改良切口关节盘锚固术治疗颞下颌关节盘不可复性前移位的临床评价

目的: 评价应用改良切口关节盘锚固术治疗颞下颌关节盘不可复性前移位的临床疗效。方法: 选取2014年9月—2016年9月我院颞下颌关节专科就诊的24例（30侧）颞下颌关节紊乱病患者,采用改良切口颞下颌关节盘锚固术进行治疗, 分析术前、术后6个月不同时期患者的疼痛值、开口度的变化及MRI影像学表现,采用SPSS17.0软件包中的t检验评价手术效果。结果: 治疗前平均开口度为（23.63±3.31）mm(17~29 mm),治疗后平均开口度为（38.00±2.30）mm(32~42 mm),治疗后开口度≥35 mm 的患者占 87.5%（21/24）;疼痛直观模拟标尺（visual analogue scale,VAS）值术前为29.76±23.35（0~80）,术后6个月为3.71±7.91（0~50）,术后6个月的开口度及VAS值均与治疗前有显著差异（P<0.05）。MRI影像学评价有效率达96.67%（29/30侧）,所有病例均无并发症发生。结论: 颞下颌关节盘锚固术能有效治疗颞下颌关节盘不可复性前移位,在复位关节盘的前提下,显著改善开口度和缓解疼痛。     

Long-term evaluation of arthroscopic discectomy of the temporomandibular joint using the Holmium YAG laser.

PURPOSE: The goal of this study was to evaluate the clinical results with arthroscopic discectomy using a Holmium YAG laser for treatment of patients with pain and dysfunction and large disc perforations resulting by advanced internal derangement. PATIENTS AND METHODS: The subjects comprised 30 patients (38 joints) who underwent arthroscopic discectomy with Holmium YAG laser. All patients had chronic pain, restricted range of motion, and a diagnosis of disc perforation (Wilkes stage IV to V of internal derangement). All patients had not responded to conventional nonsurgical treatment (eg, appliance therapy, nonsteroidal anti-inflammatory drugs, physical therapy) or previous temporomandibular joint (TMJ) arthroscopy. All patients filled out a questionnaire preoperatively and postoperatively for assessment of their signs and symptoms. The questionnaire consisted of a visual analog scale (VAS) with items on pain and diet. RESULTS: The overall success rate for arthroscopy discectomy using a Holmium YAG laser was 93.33% (28 of 30 patients) in a mean follow-up of 31.7 months. No complications were observed in this study. Maximal interincisal opening improved from a mean of 25.40 to 39.96 mm after 18 months or more from surgery. The subjective data elicited from VAS scores showed a significant improvement in pain score, in interference of pain with normal diet, and effect of pain on life in general. All preoperative scores were significantly different from postoperative scores (P <.05). CONCLUSIONS: On the basis of this follow-up study, arthroscopic discectomy for treatment of large disc perforations seems to provide an effective treatment for TMJ pain and dysfunction, decreasing the pain and improving the range of motion.     

MRI and arthroscopic findings in the temporomandibular joint after mandibulectomy including the unilateral condyle. Report of two cases

In this report, the MRI and arthroscopic findings in the temporomandibular joint (TMJ) of two patients who underwent partial mandibulectomy including the condyle are presented. The disc and superior joint compartment of the affected TMJs were preserved in both patients. MRI of the affected TMJs without condyle demonstrated that the intermediate zone of the discs was located anteriorly to the summit of the articular eminence. Joint effusion was detected in the superior joint compartment of one patient. Fibrous adhesions were observed arthroscopically in the superior joint compartment of both affected TMJs. In contrast, no specific findings were demonstrated in the contralateral TMJs connected with the residual mandibular fragment.     

