of the mandible. Since the muscle splits along its course, the action vectors of its force also diverge: the anterior component is directed upward and slightly anteriorly, while the posterior component is directed upward and posteriorly. This feature should be taken into account when diagnosing pain symptoms arising in the area of this particular muscle.

The medial pterygoid muscle consists of two heads: the main part of the muscle begins directly above the medial surface of the lateral pterygoid plate, while the superficial head begins from the maxillary tubercle and the pyramidal process of the palatine bone. The fibers of this muscle are directed downward laterally and posteriorly, and through the tendon are woven into the lower and posterior parts of the medial surface of the angle and ramus of the mandible. Insertable fibers connect this muscle with the masseter, forming common tendon slings, which allows both muscles to jointly perform the function of raising the mandible.

All of the above anatomical factors determine the direction vector of forces when activating the above-mentioned muscles. First, the directions of force of all three muscles shape the position of the condyle in the glenoid fossa: anteriorly and superiorly opposite the eminence and slightly medially, so that the medial pole of the condyle is the most load-bearing side of the joint. In other words, if we exclude the action of interdental contacts, then it is these muscles that determine the most superior position of the condyle, thereby ensuring close contact between the condyle, disc and glenoid fossa. The digastric muscle is one of the main muscles that lowers the lower jaw and opens the mouth. It begins in the area of the mastoid notch, forms a tendon along its path, and ends at the lower border of the mandible near the symphysis on the side of the digastric fossa. Since this muscle lowers the jaw, pain in this area is a rather unusual symptom. The lateral pterygoid muscle moves the lower jaw laterally and also forward. The upper head of this muscle starts from the infratemporal wing of the sphenoid bone, and the lower head starts from the lateral pterygoid plate. The muscle is woven in two bundles into the neck of the condylar process and the articular disc. Part of its function is to coordinate the position of the disc relative to the condyle to maintain the desired functional relationship, but in addition it provides support for the mandible in an eccentric position during intense clenching or bruxing when appropriate jaw movement is required to achieve maximum intercuspidation at existing tooth contacts . The three main levator muscles produce much more force than the lateral pterygoid muscle, therefore it must provide sufficient contraction to counteract the aforementioned elevator muscles. If these parameters do not correspond, painful sensations and even spasms may occur, which indicate a violation of muscle function.

Posterior teeth relationship

Pankey's first rule states that by positioning both condyles in centric relation, the posterior teeth form simultaneous and uniform contact, while the anterior teeth contact either slightly less or to a similar degree (Plates 4, 5).

Photo 4. Teeth contacts on the upper jaw.

Photo 5. Teeth contacts on the lower jaw.

Essentially, every type of occlusal design, regardless of condylar position, involves achieving multiple tooth contacts. With this ratio, the bite force is distributed more evenly over a larger number of tooth surfaces. In addition, maximal contact does not require activation of the lateral pterygoid muscles to maintain the mandible in the desired eccentric position. On the other hand, by ensuring simultaneous contact of the tooth cusps with flat bite pads, it is possible to guarantee the direction of the acting force down the long axis of the teeth, excluding the influence of deflecting lateral components (photo 6).

Photo 6. Areas of contact between the cusps.

It is the latter that provoke various structural damage to teeth, restorations, soft tissues and bone crest. And finally, with adequate contact of the posterior teeth, optimal distribution of the functional forces of the muscles that lift the mandible is ensured on both temporomandibular joints. When contact is ensured only in the area of the incisors, 60% of the total force generated by the muscles that lift the mandible is transferred to both joints, while with contact of the second molars this figure decreases to 5%. Posterior tooth contact is especially critical for painful and unstable joints.

Functional system assessment

Assessment of the functional system is a stage of diagnosing all conditions of the functioning of the dentofacial apparatus in each individual patient. The beginning of this stage is an analysis of how the patient talks to the doctor, and the idea of this approach was first proposed by Bob Barkley and later improved by Pankey. Barkley came to the conclusion that it is best when any disorders in a patient are diagnosed not only by the treating team of doctors, but also by the patient himself during diagnostic procedures. Therefore, a history review is a key initial aspect of treatment. A thorough and comprehensive patient examination algorithm was precisely described by William Lockard in his book “The Exceptional Dental Practice”.

Assessment of the functional state of the dental system includes diagnostics:

temporomandibular joints
masticatory muscles
range and pattern of movements of the lower jaw
analysis of static and dynamic tooth contacts.

The overall goal of a functional examination is to collect as much data as possible in order to determine whether the patient’s dental condition is stable or not. If the system is unstable, the doctor needs to determine where the structural damage occurred, what pathology could provoke it, and what type of dysfunction arose as a result. It is extremely important to consider all possible influencing factors before making a final diagnosis. Sometimes it happens that certain violations of functional parameters can be identified only at the end of the diagnostic process, or even between patient visits, based on his own complaints and comments that arose during a comprehensive examination. The order of diagnostic manipulations is determined by the attending physician himself, therefore the author developed the algorithm presented in the article himself, based on existing clinical experience. The first stage of diagnosis remains the assessment of joint function.

This step involves obtaining answers to the following questions:

Do you feel pain when palpating your joints? If so, what is the nature of these sensations and how strong are they?
Do you feel noises when moving your joints? If so, at what point in the movement and what is the nature of the sound? Is it painful?
Is the movement of the lower jaw free and unrestricted? Are there any deviations? If so, how significant are they and in what direction are they observed?
Can the joints withstand the forces or loads placed on them?

