突发性严重绞锁颞下颌关节的压力测量和分析

目的　了解突发性严重绞锁患者颞下颌关节上腔中的压力特点及其变化规律,初步探讨该类型颞下颌关节紊乱病的治疗机理。方法　用关节内压测量仪通过穿刺针进入突发性严重绞锁患者颞下颌关节上腔,分别测量张闭口位的关节上腔内压,记录其平均值和变化规律。结果　突发性严重绞锁患侧关节上腔开口位压力平均为-9·947 kPa±8·854 kPa,闭口位压力平均为-6·475 kPa±4·147 kPa。结论　突发性严重绞锁颞下颌关节上腔开闭口位压力明显降低,并有独特的变化规律。     

Releasing severe adhesions around the eminence and the synovial portion of the TMJ: a clinical study of combined treatment using hydraulic lavage, arthroscopic surgery and rehabilitative therapy.

This paper evaluates the effects of treatment with a pumping technique and arthroscopic lysis and lavage, followed by rehabilitative training, on condylar head mobility of the temporomandibular joint (TMJ). We studied 32 TMJs in 19 patients suffering from chronic closed lock with severe adhesion. The results were compared between cases with adhesions concentrated in two areas: mostly in the posterior and/or the anterior synovial portion of the upper TMJ compartment (11 joints) and mostly around the eminence (21 joints). The results showed a statistically significant improvement in condylar head movement for both groups between the initial and final stages of treatment. However, the results also suggested that patients with adhesion concentrated around the eminence are less likely to recover condylar head mobility to the same extent as those in the other group.     

Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements.

PURPOSE: This study was designed to investigate the efficacy of arthrocentesis with and without injection of sodium hyaluronate (SH) into the upper joint space in the treatment of temporomandibular joint (TMJ) internal derangements. PATIENTS AND METHODS: Forty-one TMJs in 5 males and 26 females aged 14 to 53 years comprised the study material. The patients' complaints were limited mouth opening, TMJ pain and tenderness, and joint noises during function. Patients were randomly divided into 2 groups in which only arthrocentesis was performed in 1 group and arthrocentesis plus intra-articular injection of sodium hyaluronate was performed in the other group. Both groups contained patients with disc displacement with reduction and with closed lock. Clinical evaluation of the patients was done before the procedure, immediately after the procedure, on postoperative day 1, and at 1, 2, 3, 4, 5, 6, 9, 12, 18, and 24 months postoperatively. Intensity of TMJ pain, jaw function, and clicking sounds in the TMJ were assessed using visual analog scales. Maximal mouth opening and lateral jaw movements also were recorded at each follow-up visit. RESULTS: Both techniques increased maximal mouth opening, lateral movements, and function, while reducing TMJ pain and noise. CONCLUSIONS: Although patients benefitted from both techniques, arthrocentesis with injection of SH seemed to be superior to arthrocentesis alone.     

Clinical symptoms of open lock position of the condyle. Relation to anterior dislocation of the temporomandibular joint.

Nine cases of open lock position of the condyle of the temporomandibular joint (TMJ) are reported. In two patients recurrent dislocation of the TMJ was diagnosed clinically, and four had previous episodes of anterior dislocation. An arthrotomographic examination revealed that the condyles of the affected TMJs were located anterior to the anterior bands of the disks at an open-mouth position. An arthrographic fluoroscopic examination showed that the anterior bands mechanically obstructed the anteriorly displaced condyles from posterior movement into the articular fossae to various degrees at open-mouth position. One cause of anterior dislocation of the TMJ is thought to be fixation of the condyle in the open lock position resulting from a disturbance of a neuromuscular mechanism. In the two patients with dislocation, occlusal treatment eliminated muscular symptoms and the dislocations completely disappeared.     

