颞下颌关节囊内黏连：内镜诊断结果与临床症状的关系

目的归纳关节镜下黏连（Intraarticular adhesion,IA）的分级及分布,阐明不同颞下颌关节（Temporomandibular joint,TMJ）结构紊乱（internal derangement,ID）分期中IA的发生率;探讨IA与患者年龄、可视化疼痛测量值（Visual Analogue Scale,VAS）、弹响持续时间、张口受限持续时间及术前张口度之间的关系;比较镜下IA治疗方法。方法关节镜诊断IA及其疗效评价,按九分法记录IA分布及分级,统计各区IA比例。将患者分为IA组和无IA组,对两组患者年龄、关节弹响持续时间、锁合期、VAS值和术前张口度进行t检验;对IA患者行临床疗效评价。结果关节镜诊断证实1822侧关节中,有524侧有IA,其比例为28.86%。IA分布为I区82.13%,Ⅱ区8.40%,Ⅲ区9.47%;各级IA为1级68.89%,2级20.61%;3级4.58%;4级5.92%;IA在ID中构成比为II期13.89%,Ⅲ期25.47%,Ⅳ期37.99%,Ⅴ期40.37%;IA术后临床评价有效率90.14%,IA组与无IA组患者平均年龄（t=10.41 P〈0.001）、术前平均张口度（t=9.54 P〈0.001）、疼痛持续时间（t=3.66,P〈0.001）、术前平均锁合期（t=3.89 P〈0.001）均有显著性差异;而弹响持续时间（t=1.08P〉0.05）则无显著性差异。结论关节镜证实IA发生率是较高的,主要发生在年龄大,锁合期长和张口度小的患者;ID分期越高,IA分级亦升高。     

颞下颌关节上腔囊内粘连的关节镜检查

目的　探讨囊内粘连与颞下颌关节内错乱(ID)分期以及与患者年龄、张口受限时间及术前张口度之间的 关系。方法　选择患有颞下颌关节ID的251例患者的280侧关节进行关节镜检查,观察颞下颌关节囊内粘连的形 态及部位,按颞下颌关节上腔九分法分区记录粘连情况,计算各区粘连所占比例和不同粘连级别与ID分期的关 系。将Ⅲ~Ⅴ期患者按关节镜检查结果分为粘连组和无粘连组,比较两组患者年龄、张口受限时间和术前张口度 的差异。结果　280侧受检关节中,有157侧发生粘连,约占56·07%,其中1级粘连占44·59%,2级粘连占 32·48%,3级粘连占7·64%,4级粘连占15·29%。粘连关节在不同ID分期的构成比分别为:处于IDⅡ期的37侧关 节有4侧发生粘连,占10·81%;处于IDⅢ期的121侧关节有59侧发生粘连,占48·76%;处于IDⅣ期的41侧关节 有31侧发生粘连,占75·61%;处于IDⅤ期的81侧关节有63侧发生粘连,占77·78%。ID分期为Ⅲ~Ⅴ期的患者 共223例(243侧),其中粘连组为136例(153侧),无粘连组为87例(90侧),两组患者的年龄、张口受限时间和术前 张口度均有统计学差异(P<0·001)。结论　颞下颌关节上腔囊内粘连发生率较高,多发生于张口受限时间长、张 口度小及年龄较大的患者,且内错乱分期愈高,粘连级别愈高。     

