经颧弓后上牵引下颌后关节盘后区适应性改建的实验研究

目的:观察经颧弓后上牵引兔下颌后颞下颌关节盘后区是否发生适应性改建及其意义.方法:在兔下颌角和颧弓处打孔后放置牵引装置,向后上方牵引下颌,于术后2、4、6 周分别处死动物,采用组织学及免疫组化方法观察负荷下关节盘后区组织的改变.结果:术后2 周兔牵引侧关节盘移位或变形,盘后区胶原密度增加;随着负荷时间的延长,关节后区成纤维细胞密度明显下降,关节盘后区结缔组织变得致密,组织内出现少量软骨样细胞出现,而对照组标本未见明显组织学改变.与对照组相比,术后2 周移位的关节盘功能区软骨基质、蛋白聚糖及Ⅱ型胶原呈弱表达,阿辛蓝染色变淡;移位至负重区的关节盘后区软骨基质、蛋白聚糖表达比对照组有所增加.随着关节负荷时间的延长,移位至负重区的关节盘后区软骨基质、蛋白聚糖及Ⅱ型胶原逐渐增强.结论:经颧弓后上牵引下颌后,关节盘后区组织内软骨基质合成增加,并有少量软骨细胞出现,发生改建以适应关节功能.     

Morphological and biomechanical features of the temporomandibular joint disc: An overview of recent findings

The temporomandibular joint is a type of synovial joint with unique structure and function. Between the mandibular condyle and the mandibular fossa there is a dense fibrocartilaginous oval articular disc, temporomandibular joint disc. This disc serves as a nonossified bone, thus permitting the complex movements of the joint, and plays a major role in jaw function by providing stress distribution and lubrication in the temporomandibular joint. Pathological mechanical loads are one of the principal causes of temporomandibular joint disc displacement.There is a high frequency of temporomandibular joint disc disorders and treatment options are very limited. For this reason, it is necessary to examine possible alternatives to current treatment options like physiotherapy, drugs, splints or surgical techniques. Recent discoveries in the field of structure and functions of temporomandibular joint disc have created the need for their particular systematization, all in order to create an implant that would be used to replace the damaged disc and be more similar to the natural one. There is a need to more fully meet the morphology and biomechanical properties of the temporomandibular joint disc, and using tissue engineering, make a substitute for it, as faithful as possible, in a case where the natural TMJ disc is damaged so much that the normal function of the joint can be preserved only through implanted disc. Therefore, the aim of this paper was to describe morphology and structure, as well as biomechanical properties of the TMJ disc, in light of the possible applications of this knowledge for the purposes of tissue engineering.     

颞下颌关节盘对不同力学类型的 反应性研究——扫描电镜研究

目的：观察人体颞下颌关节盘在拉伸和压缩状态下的超微结构改变,探讨机械应力导致关节盘破坏的有关机理。方法：用扫描电镜观察关节盘不同应变水平（２％、３％、４％、６％）拉伸试件及不同时间（１５０ｓ,３ｈ）围限压缩试件的变化。结果：关节盘在２％～４％应变下结构正常,６％应变产生中、后带局部胶原原纤维横向拉伸剪切破坏。１５０ｓ压缩,盘表面波纹尚存;３ｈ压缩,蛋白多糖大量丢失,胶原网暴露,胶原—蛋白多糖网状支架受压变形不能再复原。结论：关节盘可承受的最大横向拉应变为５％（约０．２２ＭＰａ拉应力）。持续长时压缩可造成关节盘内部构筑不可复性改变。推测机械因素可能是导致关节盘破坏的重要病理机理。     