Clinical evaluation of arthroscopic eminoplasty for habitual dislocation of the temporomandibular joint: comparative study with conventional open eminectomy

OBJECTIVE: We sought to compare the clinical courses of patients who underwent arthroscopic eminoplasty and conventional open eminectomy for habitual dislocation of the temporomandibular joint (TMJ). STUDY DESIGN: Arthroscopic eminoplasty was performed by using Segami's method in 24 joints in 13 patients (arthroscopic group) with habitual dislocation of the TMJ, while conventional open eminectomy was performed by using Myrhaug's method in 18 joints in 11 patients (open group). Clinical factors were retrospectively compared between the 2 groups. RESULTS: The operation time per joint was, on average, 14 minutes shorter in the arthroscopic group (77 minutes versus 63 minutes), and the average blood loss was less in the arthroscopic group (2 g versus 15 g). During the follow-up period (mean, 41 months), dislocation recurred in 5 TMJs (28%) in the open group and in 6 TMJs (25%) in the arthroscopic group. No major postoperative complications were observed in either group. CONCLUSION: In treating patients with habitual dislocation of the TMJ, the use of arthroscopic eminoplasty produces clinical outcomes that are as effective as those obtained with the use of conventional open eminectomy.     

The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints.

PURPOSE: The purpose of this retrospective study was to determine the efficacy of arthrocentesis in restoring the functional capacity of osteoarthritic temporomandibular joints (TMJ). PATIENTS AND METHODS: This study involved 36 patients (29 females, 7 males; age range, 16 to 54 years, mean, 37.36 +/- 14.60 years) presenting with 38 dysfunctional joints that had not responded to conservative treatment. The postarthrocentesis status (follow-up period 6 to 62 months, mean 20.7 +/- 20.5 months) of the TMJs was determined by patient self-evaluation using visual analog scales and clinical examination. RESULTS: Of the 38 TMJs treated with arthrocentesis, 26 joints reacted favorably to the treatment; pain and dysfunction scores were reduced from 9.86 +/- 0.73 to 3.39 +/- 0.76 and from 11.34 +/- 0.66 to 3.4 +/- 0.69, respectively (P <.001). Self-assessed general improvement/deterioration was +4.90 +/- 2.10 (on a scale of -7 to +7). Maximal mouth opening increased from 24.40 +/- 2.70 mm to 43.20 +/- 3.10 mm (P <.001). Lateral and protrusive jaw movements also increased in magnitude. In 14 patients in whom no improvement was noted, arthrocentesis acted as a diagnostic tool before surgical treatment. CONCLUSIONS: Arthrocentesis is a safe and rapid procedure that in many instances results in the osteoarthritic TMJs returning to a healthy functional state. Failure of arthrocentesis suggests that the painful limitation is most probably caused by changes such as fibrous adhesions or osteophytes that require surgical intervention for their removal.     

Relationship between effectiveness of arthrocentesis under sufficient pressure and conditions of the temporomandibular joint.

PURPOSE: The purpose of this study is to investigate the conditions of the temporomandibular joint (TMJ) relative to the effectiveness of arthrocentesis under sufficient hydraulic pressure in patients with chronic closed lock. PATIENTS AND METHODS: We performed arthroscopic examination and arthrocentesis as an initial treatment in 65 closed lock cases (65 joints). Changes in maximum mouth opening and joint pain were examined to determine the effectiveness of the treatment. With respect to the conditions of the TMJ before treatment, we examined the range of maximum mouth opening, joint pain at mouth opening, degrees of disc deformity and bone change evident with magnetic resonance imaging, and the degrees of synovitis, cartilage changes, and adhesion in the upper joint space evident from arthroscopic findings. These factors were statistically analyzed by using multiple regression analysis. RESULTS: Two months after treatment the maximum mouth opening of the patients increased by an average of 9.8 mm (range, 0 to 28 mm). Joint pain at opening mouth improved an average of 64.2% (range, 0 to 100%). A significant inverse correlation was found between the extent of improvement in maximum mouth opening after treatment and the initial maximum mouth opening before treatment. There was no significant correlation between improvement of joint pain and conditions of the TMJ. CONCLUSION: Pathologic conditions of the TMJ did not have an influence on the efficacy of arthrocentesis under sufficient pressure. This result suggests that this procedure has wider application than arthrocentesis under low pressure.     

