青少年单侧颞下颌关节盘前移位患者面部不对称的特征

目的: 研究青少年单侧颞下颌关节盘前移位患者面部不对称畸形的特点及其与盘前移位的关系。方法：收集经磁共振确诊为单侧颞下颌关节盘前移位的10~20岁青少年单侧盘前移位连续病例,进行X线头颅定位正位片检查并测量,采用SPSS 18.0软件包,使用独立样本t检验分析左侧移位组和右侧移位组下颌骨(颏部、下颌角、髁突)、上颌骨(前鼻棘、颧牙槽嵴)和牙列(上、下牙列中点)不对称的特点。结果：105例10~20岁(平均16.76岁)青少年单侧盘前移位患者中,下颌偏斜患者67例(63.81%)。单侧盘前移位患者移位侧下颌骨垂直向高度不足,下颌角离散度增大,颏中线和上、下颌牙列中线向移位侧偏斜(P<0.05)。左侧盘前移位患者上颌骨未见显著不对称(P>0.05),右侧盘前移位患者上颌骨显著不对称(P<0.05)。结论：青少年单侧关节盘前移位患者表现出明显的面部不对称,且与单侧盘前移位患病侧紧密相关。面部不对称以下颌骨最为明显,表现为颏部偏向移位侧,以及下颌骨整体向移位侧旋转;上颌骨则表现出移位侧垂直向发育受影响的趋势。     

The effect of disc repositioning and post-operative functional splint for the treatment of anterior disc displacement in juvenile patients with Class II malocclusion

Purpose

To evaluate the effect of temporomandibular joint (TMJ) disc repositioning and post-operative functional splint for the treatment of anterior disc displacement (ADD) in juvenile patients with Class II malocclusion.

Physiological effects of anterior repositioning splint on temporomandibular joint disc displacement: a quantitative analysis

Anterior repositioning splints (ARS) are used primarily for the management of temporomandibular joint (TMJ) anterior disc displacement with reduction (ADDwR). However, the exact physiological effects of ARS are still unclear. This study investigated the short and long‐term effects of ARS on disc and condyle angles/positions by metric analysis. Twenty‐two subjects diagnosed with ADDwR were recruited. Maxillary full‐coverage ARS were fabricated, and MRI of TMJs was obtained before splint treatment, immediate post‐insertion and 6 months after splint treatment. Disc–condyle relationship was determined by disc–condyle angle measurement. Disc and condyle positions were described as X‐Y coordinates with the summit of glenoid fossa as the origin of the coordinates. Thirty‐two TMJs were classified as ADDwR and 12 were normal. Upon ARS insertion, all TMJs with ADDwR got normal disc–condyle relationships. The condyles moved significantly forward and downward, while the discs moved significantly backward and upward. MRI at 6 months after treatment (without ARS insertion) indicated that only 40·6% (13/32) of the joints were maintained in the normal disc–condyle relationship. The majority of condyles returned to their pre‐treatment positions, while the discs generally moved anteriorly again. The use of ARS resulted in forward and downward condyle movement, and a concurrent backward movement of the disc resulting in ideal spatial disc–condyle relationship. The stability of this relationship, however, could not be maintained in the majority of TMJs upon ARS removal. Findings explain the good short‐term clinical outcomes with ARS and their relatively lower efficacy in the long term.     

颞下颌关节盘前移位和穿孔的关节内窥镜研究

目的 :探讨颞下颌关节内窥镜下颞下颌关节盘移位和关节盘穿孔的病理改变特征。方法 :76例 84侧临床诊断为颞下颌关节盘前移位以及关节盘穿孔的病例进行颞下颌关节内窥镜检查。结果 :可复性关节盘前移位的病例出现滑膜炎 ,关节腔内有絮状物 ,关节结节表面有纤维形成。不可复性关节结节表面纤维形成 ,关节软骨软化 ,软骨剥脱 ,同时伴有纤维粘连。关节盘穿孔大多数位于双板区与后带。关节盘穿孔出现滑膜增生 ,关节窝及关节结节表面纤维形成 ,软骨剥脱甚至骨质暴露。结论 :关节内窥镜检查可诊断关节盘前移位与关节盘穿孔 ,并能发现病理性改变 ,如滑膜炎 ,滑膜增生 ,纤维变性 ,软骨软化 ,关节内粘连等。在不可复性盘前移位病例中发现关节退行性改变 ,关节盘穿孔为严重的骨关节病。     