颞下颌关节上腔囊内黏连的内镜手术方法及疗效

目的：介绍颞下颌关节（TMJ）镜下治疗囊内黏连（IA）的术式,评价关节镜手术治疗TMJ上腔IA的疗效。方法：对142例（159侧）关节镜下证实有黏连的关节行黏连松解术、囊内清扫修整术或射频消融术,其中110例（123侧）伴随关节盘移位者,行关节盘复位固定术。术后随访检查包括患者的颌骨运动度、VAS疼痛测量值及自我评价。疗效分为优、良、差3级,将优、良定为手术有效;采用SPSS11.0软件包对手术前、后颌骨运动度和VAS疼痛测量值分别进行配对t检验。结果：平均随访期10.3个月（1～27个月）。疗效评价优33.80%（48/142）,良56.34%（80/142）,差9.86%（14/142）;总有效率90.14%（128/142）。93.66%（133/142）的患者自主症状较术前明显改善。术前平均开口度（23.14±5.93）mm（10～40mm）,术后平均开口度（37.48±3.51）mm（30～40mm）,较术前显著改善,经统计学处理有显著性差异（P〈0.01）。疼痛的VAS测量值术前平均28.94±23.54（0～80）,术后平均4.44±10.10（0～50）,手术前、后VAS测量值有显著差异（P〈0.05）。结论：关节镜手术治疗TMJIA疗效肯定,能增大患者的开口度,改善功能,减轻颌骨运动时的疼痛。     

Visually guided irrigation for patients with symptomatic internal derangement of the temporomandibular joint: a preliminary report

OBJECTIVE: Visually guided irrigation (VGIR) is simple joint irrigation with minimally invasive intracapsular inspection through the use of a thin arthroscope. The aims of the present study were to develop VGIR for the superior joint compartment of the temporomandibular joint (TMJ) by using a 1.2-mm-diameter rod-lens arthroscope and to examine the short-term clinical outcomes. The correlation between the clinical outcome of VGIR of the TMJ and intracapsular findings was also evaluated. STUDY DESIGN: Twenty patients who underwent VGIR for symptomatic internal derangement of the TMJ (n = 20) were enrolled in this study. The clinical outcome of VGIR was evaluated in terms of the improvement in the painless range of mandibular motion (ROM: interincisal distance in millimeters), and functional jaw pain was evaluated by using a visual analog scale (VAS) ranging from 0 to 100. Painless ROM and VAS scores 6 months postoperatively were compared with the preoperative data. A good clinical outcome was defined as an increased ROM (ROM > 38 mm) and a decreased VAS score (VAS score < 20%, and <60% of the preoperative level). With respect to these criteria, all joints were classified into either good clinical outcome (GO) or poor clinical outcome (PO) groups. The difference in the distribution of the arthroscopic findings obtained during VGIR, with respect to severity, was analyzed between the GO and PO groups. RESULTS: None of the 20 patients experienced any serious local or systemic complications, including the breakage of instruments. We were able to perform a reliable intracapsular diagnosis during VGIR. Sixteen of 20 patients (80%) had significant improvements in postoperative painless ROM and the VAS score of functional pain, thereby being classified into the GO group. The distribution of the severity of intracapsular findings did not differ significantly between the GO group and the PO group. CONCLUSIONS: VGIR is useful for the treatment and diagnosis of internally deranged TMJs. These data suggest that the clinical outcome of TMJ irrigation is not related to the intracapsular condition of the superior joint compartment.     

Single portal arthroscopic temporomandibular joint discopexy: Technique and results