颞下颌关节上腔囊内粘连的磁共振造影诊断

目的:评价磁共振造影对颞下颌关节上腔囊内粘连的诊断价值。方法:临床诊断为内错乱的连续33例(36侧)患者,进行颞下颌关节上腔磁共振造影检查,其中30例(31侧)进行关节镜检查并同期治疗,按照磁共振造影对颞下颌关节囊内粘连诊断的影像学标准,确定有无粘连,分阳性组、可疑组及阴性组;并以关节镜诊断结果为金标准,得出真、假阳性及真、假阴性关节例数。应用SPSS软件制作ROC曲线,计算ROC曲线下面积,从而评价磁共振造影诊断囊内粘连的整体准确性。结果:关节镜诊断囊内粘连为70.97%(22/31)。磁共振造影诊断结果与关节镜诊断对照后得出:阳性组20侧,其中19侧真阳性,1侧为单个游离体;可疑组3侧,其中1侧假阳性,2侧真阳性;阴性组8侧,其中1侧假阴性,7侧真阴性。ROC曲线下面积=0.91(0.86,0.95),P<0.05。结论:磁共振造影兼具平片造影和MRI的优点,诊断准确率高,而且能对囊内粘连作定位诊断,是一种诊断囊内粘连的理想方法。     

颞下颌关节上腔囊内粘连的磁共振诊断

目的:评价磁共振对颞下颌关节上腔囊内粘连的诊断价值。方法:临床诊断为内错乱的27例(33侧)患 者,进行颞下颌关节磁共振检查及关节镜诊治。按照磁共振对颞下颌关节囊内粘连诊断的影像学标准,确定有无 粘连,分阳性组、可疑组及阴性组;并与关节镜诊断结果对比,得出真、假阳性及真、假阴性关节数,应用SPSS软件 制作ROC曲线,计算ROC曲线下面积,评价磁共振诊断囊内粘连的整体准确性。结果:关节镜诊断囊内粘连为 54.55％(18／33)。磁共振诊断结果经与关节镜诊断对照后得出:阳性组11侧,其中7侧真阳性,4侧假阳性;可疑 组4侧,其中3侧真阳性,1侧假阳性;阴性组18侧,其中10侧真阴性,8侧假阴性。ROC曲线下面积=0.60 (0.41,0.80),P<0.05。结论:磁共振诊断关节囊内粘连的整体准确性较低,对大部分囊内粘连不能作出肯定的 诊断;若有关节腔积液,T2加权像可诊断囊内粘连。     

颞下颌关节上腔囊内粘连的平片造影诊断

目的 :评价X线平片造影对颞下颌关节上腔囊内粘连的诊断价值。方法 :选取临床诊断为关节内错乱患者 10 5例 ( 10 5侧 ) ,进行关节上腔平片造影及关节镜检查。按平片造影影像学诊断标准 ,确定有无粘连 ,分阳性组、可疑组及阴性组 ;并与关节镜诊断结果对比 ,得出真、假阳性 ,真、假阴性例数 ,应用SPSS软件制作ROC曲线 ,计算ROC曲线下面积。同时分析漏诊、误诊的原因。结果 :关节镜诊断囊内粘连为 5 3 .3 3 % ( 5 6/ 10 5 )。平片造影诊断与关节镜诊断对照 :阳性组 40例 ,其中 3 2例真阳性 ,8例假阳性 ;可疑组 18例 ,其中 9例真阳性 ,9例假阳性 ;阴性组 47例 ,3 2例真阴性 ,15例假阴性。造影易检出的粘连部位是外中份 ;易漏诊的部位是内 1/ 3 ;粗大粘连带易于检出。ROC曲线下面积为 0 .73 ( 0 .64 ,0 .82 ) ,P <0 .0 5。结论 :X线平片造影对诊断囊内粘连的整体准确性中等 ,但不失为一种简单、实用的影像学检查方法 ,其漏诊的主要原因与粘连带的大小和部位有关。     

颞下颌关节囊内粘连的诊治进展

颞下颌关节囊内粘连是颞下颌关节疾病的伴发病变，其诊断和治疗方法多种多样，作者综述了近几年在该病诊断和治疗上的进展，尤其是早期颞下颌关节囊内粘连的影像学诊断及其关节镜治疗。     

