创伤性颞下颌关节强直伴内侧髁突残存的手术治疗

目的:探讨创伤性颞下颌关节强直伴内侧髁突残存的手术治疗方法及疗效。方法:上海交通大学医学院附属第九人民医院口腔颌面外科关节组2001—2009年收治的内侧有髁突残存的创伤性颞下颌关节强直60例82侧关节纳入研究,分别采用外侧成形术、外侧成形+咬肌瓣和外侧成形+颞筋膜脂肪瓣进行治疗。通过临床和CT随访,评价3种治疗方法的疗效,采用SPSS 13.0软件包对术后开口度的改善进行统计学分析。结果:22侧关节采用外侧成形术;28侧关节采用外侧成形+咬肌瓣;32侧关节采用外侧成形+颞筋膜脂肪瓣。38例48侧关节术后随访1～4a。其中,4/11侧外侧成形术关节复发,占36.4%;3/17侧外侧成形+咬肌瓣治疗的关节复发,占17.6%;20侧外侧成形+颞筋膜脂肪瓣治疗的关节无一例复发。3种治疗方法中,外侧成形+颞筋膜脂肪瓣与单纯外侧成形术相比,开口度改善有显著差异(P<0.05)。结论:外侧成形术保留了残存的关节结构,与颞筋膜脂肪瓣结合,可以很好地预防颞下颌关节强直复发。     

带蒂颞深筋膜脂肪瓣在颞下颌关节重建中的应用：135例临床分析

目的：探讨以颞中血管为蒂的颞深筋膜脂肪瓣在颞下颌关节重建中的应用效果。方法：收集2012年1月—2017年12月间于上海交通大学医学院附属第九人民医院口腔外科手术治疗的颞下颌关节病患者135例（170侧）。所有患者在手术过程中均应用以颞中血管为蒂的颞深筋膜脂肪瓣,术后定期随访,至少1年以上的影像学资料齐全。根据术前诊断、手术方法等对患者进行分类,并通过影像学检查,评估该组织瓣的位置和长期稳定性。结果：135例患者中,因晚期颞下颌关节内紊乱或骨关节病,应用颞深筋膜脂肪瓣置换关节盘8例;因颞下颌关节强直,术中置入颞深筋膜脂肪瓣作为间隔物28例;因颞下颌关节-颅底区肿瘤性病变,术中置入颞深筋膜脂肪瓣作为间隔物31例;因各类疾病行关节置换后置入颞深筋膜脂肪瓣作为间隔物68例。术后即刻与术后1年以上的影像学检查均可见髁突或移植骨与关节窝之间有混杂信号影,将两者分隔开。在20~86个月的随访期内,未见组织瓣坏死、感染、供区脱发或凹陷等并发症。结论：以颞中血管为蒂的颞深筋膜脂肪瓣可用于多种颞下颌关节疾病的外科治疗,即刻位置满意且术后保持长期稳定。     

Surgical reconstruction of the temporomandibular joint for chronic subluxation and dislocation

This paper describes the use of an inferiorly based pedicled flap from the temporal fascia sutured to the anterior-lateral wall of the capsule and augmentation of the zygomatic root of the temporal bone by a bone graft from the iliac crest to prevent forward movement of the condyle beyond the eminence. It may be used for treatment of patients with chronic subluxation and dislocation of the temporomandibular joint.     

血管化腓骨肌瓣下颌骨重建中髁突不同处理方法对颞下颌关节功能的影响评价

目的 对髁突采用不同处理方法的血管化腓骨肌瓣下颌骨缺损重建后评价患者的临床及颞下颌关节(TMJ)功能状态.方法 患者41例,其中男性21例,女性20例.41例均为累及下颌升支上部且未超过下颌中线的颌骨良性病损,其中应用腓骨替代髁突法重建24例、游离髁突法重建5例、保留髁突法重建12例.采用Fricton TMJ功能量表评价患者术后的TMJ功能,并进行统计学分析.结果 所有患者均未发生关节强直,术后最大开口度31～53 mm,平均值(42.8±5.7)mm.不同术式患者术后面部外形、进食及语音功能比较,差异无统计学意义(P＞0.05);但患者的TMJ功能指数,即功能障碍指数(dysfunction index,DI)及功能紊乱指数(cramiomandibular index,CMI)间比较,差异有统计学意义(P＜0.01).保留髁突组患者的TMJ功能优于腓骨替代髁突组.结论 保留髁突的血管化腓骨瓣下颌骨重建有助于恢复TMJ功能;以腓骨瓣末端替代髁突进行下颌骨重建时,重建髁突的位置和形态对于TMJ的功能有明显影响.     

