经颌后腮腺前缘入路治疗髁突低位骨折的临床体会

目的探讨下颌骨髁突低位骨折、下颌升支骨折内固定新入路的方法及治疗效果。方法对15例单侧髁突低位骨折及下颌升支骨折患者沿耳垂下后作3 cm小切口,翻开皮肤,在腮腺咬肌筋膜浅面向前方分离,在腮腺前缘将腮腺组织向后方掀起,咬肌内钝性分离暴露骨折线后,直视下对髁突骨折、升支骨折断端进行复位固定。结果所有患者解剖复位,咬合关系良好,术后关节三维活动正常,瘢痕隐蔽。结论颌后腮腺前缘入路是治疗髁突低位骨折、升支骨折的较好方法,值得在临床推广。     

口腔内入路行髁突高位骨折复位固定的临床治疗

目的:探讨应用定量截骨锯,行口腔内入路髁突高位骨折手术治疗的效果。方法:对13例14侧下颌骨髁突颈骨折患者采用口腔内入路,用定量截骨锯将下颌骨升支后缘垂直截骨,取出升支后缘骨块,将骨折的髁突游离后取出,体外直视下将骨折片与升支后缘骨块复位固定后再从口腔内原切口回植,行颞下颌关节重建。结果:术后6、12、24月复查全部患者的开口范围25～40mm,平均为37.2mm。除1例患侧后牙早接触,下切牙中线偏斜1mm;另1例张口约25mm,轻度受限外,其余患者咬合关系良好,无其他并发症。结论:口腔内入路具有无外部皮肤瘢痕,且不损伤面神经的优点。但操作视野较小,增加了操作的难度。     

内镜辅助下手术治疗髁突骨软骨瘤临床体会

目的 :利用内镜辅助行下颌支垂直截骨提升术治疗髁突骨软骨瘤,探讨其应用范围及效果。方法 :选择2013-04—2015-05间收治的单侧髁突骨软骨瘤患者,术前进行临床资料采集、咬合关系、面形及影像学检查,对其中无正颌需求或颏点偏斜<3 mm且口内咬合稳定的患者,予以髁突肿物切除术及内镜辅助的下颌支后缘垂直截骨提升术治疗。术后临床检查关节、颌骨、咬合情况,并进行远期影像学随访。结果:共纳入5例患者,采用改良耳颞切口行开放性手术切除髁突顶部肿物,再利用内镜辅助行下颌骨支后缘垂直截骨提升术及坚固内固定,保持原下颌升支高度,其中1例患者附加下颌下缘外形修整术。术后病理提示均为髁突骨软骨瘤。术后5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,术后平均28.6个月的CT随访显示无肿瘤复发。结论:在切除髁突骨软骨瘤后,内镜辅助下颌骨升支后缘垂直截骨术,对于咬合轻度偏斜且无法进行正颌手术的髁突骨软骨瘤患者,是一种有效手术方案。该手术设计实现了切除肿物的同时,恢复保留颌骨及咬合关系,同时减小了创伤,是传统手术方案的有力补充。     

内镜辅助下经口内入路治疗下颌骨髁突囊内骨折的临床研究

目的 探讨内镜辅助下经口内入路治疗髁突囊内骨折的疗效.方法 对24例(30侧)髁突囊内骨折行内镜辅助下经口内入路治疗,术后行临床功能检查和影像学评价.结果 内镜辅助下经口内入路治疗下颌骨髁突囊内骨折患者24例,术后平均最大张口度(40.3±3.4) mm,患侧向运动度(8.0±1.6) mm,健侧向运动度(5.8士1.5)mm,前伸运动度(6.1士1.1)mm,无面神经和下牙槽神经损伤症状,无面部瘢痕,咬合关系基本恢复.1例出现关节弹响,5例大张口运动轻度疼痛.影像学检查术后下颌升支高度无明显下降,髁突改建良好,无髁突吸收、关节强直等严重并发症.结论 内镜辅助下经口内入路治疗髁突囊内骨折是一种有效的方法.     