Arthrocentesis--incentives for using this minimally invasive approach for temporomandibular disorders

TMJ arthrocentesis is a nonarthroscopic lavage performed through two needles that are introduced into the upper compartment of the joint. Complemented by joint unloading and physiotherapy, this procedure often replaces surgical intervention in the TMJ. The procedure is highly efficient for resolving TMJ disorders caused by adhering forces or friction that are eliminated by lavage, such as intermittent clicking, anchored disc phenomenon, and open lock, and releases approximately 70% of the symptomatic TMJ osteoarthritis. The outcomes are sufficiently effective to prevent further surgical intervention. Arthrocentesis is a valuable diagnostic tool and the aspirated fluid can be used efficiently for diagnosis, therapy, and research of TMJ disorders.     

Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation

Temporomandibular joint (TMJ) dislocation is an excessive forward movement of the condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position. This study was conducted to assess autologous blood injection to the TMJ for the treatment of chronic recurrent TMJ dislocation. Fifteen patients with bilateral chronic recurrent condylar dislocation were included in the study. Bilateral TMJ arthrocentesis was performed on each patient, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. Preoperative and postoperative assessment included a thorough history and physical examination to determine the maximal mouth opening, presence of pain and sounds, frequency of luxation, recurrence rate, and presence of facial nerve paralysis. Eighty percent of the subjects (12 patients) had a successful outcome with no further episodes of dislocation and required no further treatment at their 1-year follow-up, whereas three patients had recurrent dislocation as early as 2 weeks after treatment. Autologous blood injection is a safe, simple, and cost-effective treatment for chronic recurrent TMJ dislocation.     

Magnetic resonance evidence of joint effusion of the temporomandibular joint after fractures of the mandibular condyle: a preliminary report

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p < 0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p < 0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.     

Intra-articular injection of tenoxicam following temporomandibular joint arthrocentesis: a pilot study

This study examined the clinical and radiological effects of intra-articular tenoxicam injection following arthrocentesis and compared them with arthrocentesis alone in patients with disc displacement without reduction (DDwoR). 24 temporomandibular joints (TMJs) in 21 patients with DDwoR were studied. Patients were divided randomly into Group A in which only arthrocentesis was performed (14 TMJs in 14 patients) and Group AT which received arthrocentesis plus intra-articular injection of tenoxicam (10 TMJs in 7 patients). Patients were evaluated before the procedure, on postoperative day 7, then 2, 3, 4 weeks, and 2, 3, 4, 5, 6 months postoperatively. Intensity of joint pain was assessed using a visual analog scale. Maximum mouth opening was recorded at each follow-up. TMJ sounds and palpation scores were noted as positive or negative. Magnetic resonance imaging (MRI) was performed before and 6 months after treatment in both groups. Disc form, disc location during neutral position, reduction with movement, joint effusion, structures of the articular surfaces, and bone marrow anomalies were evaluated all in MRIs. Both treatments succesfully increased maximum mouth opening and reduced TMJ pain; there were no complications. Difference between the groups was not statistically significant and a larger controlled study is necessary to clarify this use of tenoxicam.     

创伤性颞下颌关节强直临床分析

目的 分析引发创伤性颞下颌关节(temporomandibular joint,TMJ)强直的高风险髁突骨折类型,初步探讨TMJ强直发生的可能性机制.方法 对18例创伤性TMJ强直进行临床、影像学检查及评估.取纤维性强直外侧变性的关节囊、关节间的致密纤维组织及骨性强直关节外侧骨块和内侧骨块,HE染色,光镜观察.结果 ...     

Relationship between arthroscopic findings of synovitis and levels of tumour necrosis factor‐alpha and matrix metalloproteinases in synovial lavage fluid from patients with unilateral high mandibular condyle fractures

Arthrocentesis has an effect of washing out inflammatory products that accumulate in the joint compartment of a dysfunctional temporomandibular joint (TMJ). The procedure removes inflammatory cytokines, which are pain‐causing substances, for early reduction of TMJ pain and quick recovery of jaw function, thus increasing the possibility of a successful rehabilitation. The aim of this study was to investigate the relationship between arthroscopy synovitis grade in patients with unilateral high condylar fractures and concentrations of the pro‐inflammatory cytokines tumour necrosis factor (TNF)‐alpha as well as of matrix metalloproteinases (MMPs) in washed‐out synovial fluid (SF) samples obtained from those patients. A total of 26 patients with unilateral high condylar fractures who underwent arthrocentesis for a therapeutic purpose were examined. SF samples were collected before performing arthroscopy to determine synovitis grade. The detection rates and concentrations of TNF‐alpha and MMPs were determined, and their association with synovitis grade was analysed. TNF‐alpha was detected in 23 and MMP‐3 in 22 of the TMJs. There was a correlation between synovitis grade and concentration of TNF‐alpha in the fracture group. Furthermore, the concentrations of TNF‐alpha and MMP‐3 were significantly higher as compared to the control group, comprised of TMJs on the non‐fracture side of the same patients, while a correlation was also noted between TNF‐alpha concentration and synovitis grade in the fracture group. The present findings may provide a biological/biochemical rationale for arthrocentesis as a reasonable treatment modality for high condylar fractures.     

