标准型人工颞下颌关节置换术应用效果初步报告

目的:介绍标准型人工全关节置换术应用于颞下颌关节重建的方法,初步评价其疗效及应用价值。方法:6例(10侧)颞下颌关节病患者,年龄49～66岁,平均59岁。3例(5侧)有既往颞下颌关节手术治疗史,3例(5侧)为内紊乱伴骨关节炎。术前均有明显开口受限及关节区疼痛,开口度1.0～2.9cm,平均1.9cm。采用标准型人工关节置换术,术后定期观察开口度及关节疼痛等变化,结合影像学检查等评价治疗效果。结果:成功完成6例(10侧)人工关节置换术。术后随访7～49个月,平均17.5个月。植入关节未出现因感染、排异、松动或断裂等导致的失败。有既往手术的病例中,1例(2侧)发生假体内侧异位成骨,1例(2侧)耳颞区疼痛无法缓解,其余4例(6侧)开口受限及关节区疼痛均有较明显改善。影像学检查均未见假体松动等异常情况。结论:标准型人工全关节置换术对缓解关节疼痛有明显效果,可有效改善开口度及提高咀嚼能力,但对咀嚼肌疼痛的缓解效果不理想。     

人工颞下颌关节的研究

人工颞下关节节用于肿瘤、外伤、关节强直等关节缺损成破坏后的重建，其研究与应用经历了设计改良、工艺革新、材料开发的长期演变与发展。Ｋｅｎｔ和Ｒａｖｅｈ成为该领域的重要贡献者。目前，人工颞下颌关节在欧美还处于探索性研究阶段，国内尚属空白，主要问题是现有关节假体在设计上还存在缺隐，临床适应证也未统一，术后效果达不到预期目的。     

个体化人工颞下颌关节置换术远期疗效报告

目的：随访2例3侧采用人工颞下颌关节置换的患者,随访时间分别为4年和4年半,以评价人工关节置换的远期临床疗效。方法：2例3侧采用人工颞下颌关节置换术进行骨关节病治疗的患者,分别进行了为期4年和4年半的临床随访。记录患者术后在关节疼痛、开口度等指标的变化及患者对治疗结果的主观评价。结果：2例患者术后受累关节疼痛、开口受限及咀嚼能力等方面均获得了满意的改善,开口度在术后4年均增加至35mm以上,未再出现明显颞下颌关节区疼痛．VAS疼痛评估为0-1。开口受限无复发,开口度维持良好。患者自觉咀嚼能力明显增强,生活质量明显提高。结论：人工关节置换术是重建颞下颌关节的一种良好术式,对恢复因骨关节病等导致的关节功能丧失是一种较理想的选择。     

人工颞下颌关节的研究

人工颞下颌关节用于肿瘤、外伤、关节强直等关节缺损或破坏后的重建,其研究与应用经历了设计改良、工艺革新、材料开发的长期演变与发展。Kent和Raveh成为该领域的重要贡献者。目前,人工颞下颌关节在欧美还处于探索性研究阶段,国内尚属空白。主要问题是现有关节假体在设计上还存在缺陷,临床适应证也未统一,术后效果达不到预期目的。     

人工颞下颌关节的研究进展

颞下颌关节结构和功能的复杂性使得其重建成为外科医生所面临的最大挑战之一。人工颞下颌关节是颞下颌关节重建的重要方式之一,主要适用于颞下颌关节强直、无法复位固定的髁突粉碎性骨折、颞下颌关节肿瘤、晚期关节内紊乱及一些先天性颅面综合征等所致的颞下颌关节发育不良等。人工颞下颌关节旨在改善颞下颌关节的功能、减少疼痛并防止严重的并发症。在口腔颌面外科,人工颞下颌关节具有能模仿正常的解剖形态、与宿主贴合、不需另行取材、术后能立即进行功能训练等优点。假体材料在人工颞下颌关节的发展中起着至关重要的作用,优良的设计、牢靠的固定都是人工颞下颌关节能够行使其功能必不可少的条件,当然关节生物力学的研究也是必不可少的。随着材料学、关节生物力学及制作工艺等相关学科的飞速发展,人工颞下颌关节在关节假体的植入材料、假体的设计等方面取得了不少进展。随着人工颞下颌关节的发展,其应用也越来越广泛。本文对人工颞下颌关节的发展及其临床应用作一综述。     