克氏针固定治疗下颌骨髁颈骨折的体会

我科于 1997年至 1999年采用克氏针内固定髁颈骨折11例 ,收到理想效果。一、临床资料 :本组病例 11例 ,男 9例 ,女 2例 ,年龄 2 0～ 6 8岁。单侧髁颈骨折 10例 (其中 6例伴有下颌骨其它部位骨折 ) ,双侧髁颈骨折 1例。髁突向内成角 6例 ,向外成角5例。单侧髁颈骨折行克氏针骨间内固定 ,双侧髁颈骨折移位明显一侧采用克氏针内固定 ,不明显一侧采用保守疗法。手术复位均在骨折 1周内进行。　　二、手术方法 :在局麻下 ,以下颌支后缘绕过下颌角距下颌下缘 1.5ｃｍ～ 2 .0ｃｍ ,长度为 4.0ｃｍ～ 6 .0ｃｍ ,逐层切开 ,暴露下颌升支外侧面至骨折…     

颌下切口下颌升支垂直截骨在髁突高位骨折手术中的应用

目的:探讨应用颌下切口下颌升支垂直截骨术治疗髁突高位骨折的效果。方法:对16例(19侧)下颌骨髁突高位骨折患者采用颌下切口下颌骨升支后缘垂直截骨取出升支后缘骨块将骨折的髁突游离后取出,体外直视下将骨折片与升支后缘骨块复位固定后再回植,行颞下颌关节重建。结果:于术后6、12、24个月复查全部患者的开口度为30～48 mm,平均34.92 mm。所有患者咬合关系良好,无关节疼痛症状。部分病人有轻度开口偏斜,均<3 mm,有1例患者有关节弹响。结论:颌下切口下颌升支垂直截骨是治疗髁突高位骨折的一种可选择方法,具有操作简便、复位准确、近期疗效满意等优点。     

双长螺钉在下颌骨髁突骨折坚固内固定中的应用

目的:探讨双长螺钉在下颌骨髁突骨折坚固内固定中的应用。方法:2007年7月～2011年12月我科收治的下颌骨髁突斜行或矢状骨折患者27例(30侧),年龄15～57岁,男性19例,女性8例。采用耳前直线切口入路,髁突复位后,用2枚18mm长2mm直径的钛钉固定断离的髁突。术后复查三维CT了解复位情况,评估术后开口度、颞下颌关节运动、咀嚼功能、咬合情况及面部外形等。结果:完全解剖复位固定的25侧髁突;5侧髁突固定良好,但髁突与下颌升支成角,角度均在15°以内;所有患者的咬合关系均恢复到受伤前状态;术后3m均能进普通饮食,开口度为(35.8±4.2)mm;4例患者术后自觉手术侧颞下颌关节运动时有摩擦音,3例患者术后2m仍觉关节区轻度疼痛;瘢痕隐蔽美观。结论:双长螺钉固定下颌骨髁突斜形或矢状骨折效果肯定。     

内镜在下颌骨和颧骨骨折中的应用研究

目的:探讨内镜和微型侧壁螺丝刀在下颌骨和颧骨骨折中的临床意义.方法:对32例下颌骨角部、升支、髁突颈和颧骨骨折患者,经口腔或发际内小切口,在内镜辅助下,采用微型侧壁电钻和螺丝刀,小型钛板微创内固定.结果:术后6月～3年复查曲面断层片或螺旋CT三维重建,骨折线对位良好.所有病例面部皮肤均无明显手术疤痕,无面瘫症状.颧骨颧弓骨折术后颧面部外形左右对称,1例颞部皮肤轻微凹陷.下颌骨骨折术后3例2处骨折患者术后前牙轻微开(牙合),经颌间牵引后好转;5例张口时颏部轻微偏患侧.结论:内镜在下颌骨和颧骨骨折中的应用,避免了颌面部皮肤疤痕,具有显著的微创和美容意义.     

