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.     

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.     

颞下颌关节镜下关节盘复位固定术患者的围手术期护理

目的探讨颞下颌关节镜下行关节盘复位固定术患者的围手术期护理措施。方法总结13例(18侧)颞下颌关节镜下行关节盘复位固定术的围手术期护理经验。术前做好患者的心理护理,增加患者对手术的认知和信心,全面评估患者情况,做好术前准备。术中正确调试仪器,配合医生操作,稳定患者情绪。术后做好仪器保养、教会患者和家属如何进行功能训练,做好患者和家属的心理护理。结果 13例患者无感染及不可复性神经损伤等重大术后并发症。随访3～12个月,手术伤口均恢复良好,磁共振成像检查显示关节盘均复位良好。结论熟练掌握颞下颌关节镜下关节盘复位固定术的护理要点,同时注意围手术期的心理护理和术后功能训练对提高术后疗效有重要意义。     

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。     

关节镜手术和非手术治疗在处理颞下颌关节病患者中的关系

作者结合文献复习和临床经验,全面论述了非手术治疗和关节镜手术在处理常见颞下颌关节病变中的价值,其主要观点是:非手术治疗和手术治疗并非互相排斥,而是相辅相成。非手术治疗适用于病变较轻者,而且是手术治疗患者手术前后的必要辅助治疗。目前对颞下颌关节病变的认识,不支持对病变的关节盘进行复位或替代;关节盘复位术总体上是失败的,因为不改变关节盘的位置,患者的症状也会得到显著改善。而通过关节盘复位术改变关节的解剖结构,对引起患者疼痛和功能紊乱的生物化学和生物机械过程的作用不大。过去15年间积累的临床、影像学和滑液分析资料足以证明,内紊乱理论存在很大缺陷,然而遗憾的是,迄今临床医生仍在强调内紊乱和关节盘复位的重要性。对颞下颌关节病变的成功处理,必须基于治疗内在的生物化学改变和组织异常。正常的滑膜和软骨组织具有很强的耐受机械负荷的适应能力,以维持组织的完整性。当关节所承受的慢性负荷超过组织的耐受力时,就会出现关节疼痛、运动受限和关节杂音。在这一过程的早期,旨在减轻关节负荷、缓解炎症和增加运动的非手术干预,加上组织本身的自然愈合能力,完全能够使组织的结构和功能恢复正常。如引起过度负荷和运动受限的病因持续存在,则病变加重,必须进行手术干预。非手术治疗的原则和目的是:减轻关节负荷,通过被动开口锻炼增加而不是限制关节运动,采用非类固醇类消炎药物如芬必得和奈普生缓解炎症和疼痛,改善患者睡眠(必要时辅以药物如benzodiazepine)。由滑膜炎、骨关节炎和黏连导致的颞下颌关节疾病的手术治疗适应证为:(1)严重疼痛和(或)功能障碍,(2)疼痛或功能紊乱系由关节内病变引起,(3)正规疗程的非手术治疗未能改善症状。手术原则是:(1)尽量微创,手术创伤越大,组织损伤和瘢痕形成的几率越大;(2)手术的目的是清除和(或)治疗已经存在的病变组织,如松解黏连,清除病变的骨关节纤维化组织;(3)辅助减轻滑膜炎症,如内镜下分离滑膜炎症组织,直视下注入高浓度的消炎药物;(4)尽量保留滑膜、关节软骨和关节盘,因为研究表明,保留穿孔的关节盘不会带来任何危害。     

硬化疗法及牵引缝合治疗复发性颞下颌关节脱位的远期疗效

目的 评判关节镜手术治疗复发性脱位患者远期疗效的稳定性。方法 ３０例患者的３４例复发性脱位关节进行了３８例次关节镜手术（关节盘后区硬化疗法和关节盘缝合牵引固定术）,其中４例次为重复关节镜手术,４例次为双侧同期手术,随访期２年以上的有２１例患者的２２侧受累关节,平均随访期４年（８年）。远期疗效：有效率９５％（２１／２２）,治愈率８２％（１２／２２）。结论 关节盘后区硬化疗法及关节盘牵引固定术对复发性     

Evaluation of an improved anchoring nail in temporomandibular joint disc repositioning surgery: A prospective study of 25 patients

To confirm the effectiveness and stability of an improved anchoring nail through a prospective study using clinical evaluation and magnetic resonance imaging (MRI).Patients undergoing TMJ disc reduction and fixation were followed up for 1 year.Visual analog scale (VAS) pain scores and TMJ range of motion (maximum interincisal opening, protrusive excursion, lateral excursion) data were gathered pre- and postoperatively, and patient satisfaction was recorded. Four time points were investigated: before surgery (T0), 1 month post-surgery (T1), 6 months post-surgery (T2), and 1 year post-surgery (T3).Twenty-five patients (50 joints) participated in the study. The overall success rates of the improved and traditional anchoring nails were 88% and 92%, respectively. One year post-surgery, the patients’ TMJ motion improved significantly (p < 0.001), and their pain was significantly alleviated (p < 0.001). Condyle height did not change significantly within 6 months (p = 0.801), but had increased by approximately 1.35 mm (p < 0.001) at 1 year post-surgery. The MRI scans also confirmed that new bone mass growth was present 1 year post-surgery.Compared with the traditional anchoring nail, the improved anchoring nail had a similar success rate and was associated with fewer foreign body sensations and less pain. Its clinical application should be further tested in studies with longer follow-up times and larger sample sizes.     