人工颞下颌关节的研究进展

人工颞下颌关节具有能模仿正常的解剖形态、与宿主贴合、不需另行取材、术后能立即进行功能训练等优点。假体材料对人工关节的发展具有先导和推动作用。良好的设计、适形与固定是假体行使功能的必要条件。本文对人工颞下颌关节的发展概况、关节假体使用材料及其设计、关节假体的适形与固定技术,存在问题及临床应用进行综述。     

数字化导板在颞下颌关节强直保留髁突手术中的指导作用

目的 设计制作数字化导板（digital guide）,用于指导颞下颌关节强直（temporomandibular joint ankylosis,TMJA）外侧成形术（lateral gap arthroplasty,LAP）中髁突残余（residual condyle）的保留,并评价其应用效果。方法 收集2012年1月—2014年1月间收治的TMJA患者,选择骨球内侧存在髁突残余者纳入研究。采用 ProPlan CMF 1.4软件进行术前设计,明确骨球范围及其与髁突残余的关系,设计数字化导板并采用快速成型技术制作完成,术中用以指导骨球的截除。评价导板的就位情况及对重要解剖结构的保护。术后拍摄CT评价截骨效果并与手术设计进行拟合,评价导板的准确性。结果 5例7侧关节手术中,导板就位稳定,指导截骨准确,未伤及颅底和外耳道前壁,有效保护了内侧的髁突残余。术后CT显示截骨与术前设计的平均误差为1.044 mm。结论 数字化导板可以准确有效地指导强直骨球的切除,有效保护了髁突残余、颅底和外耳道。     

三维可调式人工颞下颌关节的设计与性能的初步研究

本文提出了一种三维可调式人工颞下颌关节(简称TDATMJP),详细阐述了结构组成、装配连接、功能实现。在动物体内植入半年后,对各部件表面裂伤、表面形貌、材料成分、连结轴紧固强度、钛部件生物相容性做了试验检测和分析,初步性能结果符合设计要求。     

改良人工全颞下颌关节置换术及效果评价

目的 介绍一种人工全颞下颌关节（temporomandibular joint,TMJ）置换的改良术式并评价其临床应用效果。方法：自2006年9月,我院开始引进Biomet-Lorenz公司(Jacksonville, FL)标准型假体系统进行人工全TMJ置换术,对手术方法进行改良,包括①切取关节结节/髁突骨块填充关节窝,增加关节窝假体固定的稳定性;②保留关节盘,作为髁突假体的内侧充填物,防止发生异位骨化;③经下颌下切口切取皮下游离脂肪瓣,避免腹部切口。拍摄全口曲面体层片（panoramic radiographs, PR）或CT,分别于术后即刻、6个月、1年观察假体位置及其周围骨结构。采用SAS 9.13软件包对数据进行统计学处理。结果：随访12例（14侧）患者,平均随访期26.08个月（4~48个月）。11例（13侧）采用自体骨转移,辅助关节窝假体固位,其中采用关节结节骨块7例(10侧),髁突骨块2例（2侧）,下颌支残端骨块1例（2侧）;5例（5侧）保留关节盘作为髁突假体内侧充填物;10例（10侧）从下颌下切口切取皮下游离脂肪瓣。术后即刻、6个月、1年影像学（PR或CT）检查均显示关节窝及下颌假体位置良好,患者假体周围骨结构均未见异常。术后所有患者咬合关系稳定,未见假体松动现象。结论：人工全TMJ置换改良术式有助于提高假体的稳定性,减少术后异位成骨的发生,避免额外手术切口,值得推广应用。     

上颌咬合板治疗颞下颌关节紊乱病

为寻找治疗颞下颌关节紊乱病的有效方法。方法 对３４例颞下颌关节紊乱病伴前牙深覆 Ｈｅ患者给予上颌Ｈｅ板治疗。结果 上颌咬合板对颞下凳关节疼痛，弹响以及张口受限等临床症状有明显缓解作用。结论上颌咬合板可作为治疗颞下颌关节乱紊乱病的方法之一。     