The aim of the present study is to assess the outcomes of monoportal arthroscopic disc repositioning (discopexy) for disc displacement of the temporomandibular joint.A retrospective, single-institutional clinical study included patients with temporomandibular joint internal derangements diagnosed and treated by monoportal discopexy. Each patient was diagnosed as having anterior disk displacement with or without reduction. The arthroscopy treatment consists of one portal approach fixing the disc with a 3/0 nylon to the tragus cartilage without anterior liberation. Arthroscopy surgery was carried out with a 1.9-mm 0° arthroscope and only one simple cannula. We use a needle to pierce of the disc through the skin and retrieve the suture inside the joint using a blind method through the arthroscopic cannula. The evaluated variables included the maximum interincisal opening, the presence of clicking and pain score.A total of 19 patients, 21 joints, were included in the present study. Of the 21 joints, 16 were classified as disc displacement with reduction and 5 without. Visual analogue scale (VAS) values (0–10) decreased from 5.5 to 1.26 (p < 0.0001) 1 year after surgery. At the first review, all patients had a VAS of at least 4 points less than before the surgery, four patients showed a VAS of 0, and nine patients near to 1. Mouth opening increased from 36.6 (±8.09) mm to 39.37 (±4.35) mm, and no significant limitations in the mouth opening range were seen (p < 0.12) 1 year after surgery. Clicking disappeared in all patients and remained stable after 12 months of follow-up. Postoperative magnetic resonance imaging demonstrated a correct or improved position of the disc in all but one patient.A minimally invasive single portal arthroscopic discopexy is an effective technique to improve function and pain reduction in patients with anterior disk displacement with or without reduction.     

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).     

兔颞下颌关节盘移位与骨关节病关系的评价

目的评价颞下颌关节盘移位与骨关节病的关系。方法通过手术方法将２５只大耳白兔的颞下颌关节盘前移，术后１、２、４、８、１２周进行组织病理学检查。结果１１侧手术关节为部分关节盘前移位，８侧为完全性关节盘前移位，６侧为关节盘穿孔。部分关节盘前移位出现早期退行性改变和后期生理性改建，完全性关节盘前移位和关节盘穿孔出现退行性改变和严重的骨关节病。结论颞下颌关节盘前移位的程度与骨关节病有关，关节盘前移位越明显，越易出现骨关节病     

Sound analysis of temporomandibular joint internal derangements with phonographic recordings

STATEMENT OF PROBLEM: Temporomandibular joint (TMJ) sound recordings could be analyzed to assess the state of TMJ internal derangements. PURPOSE: The aim of the study was to assess the value of sound analysis in the diagnosis of the type of the TMJ internal derangements. MATERIAL AND METHODS: After clinical and radiologic examinations, phonographic sound recordings on mandibular excursions were obtained in 52 patients with TMJ internal derangements and 12 control individuals. Sound correlations were made on the basis of opening-closing, protrusive-retrusive, and lateral excursions of the mandible. RESULTS: Clicking was a consistent finding of anterior disc displacement with reduction, whereas crepitation was found in varying degrees in anterior disc displacement and osteodegenerative arthritis. Silent TMJs were the feature of normal TMJs, except for the situations of acute lock. Although in 29 TMJs opening click was followed by a closing click (reciprocal clicking), 46 TMJs with opening click also had clicking on protrusion. On the other hand, 19 TMJs with opening click also had clicking on ipsilateral motion, and 40 TMJs with opening click had clicking on contralateral motion of the mandible. The sound patterns were found to be similar in opening-protrusive clicks and opening-contralateral clicks. The lack of protrusive clicking in the presence of opening click was considered an indication of late disc reduction on opening. Crepitation was observed in advanced cases of TMJ internal derangements. CONCLUSION: Within the limitations of this study, the results suggest that TMJ sound analysis on mandibular excursions was indicative for diagnosis and establishment of severity of TMJ internal derangements. Clicking and crepitation may be looked on as signs of abnormal joint disorder, clicking indicating anterior disc displacement with reduction, and crepitation, indicating progression from anterior disc displacement without reduction to osteodegenerative arthritis.     