兔TMJ囊内黏连动物模型的建立

目的：介绍一种建立兔颞下颌关节囊内黏连动物模型的方法。方法：手术暴露16只兔右侧的颧突根部、眶下壁和眶后壁处组织,在颧突根部的前下方,用带有弹力橡皮筋的针自下向上垂直穿过关节盘的前伸部,将双股弹力橡皮筋从9.5mm向前牵引至40mm,达1.20N的牵引力,并将其固定于眶骨上制备的小孔中。术后分期进行MRI和内镜检查,确定有、无关节盘移位和黏连形成,随后处死动物取关节标本,以备光镜、电镜研究。结果：所有兔的下颌骨均不同程度地偏向对照侧,且伴有前牙的斜向磨耗。MRI证实,所有关节盘均出现了前移位,部分动物模型的实验侧关节上腔内有黏连带形成。结论：本实验提供了一种较好的建立颞下颌关节囊内黏连动物模型的方法。     

下颌髁突囊内骨折后关节强直的诊断及手术治疗

目的:对下颌髁突囊内骨折后关节强直依据其自身特点进行分类,制定相应的治疗原则,并作初步的疗效评估。方法:2001年7月至2004年10月间收治下颌髁突囊内骨折后关节强直患者19例(23侧),手术时平均年龄12.68岁,术前平均开口度5.74mm,外伤时平均年龄7.32岁。根据骨折线位置,将关节强直分为Ⅰ、Ⅱ、Ⅲ、Ⅳ4型,采用不同手术方法进行治疗。Ⅰ型和Ⅱ型采用保留内侧髁突头和关节盘的外侧关节间隙成形术(LGA),Ⅲ型和Ⅳ型采用骨球及髁突切除和肋骨肋软骨移植关节重建术(CCG)。术后1周、1个月、3个月、6个月、1a、2a和3a进行临床随访,从临床和影像学两方面评估颞下颌关节的改建情况。结果:19例(23侧)中16例(19侧)行LGA手术,3例(4侧)行关节重建术。术后平均随访11.37个月,随访期末平均开口度27.89mm。结论:LGA既解除了关节强直,又保存了关节的功能尤其是生长潜力,应加以推广,但其有一定的适应证;CCG仍然是关节强直治疗中不可或缺的一部分。     

中老年颞下颌关节紊乱病关节镜手术治疗

颞下颌关节紊乱病(temporomandibular disorders,TMD)是口腔科的常见病及多发病.部分病例病程迁延,经久不愈,严重影响口颌系统的功能.近年来,颞下颌关节镜手术治疗TMD已被普遍接受,作为介于保守治疗与开放性手术治疗之间的治疗方法,创伤小,并发症少,患者易于接受,在一定程度上可作为部分开放性手术的替代治疗手段.     

三种方法治疗颞下颌关节紊乱病的疗效比较

目的　比较关节灌洗、关节镜和关节开放手术 3种方法治疗颞下颌关节紊乱病的临床效果。方法　应用 3种方法治疗颞下颌关节紊乱病 :关节灌洗术治疗 35例 (42侧关节 ) ,关节镜术治疗 4 2例 (5 0侧关节 ) ,关节开放手术治疗 2 8例 (2 9侧关节 ) ,并对 3种方法的疗效进行比较。结果　关节灌洗组随访 2 4～ 5 2个月 ,术后张口度平均增加 (8.1± 3.9)mm ,健侧侧向运动增加 (3.8± 1.4 )mm ,85 .7%患者疼痛缓解 ,72 .2 %杂音消失 ,总有效率为 82 .9%。关节镜组随访 2 4～ 5 6个月 ,张口度平均增加 (7.5± 3.8)mm ,健侧侧向运动增加 (4.1± 1.8)mm ,88.1%患者疼痛缓解 ,79.2 %杂音消失 ,总有效率为 85 .7%。关节开放手术组 ,随访 2 4～ 5 5个月 ,术后张口度平均增加 (8.0± 5 .1)mm ,健侧侧向运动增加 (3.7± 2 .3)mm ,92 .9%患者疼痛缓解 ,总有效率为 89 3%。 3组比较 ,张口度、侧向运动改善及疼痛缓解率均无显著差异。结论　关节灌洗术、关节镜术和关节开放手术治疗颞下颌关节紊乱病均有效 ,但关节灌洗术方法简单、损伤小 ,易于推广应用。首先应选择手术创伤小的治疗方法 ,最后才选择开放手术。     