Clinical study on the relationship between chewing movements and temporomandibular joint abnormalities

Chewing movements are accomplished by the harmonious function of the stomatognathic system. Therefore, TMJs play important roles in chewing movements. Recently, significant findings on TMJ abnormalities have been obtained from many studies. However, the relationship between chewing movements and TMJ abnormalities remains unclear. The purpose of this study was to examine how TMJ abnormalities were reflected in chewing movements. Incisor point movements during chewing (chewing pattern) were investigated in 150 abnormal and 25 normal subjects using Sirognathograph Analysing System. Abnormal subjects were composed of 45 patients with anterior disk displacement with reduction (reciprocal click), 20 patients with anterior disk displacement without reduction (closed lock), 50 patients with osteoarthrosis and 35 patients with MPD syndrome. Analysis of condylar movements during chewing were also performed in 9 normal and 20 abnormal subjects. The results were as follow; 1. Subjects with TMJ abnormalities tended to show abnormal chewing patterns when chewing at their non-abnormal sides. 2. TMJ abnormality of each different type tended to show its respective characteristic chewing pattern. 1) Subjects with osteoarthrosis and reciprocal click without condylar posterior dislocation tended to show deviation of the turning point to the non-chewing side, with a convex opening path in the frontal plane and a lack of anteroposterior width in the sagittal plane. This finding was associated with the limitation in movement of the abnormal-side condyle. 2) Subjects with reciprocal click with condylar posterior dislocation tended to show a concave opening path and reversed or cross-over patterns in the frontal and horizontal planes, respectively. This finding was associated with the movement of the abnormal-side condyle in the medio-anterior direction during the initial phase of opening. 3) Subjects with closed lock without condylar posterior dislocation tended to show deviation of the turning point to the non-chewing side, with a concave opening path in the frontal plane and a lack of anteroposterior width in the sagittal plane. This finding was associated with the severe limitation in movement of the abnormal-side condyle. 4) Subjects with closed lock with condylar posterior dislocation characteristically tended to show reversed or cross-over patterns in the horizontal plane. This finding was associated with the movement of the abnormal-side condyle in the medio-anterior direction during the initial phase of opening. However, this movement was smaller than that of the reciprocal click. 3. Subjects with MPD syndrome showed chewing patterns similar to those of normal subjects. From the results, close relationships were found between chewing movements and TMJ abnormalities.     

Characteristics of condylar movements during mastication in stomatognathic dysfunction

In this investigation of the relationship between mastication and TMJ abnormalities, the movements of the incisal point and condyles during mastication were analyzed in two normal subjects and six patients with unilateral TMJ abnormalities. The path of the nonworking condyle was shorter than that of the working condyle when patients chewed on the side of the normal TMJ, causing the mandible to deviate to the abnormal side at the point of transition from opening to closing. Also, the mobility of the abnormal condyle influenced the convexity of the opening path, and posterior dislocation of the condyle resulted in a crossover chewing pattern.     

Spatial deviations of the temporomandibular joint after oncological mandibular reconstruction

Spatial deviations of the temporomandibular joint (TMJ) after oncological mandibular reconstruction are important to the aesthetic and functional rehabilitation. The aim of this study was to clarify whether and how three dimensionally (3D) printed patient-specific surgical plates, and the preservation of the condyle or ramus, affect spatial deviations of the TMJ. A total of 33 patients who underwent mandibular reconstruction via computer-assisted surgery were included. Regarding absolute deviations, patients in the 3D-printed plate group showed smaller TMJ deviations compared to those in the conventional plate group. There was no difference in absolute deviations of the TMJ regardless of whether the condyle or ramus was preserved. Regarding physiological deviations, the impact on the contralateral TMJ was smaller in the 3D-printed plate group. Patients with both the condyle and ramus removed had significantly higher deviations of the condyle and joint space. In summary, 3D-printed patient-specific surgical plates improved the spatial accuracy of the TMJ. Under physiological conditions, TMJ deviations on the operated side were mainly affected by the preservation of the condyle. Removal of both the condyle and ramus caused more severe spatial interference to the TMJ; this should be further confirmed.     