Accuracy of digital templates for guidance of custom-made total temporomandibular joint replacement

This study evaluated the application of digital templates to guide custom-made total temporomandibular joint (TMJ) replacement. Patients treated with a custom-made total TMJ prosthesis for TMJ osteoarthrosis, ankylosis, or tumours were included prospectively. Before surgery, two types of digital template (articular eminence and condyle neck templates) were designed to guide the bone osteotomy and prosthesis positioning. The reconstructive outcomes were assessed through clinical examinations and accuracy analysis by superimposing the postoperative three-dimensional craniomaxillofacial model onto the preoperative virtual plan. Thirty-seven patients (45 joints) underwent successful TMJ reconstruction with the custom-made TMJ prosthesis guided by the digital templates, without intermaxillary fixation. For all patients, the occlusal relationship was stable in reference to the preoperative state. There were significant improvements in pain and maximum inter-incisal opening. Through merging of the pre- and postoperative craniomaxillofacial models, the maximum implanted error was 1.17 ± 0.23 mm in linear measurement and 1.19 ± 0.14 mm in surface deviation. There was more deviation in the anteromedial part of the fossa and inferior part of the mandibular handle. The digital templates were able to assist in the accurate placement of the TMJ prosthesis without the need for intermaxillary fixation.     

Current status of replacement of the temporomandibular joint in the United Kingdom

Total replacement of the temporomandibular joint (TMJ) has been done in the UK since 1987. The three currently available systems are the Christensen system, the TMJ Concepts system and the Lorenz (BMF) system. Data from surgeons who replace TMJ were collated up to May 2007. There were nine units (eight NHS, one private) offering replacement. The TMJ Concepts system is the most popular of the three systems. Units are treating between five and 12 patients each year with an estimated total annual workload of 60-65 patients. The current total costs range from pound 15 000 to pound 19 000 for bilateral replacement. The most worrying complication is infection, which may affect up to 2.6% of patients.     

Treatment of end stage temporomandibular joint disorder using a temporomandibular joint total prosthesis: The Slovenian experience

Purpose

The aim of this study was to analyse treatment results after alloplastic temporomandibular joint replacement surgery.

Risk factors for intraoperative dislocation of the total temporomandibular joint replacement and its management

Total replacement of the temporomandibular joint (TMJ) is an effective treatment for intractable pain and impaired function that is a consequence of end-stage joint disease. Prospective assessment of 138 joint replacements identified an 8% risk of intraoperative dislocation of the joint, which was associated primarily with coronoidectomy (30%) and inflammatory arthropathy (24%). Management included the use of intermaxillary elastic traction and treatment of masticatory dystonia when present. Of the 11 patients who had light elastic traction for one week, only one required further treatment for dislocation. Patients with no intraoperative dislocation did not require elastics, and joints remained stable postoperatively.     

Single stage treatment of ankylosis of the temporomandibular joint using patient-specific total joint replacement and virtual surgical planning

Ankylosis of the temporomandibular joint (TMJ) is a debilitating condition that can result in pain, trismus, and a poor quality of life. It can be caused by injury, infection, and rheumatoid disease. Current management includes gap arthroplasty, interpositional arthroplasty, and reconstruction. Traditionally, joints are reconstructed using stock implants, or the procedure is done in two stages with an additional computed tomography (CT) scan between the resective and reconstructive procedures and use of stereolithographic models to aid the design of the definitive prostheses. We describe a technique for the resection of ankylosis and reconstruction of the joint in a single operation using virtually designed custom-made implants. Five patients with ankylosis of the TMJ had a single stage operation with reconstruction between 2010 and 2012. All had preoperative high-resolution CT with contrast angiography. During an international web-based teleconference between the surgeon and the engineer a virtual resection of the ankylosis was done using the reconstructed CT images. The bespoke cutting guides and implants were designed virtually at the same time and were then manufactured precisely using computer-aided design and manufacture (CAD-CAM) over 6 weeks. After release of the ankylosis and reconstruction, the patients underwent an exercise regimen to improve mouth opening. Follow-up was for a minimum of 6 months. Four patients had one operation, and one patient had two. Median/Mean maximum incisal opening increased from 0.6 mm before operation to 25 mm afterwards (range 23–27), and there was minimal surgical morbidity. This new method effectively treats ankylosis of the TMJ in a single stage procedure. Fewer operations and hospital stays, and the maintenance of overall clinical outcome are obvious advantages.     

