髁突骨折解剖复位及小型接骨板坚强内固定

目的 探讨髁突骨折解剖复位和小型接骨板坚强内固定的技术要点和并发症的发生因素。方法 髁突骨折72例97侧（单侧47例,双侧25例）。陈旧性骨折12例,髁颈和髁颈下骨折81例,移位和脱位骨折90例。8侧未手术,7侧髁突摘除,6侧升支垂直截骨间接复位,76侧直接复位。59侧单板固定,21侧双板固定,2侧螺钉穿接固定,有22侧髁突呈游离再植,68例经颌后入路,21侧经耳屏前入路。术后1～3个月复查9例,3～6个月36例,6个月以上27例,复查内容包括骨折复位准确性、固定稳定性、骨折愈合改建,伤口愈合、面型、he关系、下颌运动、关节症状、神经损伤。结果 感染2侧,错he2例,假关节2侧,接骨板断裂3侧,接骨板变形2侧,骨折块再移位7侧,髁突吸收6侧,张口受限7例,关节疼痛5侧,关节杂音5侧,面神经损伤9例。并发症发生率33%（24/72例）,排除医源性因素后的并发症率14%（10/72例）。结论 切开复位及小型接骨板坚强内固定是治疗髁颈和髁颈下移位及脱位骨折的效方法,升支垂直截骨髁突游离再植是治疗髁突陈旧性骨折的可选择方法。低位髁颈和髁颈下骨折应采用颌后入路,接骨板应沿后外缘作张力带固定,髁颈下严重移位和陈旧性骨折需在髁颈前或乙状切迹处增加补偿固定。     

可吸收钉板在下颌骨髁突骨折中的应用

目的　回顾性分析可吸收钉板在下颌骨髁突骨折中的应用，探讨其在髁突骨折治疗中的适应证、操作难点及注意事项。 方法　2012年7月至2018年6月，武汉大学口腔医院口腔颌面创伤与颞下颌关节外科应用可吸收钉板固定下颌骨髁突骨折患者82例（共106侧），其中髁突高位矢状骨折46侧，中位髁颈骨折26侧，低位髁颈下骨折34侧。髁头及髁颈骨折复位术均经耳屏前径路；髁颈下骨折复位术中，多数经耳屏前径路及颌下径路。髁突高位矢状骨折复位后以1～2枚可吸收长螺钉固定，髁颈及髁颈下骨折以2块可吸收板固定。术后随访6个月至3年。结果　所有患者术后未诉明显不适，面型基本对称，面部肌肉运动正常，咬合对位良好，开口度恢复，未见明显排斥反应及严重并发症。结论　可吸收钉板可应用于髁突高位矢状骨折、中位髁颈骨折、低位髁颈下骨折的开放复位内固定。应用可吸收钉板固定髁突骨较钛板钛钉复杂，需熟练掌握合适的操作技巧及注意事项。     

生长期山羊囊内骨折复位术中保留髁突软骨的重要性及组织学研究

目的：通过组织学观察,探讨髁突囊内骨折内固定术中保留和切除髁突软骨对髁突生长发育的影响。方法：6个月龄山羊12只,随机分为实验组（n=8）和对照组（n=4）。实验组双侧髁突造成囊内骨折并同期行手术复位固定．一侧保留髁突软骨,另一侧切除髁突软骨。术后3个月、6个月处死动物,切取髁突标本行石蜡切片和硬组织切片观察骨折愈合和髁突生长情况。结果：实验组髁突骨折愈合良好,钛板被新生骨组织覆盖;HE染色显示．保留髁突软骨组,髁突软骨结构清晰,与正常对照髁突相同,软骨成骨活跃,髁突生长发育正常;切除髁突软骨组,髁突软骨层消失,表面为成熟的骨细胞覆盖,直接与关节盘的纤维组织相连,新生骨组织少见：硬组织切片显示,钛板与骨组织直接结合．未见组织渗出和排异反应。结论：手术复位髁突囊内骨折时保留髁突软骨,不会影响髁突的生长发育;损伤髁突软骨．会造成髁突与关节盘黏连．引起髁突生长发育障碍。     