颞下颌关节镜下盘复位固定术的疗效评价

目的:介绍颞下颌关节(temporomandibular joint,TMJ)镜下盘复位固定术的磁共振(magnetic resonanceimaging,MRI)和临床评价的初步效果。方法:选取门诊就诊的TMJ疾病患者进行临床检查,在初步诊断为结构紊乱(internal derangement,ID)后进行MRI检查,以获取评价关节盘情况的影像学依据,并按照Wilkes-Bronstein分期标准进行分期,将处于Ⅱ～Ⅴ期的患者纳入治疗范围,进行关节镜下盘复位固定手术。术后对接受关节镜下盘复位固定术的911例患者(1103侧关节)再次进行MRI检查,根据MRI评价标准,评价关节盘复位的效果。对复位"差"者再次进行手术,或改为开放性锚固术。结果:MRI评价显示,1032侧关节达到良以上,有效率达93.56%(1032/1103);仅有71侧、6.44%(71/1103)的关节进行了二次关节镜手术或开放性手术。临床评价的平均随访期为15.3个月(2～29个月),结果为优者32.88%(48/146),良者57.53%(84/146),差者9.59%(14/146);总有效率为90.41%(132/146)。92.47%(135/146)的患者自主感觉较术前明显改善。有效组开口度改善(14.34±5.87)mm(P<0.001)。VAS术前29.76±23.35(0～80),术后3.71±7.91(0～50)(P<0.05)。失败组开口度改善不明显(P>0.05)。VAS术前3.33±5.77,术后36.67±30.55(P<0.01)。对MRI评价与临床评价2种方法进行χ2检验,两者之间无显著性差异。结论:TMJ内镜下盘复位固定术是一种能将关节盘复位的、有效的微创术式,但其长期稳定性尚需进一步评价。     

颞下颌关节灌洗术治疗不可复性关节盘前移位的临床研究

目的 评价颞下颌关节上腔灌洗术治疗不可复性关节盘前移位的临床疗效。方法 ３８例因不可复性关节盘多位引起张口受限的患者行关节上腔灌洗治疗,分析治疗不同时期患者的疼痛值、下颌运动度变化,通过关节造影判定治疗前后关节盘位置的变化。结果 治疗后不同时期的下颌运动均较治疗前的显著增加（Ｐ〈０．００１）,特别在治疗后１个月内增加明显,疼痛亦有显著缓解（Ｐ〈０．０１）。关节造影显示仅有２患者的关节盘部分复位。结     

The effect of interocclusal appliances on temporomandibular joints as assessed by 3D reconstruction of MRI scans

Magnetic resonance imaging (MRI) enables simultaneous visualization of hard and soft tissues. The aims of the present study were to computer generate three-dimensional (3D) images, reconstructed from MRI scans of normal temporomandibular joints (TMJ), to assess the relative positions of the disc, condyle and articular surface of the temporal bone and to study the effect of two mandibular group function interocclusal appliances (IOAs). Bilateral MRI scans of 2 mm slice thickness were generated for the TMJs of 12 asymptomatic subjects with the image acquisition coils orientated in a corrected oblique sagittal plane. MRI scans were generated for all subjects with 3 mm interincisal distance IOAs, while a subgroup (n = 4) was also scanned with a 5 mm interincisal IOA in situ. An average of 10 slices through each TMJ were generated for the closed mouth and IOA positions. Three-dimensional reconstruction was performed on a 486 IBM compatible computer using a suite of nine programs not commercially available. Three-dimensional images allowed visualization of composite images of joint relationships. Subjective assessment indicated that joint relations in 3D were more informative than multiple separate 2D MRI scans. With the 3 mm IOA in situ, the disc was positioned posteriorly and superiorly to the condyle in three of 12 cases. In four of 12 cases the condyle, and in two of 12 cases both the disc and condyle, were positioned anteriorly and inferiorly. With the 5 mm IOA changes in condyle/disc and condyle/fossa relationships were more variable. It was concluded that 3D images of TMJs enabled the assessment of the positional changes of the condyle/disc and condyle/fossa relationships as altered by IOAs. However, the role of IOAs on the internal arrangements within the TMJ remains variable and is deserving of further study.     