A new surgical approach for the treatment of chronic recurrent temporomandibular joint dislocation

Chronic recurrent temporomandibular joint (TMJ) dislocation is defined as the complete loss of articular relationships, during mouth-wide opening, between the articular fossa of the temporal bone and the condyle-disk complex. The most frequent pathogenetic factors involved in chronic recurrent dislocation of the TMJ are supposed to be trauma, abnormal chewing movements, TMJ ligaments, capsule laxity, and masticatory muscles disorders. In fact, TMJ dislocation occurs more frequently in people with general joint laxity and in patients with internal derangement of the TMJ or with occlusal disturbance.Management of TMJ dislocation remains a challenge. Eminectomy, whose validity has been demonstrated by several authors, acts on the bony obstacle, preventing condylar locking, but does not have a therapeutic effect on TMJ ligament and capsular laxity or masticatory muscle incoordination, which seem to be the real cause of TMJ dislocation in most cases.The authors present a mini-invasive modified technique of eminectomy, which aims to act on both the obstacle and the cause with respect and restoration of TMJ biomechanical constraints.     

Arthrocentesis followed by intra-articular autologous blood injection for the treatment of recurrent temporomandibular joint dislocation

Temporomandibular joint (TMJ) dislocation is an excessive forward movement of the condyle beyond the articular eminence with complete separation of the articular surfaces and fixation in that position. This study was conducted to assess autologous blood injection to the TMJ for the treatment of chronic recurrent TMJ dislocation. Fifteen patients with bilateral chronic recurrent condylar dislocation were included in the study. Bilateral TMJ arthrocentesis was performed on each patient, followed by the injection of 2 ml of autologous blood into the superior joint compartment and 1 ml onto the outer surface of the joint capsule. Preoperative and postoperative assessment included a thorough history and physical examination to determine the maximal mouth opening, presence of pain and sounds, frequency of luxation, recurrence rate, and presence of facial nerve paralysis. Eighty percent of the subjects (12 patients) had a successful outcome with no further episodes of dislocation and required no further treatment at their 1-year follow-up, whereas three patients had recurrent dislocation as early as 2 weeks after treatment. Autologous blood injection is a safe, simple, and cost-effective treatment for chronic recurrent TMJ dislocation.     

Mandibular condylectomy with osteoarthrectomy with and without transfer of the temporalis muscle

Twenty-two patients with chronic arthritis and ankylosis of the temporomandibular joint (TMJ) were treated by resection of the condyle with osteoarthrectomy and interposition with a temporalis muscle flap. We compared them with 14 patients who were treated by condylectomy and osteoarthrectomy alone. All patients were evaluated prospectively. Most patients had had a previous operation on the disc. Variables investigated before and after operation were pain during mandibular movements (using a visual analogue score (VAS) of 1–10) and impaired mandibular function such as chewing and biting off (also using a VAS of 1–10). Maximum interincisal opening was measured with a ruler. Both groups of patients showed significant improvements in all the variables evaluated. Using the predefined success criteria, both methods showed good success rates with few complications. The patients treated by interposition of the temporalis muscle tended to do better, but not significantly so. Both methods induced occlusal changes and some needed dental treatment postoperatively.     

自体喙突移植重建髁突对儿童颞下颌关节强直患者下颌骨生长的远期影响

目的 儿童期下颌骨髁突受损通常导致错颌畸形和面部生长不协调。本研究目的是评价自体喙突移植重建下颌骨髁突对儿童颞下颌关节强直患者面部生长发育的远期影响。方法 追踪评估2008年1月1日至2016年12月31日期间收治于四川大学华西口腔医院正颌及关节外科的10名单侧颞下颌关节强直的儿童患者,其中包括3名男性和7名女性,于5~12岁期间接受了关节间隙成形术、同侧喙突移植髁突重建术和带蒂颞筋膜瓣置入术。术后追踪3~8年,平均4.9年。术后拍摄曲面断层X线片,测定患侧下颌体长度和下颌支高度的生长量并与健侧相比较。结果 所有患者术后恢复良好,追踪结束时10名患者的最大开口度为32~41 mm,平均35.6 mm。自体喙突移植重建髁突解除强直后下颌支高度和下颌体长度均继续生长,但是依然存在生长不足的现象。与初始数据（术后）相比,患侧下颌支高度（随访结束）增加了25.3%（P<0.05）,患侧下颌体长度增加了26.1%（P<0.05）。对比患侧与健侧的下颌骨生长率,患侧下颌支高度增长量与健侧相比少47.1%（P<0.05）,患侧下颌体长度的增长量与健侧相比少27.2% （P<0.05）。结论 自体喙突移植重建下颌骨髁突治疗儿童颞下颌关节强直后,患侧下颌骨可继续生长,但依然会存在生长不足的现象。在颞下颌关节强直治疗完成后,相比于健侧,患侧的生长率是减小的。     

Movement of temporomandibular joint tissues during mastication and passive manipulation in miniature pigs