24例髁突骨折经下颌后进路行坚强内固定的疗效观察

目的:介绍发生于髁突颈和髁颈以下髁突骨折用小型钛板经下颌后进路行解剖复位、坚强内固定术的方法和经验。方法:发生于髁突颈和髁颈以下骨折24例30侧,经下颌后进路以小型钛板行坚强内固定术。术后3～6个月后复查并评价疗效,复查内容包括:张口度、张口型、咬合关系、X线表现、面神经损伤情况。结果:张口度较术前明显增大,张口型偏移明显改善,错牙合3例,面神经下颌缘支损伤2例。X线检查:髁突骨折复位良好,髁突无移位。结论:下颌后进路是一种治疗髁突颈和髁颈以下骨折的有效方法。     

成人下颌升支应用解剖的研究

目的　研究成人下颌升支后份及髁突的应用解剖。方法　对 16个成人离体下颌升支后缘高度、升支后份厚度 ,下颌孔后缘至下颌升支后缘的距离、髁突高度、髁突颈前后径、内外径测量分析。结果　下颌升支后缘前方 15mm范围内由后向前逐渐增厚 ,部分下颌升支在下颌孔上方 10mm处无松质骨。结论　应用拉力螺钉进行髁突骨折复位固定时应参照以上解剖规律进行。     

简易穿颊器在下颌骨骨折中的临床应用

目的探讨简易穿颊器在下颌骨骨折内固定中的临床意义。方法对36例下颌骨角部、升支骨折患者,采用口内切口,利用骨科打孔导向器改制成的简易穿颊器和骨科用手枪电钻,经颊部皮肤穿刺打孔,小型钛板内固定。结果所有病例面部皮肤均无明显手术疤痕,无面瘫症状。术后3个月～3年复查曲、面断层片或螺旋CT三维重建,骨折线对位良好。31例咬合关系完全恢复,3例下颌骨两处骨折患者术后前牙轻微开(牙合),经颌间弹性牵引一周后好转。2例术后伤口积液血肿,经口内再次皮片引流后愈合。结论利用简易穿颊器辅助,经口内切口内固定下颌骨角部和升支部骨折,可避免颌面部皮肤明显的手术疤痕和面神经损伤的风险,具有一定的临床应用价值。     

口内入路治疗髁突低位骨折

目的:探讨口内入路治疗髁突低位的安全性及有效性。方法:回顾性研究本院2014年1月~2016年4月所收治8例髁突低位骨折的患者,选择口内入路对髁突低位骨折进行切开复位内固定术。结果:8例患者,10侧髁突低位骨折,其中5例患者合并下颌骨体部骨折。髁突低位骨折患者行内窥镜辅助下穿颊器或侧壁螺丝刀口内入路进行手术治疗。术后患者创口均Ⅰ期愈合,未发现面瘫及涎瘘等并发症,术后复查全口曲面断层片和三维CT示骨折断端对位良好。3个月后复查,面部无明显疤痕,张口度正常,咬合关系良好。结论:利用穿颊器或侧壁螺丝刀口内入路治疗髁突低位骨折,相对于传统的耳前、颌下及颌后入路,手术创伤小,面部无明显瘢痕,外形良好,配合内窥镜的使用,更加便于直视下完成骨折复位固定,是治疗髁突低位骨折安全有效的手术入路。     

内镜辅助髁突下骨折的复位与内固定

目的：为减少明显的瘢痕和面神经损伤的机会,采用内镜辅助经口内入路进行成年人髁突下骨折的复位与固定。方法：从2003年4月—2005年12月就诊的11例髁突下骨折病例,全麻下口内切开,内镜辅助下进行髁突下骨折的复位与内固定,同期行其他部位骨折的复位与固定。结果：11例患者中有9例获得了良好的解剖复位,另2例因存在骨质缺损未能达到精确的解剖复位。手术后恢复较快,均无面神经损伤症状。随访期为1.5～3.8a,平均2.2a。术后6个月内关节功能正常,瘢痕不明显;随访期末,平均开口度为3.6cm,2例患者出现关节弹响,但不影响生活。结论：经口内入路内镜辅助的下颌骨髁突下骨折复位与固定可达到开放性手术类似的疗效,并可减少瘢痕的形成和面神经损伤的发生。     