再定位垫治疗颞下颌关节盘可复性移位伴间断性 锁结患者的临床观察

目的 观察再定位垫治疗颞下颌关节盘可复性移位伴间断锁结患者的临床疗效。方法 选取2017年12月至2018年6月大连市口腔医院颞下颌关节门诊接诊的34例患者（男9例,女25例,平均年龄31岁）,经MRI确诊为颞下颌关节盘可复性移位伴间断性锁结,采用再定位垫治疗,治疗期限为6个月,治疗后1个月和3个月进行随访,比较戴用再定位垫3个月、6个月,取下垫后1个月和3个月复查时的关节弹响,疼痛程度、颞下颌关节功能障碍指数和紊乱指数。结果 治疗结束时,34例患者中32例（94.12%）弹响完全消失,1个月复查时,弹响消失患者占88.24%,3个月复查时,弹响消失患者占76.46%;治疗开始后3个月患者疼痛主诉与治疗前相比有明显下降;颞下颌关节功能障碍指数、肌肉压痛指数和颞下颌关节功能紊乱指数均有显著下降。结论 再定位垫治疗关节盘移位伴间断性锁结,在短期内可有效消除关节弹响,缓解疼痛症状,解除功能障碍,利于关节盘获得良好的盘突关节。     

三种牙合板结合肌松剂治疗可复性关节盘前移位

目的：对松驰型牙合板、稳定型牙合板及调位牙合板结合肌松剂Ｍｙｏｎａｌ治疗可复性关节盘前移位的疗效观察。方法：临床分组治疗，随访。结果：松驰型牙合板、稳定型牙合板及调位牙合板分别对９例，１２例和１８例可复性盘前移位病例的弹响消除或明显减弱效果达８８．９％，７５．０１％，１００．０％，结合Ｍｙｏｎａｌ治疗，３９例患者关节疼痛消除或减弱，开口度增大至正常。结论：松驰牙合板、稳定型牙合板及调位牙合板对可复性盘前移位有较好的治疗作用。     

Incidence of anterior disc displacement without reduction of the temporomandibular joint in patients with dentofacial deformity

The aim of this study was to investigate the incidence of anterior disc displacement without reduction (ADDwoR) of the temporomandibular joint (TMJ) in patients with dentofacial deformity. Eighty-eight female patients (176 joints) with skeletal class III malocclusion and 33 female patients (66 joints) with skeletal class II malocclusion, with or without anterior open bite and asymmetry, were evaluated. Magnetic resonance imaging (MRI) of the TMJ was used to diagnose ADDwoR. A statistical analysis was performed to examine the relationship between ADDwoR and skeletal structure. ADDwoR was present in 37 of the 66 joints (56.1%) in class II compared to 34 of the 176 joints (19.3%) in class III (P < 0.05). In class III, ADDwoR was significantly more common in joints with mandibular asymmetry (24/74; 32.4%) than in joints with open bite (9/62; 14.5%) and joints with open bite and without mandibular asymmetry (1/38; 2.6%). In class II, ADDwoR was significantly less common in joints with mandibular asymmetry and without open bite (1/8; 12.5%). ADDwoR was only observed on the deviated side in both class III and class II with mandibular asymmetry. The prevalence of ADDwoR differed according to the dentofacial morphology.     

