化脓性颞下颌关节炎的治疗

目的 探讨化脓性颞下颌关节炎的治疗方法及其疗效。方法 对我科近5年就诊的30例化脓性颞下颌关节炎患者，关节局部进行单针低压灌洗、双针低压灌洗、关节腔灌洗结合颞下间隙切排及关节内镜手术等4种方式治疗；治疗效果通过关节腔穿刺、张口度、颌疼痛和颌功能等方面的检查来评判；随访观察后遗症的发生情况。结果 治疗的总有效率为100％(30／30)；单针低压灌洗、双针低压灌洗、关节腔灌洗结合颞下间隙切排和关节内镜手术的有效率分别为14／20、9／13、1／1和4／4；后遗症主要为骨关节病。结论 化脓性颞下颌关节炎急性期的治疗要素是适当的关节腔低压灌洗、减轻关节负荷及全身配合应用抗生素；对伴有颞下间隙脓肿的患者，在进行关节腔灌洗的同时，还可行下颌下切口的颞下间隙引流；对一些灌洗治疗无效或有后遗症的患者，关节内镜手术有优异的疗效。     

化脓性颞下颌关节炎的特征与诊断

目的探讨化脓性颞下颌关节炎的临床特征及其早期诊断方法。方法收集我科近5年的30例化脓性颞下颌关节炎患者,对其临床症状,关节液的性质和量,关节液的组织学和细菌学表现,影像学检查,其它实验室检查及后遗症进行分析。结果患者主要为成年人(>18岁占29/30);血源性感染多见;多数(25/30)局部症状轻,全身反应不明显;关节液组织学检查见大量粒细胞,可伴纤维蛋白或纤维软骨碎片;15/30患者关节液细菌学检查见到细菌,培养出的病原菌主要为金黄色葡萄球菌和腐生葡萄球菌;后遗症轻,主要为继发性骨关节病。结论当今化脓性颞下颌关节炎表现出感染源隐匿性、症状不典型性、后遗症轻等特点;关节腔穿刺和关节液分析是其必要的诊断手段。     

颞下颌关节上腔灌洗术临床疗效观察

临床研究证实[1,2 ] ,颞下颌关节上腔灌洗术治疗颞下颌关节紊乱病有较好的临床疗效 ,特别是在某些类型关节病的治疗方面与颞下颌关节镜治疗相比 ,有相同的疗效[3 ] ,且该方法操作简单 ,易于推广。本文观察 46例颞下颌关节上腔灌洗术 ,对并发症及其预防与治疗进行讨论1　材料和方法1.1　一般资料收集 1995年 8月～ 1997年 5月上海第九人民医院口腔颌面外科关节专科门诊的 46例颞下颌关节病患者。其中 ,不可复性关节盘前移位 38例 ,化脓性关节炎 2例 ,类风湿关节炎 3例 ,骨关节病 3例 ;男 8例 ,女 38例 ;年龄 17～ 6 5岁 ,平均 35岁 ;病程 2周…     

颞下颌关节化脓性关节炎研究进展

颞下颌关节化脓性关节炎常见于成年人，多为血源性感染，病源菌主要为金黄色葡萄球菌，成人颞下颌关节化脓性关节炎症状具有不典型性，诊断较困难，治疗不及时可引起后遗症。作者对该病的发病特点，临床表现及诊疗现状的最近研究进展作一综述。     

2例个体化人工关节用于颞下颌关节置换的初步效果评价

目的：采用CAD／CAM技术设计个体化人工全颞下颌关节，通过全关节置换，治疗严重颞下颌关节病，对其疗效进行初步评价。方法：2例女性颞下颌关节疾病患者，年龄分刖为53岁和60岁。术前经MRI等检查发现严重的关节盘及髁突病变，开口度分别为2．0cm和1．8cm，均表现有明显的关节疼痛。2例患者均采用TMJ Concepts公司的个体化人工颞下颌关节全关节置换术。结果：成功完成了2例3侧颞下颌关节的置换手术。未出现术后并发症。关节疼痛在术后2周后逐渐缓解。6个月后开口度分别为2．7cm和2．9cm。术后口颌功能改善良好。结论：人工全颞下颌关节置换治疗严重颞下颌关节骨关节病具有良好的效果，个体化设计可为人工关节发挥良好功能提供有效的保证．     