颞下颌关节疾病的外科手术治疗

目的 :颞下颌关节疾病的治疗包括保守治疗和外科手术治疗 ,本研究目的是探讨颞下颌关节疾病外科手术治疗的适应证以及手术方法。方法 :对 1988年至 2 0 0 0年共收治的 76 5例颞下颌关节疾病患者进行回顾性研究。其中颞下颌关节紊乱病患者共 4 18例 ,颞下颌关节外伤 15 9例 ,颞下颌关节强直 131例 ,髁状突肥大 38例 ,颞下颌关节肿瘤 18例 ,颞下颌关节感染 1例 ,其中 6 37例进行了外科手术治疗。结果 :颞下颌关节紊乱病患中 2 18例行颞下颌关节内窥镜术 ,2 1例行颞下颌关节盘复位术 ,91例行颞下颌关节盘修补术 ,11例行陈旧性关节脱位开放复位术 ;131例行颞下颌关节成形术 ;10 9例行髁状突骨折开放复位术 ;38例行髁状突截骨术和正颌手术 ;18例行颞下颌关节肿瘤切除术。结论 :颞下颌关节紊乱病、损伤、关节强直、肿瘤、畸形以及其他关节疾病的手术适应证范围在不断地扩大 ,颞下颌关节外科的手术方法也在不断地改良。颞下颌关节外科手术治疗正向着微创和恢复关节功能的方向发展     

颞下颌关节间接性损伤后MRI表现及其意义

目的：研究羊颞下颌关节（TMJ）间接性损伤后关节结构的变化。方法：用自制撞击装置造成山羊双侧颞颌关节间接性损伤,分别于伤后2h、7h、1月、3月行MRI观察后处死取材,并进行组织学观察,正常关节作为对照,结果：TMJ损伤后MRI观察发现：TMJ间接性损伤后可导致关节软、硬组织结构的变化。在损伤早期1月内表现为髁突表面软骨的碎裂,关节盘挫裂和移位,关节间隙的减小和关节腔内出现血性渗液;在损伤后期1-3月表现为髁突表面软骨的破坏和吸收,关节盘畸形,关节间隙减小,结论：MRI不但能够清楚、全面地反映关节损伤后软、硬组织结构和形态的变化,还是一种可用于研究TMJ损伤后转归和后遗症发生机理的较好的、精确的观察手段。     

髁突骨髓腔MRI信号异常与颞下颌关节疼痛的关系

目的:探讨髁突骨髓腔信号异常与关节疼痛的关系。方法:利用MRI金标准,对44例单侧关节疼痛TMD患者88侧关节进行闭口斜矢状位T1W和T2W扫描,以非疼痛侧作为自身对照;利用可视疼痛模拟标尺(VAS)进行疼痛程度的判定,观察髁突髓腔信号异常与疼痛的关系。结果:44个疼痛关节中,11个关节(25％)出现髓腔信号异常,均为水肿型;而44个非疼痛关节中,仅2个关节(4.5％)出现髓腔信号异常,分别表现为硬化型和混合型,经统计学分析,TMJ疼痛与髓腔信号异常有显著相关性(P<0.01)。44个疼痛关节中,骨髓腔信号异常及正常患者VAS平均值分别为39.5±27.5和42.6±21.9。经t检验,两组问差别无统计学意义(P=0.696)。结论:髁突髓腔信号异常与关节疼痛密切相关,而与TMJ疼痛程度无关。     

Comparison of cytokine level in synovial fluid between successful and unsuccessful cases in arthrocentesis of the temporomandibular joint.