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。     

青少年单侧颞下颌关节盘不可复性前移位对髁突高度的影响

目的 基于磁共振测量,研究青少年单侧颞下颌关节盘不可复性前移位对髁突高度的影响。方法 选择2010年1月—2013年6月就诊并行随访观察的单侧颞下颌关节盘不可复性前移位青少年患者124例,平均年龄16岁,平均随访时间13.6个月。在磁共振片上测量髁突高度、盘长度及盘移位距离,比较健、患侧以及随访前、后的差异。采用SAS 9.13软件包对所得数据进行统计学分析。结果 患侧关节盘移位距离从5.44 mm增大至6.83 mm（P<0.05）;患侧关节盘长度从9.06 mm缩短为8.12 mm（P<0.05）;健侧髁突高度从26.07 mm增加至26.82 mm（P<0.05）;患侧髁突高度从24.22 mm降低为23.81 mm（P<0.05）;健、患侧髁突高度差异从1.85 mm扩大为3.00 mm（P<0.05）。结论 在青少年单侧颞下颌关节盘不可复性前移位患者病程中,患侧器质性病变继续进展,可能是单侧关节盘移位患者发生下颌偏斜的主要原因。     

颞下颌关节盘前移位关节间隙改变的X线研究

目的测量颞下颌关节盘前移位患者与健康成人许勒位片上的关节间隙,分析髁突在关节窝中的位置,探讨髁突后移位在关节盘前移位临床诊断中的价值。方法选择120例（120侧）关节盘前移位患者和30例健康成人,拍摄许勒位片,使用AutoCAD计算机软件,采用2种线距测量方法（张震康法和Kamelchuk法）在许勒位片上测量关节间隙,并计算ln（P/A）值,比较关节盘前移位患者与健康成人（对照组）关节间隙的差异。结果2种测量方法的测量结果均显示：关节盘前移位组的关节上间隙和后间隙均小于对照组,其差异有统计学意义（P<0.05）,而关节前间隙与对照组的差异无统计学意义（P>0.05）;关节盘前移位组ln（P/A）值均小于对照组相应ln（P/A）值,其差异有统计学意义（P<0.05）。结论许勒位片上显示的颞下颌关节髁突后移位在一定程度上提示有关节盘前移位的存在;但正常髁突位置也存在变异,单纯的许勒位片尚不能作为关节盘前移位的确切诊断依据。     

青少年关节镜下盘复位术后颞下颌关节间隙及髁突位置的改变

目的: 通过颞下颌关节(temporomandibular joint,TMJ)磁共振(MRI)图像测量关节间隙,比较颞下颌关节盘前移位青少年患者关节镜盘复位术前与术后关节间隙和髁突位置的变化。方法: 选取2016年1月至12月因关节盘前移位(anterior disc displacement,ADD)行关节镜盘复位术的青少年患者88例(137侧关节),在术前和随访MRI图像上对关节前、上、后间隙分别进行测量,采用SPSS 17.0软件包中的t检验、 χ²检验及Empowerstats软件中的广义相加效应模型进行统计学分析。结果: 患者手术时的平均年龄为(16.40±2.14)岁,术后平均随访(7.96±4.15)个月。术后1周,关节前间隙均值为(2.62±0.86)mm,上间隙为(4.42±1.01)mm,后间隙为(4.75±1.25)mm;关节上间隙及后间隙较术前显著增加,与随访时间呈负相关;前间隙显著减小,与随访时间呈正相关(P<0.05);术后髁突主导位置由中位(49.6%)变为前位(77.4%),并随着随访时间延长而逐渐后移。结论: 关节镜术后1周,关节上间隙及后间隙显著增加;随着随访时间延长逐渐减小,术后1年仍显著大于术前。     