Positioning at the 12 o'clock position allows the doctor to examine the patient along the long axis of the head and at the same time analyze the existing deviations in movements and symmetrical relationships. In adult patients, full mouth opening exceeds 40 mm, and in some patients this parameter even goes beyond 50 mm. The lateral movement of the lower jaw is normally about 10 mm. In this case, the doctor must determine whether pain occurs during lateral movements? Do the ranges of lateral motion differ in any particular direction? The nature of the movements of the lower jaw is determined simultaneously by the state of the condylar process, disc, articular fossa and tubercle, as well as the stability of the lateral pterygoid muscles and the muscles that provide mouth opening. It is logical that movements in a damaged or unstable joint will be more limited than movements in a healthy state of the dental system. Therefore, assessment of the initial parameters of movements in the joint is a mandatory stage of a complex diagnostic algorithm. In addition, it is very important to record the position of the joint in the centric relation position. The author uses the bimanual centric relation technique developed by Dawson, as well as a leaf calibrator, a luchiu jig, and various types of frontal stoppers. The lack of contact in the area of the posterior teeth allows the muscles that elevate the mandible to position the condylar head more highly before the disc-fossa complex of the joint limits its position. The use of front stoppers is a fairly reliable method for recording centric relation. The patient is asked to stick the lower jaw forward and repeat this several times in the position of the frontal stopper - in this way it is possible to achieve activation of the muscles that understand the lower jaw. Initial attempts to determine the centric relation may be unsuccessful due to disc impairment, or fluid swelling within the joint capsule, not to mention possible spasms of the lateral pterygoid muscles. In such cases, the doctor will be able to determine only a preliminary central ratio. As the joints and muscles stabilize, more accurate centric relation parameters can be determined. Using the same three recording methods above, the doctor can also test the ability of the joints to tolerate force applied to them. In other words, the physician can determine whether the present condyle/disc/fossa condition is stable and healthy enough to withstand the forces of normal functional loading or even parafunctional conditions? In most cases, joint instability is caused by disorders such as inflammation, disc lesions, disturbances between the constituent surfaces, and pain in the area of attachment of the lateral pterygoid muscle to the condyle and disc. By repeated protrusive and retrusive movements of the patient using a sheet calibrator and a Lucia Jig, the condition of the joint and the lateral pterygoid muscle can be diagnosed. Adaptation to stress is tested using a bimanual technique, increasing the upward pressure force. After diagnosing the joint, they begin to evaluate muscle function. This part of the inspection is to determine the following:

condition of the three muscles that lift the mandible. Is there any discomfort during palpation? What is the approximate cross-sectional thickness of the muscle? What level of tension is present when they are active? How does the patient react to palpation performed by the doctor?
condition of the lateral pterygoid muscles. Does pain occur with palpation or the action of any other factor?
condition of the muscles of the floor of the mouth.
condition of the muscles in the neck and shoulders.

Palpation of each of these muscles is slightly different, but the doctor should palpate as many of them as possible. The physician should increase the pressure gently and slowly while observing the patient's response while rating their pain response on a scale of 1-2-3 (mild to moderate to severe). In addition, the clinician should analyze the relative cross-sectional thickness of the masseter and temporalis muscles, as this parameter is a reliable indicator of the patient's ability to generate loads of a certain force during jaw clenching or towing. Based on existing observations, it is known that patients with a shallower mandibular angle tend to have thicker masticatory muscles, which in turn allows them to generate more force during function.

And finally, the doctor needs to determine the nature of tooth contacts at different jaw ratios for a final understanding of the patient’s functional state. First, the first contact at centric relation must be determined, which will be considered the critical cutoff point, even if the patient has not reached the stage of restoration of centric relation. For this manipulation, the author uses a bimanual technique and a sheet calibrator. In addition, for the same purpose, you can use the “luchiu jig”, deprogramming the patient’s masticatory muscles, and then proceed to the bimanual technique with a progressive increase in the thickness of the calibrator sheets: this is how it is possible to evaluate the upper movement of the condyle deep into the articular fossa, and as a result, the area of occurrence of the most early contact in the dental area. This manipulation helps the clinician form an idea of the need to correct the corresponding vertical and horizontal components in order to achieve maximum contact between the antagonist teeth. To perform such a correction, it may be necessary to use various treatment methods, while at the same time it is necessary to evaluate whether such an intervention will be so effective as to compensate for all the changes in the dentofacial apparatus expected during its implementation, or whether performing it as a whole will be considered inappropriate.

conclusions

Understanding the anatomy of the joints, muscles and dentition, as well as their relationship, helps the doctor to objectively assess the parameters of the bite and the function of the dentofacial apparatus. This knowledge determines the adequacy of the choice of one or another treatment approach, based on the specific clinical conditions of each individual patient. Determining the forces generated during function and parafunctional states is a key step in diagnosing and solving the main clinical problems associated with occlusion and its constituent components. The following article will examine the features of the relationship of the anterior teeth and the dynamics of the movement of the lower jaw in case of malocclusion and various dysfunctions, including pathological abrasion of teeth. In addition, the concepts of treatment planning based on changes in the patient’s appearance remain promising in the structure of algorithms for restoring articulatory patterns, while helping to reduce the destructive influence of excessive forces on the state of the entire functional system.

Posted by Edwin A. McDonald III, DDS

Treatment of occlusion of the central nervous system

The chances of restoring blood circulation and saving the retina from necrosis/infarction are determined by how quickly help is provided. Inpatient placement is required. Standard medical response regimens include vasodilators, antihypertensives, anti-inflammatory drugs, diuretics (diuretics), and anticoagulants (drugs that reduce blood clotting). Blood pressure, blood composition (primarily coagulation factors), as well as the clinical picture of concomitant systemic diseases, if any, should be constantly monitored.

Even if a vascular accident in the central retinal artery basin is experienced more or less well, in the future a comprehensive examination will be required (to diagnose and clarify the causes of the incident), treatment and intensive prevention of exacerbations of the underlying pathology, as well as regular ophthalmological monitoring and strict adherence to all recommendations.