Magnetic resonance imaging in the diagnosis of intra-articular adhesions of the temporomandibular joint

We aimed to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis of intra-articular adhesions of the temporomandibular joint (TMJ). We diagnosed 27 consecutive patients with internal derangement of the TMJ (33 TMJs) between 1 December and 31 July 2003 in our department. All patients were examined by MRI and arthroscopy. The MRI findings were recorded as "positive", "suspicious", or "negative", and were compared with those of arthroscopy to obtain the numbers of true positive, true negative, false positive, and false negative results. Arthroscopy confirmed that 18 of the 33 TMJs contained adhesions. MRI showed that 11 were "positive", 4 were "suspicious", and 18 were "negative". After comparing these results with those of arthroscopy, 7 TMJs were true positives and 4 were false positives of the 11 "positive" TMJs. Three of the 4 "suspicious" TMJs had adhesions. Of the 18 negative TMJs, 10 were true negatives and 8 were false negatives. We concluded that the diagnostic accuracy of MRI for intra-articular adhesions was poor; most of the adhesions were not diagnosed by MRI, but intracapsular adhesions could be detected on T2 weighted-images with existing synovial fluid.     

Arthroscopic surgery for treatment of anterior displacement of the disc without reduction of the temporomandibular joint

The aim of this study was to investigate the clinical results and efficacy of an arthroscopic approach to correct anterior displacement of the disc without reduction of the temporomandibular joint (TMJ) with limitation of mouth opening. We studied 28 joints with internal derangement in 23 patients, all of whom had had arthroscopic surgery (lavage, lysis of adhesions in the superior compartment, incision parallel to the disc-synovial crease of the upper joint compartment, and pull back of the anteriorly located disc). Objective and subjective data (increase in maximal interincisal opening, magnetic resonance imaging, and visual analogue pain score, VAS) were collected preoperatively and at 7, 30, 60 days, and 6 months or more postoperatively. Maximal interincisal opening improved from a mean (SD) of 20.4 (±4.5) mm preoperative measurement to 38.9 (±3.2) mm by 6 months postoperatively where indicated in previous line. The VAS showed a significant improvement in pain score (p=0.0023). Sixty days postoperatively the positions of the discs in 14 of the TMJs had improved considerably. In 13 of the TMJs the positions had improved slightly. Only 1 of the TMJs had not improved at all. There were no complications in any patient. Our arthroscopic procedure is safe, minimally invasive, and effective for the treatment of patients with displacement of the disc anteriorly without reduction of the TMJ.     

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。     

颞下颌关节囊内色素沉着绒毛结节性滑膜炎的关节镜治疗

目的探讨关节镜在颞下颌关节囊内色素沉着绒毛结节性滑膜炎诊断和治疗中的应用。方法回顾性分析在2002至2009年间接受过关节镜治疗局限于关节囊内经病理确诊为颞下颌关节色素沉着绒毛结节性滑膜炎的4例患者。结果4例患者中,3例为女性,1例为男性,诊断时平均年龄46岁,共同症状是张口困难和疼痛,均无耳前区肿胀或肿块。磁共振成像（MRI）和关节腔造影检查显示关节盘前移位、关节盘穿孔、髁突骨赘形成或关节腔积液。关节镜下观：1例可见关节上腔内一黄色结节和数枚软骨样游离体,其余3例患者可见上腔滑膜局部或全部呈黄色或棕色病理性增生,2例患者可见关节软骨呈退行性变。每例患者均采用局部滑膜切除术和关节面修整术,其中2例年轻患者同时进行关节盘复位缝合固定术。术后病理检查确诊为颞下颌关节色素沉着绒毛结节性滑膜炎。平均随访时间为57．4个月,未见复发。结论本研究提示关节镜是诊断和治疗局限于关节囊内的色素沉着绒毛结节性滑膜炎的一种有效方法。     