Validation of an extended total joint replacement (eTJR) classification system for the temporomandibular joint (TMJ)

The aim of this paper was to validate a previously described classification system for extended total joint replacements (eTJRs) of the temporomandibular joint (TMJ). We engaged an expert panel to review 60 TMJ eTJR devices and classify them using the system, examining their responses for inter-rater agreement and concordance with the correct response as determined by the authors. Conger's kappa was 0.34 for the fossa (F) component sub-classification and 0.67 for the mandibular (M) component. A posthoc analysis showed improvements in inter-rater agreement for a modified three-tiered F sub-classification system which is suggested in a revised version of the TMJ eTJR classification system.     

Predictive risk factors for facial nerve injury in temporomandibular joint replacement surgery

The objective of this study was to determine the prevalence of temporary and permanent facial nerve injury in total temporomandibular joint (TMJ) replacement surgery and to identify potential predictive risk factors. We made a retrospective review of case notes and opportunistic review of patients treated in a single tertiary referral unit by a single surgeon. For each patient a number of potential risk factors were determined, and the presence or absence of nerve injury recorded at 2 week follow up and a minimum of 12 months follow up. At 2-week review, facial nerve weakness was noted in 38/133 cases (28%) and at last follow up there were 4/133 cases (3%) with continuing (permanent) facial nerve weakness. Bilateral surgery, revision TMJ replacement, primary diagnosis, the number of previous surgeries and a history of recovered facial nerve injury all significantly increased the likelihood of temporary facial nerve injury, but not the likelihood of permanent facial nerve injury. Factors which increase the risk of temporary facial nerve injury are relatively predictable and include bilateral surgery, revision TMJ replacement, and multiple open TMJ surgeries. Risk factors associated with permanent injury are less predictable but are likely to be similar. The identification of such factors allows for the risk stratification of patients and improve informed consent. We also recommend that patients with a single, previously failed open TMJ surgery should be considered for early TMJ replacement and in multiply operated patients a subfascial plane of dissection is adopted.     

One stage management of ankylosis of the temporomandibular joint with a custom-made total joint replacement system

Alloplastic joint prostheses have been used in the treatment of severe diseases of the temporomandibular joint (TMJ) for many years. Treatment of ankylosis of the TMJ has been difficult, with many surgical approaches being used that traditionally involved multistage procedures, long treatment times, and increasing expense. We report a single stage technique for replacement of an ankylosed joint using a custom-made prosthesis, and discuss the technical aspects of the procedure, including our use of a custom-made acrylic glenoid fossa template.     

Review of emerging temporomandibular joint total joint replacement systems

Total temporomandibular joint (TMJ) replacement has been documented as a viable option for the management of end-stage TMJ disease, but data on long-term outcomes have been reported for only two established systems: TMJ Concepts, and Zimmer Biomet. Other devices are now emerging globally, but reports of preclinical laboratory and clinical outcomes are limited. We retrieved information on the design, material composition, preclinical laboratory tests, regulatory status, and clinical outcomes of new TMJ replacement systems from PubMed and Google, and from personal correspondence with surgeons worldwide. Fifteen countries have developed, or are developing, 27 TMJ replacement systems, of which 21 are custom-designed, but to date, only four have been given regulatory approval. All the devices are designed to have both a skull-based glenoid fossa component and a mandibular ramus or condyle, and 22/27 are similar to the designs of the two established systems. Twenty-one devices use an ultra-high-molecular-weight polyethylene (UHMWPE) fossa-bearing surface, and 10 have a titanium alloy condyle. Nineteen manufacturers report that a titanium alloy is used for the ramus portion of the condyle/ramus component. Preclinical laboratory tests on 12 of the systems have been reported but, to our knowledge, no outcomes have yet been reported on nine of the 27 reviewed. Not all systems are equal in terms of design, material composition, preclinical laboratory testing, manufacturing methods, regulatory status, and reports of clinical outcomes.