应用穿颊器口内入路微创治疗下颌骨角和升支骨折

目的:观察口内和穿颊的手术入路处理下颌骨角部和升支骨折,并用小钛板坚强内固定的疗效。方法:对2004-01~2005-07间18例连续的下颌骨角部和升支骨折患者,用穿颊器经过颊部小切口联合口内切口复位内固定。随机选取同时期的另外20例同类型骨折患者,仍按照传统口外入路行手术切开复位内固定,2组间进行对比。结果:用口内和穿颊入路患者中有1例内固定术后骨折处仍有小幅动度,还需辅以颌间固定;口外入路行内固定手术的患者中有2例需行术后颌间固定。没有术后感染发生,没有出现需要行切开引流或需取出固定物的病例。结论:通过口内和穿颊入路行坚强内固定适用于不伴有严重错位或粉碎性骨折的下颌骨角部和升支部骨折的病例。     

Endoscopic-assisted repair of subcondylar fractures

OBJECTIVE: To evaluate outcomes of a series of mandibular subcondylar fractures repaired with endoscopic reduction and fixation.Study design Six consecutive subcondylar fractures were treated endoscopically. Intermaxillary fixation was used intraoperatively to aid in fracture reduction. A modified Risdon incision was used to gain access to the lateral ramus, and a modified retractor and endoscope were used for retraction and visualization. Fracture fixation was achieved with a 2-mm titanium plate and screws. Patients were evaluated clinically and radiographically for 6 months and functional, radiographic, and esthetic parameters were assessed at each time period (1, 2, 4, 12, and 24 weeks). RESULTS: All patients demonstrated a stable occlusion in the postoperative period and anatomic alignment of the condyle radiographically. By 1 month, maximum interincisal opening was 42.2 +/- 5.7 mm. There was no joint noise or temporomandibular joint (TMJ) pain postoperatively. Radiographs at each follow-up visit indicated the ramus height was maintained in most cases. There was minimal transient facial nerve paresis following surgery. Scar perception was considered acceptable by all patients. Operative times were acceptable as well. CONCLUSION: Endoscopic-assisted repair of subcondylar fractures is an additional tool for management of subcondylar fractures, however there is a steep learning curve based on this study. The technique allows good visualization of the fracture site for reduction through an incision with an acceptable cosmetic result.     

The retromandibular transparotid approach to mandibular subcondylar fractures

The aim of this study was to evaluate the safety, utility and morbidity associated with the treatment of mandibular subcondylar fractures using the retromandibular transparotid approach and to evaluate the stability of a single 2mm miniplate fixation system for such fractures. Forty-two cases with 48 mandibular subcondylar fractures were analysed prospectively for 12 months and evaluated for functional results, scar, postoperative complications and stability of fixation. There were three cases of suboptimal occlusal status, two cases of haematoma that were drained and resolved, eight patients with facial nerve weakness which resolved in a few weeks, and three cases of salivary fistulae that resolved after treatment. All cases showed stable osteosyntheses. Maximal postoperative interincisal distance was 32-61 mm (mean 44 mm). Four patients had deflection on opening, while clicking on opening or chewing was observed in five patients. The postoperative scars were well accepted by all patients. The results of this study suggest that a retromandibular approach will facilitate accurate reduction and fixation of subcondylar fragments with a good cosmetic result and minimal complications. A single 2 mm miniplate fixation provides stable results.     