急性颞下颌关节盘不可复性前移患者手法复位结合综合物理疗法的近期疗效观察

目的: 观察手法复位结合综合物理疗法治疗急性颞下颌关节盘不可复性前移患者的近期临床疗效。方法: 总结我院康复医学科门诊自2017年1月—2017年12月收治的急性开口受限（病程在2个月以内）且经MRI证实颞下颌关节盘不可复性关节盘前移40例患者（男4例,女36例）的临床资料。治疗首先施予健康教育、物理因子治疗（超短波治疗、超声治疗、激光治疗）,随后予手法复位,即刻配戴硬质热塑再定位垫,同时进行运动疗法（软管盘复位训练、关节稳定性训练和颈椎姿势训练）。每周5次,连续治疗2周。所有患者均于治疗前和治疗后采用最大主动开口度（mm）、视觉类比评分（visual analogue pain score,VAS）（0~10分）、下颌功能损害问卷评分（mandibular function impairment questionnaire,MFIQ）进行疗效评估。治疗结束后MRI复查盘-髁关系。采用SPSS22.0软件包对数据进行配对t检验和Wilcoxon符号秩检验。结果: 治疗结束后即刻,最大主动开口度从（24.5±6.4）mm 增加到（40.1±4.4）mm,开口末VAS从2（0,3）分下降到0（0,0）分,咀嚼VAS从1（0,3）分下降到0（0,0）分,下颌功能损害问卷评分从（25.0±6.5）分下降到（12.3±6.4）分,均具有统计学意义（P<0.05）。静息VAS 从0（0,0）分下降到0（0,0）分,无统计学差异（P>0.05）。40例患者在治疗结束后平均（3.6±3.1）周MRI 显示正常盘-髁关系23例（占 57%）,可复性关节盘前移位9例（占23%）,不可复性盘前移位 8例（20%）。结论: 手法复位结合综合物理疗法治疗急性颞下颌关节盘不可复性前移可以即刻增加开口度,缓解疼痛,改善TMJ功能,并对维持正常盘-髁关系有一定作用。     

关节盘锚固定术治疗颞下颌关节盘前移位的临床应用

目的 通过对不可复性盘前移位的患者行关节盘复位锚固定术,探讨关节盘锚固定术治疗不可复性盘前移位的疗效。方法 对根据临床症状及磁共振成像诊断为不可复性盘前移位的患者15例（20侧关节）行关节盘锚固定术。结果 15例20侧关节接受关节盘复位固定术,手术后MRI显示12例16侧达到优,2例3侧达到良,有效率为95%,仅有1侧为“差”,占5%。所有不可复性盘前移位患者术后3、6、12个月较术前的疼痛改善依次为90%、95%、90%,下颌最大侧向运动改善依次为0.4、3.2、5.9 mm,最大张口度改善依次为8.6、16.2、22 mm。结论 关节盘锚固定术治疗不可复性盘前移位具有显著疗效。     

A study of factors for successful splint capture of anteriorly displaced temporomandibular joint disc with disc repositioning appliance

The purpose of this study was to analyse the factors which influenced the success of disc recapture by the insertion of a disc repositioning appliance. Fifty-one joints with joint clicking that occurred at both middle to late opening and late closing (near maximum cuspation) of the mandible were splinted with a mandibular full-coverage repositioning appliance. The clinical and MR findings were compared between the joints with successful and unsuccessful splint disc capture. Thirty-two clicking joints with reducibly displaced discs (DDWR) had successful disc recapture, while six of 19 joints with displaced disc without reduction (DDWOR). Unsuccessful joints with DDWOR had significantly higher prevalence of deformed disc and joint effusion, higher VAS quantitative pain score, and severe disc displacement especially in medial part of the joint (P < 0.05). From the results of this study joints with DDWR can be expected to have successful disc recapture with the insertion of the appliance. In joints with DDWOR, presence of inflammatory conditions, changed disc morphology and extensive disc displacement in medial part of the joint are negative factors.     

可复性关节盘前移位对颞下颌关节三维形态学参数的影响

目的通过三维形态学测量方法探究可复性关节盘前移患者(ADDwR)与正常人颞下颌关节(TMJ的差异。方法招募了15名ADDwR患者和10名无症状的正常人,在MIMICS 20.0软件中重建出上、下颌骨的三维模型,在三维模型上测量双侧TMJ的9个形态学参数,分析ADDwR患者患病侧与正常人两侧之间的差异。结果 ADDwR患者患侧的水平髁突角、冠状髁突角均显著大于正常人(P<0.01),矢状升支角、关节腔内间隙、关节腔外间隙、关节腔上间隙、关节腔前间隙和关节腔后间隙均显著小于正常人(P<0.01)。结论ADDwR将导致患病侧的髁突角显著大于正常人,下颌矢状升支角、关节间隙显著小于正常人,从而导致髁突向上移位,更接近关节窝。     