硬化疗法结合缝合牵引术治疗颞下颌关节盘移位的疗效分析

目的为弥补关节镜滑膜下硬化疗法１周后瘢痕化的缺陷，使复位的关节盘即刻获得牵引固定。方法对３１侧颞下颌关节盘移位（可复性１５侧，不可复性１６侧）经关节镜确定移位的方向及程度，在关节盘复位操作及盘后区硬化疗法的基础上，采用后向和（或）侧向缝合牵引固定技术，术后即刻用关节镜评判盘复位情况。结果随访期２７个月（６～３９个月），总疗效７４２％（２３／３１），可复性盘移位疗效为９３３％（１４／１５）；不可复性为５６４％（９／１６）。结论本术式对关节盘移位，尤其是可复性移位的疗效优异；建议关节镜诊断、治疗及疗效评判同期进行     

Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease?

Effusions are common among patients with disorders of the temporomandibular joint (TMJ), but publications are limited and results inconsistent about the correlation between them and important clinical variables, in particular severity of pain and degenerative disease. We organised a retrospective study of patients who presented for the evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Inclusion criteria were: patients who had pain that was primarily arthrogenous, and coexisting myogenous pain, who had had initial non-surgical treatment, and arthroscopy of the TMJ with or without intramuscular injection of onabotulinumtoxinA (Botox,^® Allegan, Weston, Fl, USA). The primary outcome variables were pain at rest as measured by visual analogue score (VAS) and the presence of degenerative disease of the joint. The secondary outcome variables included the position of the disc and whether it was perforated, signs of synovitis, maximal interincisal opening (MIO), and duration of symptoms. We studied 47 patients (94 TMJ) who met the inclusion criteria. We found no significant differences in pain at rest before or after arthroscopy, between patients with and without effusions, or in maximal MIO or duration of symptoms between the two groups. There was, however, a significant relation between effusions and degenerative joint disease. Effusions were also associated with a lower probability of the disc being in a normal position and a higher probability of anterior disc displacement without reduction.     

颞下颌关节镜治疗关节盘前移伴穿孔患者的全程康复护理探讨

目的: 探讨颞下颌关节镜下盘复位手术对治疗关节盘前移伴穿孔患者全程康复护理的应用效果。方法: 回顾分析2017年1月—2018年12月间因颞下颌关节盘前移伴穿孔而接受颞下颌关节镜下盘复位治疗的54例患者,配合实施全程康复护理干预。比较治疗前、后的疼痛视觉模拟量表(VAS)和最大开口度(MIO),以及术后生活质量评分指标。评价全程康复护理配合关节镜治疗的疗效。采用SPSS 24.0 软件包对数据进行统计学处理。结果: 所有患者全程配合度好、依从性好,均能定期复诊,无失访病例,并按规定完成术后开口训练及垫配戴。术后6个月随访显示,MIO平均值由术前的(31.76±7.40)mm增至(35.24±6.22)mm(P=0.001);VAS平均得分由术前的(3.13±2.76)分降至(0.96±1.26)分(P=0.04)。治疗后生活质量评分指标的平均得分为42.11±2.21,患者满意度为90%(≥40)。结论: 全程康复护理通过对患者进行术前、术中、术后一体化、个体化优质护理,有助于提高颞下颌关节镜下盘复位手术对关节盘前移伴穿孔的治疗效果,改善开口功能,缓解疼痛。     

The posterior double pass suture in repositioning of the temporomandibular disc during arthroscopic surgery: A report of 16 cases

Aim

Several procedures have been described to reposition and secure the disc during arthroscopic surgery of the temporomandibular joint. The usefulness of these procedures remains controversial since simple lysis and lavage shows a high percentage of clinical success and it is difficult to obtain radiological imaging of the surgically acquired new disc position. This report describes a new arthroscopic discopexy method, and the clinical as well as radiological results obtained with this new technique.