5种不同张口位时下颌骨颏部受力瞬间对TMJ关节盘及髁突软骨影响的有限元分析

目的:利用三维有限元分析法,从生物力学角度探讨颏部受力瞬间关节盘及髁突软骨的应力变化。方法:建立5个不同张口度(闭口位、1 cm、2 cm、3 cm、4 cm张口位)包含下颌骨的颞下颌关节(TM J)三维有限元数字模型;于颏部正中矢状面内分别施以与眶耳平面(参考平面)垂直、呈60°夹角、平行3个不同方向的1 000 N压力。获取受力后TM J(左侧)的关节盘和髁突软骨产生的平均主应力的分布情况及其峰值大小。结果:1)在不同施力方向、不同张口位时,关节盘EQV应力峰值多位于后带,髁突软骨则多位于前斜面;2)不同施力方向对比,平行施力时关节盘和髁突软骨平均主应力峰值明显较大;3)闭口位时,3个方向的力在TM J上产生的平均主应力峰值都明显较小。结论:1)本组模型较精确的反映了实物,并且实验结果与临床实际相接近,成功地解决了以往实验中遇到的一些问题,为TM J的生物力学研究提供了新的途径。2)关节盘后带病变及髁突器质性病变可能由下颌骨创伤后造成的TM J间接性损伤引起;颏部受到平行于正中矢状面的外力时,由前方打击颏部较下方打击引起的TM J间接性损伤更严重。3)稳定的咬合关系可以明显减小TM J的间接性损伤。     

老年人穿孔的颞下颌关节盘解剖特点

目的：探讨老年人穿孔的颞颌关节盘特点和规律。方法：113具老年尸体标本266侧颞下颌关节，福尔马林液固定1年，常规解剖取出关节盘观察，取全部穿孔的关节盘，记录穿孔的部位、大小。结果：①样本平均年龄女性高于男性，穿孔者与非穿孔者无明显差别；②30例40侧颞下颌关节有关节盘穿孔；③矢状方向上关节盘中1／3及双板区的穿孔分别为25／69（36．2％）和24／69（34．8％），冠状方向上关节盘中1／3和外1／3的穿孔依次为33／69（47．8％）和30／69（43．5％）；④大于关节盘本体部表面积1／9的穿孔占80％。结论：老年人关节盘穿孔主要发生在关节盘中带的外、中份及双板区的外、中份。     

MRI evaluation of the classification,frequency, and disc morphology of temporomandibular joint disc displacements: a multicenter retrospective study in a Turkish population

Objectives  Magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) and temporomandibular disorders (TMDs) have been discussed in detail for various populations. As no such study has examined the Turkish population, we determined the frequency of TMDs in the Turkish population through a multicentric investigation using MRI. Methods  This retrospective study examined 504 TMJs of 252 symptomatic patients who had undergone bilateral MRI investigation in four different dental schools. The image analysis included the assessment of disc position and morphology, and recaptured the coronal and sagittal planes in the closed and open mouth positions. The TMJ disorders were classified using the Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD). The correlations among the groups of TMJs and disc morphologies were analyzed statistically using the chi-square test (P ≤ 0.05). Results  Disc displacement and abnormal disc morphology were detected in 69.5% of the symptomatic TMJ patients. Of the joints examined using MRI, 154 were normal, 135 had anterior disc displacement with reduction (ADDwR), 145 had anterior disc displacement without reduction (ADDwoR), 30 had partial anterior disc displacement, and 18 had sideways disc displacements. Regarding disc morphology, enlargement in the posterior band was the most commonly encountered type and was observed in 152 TMJs. Overall, the average time for referral for treatment, which was defined as the time from symptom onset until the time of referral, was 1.5 years. Conclusions  The most common type of disc displacement found in the Turkish population studied was ADDwoR. In addition, patients did not perceive the symptoms of TMDs as a disease and did not seek help until the TMJ derangement caused a major complaint.     