颞下颌关节内粘连的影像学诊断

目的探讨颞下颌关节内粘连的影像学诊断标准。方法从１０３例颞下颌关节内疾患的病例中收集了２６例颞下颌关节内粘连病例，将临床检查、关节造影检查与颞下颌关节内窥镜检查相对照。结果颞下颌关节内粘连的关节造影检查可见：关节腔造影剂量减少，关节上腔造影剂变薄、狭窄；开闭口位时关节盘后带的压迹部位始终位于同一位置；造影剂边缘不整齐或造影剂中断以及关节内粘连伴有关节盘前移位。结论以上结果可作为关节造影诊断关节内粘连的依据。     

涎腺腺样囊性癌p53基因蛋白的表达及其临床意义

目的 为探讨涎腺腺样囊性癌ｐ５３基因蛋白的表达及其临床意义。方法 作者应用流式细胞术及细胞免疫荧光染色技术,对涎腺腺样囊性癌ｐ５３基因蛋白的表达进行了定量研究。结果 结果表明,正常涎腺组织ｐ５３表达均为阴性,涎腺腺样囊性癌ｐ５３基因蛋白表达量及表达阳性率与该肿瘤的浸润情况密切相关,ｐ５３基因蛋白表达量与预后亦有相关性。结论 ｐ５３基因蛋白表达量及表达阳性率与腺样囊性癌组织学分型、ＤＮＡ倍体水平及细     

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.     

Adhesions in the temporomandibular joint: formation and significance

BACKGROUND: Adhesions are frequently seen in the deranged temporomandibular joint (TMJ). In the early stage of the degenerative process the adhesion does not seem to be a significant factor in reduced mandibular movement. This is reversed in advanced degenerative joint disease where the adhesion requires release to achieve a satisfactory clinical result. Correlation of clinical history and findings within the joint should increase understanding of limited jaw movement. METHODS: Arthroscopic examination of deranged TMJs was performed on 75 patients with limited jaw opening and correlated with the history of the derangement. RESULTS: A progressive maturation of adhesion formation was observed with longer standing symptoms. A different adhesion pattern was noted with derangement caused by direct trauma on the joint. CONCLUSIONS: Internal derangement of the TMJ is associated with formation of intra-articular adhesions. These are unlikely to be associated with reduced condyle movement in the early phase of the derangement. Later stage adhesions are more substantial and require release to achieve a satisfactory clinical outcome.     

颞下颌关节上腔内粘连的组织学研究

目的：观察颞下颌关节(TMJ)上腔内粘连的组织学及超微结构,探索粘连带的形成机制。方法：关节镜直视下,采用内镜杯状钳留取21例(21侧)TMJ的Ⅰ～Ⅳ级粘连带标本,每个TMJ各留取粘连标本2份,其中1份立即以4%甲醛溶液固定,常规石蜡切片,HE染色,光镜观察。同时进行改良雷锁辛复红液弹力纤维染色及Marson染色(三原染色),观察弹力纤维和胶原纤维的数量和分布。另1份标本立即以2%戊二醛溶液固定,制备电镜标本,观察粘连带的超微结构。结果：各级粘连带在光镜下均为致密结缔组织。在透射电镜下,Ⅰ级和Ⅲ级粘连中,胶原纤维束排列有序；Ⅱ级粘连中,可观察到有序或随机排列的胶原纤维束,有滑膜覆盖者,胶原纤维束内含有粗大的弹力纤维,可见活性较差的成纤维细胞；Ⅳ级粘连中,胶原纤维和弹力纤维排列不规则,其中可见散在的滑膜细胞和软骨样细胞；亦可见分泌活跃的成纤维细胞．其胞质内可见大量的粗面内质网。结论：TMJ的各级粘连带中,纤维成分的种类及排列不同,此有助于探讨其形成机制。