穿腮腺入路治疗髁颈及髁突基底部骨折

目的：探讨穿腮腺入路治疗髁颈及髁突基底部的安全性及有效性。方法：对15例（21侧）髁颈及髁突基底部骨折患者选择穿腮腺入路切开复位内固定术。结果：15例患者,21例侧髁突骨折行手术治疗。19例侧髁突骨折选择2块接骨板固定,2例侧选择1块接骨板固定。所有患者伤口均一期愈合,术后复查全口曲面断层片或三维CT示骨折断端对位良好。除1例患侧后牙暂时性轻度开外,所有患者咬合关系恢复良好。术后1个月复查,张口度32～45mm（平均38mm）。3例侧出现面神经损伤症状,术后3个月内均恢复正常,无1例出现永久性面瘫。所有患者均未出现涎瘘、感染等并发症。结论：相对于髁突骨折的颌后及颌下入路,穿腮腺入路行髁突骨折切开复位内固定术,容易暴露,可直视下完成骨折复位固定,是治疗髁颈和髁突基底部骨折安全有效的手术入路。     

髁突囊内骨折软组织损伤分类及预后评价

目的: 分析髁突囊内骨折软组织损伤的类型和自然愈合情况。方法: 回顾2010—2013年收治的髁突囊内骨折（intracapsular condylar fracutre, ICF）自然愈合的患者,要求有受伤1周内及3个月以上冠状CT、MRI随访资料,利用MRI对软组织损伤进行分类和随访,包括关节盘的移位情况、下颌支残端有无关节盘覆盖、盘后区撕裂和改建情况、关节囊外侧损伤、关节腔积液等,分析软组织损伤对ICF愈合的影响。结果: 12例患者的17侧髁突纳入研究。软组织损伤类型中,关节盘随髁突骨折块前移位17侧,占100%;下颌支残端有关节盘覆盖10侧,占58.8%,下颌支残端无关节盘覆盖7侧,占41.2%;盘后区撕裂11侧,占64.7%;关节囊破裂7侧,占41.2%;关节腔积液17侧,占100%。随访MRI显示,17侧关节盘位置与受伤时比较无改变;髁突表面均有新骨形成17侧,占100%;关节盘后区以增厚改建为主15侧,占88.2%;2例出现盘后区类骨样变伴撕裂,占11.8%;7侧关节囊损伤均修复;关节腔积液6侧完全吸收（35.3%）。结论: ICF软组织损伤类型有关节盘随髁突骨折块移位,盘后区撕裂,关节囊破裂和关节腔积液等。愈合方式以盘后区增厚改建、髁突表面新骨形成为主。     

髁突矢状骨折坚固内固定后骨折愈合进程的生物力学分析

目的 从生物力学角度分析髁突矢状骨折（sagittal fracture of the mandibular condyle, SFMC）坚固内固定术后的骨折愈合进程,为治疗SFMC提供依据。方法以三维有限元法（three dimensional finite element analysis, 3D-FEA）构建包含双侧髁突的下颌骨模型;设右侧髁突为骨折侧,模拟以4孔微型接骨板坚固内固定治疗法,设计术后0、4、8、12周为SFMC骨折愈合进程中的观测点,测算髁突应力分布变化,骨折断端位移、微接骨板受力、应力遮挡状况。结果正常髁突最大等效应力位于髁颈部,分布于髁颈中1/3的片状区域。术后0周,患侧髁突最大等效应力为正常值的23倍,位于近骨折线中下1/3的髁突残端和近骨折线的螺钉固定处的接骨板上,呈点状分布;髁突及接骨板的其余部分几乎不受应力作用。术后4~12周,患侧髁突的最大等效应力趋于平稳,但仍为正常值的6倍左右。位于近髁突残端的镙钉固位处与髁颈中外1/3 处的点状区域,其余部分几乎不受应力作用。髁突总位移及总转角在骨折愈合进程中增加0.57~0.75 mm及0.01~0.09°。髁突残端术后0周的最大等效应力是术后4~12周的5~6倍。髁突游离端在骨折愈合进程中的最大等效应力、总位移及总转角值均无显著变化。接骨板术后0周最大等效应力为术后4~12周的7~9倍。结论SFMC愈合进程中,髁突承载应力及应变改变、接骨板的应力遮挡可能与髁突吸收、改建有关。内固定4周内,接骨板、髁突残端承载的最大等效应力、髁突总位移与总转角明显增大,可弹性颌间牵引,以减少髁突总位移及总转角;流质饮食可减少髁突等效应力,利于骨折愈合。内固定4周后,下颌骨及髁突已能承载正常负荷,可行康复训练,以尽早恢复TMJ的正常功能。     