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。     

Arthroscopic discopexy versus natural course of temporomandibular joint anterior disc displacement: a longitudinal study of clinical and radiological outcomes

The aim of this study was to assess the various outcomes of arthroscopic discopexy compared to the natural course of anterior disc displacement (ADD) longitudinally in the same patients. A retrospective review was performed of 108 patients (152 joints) who experienced the natural course of ADD for a period of time and then underwent arthroscopic discopexy. The outcome was evaluated clinically and by magnetic resonance imaging. The natural course of ADD showed significant deterioration in pain, diet, and quality of life, and also a significant reduction in inter-incisal opening (all P < 0.001), while significant improvements in all clinical parameters were observed at the final postoperative follow-up (all P < 0.001, compared to the last preoperative visit). During the natural course, there was a significant shortening of condylar height, mandibular height, and disc length, and an increase in disc displacement distance (all P < 0.001). Postoperative follow-up revealed the restoration of condylar height and mandibular height, and all discs were significantly repositioned with an increased disc length (unfolded) (all P < 0.001). Bearing in mind the assumption of a low evidence base due to bias resulting from the retrospective non-double-blinded study design and the variable duration of the natural disease course prior to surgery, this study found that the natural course of ADD led to degenerative changes in the joint structures and clinical symptoms, whereas arthroscopic discopexy led to a restoration of the bony structures and the alleviation of clinical symptoms.     

Synovial Chondromatosis of the Temporomandibular Joint: A clinical and arthroscopic study of 16 cases

Objectives

Present and overview the clinical finding, management and arthroscopic study of Synovial Chondromatosis (SC) cases in Temporomandibular Joint (TMJ) treated by our team.

颞下颌关节滑膜软骨瘤病2例报告

结合2例颞下颌关节滑膜软骨瘤病的临床表现,X线、CT和MRI特征,以及术中所见,分析发生于颞下颌关节的滑膜软骨瘤病的临床特点、诊断及治疗方法.2例患者术前均有关节区疼痛、肿胀,无开口受限.X线片见颞下颌关节间隙增宽,其中1例CT显示颞下窝关节面骨质破坏并硬化,MRI可见关节腔内多发小结节状影.术后未出现咬合紊乱及开口受限.颞下颌关节滑膜软骨瘤病少见,临床表现无特异性,好发于关节上腔,钙化性游离体是其影像学特征,组织病理学常见软骨结构样小体,伴周围组织慢性炎症及纤维增生,一般需手术治疗.     

颞下颌关节镜手术少见并发症的防治

目的:总结颞下颌关节镜手术的并发症,探讨其防治措施。方法:回顾1997年5月—2009年9月在我院进行关节镜手术治疗的2034例(2431侧)患者的临床资料,分析其少见的并发症,包括知名血管出血、咬肌神经损伤、器械折断、排异反应、外耳道穿孔等,探讨其发生的原因及其防治措施。结果:2034例(2431侧)患者中,知名血管出血5侧,咬肌神经损伤5侧,器械折断3侧,排异反应2侧,外耳道穿孔2侧。结论:关节镜手术是一种安全有效的治疗方法,其并发症发生率较低,但此项技术需由有经验的医师进行操作。     

颞下颌关节镜盘复位固定术

目的：介绍一种颞下颌关节镜下盘复位固定新技术及其临床应用的初步效果。方法：选取门诊就诊的颞下颌关节疾病患者进行临床检查,在初步诊断为结构紊乱后进行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,主要操作要点为前附着松解和关节盘的水平褥式牵引缝合。术后连续对2004年8月—2007年3月期间接受关节镜下关节盘复位固定术的639例（764侧）患者进行随访观察。术后再次进行MRI检查,并根据自定的MRI评价标准,评价关节盘复位的效果。优为3个层面完全复位;良为2个层面完全复位;差为仅1个层面复位或完全未复位。将＂优＂和＂良＂定为有效,对复位＂差＂者再次进行手术、或改为开放性锚固术。结果：764侧关节中,术后MRI显示729侧为＂优＂,占95.42%（729/764）;24侧为＂良＂,占3.14%（24/764）;11侧为＂差＂,约1.44%（11/764）。结论：颞下颌关节镜盘复位固定术是一种能将关节盘复位的有效术式,但其长期的稳定性尚需进一步评价。     