Movement is an important aspect of the biomechanics of the temporomandibular joint (TMJ). To track the relative movements of TMJ components, radio-opaque markers were implanted in the left squamosal bone, mandible and retrodiscal tissue of miniature pigs. Medial-lateral (ML) and dorsal-ventral (DV) fluoroscopic records were made 8-10 weeks later during chewing and passive manipulation. Marker movements were digitized from the videotapes. During passive manipulation, the deformation of the lateral capsule was also measured with a differential variable-reluctance transducer. The results provide new details about porcine chewing pattern, which is distinguished by a regularly alternating chewing side. During masticatory opening, the mandible had a centre of rotation (CR) well inferior to the condyle and close to the angle. In contrast, the passive opening movement showed a higher CR location close to the condylar neck, indicating a different motion from masticatory opening. The retrodiscal tissue followed the movements of the mandibular condyle during both mastication and passive manipulation. The lateral capsule elongated during ipsilateral shifts and retrusion, implying a possible role in limiting such movements. These movement characteristics provide a useful reference for studies on the TMJ using pigs.     

The temporalis muscle flap in temporo-mandibular joint surgery

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.     

Treatment of TMJ ankylosis in Jordanian children - a comparison of two surgical techniques.

INTRODUCTION: The aim of this study was to report Jordanian experience in surgical treatment of TMJ ankylosis in 22 children. PATIENTS AND METHODS: This retrospective clinical study included children who were diagnosed with TMJ ankylosis and were treated in a dental teaching centre between 1993 and 2001. Patients underwent the release of 24 temporomandibular joint ankyloses and two different surgical techniques were used: either reconstruction of the condyle using costochondral grafts, or using the temporalis muscle as an interpositional material. Patients were followed up for 1-8 years. RESULTS: Twenty-two children (13 males and 9 females) were included in the study. Costochondral grafts were used as a reconstruction material in 16 TMJs (67%), whilst temporalis muscle was used as an interpositional material in 8 joints (33%). The mean preoperative maximum interincisor distance was 6.6 mm+/-1.3, which was increased to a mean of 30.3 mm+/-2.5 postoperatively. Two female patients (9%) suffered recurrence of the ankylosis within 6-12 months postoperatively. In one of these, a costochondral graft was used and temporalis muscle interposition in the other. CONCLUSION: Costochondral graft as a reconstruction material and temporalis muscle as an interpositional material showed comparable success rates when treating TMJ ankylosis in 22 children.     

应用颞中动静脉为蒂的颞肌筋膜瓣置换颞下颌关节盘

目的:介绍一种治疗中晚期颞下颌关节(temporomandibularjoint,TMJ)结构紊乱(internal derangement,ID)的手术方法,即以颞中动静脉为蒂的颞肌筋膜瓣(temporalis myofascial flap,TMF)置换关节盘.方法:对48例TMJ ID患者(52侧)进行颞中动静脉为蒂的颞肌筋膜瓣关节盘置换术.颞肌筋膜瓣血管蒂采用颞浅动静脉的分支一颞中动静脉,在关节盘切除后转移入关节间隙内.结果:所有手术均顺利完成.术后MRI显示,髁突与关节窝之间均由混合信号物质充填,两者完全隔开.结论:颞中动静脉为蒂的颞肌筋膜瓣是关节盘的良好替代物.     

Discal attachments of the human temporomandibular joint

BACKGROUND: Despite its clinical significance, the anatomy of the human temporomandibular joint (TMJ) and its relationship to the lateral pterygoid muscle remains poorly described and often misrepresented in standard texts. The aim of this study was to describe how the anterior and posterior attachments of the TMJ disc vary between lateral, central and medial regions of the joint. METHODS: Ten left TMJs were removed en bloc from cadavers and serial sections were made at 3-4mm intervals. Observations were made to ascertain the anterior and posterior attachments of the disc and the joint structures were traced from standardized photographs. RESULTS: Laterally, the capsule and lateral discal ligament merged prior to their attachment at the condylar pole. Medially, muscle fibres, capsule and the disc converged on the medial pole of the condyle. There was no evidence that fibres of the upper head of the lateral pterygoid muscle inserted directly into the disc. The upper head inserted into the condyle either directly at the pterygoid fovea or via a central tendon or indirectly via the capsule. Posteriorly, the superior part of the posterior attachment of the disc attached to the cartilaginous meatus and tympanic part of the temporal bone. The inferior part of the posterior attachment of the disc attached to the posterior surface of the condyle. In four joints, this attachment was folded beneath the posterior band of the disc, creating a wedge-shaped flap that ran medio-laterally. CONCLUSION: This study is in broad agreement with other anatomical TMJ studies but there are two main points of difference. Firstly, a true muscle insertion of the superior head of the lateral pterygoid muscle to the disc was not observed. Secondly, a wedge-shaped flap of retrodiscal tissue was identified between the condyle and the disc.     