颞下颌关节盘移位对面型影响的研究进展

颞下颌关节盘移位是由多种因素导致的关节结构内紊乱疾病,人群中发生率较高,在青少年与成人均有分布。临床表现为关节弹响、疼痛、开口受限或咀嚼困难,也可无症状,结合磁共振成像可明确诊断。但由于关节盘移位的病因复杂、发病机制不明,其对面型的影响及因果关系尚存争议,近年来受到研究者的普遍关注。本文探讨不同类型关节盘移位与偏颌、下颌后缩等面型的相关性,将髁突、关节盘与关节间隙、关节窝的结构与位置变化及可能的机制作一概述,为临床诊疗及相关研究提供思路。     

颞下颌关节盘前移位病因研究进展

颞下颌关节盘前移位(temporomandibular joint anterior disc displacement, TMJ ADD)是临床上常见的一种颞下颌关节紊乱病(temporomandibular disorder, TMD),主要表现为疼痛、关节弹响和下颌运动受限,严重者影响日常生活。但其病因复杂,至今尚无统一结论,对其发病机制也缺乏明确而全面的认识。本文将对ADD的病因以及发病机制作一综述。     

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。     

颞下颌关节盘前移位后VEGF-C基因在髁突软骨中的表达及意义

目的:探讨血管内皮细胞生长因子C在颞下颌关节盘前移位后髁突软骨中的表达及意义.方法:采用日本大耳白兔60只,48只用弹力丝牵拉关节盘前移,建立关节盘前移模型,分别于术后1、2、4、8周处死12只,12只空白对照组同期处死,取出颞下颌关节标本.利用基因芯片技术进行筛选,实时荧光定量PCR进行验证和SP免疫组化技术检测不同组内髁突软骨中VGEF-C的表达与分布.采用SPSS19.0软件包对每组样本实验组和对照组数据进行配对t检验.结果:颞下颌关节盘前移位后,在基因水平上VEGF-C相比于正常对照组均有不同程度变化,早期VEGF-C表达减少,第2周时降至最低水平,差异显著(P＜0.05);第8周时,VEGF-C表达有所增加.镜下观察可见VEGF-C在髁突软骨增殖层、肥大层及钙化软骨层中均有表达,1周组阳性表达主要见于增殖深层和肥大层,钙化软骨层也有弱阳性表达.2周组和4周组阳性表达主要位于肥大层,且在钙化软骨层中表达逐渐增强.8周组肥大层有阳性表达,钙化软骨层未见明显阳性表达,8周组与对照组相比有显著差异(P＜0.05).结论:关节盘前移位后早期髁突软骨VEGF-C基因的转录与表达有所下降,而在后期升高,可能参与关节盘移位后髁突软骨的改建.     

Ruptured disc after arthroscopic repositioning in the temporomandibular joint: a retrospective magnetic resonance imaging study

Our aim was to explore the incidence of rupture after arthroscopic repositioning of the disc of the temporomandibular joint (TMJ) by reviewing magnetic resonance images (MRI) of the TMJ taken before and after operation, and to investigate correlations retrospectively. We studied 247 patients with anterior disc displacement of the TMJ, and categorised them into 3 groups based on the postoperative MRI. The first group comprised those whose disc ruptured after repositioning, the second those who had a possible rupture of the disc after repositioning, and the third had no rupture of the disc after repositioning. Age, sex, duration of symptoms, maximum incisal mouth opening, whether the anterior disc displacement was unilateral or bilateral, and the Wilkes stage, were included in the analysis. The incidence of rupture (5/247) was 2%. Weak points at the intermediate zone of the disc were found in 4 of the 5 joints. The patients whose discs ruptured were significantly younger than the other 2 groups (p = 0.001). There was no statistically significant difference in preoperative duration of symptoms and mouth opening among the groups. The proportions of unilateral and bilateral disc displacement (p = 0.047) and Wilkes stage (p = 0.027) differed among the 3 groups. The Wilkes stages was significantly more advanced in the ruptured group than in the other 2 groups (p = 0.027) with 4/5 being bilateral. The weak point in the intermediate zone of the disc on MRI could be a sign of rupture. Teenagers and young adults with anterior disc displacement without reduction, particularly those in whom it is bilateral, are at a higher risk of a rupture after repositioning of the disc by arthroscopy.