下颌升支垂直截骨内固定术治疗髁突高位骨折

目的:比较手术和非手术方法治疗单侧下颌骨髁突高位骨折的临床效果。方法:19例髁突高位骨折患者,其中10例行下颌升支截骨内固定术+颌间牵引术(手术组),其余9例单纯行颌间牵引术(非手术组),随访0.5～1年。结果:手术组和非手术组之间比较,开口度及前伸运动度均无显著性差异(P>0.05);侧方运动度手术组优于非手术组,有显著性差异(P<0.01)。非手术治疗的患者,下颌骨平面不对称,X线片显示髁突的解剖位置欠佳。手术患者,下颌下区存在线形疤痕,但下颌骨平面对称,X线片显示患侧髁突与健侧形态相似。19例中无1例出现明显的颞下颌关节紊乱综合征。结论:采用下颌升支垂直截骨内固定术+颌间牵引术治疗下颌骨髁突高位复杂骨折,兼顾美观和功能,手术简便,不失为一种理想的治疗方法。     

Plate fixation of extra-oral subcondylar ramus osteotomy for correction of mandibular prognathism: clinical aspects and short term stability.

AIM: The present study describes an extra-oral approach for subcondylar oblique ramus osteotomy using stable fixation for setback of the mandible. The aim was to investigate the incidence of neurosensory disturbances of the mandibular nerve, evaluate facial scar appearance, and assess skeletal stability following the procedure. METHODS: Forty-two consecutive patients with mandibular prognathism were operated upon using the subcondylar oblique ramus osteotomy and plate fixation. The patients were followed up for 6 months following surgery. Intra-operative and postoperative complications, neurosensory function, and facial scar characteristics were recorded. Lateral cephalograms were available immediately before operation, and immediately after operation and 6 months postoperatively. Skeletal stability was based on cephalometric assessment. RESULTS: Among the 19 patients operated earliest, neurosensory disturbances were recorded in five individuals at the 6 month follow-up. In the subsequent group of 23 patients, no disturbances were reported. All but two patients were not concerned about the facial scar 6 months postoperatively. Mean anterior relapse at the 6 month follow-up was 0.5 mm, representing 9% of the surgical setback. CONCLUSION: Extra-oral subcondylar oblique ramus osteotomy with plate fixation is a stable procedure with a low incidence of neurosensory disturbances if the osteotomy is placed well behind the mandibular foramen. Facial scar appearance was rarely a matter of concern to the patients.     

Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs intraoral approach

By using an endoscopy assisted extraoral and transoral approach for open reduction of condylar mandible fractures with limited incisions, the risk of facial nerve damage and extensive visible scars can be reduced. The endoscopy-assisted treatment of 17 consecutive patients with fractures of the condyle was performed from April 1998 to December 1999. Of the 17 patients, 13 presented with additional mandibular fractures. Nine of the 17 patients were treated by a submandibular approach and eight by a transoral approach. Adequate anatomic reduction was achieved by the submandibular and transoral approach using an endoscopy-assisted technique. The transoral approach proved to be a reliable surgical approach for fractures of the mandibular condyle, even when dislocation with lateral override was present. In four patients, angulated drills and screwdrivers facilitated the transoral treatment of condylar fractures. Transbuccal stab incisions and the use of trochars were not needed in these four patients. The extraoral approach was indicated for severely dislocated fractures such as fractures with medial override or comminution.     

Retromandibular approach to condyle fractures: two case reports

Retromandibular approach was first described in 1967 for vertical subcondylar osteotomy and later became popular for surgical treatment of temporomandibular joint dysfunction and low condyle fractures. The trajectory of the incision, parallel to the posterior border of the mandibular ramus, allows a good approach with easy separation of the buccal and marginal mandibular branches of the facial nerve, when they are present in the surgical field. When open reduction and internal rigid fixation with plates and screws are indicated for condylar fractures, retromandibular approach offers an excellent esthetic result with low morbidity. Two clinical cases are presented, in which the surgical treatment was carried out for condylar fractures, and clearly illustrate the proposed approach.