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 articular disc position relative to the mandibular condyle in patients with skeletal class III malocclusion on MRI

Objectives To investigate the status of the articular disc of the temporomandibular joint (TMJ) in patients with skeletal Class III malocclusion by means of magnetic resonance (MR) imaging. Methods The position of the articular disc of the TMJ in closed-and opened-mouth positions was investigated in 50 adult patients with untreated skeletal Class III malocclusion by means of proton-density weighted MR imaging. Results Of 100 joints of 50 patients, the lack of positional change of the articular disc relative to the mandibular condyle in both closed- and opened-mouth positions was observed in 62 joints. Conclusions Although the cause of the lack of positional change of the disc relative to the condyle was unclear, this peculiar relationship of the disc and the condyle might possibly be associated with the function of the temporomandibular joint in skeletal Class III malocclusion.     

无症状人群颞下颌关节盘位置的核磁共振研究

目的 观察无症状志愿者颞下颌关节盘的位置,了解无症状人群中是否存在关节盘位置的异常,及其性别、左右侧分布特点.方法 无颞下颌关节病症状及病史的志愿者30名,共60例关节,其中男、女各15名,对其双侧颞下颌关节行开闭口轴位、斜矢状位和斜冠状位扫描,根据扫描结果对关节盘位置进行分类.结果 30名无症状志愿者中,正位关节盘45例,发生率为75%,其中女性20例,男性25例,右侧23例,左侧22例;前移位关节盘7例,发生率为11.67%,其中女性5例,男性2例,右侧5例,左侧2例;外侧移位关节盘6例,发生率为10%,其中女性3例,男性3例,右侧2例,左侧4例;内侧移位关节盘2例,发生率为3.33%,其中女性0例,男性2例,右侧0例,左侧2例;后移位关节盘0例,发生率为0.不同性别比较,差异无统计学意义(P>0.05),左右侧关节比较,差异无统计学意义(P>0.05).结论 无症状志愿者关节盘多为正位,但无症状人群的关节盘移位确实存在,且以前外侧旋转移位最为常见,关节盘移位类型与性别无关,左右侧分布无差异.     

Biomechanical response of bovine temporomandibular joint disc to prolonged tensile stress

This study was designed to evaluate the influence of prolonged tensile stress on the viscoelasticity of the temporomandibular joint (TMJ) disc. Twenty discs from 10, 3-year-old cattle were used. Tensile stress of 1.5 MPa was applied to specimens from the discs for 10, 20, 40 and 60 min. Following the prescribed period of tension for creep, the specimens were removed from the tension device and any recovery observed for 20 min. In all specimens, strain increased at the onset of stress application and reached almost steady conditions after 5 min. Although, the strain became slightly larger when the creep time was longer, no significant differences were found in the strains between any two tests with different periods of creep. The residual strain increased significantly with creep duration, and similarly the degree of recovery decreased significantly. In 10- and 20-min creep tests, the residual strains were 0.1 and 1.0%, the specimens in 40- and 60-min tests revealed irreversible changes in length. It was concluded that continuous loading for >40 min causes creep damage in bovine TMJ disc, and that prolonged sustained tension affects the recovery of joint homeostasis.     

颞下颌关节盘前移位关节盘及盘后区超微结构变化的实验研究

目的通过建立关节盘前移位实验动物模型的方法,研究颞下颌关节盘前移位后关节盘及盘后区早期超微结构的变化。方法10只兔左侧关节经手术诱导为关节盘前移位模型,右侧为手术对照组;2只为正常对照组。术后24小时、1周、2周、3周、4周,麻醉下活体各切取2只手术组实验动物同一部位的关节盘和关节盘后区组织,制成透射电镜标本观察。结果关节盘组织中软骨样细胞逐渐增多,细胞周围的淡区逐渐变小并消失,胞浆中微丝增加,胶原纤维间排列紊乱数量减少,并见新生毛细血管及神经纤维,最后软骨样细胞转化为纤维母细胞和肌纤维母细胞。盘后区早期出现幼稚的软骨样细胞,有排列相对致密的胶原纤维,最后转化成类似于关节盘样组织。结论颞下颌关节盘前移位后,关节盘失去纤维软骨盘的特性转化为纤维结缔组织;盘后区则由疏松的结缔组织变成纤维软骨盘样组织。     