利用夹板治疗髁状突纵形骨折突、盘的组织学变化

目的：观察髁状突纵形骨折后及牙合夹板治疗时髁状突、关节盘的改变。探讨牙合夹板治疗机制。方法：实用小型猪１８头,随机分为髁状突纵形骨折后未治疗组,牙合夹板治疗组及对照组各６头。实验后３、６、１２周取材,光镜扫描电镜观察。结果：牙合板治疗髁状突纵形骨折１２周,骨折愈合,无盘突粘连。生发层细胞和表层纤维连续,其下是新生软骨细胞和大量软骨内化骨现象。未治疗组３周关节盘轻度变形,１２周关节盘与髁状突、颞下凹粘连,呈双髁突畸形。电镜下牙合夹板治疗组骨折侧髁突表面凝胶样物质尚存,细胶原纤维暴露。未治疗组骨折侧髁突表面凝胶状物质消失,有的部位胶原纤维粗大,有的部位细小。结论：髁状突纵形骨折未治疗后果为盘突粘连,双髁突畸形。牙合夹板具有防止盘突粘连,使髁状突恢复正常生长发育的作用。     

可吸收小夹板内固定治疗髁突骨折的疗效观察

目的:观察颗突骨折应用可吸收小夹板内同定手术后的临床效果。方法：对10例12侧髁突骨折的患者行手术切开解剖式复位，应用可吸收小夹板进行内固定，术后观察骨折复位愈合、张口度及(牙合)关系等情况。结果：全部病例术后伤口均Ⅰ期愈合，X线检查髁突复位良好，无断端移位、骨不愈或缓迟愈合表现，术后(牙合)关系恢复良好，下颌功能恢复满意。结论：应用可吸收小夹板治疗髁突骨折，手术可达解剖式复位，固位效果可靠，能自体降解固定材料，无骨折不愈和缓迟愈合表现，其临床治疗效果满意，是髁突骨折较理想的内固定材料。     

髁突矢状骨折继发颞下颌关节强直动物模型的初步建立

目的:建立髁突矢状骨折继发颞下颌关节强直动物模型.方法:实验用小型猪4头.手术造成右侧髁突矢状骨折,切除部分关节盘,破坏颞骨和髁突的关节面,制动关节.术前及术后4个月测量下颌张口度,作CT检查,进行组织学分析.结果:实验动物中的2只术后4个月时张口度减小近1/2;CT显示关节窝与和髁突之间有骨痂形成;组织学证实关节窝与髁突之间被大量纤维组织占据,其中间杂有新生骨岛和骨桥.结论:初步成功建立髁突矢状骨折继发关节强直的动物模型,但可重复性有待改善.     

改良入路复位内固定治疗髁突骨折的疗效

目的:介绍一种改良的腮腺切口入路治疗髁突骨折的手术方法并作疗效分析.方法:通过类"S"腮腺切口,经改良的腮腺入路,直达髁突骨折处,对髁颈和髁颈下骨折27 例34 侧行小型钛板坚强内固定术,术后3 月～5 年复查,包括拍摄全景片,记录张口度,开口型,咬合关系,外伤前后咬合力的改变,面神经损伤情况.结果:1 例 1侧钛板断裂,2 例2 侧骨折未完全复位; 6 例7 侧出现面神经损伤症状,其中,2 例2 侧部分恢复,4 例5 侧完全恢复.2 例张口受限,轻度咬合痛,3 例关节弹响.结论:改良的腮腺入路法治疗髁突骨折,手术创伤小,操作简单,能达到髁突骨折解剖复位,钛板坚强内固定的要求.     