Methods

Sixteen patients with a clinical and radiological diagnosis of Temporomandibular Joint (TMJ) dysfunction (TMD) were treated using our discopexy method. Each patient was evaluated with a visual analogue scale (VAS) for pain, radiological and functional parameters. The evaluation also included a clinical examination. Each patient was recorded at baseline before surgery and at a one-year follow-up. Statistical analysis was performed to evaluate the differences in VAS, maximum opening and lateral movements before and after treatment and were considered statistically significant when p < 0.05.

Results

Patient evaluation showed an improvement in the clinical parameters. There were statistically significant reductions in the amount of pain according to the VAS (p < 0.01). Maximal interincisal opening (MIO) and contralateral translation movement (CTM) (p < 0.05) were substantially improved one-year after operation. In the post-surgical MRI study at the one-year follow-up, a significant improvement in the disc position was observed in 13 out of the 16 joints operated on.

Conclusion

This method of arthroscopic disc repositioning is an effective surgical method for treating symptomatic patients with a diagnosis of TMJ disc displacement. Because of the minimally invasive character of the procedure, it should be considered in the surgical treatment of TMJ dysfunction.     

Arthroscopic lavage and lysis of the temporomandibular joint: a change in perspective

Arthroscopic surgery was applied to correct various disorders of the temporomandibular joint (TMJ). Lysis and lavage of the upper TMJ compartment proved of value in patients with anterior disc displacement without reduction ("closed lock"), because it increased the range of mouth motion and alleviated pain in the TMJ. Because this beneficial arthroscopic intervention did not encompass repositioning the disc, its surgical relocation when attempting to overcome dysfunction and pain in the TMJ is questioned.     

可吸收带线锚固钉与金属锚固钉治疗颞下颌关节盘不可复性前移位的短期疗效比较

目的:研究可吸收带线锚固钉与金属锚固钉应用于颞下颌关节盘锚固术治疗颞下颌关节盘不可复性前移位(anterior disc displacement without reduction,ADDWoR)的短期疗效比较.方法:选取2019年1月—2020年12月于我院行颞下颌关节盘锚固术的40例(52侧)患者,使用钛合金金属...     

透明质酸钠注射治疗不可复性关节盘前移位的CBCT影像学评价

目的:对比治疗前后CBCT影像,观察透明质酸钠治疗颞下颌关节不可复性盘前移位后髁突位置及形态变化.方法:对40例患者进行3次透明质酸钠关节上腔注射治疗.通过治疗前、治疗后3、9、12个月CBCT影像学检查及临床检查,从髁突位置形态变化、疼痛度(VAS)、最大开口度(MMO)、Fricton指数观察透明质酸钠对颞下颌关节不可复性关节盘前移位的治疗效果.结果:CBCT显示不可复性关节盘前移位伴骨关节病患者治疗前与治疗后9、12个月比较,髁突骨质有明显改建,骨面变得平整光滑,骨赘减小(P =0.026,P=0.001),部分单纯不可复性关节盘前移位患者治疗后9个月髁突可以向前移动(P=0.038);治疗后患者MMO增大,VAS减小(P＜0.05),Fricton指数降低.治疗后3～12个月Fricton指数无显著变化(P＞0.05).结论:CBCT显示透明质酸钠可促进已破坏髁突表面骨质改建,但不能使后移位的髁突回到关节窝中央.     

Correlation between pain and dysfunction and intra-articular adhesions in patients with internal derangement of the temporomandibular joint.

The correlation between pain and dysfunction scores obtained by questionnaire and an adhesions index obtained via arthroscopic inspection was investigated in 28 patients with internal derangements (closed lock) of the temporomandibular joint (TMJ). A weak correlation was found between pain scores and the adhesions index. However, joint noise had a negative correlation with both severity and distribution of adhesions in the TMJ. A weak, but statistically significant, negative correlation also was found between the degree of interincisal opening and the adhesions index. This study indicates that intra-articular adhesions are one of the factors contributing to limited mouth opening in patients with closed lock, but that they do not cause TMJ pain.