高渗葡萄糖关节上腔注射治疗颞下颌关节囊松弛（半脱位）和复发性脱位的临床应用

目的：探讨高渗葡萄糖硬化治疗颞下颌关节囊松弛（半脱位）和复发性脱位的效果。方法：采用50%葡萄糖注射剂行关节上腔注射治疗6例颞下颌关节半脱位的患者和7例复发性颞下颌关节脱位的患者,观察疗效;并对其治疗前后Fricton颞下颌关节紊乱指数进行评分,评价患者颞下颌关节功能的变化。结果：13例患者临床疗效满意,随访2月至半年无复发,治疗后患者的颞下颌关节紊乱指数明显改善。结论：采用50%葡萄糖注射剂行关节上腔注射治疗颞下颌关节半脱位和复发性脱位具有良好的效果。     

无髁突骨折颞下颌关节急性创伤后的变化:影像学和手术所见

目的:通过CT、MRI及手术探查观察无髁突骨折颞下颌关节急性创伤后的变化,为该疾患的早期诊治提供依据。方法:上海交通大学医学院附属第九人民医院口腔颌面外科关节组2009—2010年收治的无髁突骨折颞下颌关节急性创伤患者7例11侧关节纳入研究。所有患者伤前均无关节症状,但在伤后出现长时间的关节区疼痛和开口受限,其中6例合并面部骨折,曾在其他医院或由其他医师手术治疗。所有患者均进行了关节区的MRI检查,对受伤后即刻和再次就诊的CT进行比较。所有病例进行了手术探查,术中所见进一步证实影像学的变化。结果:CT显示,87.5%(7/8)的髁突在受伤即刻表面骨质"完好",而伤后1个月至1a出现骨质破坏。伤后1个月至1a的MRI检查显示,所有11侧关节均出现盘前移位,90.9%(10/11)的髁突伴骨质破坏。手术探查显示,2侧关节出现骨性黏连,3侧关节髁突表面骨质破坏与关节窝纤维性黏连,5侧关节髁突表面软骨变性伴黏连,1侧关节髁突表面软骨无明显破坏,关节盘前移位但形态尚可。结论:无髁突骨折的颞下颌关节急性创伤如伴关节盘前移位,可导致骨关节病和(或)关节强直。     

经颞下颌关节镜射频冷消融技术治疗颞下颌关节内错乱

目的：探讨经颞下颌关节镜射频冷消融技术治疗颞下颌关节内错乱的疗效及优点。方法：自2001年7月～2005年5月间，在286侧颞下颌关节镜手术中采用了射频冷消融技术，分别用于囊内黏连的松解消融、关节盘前附着松解、关节盘及关节面的修整，并进行术中内镜即刻评价和临床随访。结果：镜下观察，术后黏连、病变关节盘及软骨彻底清除，余留关节表面光滑、无碳化，无明显出血。临床经0．5～46个月（平均15．1个月）的随访，手术有效率达91．13％，3例（3侧）出现咬肌萎缩（随访期内未恢复）。结论：射频冷消融技术具有操作精确、残留物少、热损伤小、平整性好和同步止血等优点，适用于颞下颌关节镜多项手术操作的需要。     

内镜辅助开放性手术治疗颞下颌关节滑膜软骨瘤病36例临床分析

目的:利用内镜辅助开放性手术治疗颞下颌关节滑膜软骨瘤病,探讨其适应证及应用效果。方法 :选择2010年9月—2015年2月间收治的36例滑膜软骨瘤病患者,术前进行临床资料采集及影像学检查,明确诊断并确定病灶范围。对其中病变位于关节上腔,且MRI冠状位重建上显示关节囊内侧沟扩张低于髁突内侧嵴而未达颞下间隙的患者,选择开放性手术配合内镜行游离体摘除,并彻底进行关节囊及滑膜清扫。术后临床检查关节-颌骨-咬合情况并进行远期影像学随访,以评价应用效果。结果:36例患者先行开放性手术摘除关节腔内可见游离体,再利用内镜行关节上腔探查,发现14例患者在内侧沟、前后隐窝等区域存在游离体残余,配合杯状钳取出,最后行关节囊清扫和病变滑膜切除,术后病理提示滑膜软骨瘤病。术后33例患者完成随访,其颞下颌关节功能恢复良好,咬合及面型稳定,平均33.3个月的磁共振随访显示无肿瘤复发。结论:颞下颌关节镜辅助开放性手术可观察关节腔各个位置,以彻底清除病灶,避免术中截骨和病灶残留,减小手术创伤并缩短手术时长,是传统手术方案的有力补充。     