MRI assessment of temporomandibular disc position among various mandibular positions: a pilot study

Purpose: The aim of this pilot study was to assess temporomandibular joint disc movement relative to the condyle among centric relation (CR), physiologic rest position (PRP), and maximal intercuspation position (MIP) in healthy patients without signs or symptoms of any temporomandibular disorder. The hypothesis was that as the condyle rotated clockwise or translated anteriorly, the disc would also move in an anterior direction. Material and methods: Magnetic resonance images were obtained on 20 volunteers in CR, physiologic rest, and MIP. Three investigators measured the location of the disc among the different mandibular positions. Results: Disc location differences between CR and PRP exhibited the widest range of measurement. The largest amount of disc protrusion relative to the condyle was found between CR and PRP on the right side. The largest amount of disc retrusion relative to the condyle was found between CR and MIP on the right side. The hypothesis was not supported by the results. Conclusions: According to the results of this pilot study, the direction of movement of the temporomandibular disc does not correlate with the rotational movement of the condyle in hinge positions. Clinical implications: Increased knowledge of temporomandibular disc movement among various mandibular positions in asymptomatic patients may help clinicians recognize deviations in symptomatic patients.     

颞下颌关节盘移位自然转归的MRI评价

目的:借助磁共振技术,对未经治疗的颞下颌关节盘前移位患者的盘-髁距离、关节盘长度及髁突高度的变化进行定量测量分析,从而为制订治疗计划提供参考。方法:收集62例(83侧关节)在随访期间未经有创或不可逆治疗的颞下颌关节盘移位患者,在初诊及随访结束时拍摄MRI,分别对盘-髁距离、关节盘长度及髁突高度进行测量,采用SPSS13.0软件包对源数据进行t检验。结果:患者初次就诊时,平均年龄为30.4岁,平均随访时间10.9个月。初诊时,39侧关节为可复性关节盘前移位,其中27侧随访期结束时变为不可复性关节盘前移位。随访结束时,盘-髁平均距离从初诊时的5.28mm增加至6.73mm,而关节盘的平均长度从8.31mm缩短至6.91mm,髁突高度从5.21mm降为4.65mm,以上变化均存在统计学差异(P<0.01)。结论:在颞下颌关节盘前移位的自然转归过程中,关节盘前移距离逐渐增大,关节盘长度逐渐缩短,髁突高度逐渐下降,但需更长期的随访及分层研究。     

自体喙突移植重建下颌髁突的实验研究

目的:研究运用自体喙突移植重建髁突的可行性及其整复效果。方法:选取12只成年雄性山羊,手术截除右侧髁突与关节盘,取同侧喙突以L型钛板固定在下颌升支。分别在术后第4、12、24周各处死4只动物。通过大体观察、三维CT分析和组织学检查等方法评价自体喙突移植后的形态学和组织学变化。结果:所有动物术后咬合基本正常。术后4周可见喙突再生,术后24周时自体喙突形态基本接近正常髁突。新生髁突表面有较厚的致密纤维结缔组织覆盖,其下方的组织结构类似正常髁突表面的关节软骨。结论:自体喙突移植可以重建一个形态和功能都基本接近正常的髁突,因此这种技术可以作为一种整复TMJ缺损的新方法。     

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.     