Histomorphometric study of trabecular bone remodeling during condylar process fracture healing in the growing period: experimental study

Trabecular bone remodeling during condylar fracture healing in the growing period was analyzed by histomorphometry with a synchronous system. Data from the study showed displacement of the fractured condyle was compensated by the changes in remodeling ascribed to the pubertal spurt of growth, and that such remodeling still continued even after clinical healing. The regional acceleratory phenomenon, evolved to potentiate tissue healing, was observed 1 week after induction of the fracture. Mesenchymal cells were presumably modulated into chondroblasts that promoted endochondral ossification. It was concluded that trabecular bone remodeling plays an important role in healing of condylar fractures during the growth period.     

Endochondral ossification of the condyle in rats on a strontium or low-calcium diet

The mechanism of abnormal endochondral ossification induced by administration of strontium salts was studied in the mandibular condyles of rats by radiographic, histologic, and histochemical methods. It was shown by radiographic and histologic findings that ossification of the mandibular ramus was clearly inhibited in rats fed a low-calcium diet and rats fed a strontium diet. The change in appearance of the mandibular condyles of the rats fed strontium was more severe than that in those fed low amounts of calcium. From the histochemical findings, it was suggested that the metabolic dysfunction of chondroitin sulfate, periodic acid-Schiff positive materials, and collagen in the hypertrophic zone of the condylar cartilage (or in the part corresponding to trabecular bone of the mandibular ramus) was one factor inhibiting normal endochondral ossification.     

The role of type X collagen in facilitating and regulating endochondral ossification of articular cartilage

AUTHOR: Shen G Objective -This review was compiled to explore the role of type X collagen in growth, development and remodeling of articular cartilage by elucidating the linkage between the synthesis of this protein and the phenotypic changes in chondrogenesis and the onset of endochondral ossification. DESIGN: The current studies closely dedicated to elucidating the role of type X collagen incorporating into chondrogenesis and endochondral ossification of articular cartilage were assessed and analyzed to allow for obtaining the mainstream consensus on the bio-molecular mechanism with which type X collagen functions in articular cartilage. RESULTS: There are spatial and temporal correlations between synthesis of type X collagen and occurrence of endochondral ossification. The expression of type X collagen is confined within hypertrophic condrocytes and precedes the embark of endochondral bone formation. Type X collagen facilitates endochondral ossification by regulating matrix mineralization and compartmentalizing matrix components. CONCLUSION: Type X collagen is a reliable marker for new bone formation in articular cartilage. The future clinical application of this collagen in inducing or mediating endochondral ossification is perceived, e.g. the fracture healing of synovial joints and adaptive remodeling of madibular condyle.     

Mechanism in favorable prognosis of pediatric condylar fractures managed by closed procedures: an experimental study in growing rats

Abstract – The purpose of this study was to investigate the underlying mechanism in favorable prognosis following pediatric condylar fractures managed by closed procedures. Seventy‐five 1‐month‐old male Wistar rats were used in this experiment. Unilateral medially rotated condyle fracture in growing rats was adopted as the condyle fracture model to investigate the mechanism in favorable healing of pediatric condylar fractures. The entire fracture healing process was investigated. The rotated subcondylar fractures in young rats healed by means of callus formation, with simultaneous and prompt repositioning of the condyle. The positive outcome in these condyle fractures was also associated with active cell proliferation potential in the condyle, as well as the condyle’s remodeling capability. The growth potential and remodeling capability of the condyle during the growing period might be the intrinsic factor for favorable healing following pediatric condylar fractures managed by closed procedures.     

生长期兔颞下颌关节盘前移位后髁突软骨胶原表达的变化

目的:建立生长期兔颞下颌关节不可复性关节盘前移位动物模型,检测髁突软骨内Ⅱ型胶原和X型胶原的表达,探讨青少年颞下颌关节盘不可复性前移位与髁突软骨内成骨的关系,及其与下颌骨发育不对称畸形之间存在相关性的机制.方法:取生长期新西兰大白兔40只,右侧颞下颌关节手术建立不可复性关节盘前移位模型,左侧行假手术作为对照.实验动物于建模后24 h、1、4、8、12周分组处死取材.通过免疫组织化学方法检测髁突软骨组织内Ⅱ型胶原和X型胶原在蛋白水平的表达,采用PASW statistics 18.0软件包对每组样本实验侧和对照侧进行配对t检验.结果:Ⅱ型胶原在盘移位后24h、1、4、8周时与对照侧均无显著差异,12周时较对照侧表达升高(P＜0.05).X型胶原在盘移位后24 h(P＜0.01)、1周(P＜0.01)、4周(P＜0.05)时较对照侧显著降低,8周、12周时实验侧与对照侧间无显著差异.结论:不可复性关节盘前移位对兔髁突软骨内成骨过程造成干扰,这种影响可能是单侧颞下颌关节盘前移位后患侧下颌支高度不足和下颌骨不对称畸形的重要原因.     

