正颌外科与颞下颌关节的研究进展

正颌外科的迅速发展，带来了许多正颌手术与颞下颌关节关系的问题。正颌外科手术对颞下颌关节有何影响？对已有关节症状的患者正颌手术有无作用？颞下颌关节的改变与手术效果有何关系？有关这方面的研究很多，现就近年来的文献对正颌外科与颞下颌关节的关系作一综述。１?..     

正颌手术对颞下颌关节影响的研究进展

正颌术术后的复发往往与颞下颌关节（TMJ）结构和位置异常有关,包括髁突移位、进行性髁突吸收和关节盘移位等。正颌外科作为一种创伤性的手术,对TMJ的结构和位置能产生一定的影响。由于牙颌面畸形患者往往术前即有TMJ的疾病,因此正颌手术本身对TMJ的影响是否导致了复发和产生颞下颌关节紊乱病（TMD）需要多项研究探索。有一些学者提出,正领手术同期行关节盘复位术可提高手术效果稳定性。对预防由于TMJ结构和位置异常引起的复发或TMD,目前临床尚无特定方法。鉴于此,本文将在正颌外科对TMJ结构的影响,与TMD的关系,以及预防术后复发和TMD的方法等三个方面进行综述。     

正颌外科治疗后颞下颌关节改变的X线研究

目的 了解正颌外科手术后颞下颌关节（ｔｅｍｐｏｒｏｍａｎｄｉｂｕｌａｒ ｊｏｉｎｔ,ＴＭＪ）形态的改变,探讨手术方式不同对ＴＭＪ的影响。方法 正颌手术患者５７例,术前、术后１周、１年分别拍摄定位许勒位片用于观察髁突位置及关节形态的变化。结果 ①正颌手术可导致髁突移位,但大多数关节适应后并不发生病变,术后１年髁突位置已调整到术前相似的位置。②手术方式不同髁突位置的变化也不尽相同。③８６．４％的患者关节无明显变化或发生了适应性改建;１３．６％患者关节发生了退行性改变。结论 正颌手术可对ＴＭＪ产生影响,但大部分处于关节的正常适应范围内。     

正颌手术与颞下颌关节的关系研究进展

正颌手术改变颌骨间的位置关系后，将不可避免地影响到具有精细解剖结构的颞下颌关节。为明确二者间的关系，本文就正颌手术与颞下颌关节紊乱综合征、正颌手术引起的关节结构的改变以及坚固内固定和牵张成骨术对于关节的影响等问题的研究进展作一系统回顾。     

偏颌畸形及其正颌手术对颞下颌关节的影响

<正>偏颌畸形(facialasymmetricdeformity)是颌骨畸形中比较常见的类型,包括先天性及发育性偏颌畸形,可分为偏侧小颌畸形及偏侧突颌畸形两类,多见于下颌骨,表现为面部左右不对称,上下中切牙的中线不一致,颏部及下颌中线偏向一侧,可有反或锁[1]。研究发现,偏颌畸形与颞下颌关节紊乱(temporomandibulardisorders,TMD)关系密切。TMD是颞下颌关节、咀嚼肌及周围相关结构表现的不同症状及体征的一个总称,临床表现主要包括关节区疼痛、关节杂音及功能障碍,伴或不伴有下颌骨运动受限、颞下颌关节(temporomandibularjoint,TMJ)及相关肌肉触痛等[2]。偏颌畸形严重影响患者的容貌、咀嚼和发音功能,随着正颌手术的顺利开展,正颌-正畸联合治疗不仅可以使偏颌患者恢复面容的正常和美观,而且可以使牙、、颌的形态和功能达到协调、美观和稳定,但正颌手术对其颞下颌关节的影响还在研究之中。     

单侧颞下颌关节强直伴上颌骨发育障碍的正颌外科治疗

作者就8例单侧颞颌关节强直伴同侧上颌骨发育障碍的病员。在颞颌关节成形术的同期(或分期)行上颌骨Lefort Ⅰ型截骨手术。在恢复病员张口度同时，通过正颌治疗。使变位的上下颌骨处于正常解剖位置。再行正畸治疗。达到病员咀嚼、呼吸功能与外貌最佳状态。作者就该类病变的正颌外科方法的选择、适应证及手术中应注意的问题进行了讨论。     

正颌手术前、后颞下颌关节间隙三维重建及对比分析

目的: 采用新的方法重建正颌患者手术前、后的颞下颌关节间隙,比较术前、术后关节间隙的变化,为正颌术后颞下颌关节功能评价提供参考。方法: 收集20例骨性Ⅲ类正颌患者手术前及术后半年的CT影像资料,利用Mimics软件三维重建手术前、后颞下颌关节间隙,进行容积计算。采用SPSS 22.0软件包对数据进行统计学分析。结果: 术后双侧关节间隙有不同程度增大,右侧关节及双侧关节间隙的增大有统计学意义（P<0.05）。通过线性回归分析,正颌手术前、后双侧关节间隙容积呈明显正相关（手术前r=0.54,P=0.014;手术后r=0.59,P=0.006）。手术前、后性别间无统计学差异。结论: 利用Mimics软件重建正颌手术前、后颞下颌关节三维结构,可更直观地显示关节间隙容积与三维结构的变化,为关节间隙的研究提供了一种新的方法。通过比较正颌手术前、后颞下颌关节间隙容积,发现术后6个月髁突未恢复到术前位置。     