PURPOSE: The aim of this study was to compare proinflammatory cytokine levels between successful cases and unsuccessful cases of arthrocentesis in patients with internal derangement of the temporomandibular joint (TMJ). PATIENTS AND METHODS: This study involved 73 joints judged as successful and 30 judged as unsuccessful of 103 joints in 100 patients diagnosed with internal derangement of the TMJ and who underwent arthrocentesis. The diluted synovial fluid before undergoing arthrocentesis was aspirated from the superior joint space. The concentrations of interleukin (IL)-1beta, tumor necrosis factor-alpha, IL-6, and IL-8 were measured using an enzyme-linked immunosorbent assay. The differences in the detection rate and concentration of each cytokine between successful cases and unsuccessful cases were analyzed statistically. RESULTS: There was a statistically significant difference between successful cases (72.2%) and unsuccessful cases (95.5%) in the detection ratio of IL-6 (P <.05). There was a statistically significant difference between successful cases (0.017 pg/100 microg protein) and unsuccessful cases (0.046 pg/100 microg protein) in the concentration of IL-1beta (P <.05). CONCLUSION: It has been shown that the presence of IL-1beta and IL-6 in synovial fluid may be indicators of possible unsuccessful treatment following arthrocentesis for internal derangement of the TMJ.     

Prognostic indicators of the outcome of arthrocentesis with and without sodium hyaluronate injection for the treatment of disc displacement without reduction: a magnetic resonance imaging study

This study analysed the prognostic factors for successful arthrocentesis with and without sodium hyaluronate (SH) injection for the treatment of temporomandibular joint (TMJ) disc displacement without reduction (DDwoR) using clinical and radiological results. 29 TMJs in 25 patients with DDwoR were included. Patients were treated with arthrocentesis or arthrocentesis followed by intra-articular (i.a.) injection of SH. Treatment was evaluated for postoperative range of maximum mouth opening and the degree of postoperative pain on a VAS. Prognostic factors analysed were age, sex, duration of locking, trauma history, previous TMJ treatment, depression, bruxism, malocclusion and missing teeth. Degenerative changes were evaluated as probable prognostic factors. After treatment, 24 joints (83%) fulfilled the criteria for success. Duration of locking and present preoperative degenerative changes were the most significant factors for treatment outcome. The results suggest it is sufficient to use only arthrocentesis in patients without preoperative degenerative changes and arthrocentesis with SH in patients with degenerative changes on their preoperative MRIs, but because there were some significant differences between the two groups preventing the authors from comparing them statistically, they cannot come to that conclusion. To clarify the use of SH in such cases, standardized study groups are necessary for future studies.     

Clinical Indications for Simultaneous TMJ and Orthognathic Surgery

Abstract

There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction, and disability. The most common of these conditions include: 1. articular disk dislocation; 2. reactive arthritis; 3. adolescent internal condylar resorption; 4. condylar hyperplasia; 5. osteochondroma or osteoma; and 6. end-stage TMJ pathology. These conditions are often associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. Open joint surgery provides direct access to the TMJ allowing manipulation, repair, removal and/or reconstruction of the anatomical structures that cannot be accomplished by other treatment methods. TMJ surgery and orthognathic surgery can be predictably performed during one operation with high success rates. This paper discusses the most common TMJ pathologies and presents the surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.     

Clinical indications for simultaneous TMJ and orthognathic surgery

There are many temporomandibular joint (TMJ) conditions that can cause pain, TMJ and jaw dysfunction, and disability. The most common of these conditions include: (1) articular disk dislocation; (2) reactive arthritis; (3) adolescent internal condylar resorption; (4) condylar hyperplasia; (5) osteochondroma or osteoma; and (6) end-stage TMJ pathology. These conditions are often associated with dentofacial deformities, malocclusion, TMJ pain, headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Patients with these conditions may benefit from corrective surgical intervention. Open joint surgery provides direct access to the TMJ allowing manipulation, repair, removal and/or reconstruction of the anatomical structures that cannot be accomplished by other treatment methods. TMJ surgery and orthognathic surgery can be predictably performed during one operation with high success rates. This paper discusses the most common TMJ pathologies and presents the surgical management considerations to correct the specific TMJ conditions and associated jaw deformities.