Arthroscopic discopexy technique with anchors for treatment of temporomandibular joint internal derangement: Clinical and magnetic resonance imaging evaluation

PurposeThe objective of this study was to describe a technique of arthroscopic discopexy with anchors used to treat temporomandibular joint internal derangement.Materials and methodsThis study involved patients with unilateral temporomandibular dysfunction refractory to conservative treatment, and whose magnetic resonance imaging (MRI) examinations showed internal derangement of the temporomandibular disc, with anterior disc displacement. Maximal interincisal opening (MIO), joint pain, joint noise, and disc position were the variables assessed by clinical examination and MRI before and 6 months after the surgery.ResultsThe sample consisted of 20 patients. In the postoperative evaluation, MIO had increased from 33.8 ± 4.83 mm to 35.1 ± 4.08 mm (p = 0.04), while joint pain had decreased from 7.5 ± 1.42 points to 2.05 ± 1.47 points (p = 0.001). With regard to joint noise, 19 of the patients had presented with clicking or crepitation but after 6 months these were completely absent. Disc repositioning was complete in 15 of the patients and partial in the other five.ConclusionThe technique of arthroscopic discopexy with anchors was shown to be effective in treating temporomandibular internal derangement, with good clinical results.     

Effects of soft tissue injury to the temporomandibular joint: report of 8 cases

Our aim was to describe the effects of soft tissue injury to the temporomandibular joint (TMJ), to analyse possible reasons for it, and to evaluate the results of treatment. Eight patients (12 joints) who developed disorders of the TMJ after trauma to the mandible without fracture of the condyle were treated in our department from 2009 to 2010. Magnetic resonance imaging (MRI) and computed tomography (CT) were used to check the condition of the joint. Five patients had their joints explored to relieve pain and improve mouth opening. MRI showed all 12 joints had displaced discs. CT showed that the surface of the condylar bone was “intact” immediately after injury but destroyed later in 8 joints. Exploration showed fibrous ankylosis in 5, osteoarthritis with intra-articular adhesions in 2, and internal derangement in 1. Four were treated by costochondral graft (CCG) with 7 symptomatic joints. The disc was repositioned in 1 case with 1 affected joint. The mean maximal incision opening at follow-up were significantly better than the one before treatment (mean 34 compared with 23 mm, p = 0.02). Pain in the TMJ was relieved by operation in all patients so treated. The other 3 patients (4 joints) had no treatment because their symptoms were minor and mouth opening was not restricted. Soft tissue injuries of the TMJ can potentially lead to internal derangement, osteoarthrosis, and possibly fibrous ankylosis, which should be considered during follow-up. Displacement of the disc and damage to the condylar cartilage seem to be the causes of these complications. Surgical management is effective in the short term.     

肌激动器治疗前后关节盘矢状位置与颞下颌关节临床症状和体征的关系

目的 探讨功能矫治中关节盘矢状位置对颞下颌关节临床功能的影响.方法 选择20个AngleⅡ1错(牙合)患者,采用Activator功能矫治器治疗.用MRI检查治疗前后关节盘位置, Helkimo指数评价功能矫形前后的颞下颌关节功能.探讨治疗前后关节盘位置的改变及其与颞下颌关节症状之间的关系.结果 治疗前关节盘位置正常者,治疗后临床检查指数有下降趋势;治疗前关节盘前移位者,治疗后临床检查指数升高.结论 功能矫形虽然不会导致关节盘前移位的发生,但对于治疗前已经存在关节盘前移位者,治疗后可能会引发或加重其TMD症状和体征.     

The outcome of arthroscopic treatment of temporomandibular joint arthropathy

Ninety patients underwent arthroscopic temporomandibular joint surgery to 124 joints for arthropathy which had failed to respond to at least six months of non-surgical treatment. They were surveyed at between 6 months and 5 years (mean 2.5 years) after surgery and 63 per cent responded to the survey. They reported an 82 per cent improvement for pain (50 to 100 per cent better), 80 per cent for clicking and 82 per cent for locking. There was no morbidity following the treatment. Arthroscopic surgery should be considered for advanced temporomandibular joint arthropathy which is refractory to non-surgical treatment.     

再定位(牙合)垫治疗颞下颌关节可复性盘前移位的临床效果分析

目的 分析再定位(牙合)垫的治疗效果。方法 对再定位(牙合)垫治疗颞下颌关节可复性盘前移位的临床治疗方法、治疗效果进行总结。结果 33例用再定位(牙合)垫治疗颞下颌关节可复性盘前移位治愈18例(55％),效果良好10例(30％),总体有效率为85％;治疗失败5例(15％)。结论 再定位(牙合)垫是治疗颞下颌关节可复性盘前移位的一种有效方法。