Combined surgical therapy of temporomandibular joint ankylosis and secondary deformity using intraoral distraction

Temporomandibular joint (TMJ) ankylosis is a pathological process caused by damage of the mandibular condyle. When this event takes place in subjects during the developmental age, it results in an alteration of the entire maxillofacial complex. Therefore, surgical methods able to remove the temporomandibular ankylosis also include necessary operations to correct the secondary maxillofacial deformity. The distraction osteogenesis has induced our center to modify the surgical protocol for the therapy of patients who have developed TMJ ankylosis and secondary maxillomandibular deformity. We have treated four patients with monolateral ankylosis of the TMJ and serious deformities of the maxillomandibular complex secondary to functional limitation. During the same operation, arthroplasty was performed with the removal of the ankylotic block and the interposition of a temporal muscle flap in the new articular space; an intraoral osteodistractor was also positioned to lengthen the mandible. All patients showed recovery of the eurhythmy of the face and good re-establishment of the symmetry. An average 12-month follow-up showed the average opening of the mouth to be at least 35 mm. The combination of TMJ arthroplasty and intraoral osteodistraction provides good functional and aesthetic results in patients affected by ankylosis who have developed secondary maxillofacial deformities.     

游离腓骨肌筋膜瓣修复肿瘤切除后颌骨和口腔黏膜缺损

目的 ：腓骨肌皮瓣广泛用于口腔颌面部软、硬组织缺损修复,然而,其皮岛在口腔内常显得臃肿,特别是在牙槽区,不利于义齿修复。为寻找一种更适合的口腔衬里,本研究采用腓骨肌筋膜瓣代替传统的腓骨肌皮瓣,以避免后期牙列修复所面临的诸多问题。方法 ：2012年5月—2014年5月间,38例上、下颌骨肿瘤切除术后患者行腓骨肌筋膜瓣修复,33例患者行常规腓骨肌皮瓣修复。对患者年龄、颌骨缺损类型、筋膜（皮）瓣大小、去除臃肿皮瓣手术次数、供区和受区并发症以及牙列修复情况进行统计分析。结果 ：所有筋膜瓣全部存活并黏膜化。筋膜瓣组牙列修复患者无需行额外手术去除臃肿组织,84% (32/38)患者行活动义齿修复,其美观和咀嚼功能满意。而肌皮瓣组仅52%(17/33)患者行活动义齿修复,其中10例义齿修复前需行手术去除臃肿软组织。结论 ：腓骨肌筋膜瓣可提供一种理想的口腔衬里,避免了牙列修复前去除臃肿皮岛的手术;同时无毛发生长,患者口腔更舒适且有利于口腔自洁,并避免小腿植皮手术,减少供区并发症。     

Free grafting of traumatically displaced or resected mandibular condyles

A technique of free grafting of the mandibular condyle with a vertical ramus osteotomy is advocated in cases presenting with markedly displaced fracture dislocation of the condyle, in reconstruction of the TMJ after mandibular resection, and in providing access for vascular surgery approaches to the treatment of carotid aneurysms. The technique of free transplantation of the condyle did not result in any aseptic necrosis or any arthritic changes in 35 patients observed over a period of 3 to 15 years. All patients had excellent TMJ function.     

Temporomandibular joint reconstruction with medial femoral condyle osseocartilaginous flap: a case series

Reconstruction for large-scale temporomandibular joint (TMJ) defects can be challenging. We have used the medial femoral condyle (MFC) osseocartilaginous flap for repair of TMJ defects. The aim of this paper was to describe our technique and to present the preliminary results. The MFC osseocartilaginous flap was used as a free vascularized graft for TMJ defect in four patients who had undergone resection for benign tumor of the TMJ region (n = 2) or TMJ ankylosis (n = 2). A computer-assisted technique was used in all cases. Symmetry of the mandible was objectively evaluated by postoperative computed tomography. Complications were recorded during follow-up visits. Lower extremity functional status was assessed by the Lower Extremity Functional Scale (LEFC) questionnaire. The MFC osseocartilaginous flap success rate was 100%; bony union was obtained in all four patients, and normal occlusion was achieved within 6–11 months after surgery. No flap-related complications occurred. All patients were satisfied with their postoperative facial symmetry and oral function. The LEFC score ranged from 72 to 80, indicating normal lower extremity function. Vascularized MFC osseocartilaginous flap appears to be a reliable option for reconstruction of large-scale TMJ defects.