喙突移植治疗双侧真性颞下颌关节强直

目的:观察喙突移植治疗真性颞下颌关节强直的手术效果。方法:对我院近十年行双侧喙突切除后左右侧交换移植成形双侧颞下颌关节治疗的4例双侧颞下颌关节强直患者进行回顾性分析。结果:全部病例经4～7年的临床随访,效果满意。结论:喙突切除移植成形双侧颞下颌关节术是防止关节强直复发的有效外科治疗方法。     

Closed lock (MRI fixed disc): a comparison of arthrocentesis and arthroscopy

Twenty-six patients with a sudden-onset of persistent limited mouth opening and with MRI signs of articular discs fixed to the glenoid fossa were studied. After unsuccessful non-surgical treatment, arthroscopy with sodium hyaluronate infusion was performed in 16 joints. Follow-up ranged from 24 to 60 months (mean: 30.3 months). All patients were clinically assessed preoperatively, and at 1, 3, 6, 9, 12, 18 and 24 months postoperatively. The clinical variables analysed were: joint pain using a visual analogue scale (VAS) (1-15), joint noises (clicking, crepitus or none), history of locking, duration of the symptoms, maximal interincisal opening (MIO), maximal protrusive movement (MP) and maximal contra-lateral movement (ML). MRI images were obtained preoperatively to analyse the morphological and dynamic characteristics of the temporomandibular joint. Eight of the patients who refused to undergo arthroscopy were treated with arthrocentesis. These patients were studied following the same criteria as stated above. Mean age of the group was 24.3 years (16-35 years). 20 patients were female and 6 male. The preop-MRI examination revealed a normal disc position in 16 joints and an anteriorly displaced disc in 10 cases. All of the discs were fixed to the glenoid fossa preventing an anterior translation of the condylar head. After non-surgical treatment only two patients improved while all the other patients showed a severe decrease in the MIO (mean 23.3 +/- 2.2 mm), LM (3.8 +/- 1.4) and a high pain level (9.7 scale). Sixteen patients underwent arthroscopy. A significant reduction in pain was noted after arthroscopy. Furthermore, a significant increase in MMO and LM was demonstrated postoperatively. Arthroscopic findings included the presence of adherences and synovitis. Eight patients who refused arthroscopy were treated with TMJ arthrocentesis. All such patients improved their symptoms postoperatively. In conclusion both TMJ arthroscopy and arthrocentesis give good results upon treating patients with anchored disc phenomenon (ADP).     

A prospective evaluation of the effectiveness of temporomandibular joint arthroscopy

This is a prospective study to evaluate therapeutic arthroscopy for internal derangement of the temporomandibular joint (TMJ). Fifty-nine patients with 76 abnormal joints were evaluated preoperatively for pain, noise, maximal incisal opening (MIO), and deviation on opening. Preoperative and postoperative magnetic resonance imaging (MRI) scans were obtained for 29 joints. Patients were treated by superior joint arthroscopy, lysis of adhesions, lavage, and steroid injection, along with preoperative and postoperative splint and physiotherapy. Pain, noise, and motion were evaluated at three time periods: 1) early (10 to 30 days); 2) intermediate (1 to 6 months); and 3) late (greater than 6 months). At early, intermediate, and late follow-up, increase in MIO was statistically significant (P less than .05). Noise did not return in the majority of patients. Disc position, evaluated by MRI, did not appear to change in 25 of 29 joints and did not correlate with clinical outcome. The results of this study indicate that TMJ arthroscopy is effective in reducing pain and increasing motion in patients with TMJ internal derangement.     

Magnetic resonance imaging or arthrographic diagnosis of internal derangement of the temporomandibular joint: Correlation comparison study with arthroscopic surgical confirmation

Although arthrography has long been considered a gold standard for the diagnosis of internal derangements of the temporomandibular joint, magnetic resonance imaging has rapidly proved to be a valuable tool for other insights into soft tissue structures. The goals of this study were twofold: (1) to compare the diagnostic efficacy of arthrography with magnetic resonance imaging and (2) to compare these results with the actual arthroscopic findings. The correlation between arthroscopic examination and independent fluoroscopic arthrogram and magnetic resonance imaging was high for the diagnosis of anterior disk displacement, as were the correlations between arthroscopic examinations and fluoroscopic arthrograms on diagnosing disk perforations. These findings, together with the apparent specialized abilities of the arthroscopic examination to yield information on the quality of the surface tissues (e.g., cartilage degeneration, synovitis, proliferations) led us to conclude that diagnostic arthroscopy may prove to be as valuable to the maxillofacial surgeon for the diagnosis of intracapsular temporomandibular joint disorders as it is for the orthopedic surgeon in diagnosing other joint disorders.     