保守序列方法治疗颞下颌关节不可复性盘前移位的临床研究

目的:观察保守序列方法治疗颞下颌关节不可复性盘前移位的临床效果.方法:纳入颞下颌关节不可复性盘前移位患者300例,其中,男性110例,女性190例,年龄16 ～ 85岁.第1组200名,采用保守序列治疗方法,即关节上腔单针灌洗+透明质酸钠凝胶注射+理疗+手法复位+口腔操,第2组100名,采用单纯透明质酸钠凝胶关节上腔注射法.利用MMO(最大张口度,mm)及VAS(视觉类比量表)评价治疗前后患者张口度及颞下颌关节疼痛值的变化.结果:第1组总有效率95.5％(191/200),治疗前MMO为(22.90±3.18)、VAS为(5.81±0.32);治疗后3个月MMO为(37.05±4.43)、VAS为(1.29±0.19);治疗后6个月MMO为(36.29±4.08)、VAS为(1.37±0.22);治疗后12个月MMO为(35.76±3.87)、VAS为(1.52±0.28).第2组总有效率78％(78/100),治疗前MMO为(23.12±4.02)、VAS为(6.11±0.67);治疗后3个月MMO为(36.11±4.02)、VAS为(1.89±0.21);治疗后6个月MMO为(35.49±3.78)、VAS为(2.21±0.32);治疗后12个月MMO为(31.53±4.87)、VAS为(3.88±0.51).2组逐项比较差异均有统计学意义(P＜0.05).结论:保守序列治疗方法对治疗颞下颌关节不可复性盘前移位无论近期还是远期都有良好的治疗效果.     

人体颞下颌关节盘弹性模量的测定

目的 :了解颞下颌关节盘的生物力学性质。方法 :采用软组织拉伸力学实验方法 ,对 4具新鲜尸体的颞下颌关节盘进行了等应变速度 (0 .0 5mm/s)下的拉伸试验 ,测定了关节盘横向拉伸弹性模量值。结果 :关节盘弹性模量分为二类 ,初始段模量范围为 3.80～ 4.80MPa ,各区段无明显差异。结论 :二类弹性模量代表了关节盘在缓冲关节压力过程中的生物力学弹性响应特性 ,关节盘不同区带对外部载荷具有良好的适应能力     

L-单甲基-精氨酸对颞下颌关节骨关节病治疗作用的实验研究

目的　研究一氧化氮合酶抑制剂L 单甲基 精氨酸对山羊实验性颞下颌关节骨关节病的治疗作用及可能机制。方法　通过双侧颞下颌关节上腔内注射胶原酶建立骨关节病模型 ,从注射胶原酶第 4周起 ,在左侧关节上腔内每隔 3d注射 0 5 %L 单甲基 精氨酸 0 5ml,共 7次 ,右侧同期注射生理盐水 0 5ml。注射胶原酶后 1 2周处死所有动物 ,取双侧关节标本作组织学检查并根据改良Mankin骨关节病评价标准评分。结果　评分结果 :L 单甲基 精氨酸侧为 3 83 ,而对照侧为 6 33 ,两者比较差异有高度显著性 (P <0 0 1 )。结论　L 单甲基 精氨酸关节腔内注射对山羊实验性颞下颌关节骨关节病的发展有抑制作用 ,其作用机制可能与L 单甲基 精氨酸抑制一氧化氮合酶在关节局部产生过多的一氧化氮有关     

Dextrose prolotherapy for pain and dysfunction of the TMJ reducible disc displacement: A randomized,double-blind clinical study

To assess the efficacy of dextrose prolotherapy on the clinical signs and symptoms of patients having disc displacement with reduction (DDWR).This prospective, randomized, double-blind clinical study included thirty patients suffering from bilateral DDWR. The patients were randomly divided into two equal groups. After induction of local anesthesia, each joint was injected in two sites; one in the superior joint space and the other in the retrodiscal tissue, using 25% dextrose solution in group I and normal saline in group II. Pain intensity, maximal interincisal opening (MIO), and joint sounds (JS) were evaluated preoperatively, 1 week after each injection, and 3 months and 6 months after the last injection.Patients in group I showed significant improvement in pain and MIO, and higher satisfaction with treatment than patients in group II. Compared to saline injection, dextrose injection resulted in an improvement in JS but without significant difference within and between groups.Intra-articular injection of 25% dextrose is effective in the treatment of pain and dysfunction of TMJ DDWR as shown by significant improvement in pain and MIO and patient satisfaction. The technique is simple, easy to do, safe and should be adopted whenever appropriate.     

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。