下颌下小切口入路行髁突颈部骨折复位固定术的疗效观察

目的：观察下颌下小切口入路用于髁突颈部骨折复位固定的疗效。方法：纳入研究病例26例,术前确诊为髁突颈部骨折并且具备手术适应证。于下颌角位置做小切口,分离并保护面神经下颌缘支,于该神经上横断咬肌后1/3,骨折断端暴露后,解剖复位并钛板固定。结果：26例患者均恢复正常咬合关系,开口度和开口型均正常,面部对称,无面神经损伤。结论：下颌下小切口入路利用面神经下颌缘支和下颊支之间的解剖间隙,在髁突颈部骨折治疗中效果良好。     

翼外肌在髁突矢状骨折愈合过程中对髁突形态改建的影响

目的：本实验的目的是检查翼外肌在髁突矢状骨折愈合过程中,对髁突形态改建的影响。方法：20只1岁龄成年绵羊,随机分为两组,每组10只动物,所有绵羊都用超声骨刀造成髁突矢状骨折,剪断关节盘前后附着并将其推向内侧,其中组1动物切断翼外肌,组2动物保留翼外肌功能。每组动物分别在术后4周（各2只）、12周（各4只）、24周（各4只）处死。处死后行CT检查,CT三维重建观察髁突形态,并解剖颞颌关节（TMJ）以观察髁突形态。结果：组2即保留翼外肌功能组,较组1髁突有更多新骨形成,髁突形态改变更严重。结论：翼外肌在髁突矢状骨折愈合过程中对髁突形态改建的影响起非常重要的作用。     

Expression of bone morphogenetic proteins during mandibular distraction osteogenesis in rabbits.

PURPOSE: We examined the expression pattern of bone morphogenetic proteins (BMPs) during mandibular distraction osteogenesis in rabbits and also investigated the mechanism of membranous bone distraction. MATERIALS AND METHODS: Twenty-three rabbits underwent mandibular distraction (protocol; no latency period, a 1-week distraction at 0.5 mm/d, and a 2-week consolidation period). Samples were collected at 3, 5, and 7 days of distraction and at 1-week and 2-week consolidation. We prepared undecalcified fresh-frozen sections and immunohistochemically evaluated the expression of BMPs 2 through 8. RESULTS: Both endochondral ossification and intramembranous ossification were observed. The expression of BMPs 2, 4, 5, and 6 was observed continuously from the beginning of distraction. BMP-7 was expressed weakly. The expression of BMP-3 was not observed conspicuously during distraction but was strongly expressed at 1- and 2-week consolidation. CONCLUSION: The expression pattern of BMPs during membranous bone distraction was similar to that during long bone distraction, but it differed from the expression pattern of long bone distraction in that the expression of BMPs was maintained for 2 weeks after the completion of distraction.     

骨痂中碱性成纤维细胞生长因子的免疫组化定位

目的：观察碱性成纤维细胞生长因子在人颌面部骨折愈合过程中的表达及量的变化。方法：于颌面部骨折的患者行切开复位内固定术时，取骨断端间骨痂，利用ＡＢＣ免疫组织化学方法检测了骨折后不同时间碱性成纤维细胞生长因子在骨痂组织中的分布。结果：在骨折修复初期的骨痂中，新生骨基质、未分化间充质细胞、成骨细胞、幼稚的软骨细胞、骨细胞及血管内皮细胞的免疫组化染色均为强阳性。随着骨化的进行及软骨的成熟，成熟钙化的骨基质、处于分化末期的肥大的软骨细胞染色为阴性，成骨细胞、骨细胞及血管内皮细胞仍有部分呈阳性反应，但阳性着色的细胞数及阳性反应程度均较前明显下降。结论：碱性成纤维细胞生长因子参与了人颌面部骨折修复的全过程，在骨折愈合中发挥着重要的作用。