The agreement between magnetic resonance imaging and arthroscopic findings in temporomandibular joint disorders

The aim of this retrospective observational study was to assess the potential agreement between independent magnetic resonance imaging (MRI) and arthroscopic findings and their respective contributions to a final diagnosis in patients with refractory temporomandibular joint disorders. Two dentomaxillofacial radiologists and two oral and maxillofacial surgeons scored 50 joints. All observers, who were blinded to additional clinical information, used a specific scoring form and selected one or more diagnostic labels. Agreement between MRI and arthroscopy and their contributions to the final diagnosis were assessed as primary outcomes using Fleiss’ kappa. Intra-modality agreement and the correlation between signal intensity ratio (SIR) measurements on MRI and synovitis grading on arthroscopy were assessed as secondary outcomes. Agreement between MRI and arthroscopy was poor. A fair level of agreement was only reached for reduction capacity of the disc and disc perforation. Arthroscopic diagnostic labels matched better with the final diagnosis, suggesting a bigger contribution to that diagnosis. Higher SIR measurements correlated with higher synovitis grading scores for the retrodiscal tissue and the posterior band of the disc. Intra-modality agreement was better in arthroscopy. When blinded to clinical information, arthroscopy and MRI observations can lead to different conclusions. The diagnostic outcomes of both examinations should be considered and integrated into a final diagnosis.     

Arthroscopic TMJ surgery: effects on signs, symptoms, and disc position

Nineteen subjects with documented intra-articular pathology refractory to nonsurgical therapies underwent temporomandibular joint (TMJ) arthroscopy involving lysis and lavage in the superior joint space. Following surgery, subjects were evaluated for 6 to 12 months by clinical examinations and questionnaires at designated time periods and by postsurgical joint imaging. Significant improvement was noted in pain, mandibular movement, and diet. No improvement was noted in the incidence of joint sounds, and disc position was unchanged in 80% of the joints. The findings suggest that disc repositioning may not be needed to achieve clinical success.     

Magnetic resonance imaging in the diagnosis of intra-articular adhesions of the temporomandibular joint

We aimed to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis of intra-articular adhesions of the temporomandibular joint (TMJ). We diagnosed 27 consecutive patients with internal derangement of the TMJ (33 TMJs) between 1 December and 31 July 2003 in our department. All patients were examined by MRI and arthroscopy. The MRI findings were recorded as "positive", "suspicious", or "negative", and were compared with those of arthroscopy to obtain the numbers of true positive, true negative, false positive, and false negative results. Arthroscopy confirmed that 18 of the 33 TMJs contained adhesions. MRI showed that 11 were "positive", 4 were "suspicious", and 18 were "negative". After comparing these results with those of arthroscopy, 7 TMJs were true positives and 4 were false positives of the 11 "positive" TMJs. Three of the 4 "suspicious" TMJs had adhesions. Of the 18 negative TMJs, 10 were true negatives and 8 were false negatives. We concluded that the diagnostic accuracy of MRI for intra-articular adhesions was poor; most of the adhesions were not diagnosed by MRI, but intracapsular adhesions could be detected on T2 weighted-images with existing synovial fluid.     

The value of patient feedback in the audit of TMJ arthroscopy

AIM: This study assessed the patients' and clinicians' perception of the outcome of temporomandibular joint arthroscopy. METHOD: All patients who underwent TMJ arthroscopy for both diagnostic and therapeutic purposes over a 6-year period were sent a questionnaire that asked about various symptoms attributable to the TMJ. Additionally a review of the clinical notes was performed. RESULTS: 83 patients underwent arthroscopy to 127 temporomandibular joints. The mean follow up was 3.6 years. 55% of patients assessed their jaw function as being effective, jaw movement, pain control, and overall satisfaction were satisfactory in 37%, 57%, and 48% of cases respectively. The clinicians' assessment revealed that 45% of patients had no joint tenderness, 74% of patients were able to open to > 35 mm and 74% of patients were free of any joint noise. 66% of patients were prepared to undergo a second procedure if indicated. CONCLUSION: Overall, 50% of patients seemed to view arthroscopy favourably although many patients still felt that jaw opening was restricted. The outcome was not related to the position and reducibility of the disc at surgery and other variables may be responsible. The disparity between the clinical evaluation and the patients' perception of effectiveness emphasises the importance of patient feedback.     

Plain film arthrography applied to the diagnosis of intra-articular adhesions of the temporomandibular joint.

PURPOSE: To evaluate the diagnostic accuracy of plain film arthrography (PFA) on the presence of intra-articular adhesions of the temporomandibular joint (TMJ). PATIENTS AND METHODS: The study population included 105 consecutive patients (105 TMJs) and data collected in our department. All patients were examined by PFA and arthroscopy. The findings of interpreting PFA were recorded as positive, suspicious, or negative according to the PFA radiographic criteria. After comparing the findings of PFA with those of arthroscopy, the comparison data were assessed by generating receiver operating characteristic curve (ROC curve) and analyzing the area (A(z)) under the curves with SPSS 11.0 (SPSS, Inc, Chicago, IL), and the area under the ROC curve was calculated. According to the area, the diagnostic value of PFA was evaluated. Meanwhile, the causes of misdiagnosis and underdiagnosis of intra-articular adhesions were analyzed. RESULTS: Arthroscopic surgery results confirmed that 56 TMJs in 105 patients had adhesions. The area under ROC curve was 0.73 (confidence interval, 0.64, 0.82; P < .05). The adhesions located in the medial groove could hardly be detected through PFA, while those located in the lateral two thirds of upper joint compartment could easily be detected. CONCLUSION: Although the diagnostic accuracy of PFA was fair, it was a simple and effective modality to diagnose intra-articular adhesions of the TMJ. The causes of misdiagnosis and underdiagnosis were related to the size and location of the intra-articular adhesions.     

颞下颌关节上腔囊内粘连的平片造影诊断

目的 :评价X线平片造影对颞下颌关节上腔囊内粘连的诊断价值。方法 :选取临床诊断为关节内错乱患者 10 5例 ( 10 5侧 ) ,进行关节上腔平片造影及关节镜检查。按平片造影影像学诊断标准 ,确定有无粘连 ,分阳性组、可疑组及阴性组 ;并与关节镜诊断结果对比 ,得出真、假阳性 ,真、假阴性例数 ,应用SPSS软件制作ROC曲线 ,计算ROC曲线下面积。同时分析漏诊、误诊的原因。结果 :关节镜诊断囊内粘连为 5 3 .3 3 % ( 5 6/ 10 5 )。平片造影诊断与关节镜诊断对照 :阳性组 40例 ,其中 3 2例真阳性 ,8例假阳性 ;可疑组 18例 ,其中 9例真阳性 ,9例假阳性 ;阴性组 47例 ,3 2例真阴性 ,15例假阴性。造影易检出的粘连部位是外中份 ;易漏诊的部位是内 1/ 3 ;粗大粘连带易于检出。ROC曲线下面积为 0 .73 ( 0 .64 ,0 .82 ) ,P <0 .0 5。结论 :X线平片造影对诊断囊内粘连的整体准确性中等 ,但不失为一种简单、实用的影像学检查方法 ,其漏诊的主要原因与粘连带的大小和部位有关。     

Can arthrocentesis release intracapsular adhesions? Arthroscopic findings before and after irrigation under sufficient hydraulic pressure.

PURPOSE: To investigate the effect of release of intra-articular adhesions of arthrocentesis, we examined patients with closed lock of the temporomandibular joint by arthroscopy before and after irrigation. PATIENTS AND METHODS: In 6 closed lock cases in which adhesions in the upper joint space were observed by arthroscopy before arthrocentesis, arthroscopic examination was performed again to confirm whether the adhesion was released after the procedure. Range of mouth opening and joint pain were examined to determine the clinical efficiency of the procedure. RESULTS: Adhesion was not released by irrigation under low pressure but could be released by irrigation under high pressure. After irrigation under low and high pressure, the maximum mouth opening of the patients improved from 0 to 1 mm (average, 0.3 mm) and 2 to 6 mm (average, 3.7 mm), respectively. CONCLUSIONS: The results indicate that arthrocentesis with sufficient pressure could be effective for closed lock cases with adhesions in the upper joint compartment.