正颌外科治疗颞下颌关节强直伴阻塞性睡眠呼吸暂停综合征

目的 评价正颌外科手术治疗颞下颌关节强直伴阻塞性睡眠呼吸暂停综合征(OSAS)的效果。方法 12例颞下颌关节强直伴OSAS患者(男4例，女8例，年龄10～25岁，平均18．4岁；双侧颞下颌关节强直8例，单侧颞下颌关节强直4例)，采用颞下颌关节成形术、下颌矢状劈开前徙术、颏前徙成形术、舌骨悬吊术以及牵张成骨术移动下颌骨和舌骨。术后随访3～36个月。结果 12例患者张口度由术前的0～2mm增大到术后25～40mm；术后患者颜面形态明显改善；其连续血氧饱和度最低值由术前的42％提高至术后的90％以上，睡眠呼吸障碍解除和睡眠质量获得提高。结论 在颞下颌关节强直伴OSAS患者的治疗中，行颞下颌关节成形术的同时，辅助正颌外科手术，不仅可以增大患者的张口度，而且还能解决患者下颌后缩的畸形，同时解除上气道狭窄，从而缓解或纠正患者的低氧血症。     

正颌外科与颞下颌关节

牙颌面畸形是一种严重影响患者的咬合功能及颜面外形,并造成其精神创伤及心理异常的口腔常见多发病。据资料统计,约４０％的人群患者有错畸形,其中约５％属于颌骨发育异常所致,需要采取外科—正畸联合矫治的方法进行治疗。近１０年来正颌外科获得飞速发展,已经成为...     

The effect of orthognathic surgery on temporomandibular disorder

This study aimed to evaluate the difference in prevalence of temporomandibular disorder (TMD) before and after orthognathic surgery (OGS), particularly in patients with mandibular asymmetry.A prospective cohort study of patients undergoing corrective orthognathic surgery was conducted. Pre-operative and post-operative (3 months, 6 months and 1 year) TMD assessment were performed according to the Diagnostic Criteria for TMD (DC/TMD) protocol.64 patients were included in the study. Overall, there was a significant reduction of 26.5% in TMD prevalence from 60.9% pre-operatively to 34.4% 1-year post-operatively (p = 0.003). In all, 37.5% of patients had their TMD condition treated, 50% had no change in their symptoms while 12.5% experienced a worsening of their symptoms. No significant difference in terms of change in TMJ status was observed among the different ramus procedures, the type and magnitude of mandibular movement, skeletal class, and presence of mandibular asymmetry.In conclusion, it appears that corrective orthognathic surgery for dentofacial deformities might provide a secondary benefit of treating TMD. However, surgeons have to be aware that a small percentage of patients might experience a deterioration of their TMD condition, and that those who were previously asymptomatic may develop TMD symptoms after surgery.     

正颌外科技术治疗颞颌关节强直后睡眠呼吸暂停综合征(附9例报告)

目的：评估用正颌外科技术矫治９例颞颌关节强直所致睡眠呼吸暂停综合征的效果。方法：采用患侧关节成形,下颌升支、体部的“Ｌ”型半层截骨及健侧矢状截骨术,将患侧下颌升支加高固定,下颌前部整体前移。结果：９例颞颌关节强直后睡眠呼吸暂停综合征患者术后张口度达２．５～３．５ｃｍ,连续血氧饱和度最低值由术前的５８％提高至术后的９５％以上,唾眠呼吸暂停综合征得以治愈。结论：颞颌关节强直后睡眠呼吸暂停综合征患者通过正颌外科手术可以在关节成形的同时,解决患者下颌后缩的缺陷,解除上气道狭窄,从而缓解或纠正患者的低氧血症。     

下颌骨矢状劈开后退术对颞下颌关节的影响

目的:评价下颌骨矢状劈开后退术对颞下颌关节(TMJ)的影响.方法:研究我院50 例术前有颞下颌关节病(TMD),且行下颌骨矢状劈开后退术的患者,从关节压痛、弹响、张口度、张口型等方面量化评估术前、术后颞下颌关节症状变化情况.结果:从关节压痛、弹响、张口度、张口型等各方面评估均显示术后颞下颌关节症状评分均显著低于术前(P<0.05).结论:对于术前有颞下颌关节病的患者,行下颌骨矢状劈开后退术可以有效改善颞下颌关节症状.     

Effect of bimaxillary orthognathic surgery on dysfunction of the temporomandibular joint: a retrospective study of 500 consecutive cases

We investigated the effect of bimaxillary orthognathic surgery on symptoms in the temporomandibular joint (TMJ) and predictive factors for postoperative dysfunction. A total of 500 patients with different craniofacial deformities who were having bimaxillary orthognathic surgery were assessed for overjet, overbite, maximal mouth opening, maximal protrusion, maximal lateral movement to both sides, and symptoms of TMJ dysfunction (pain on palpation, clicking, or crepitus) before operation and one year postoperatively. The panoramic radiographs taken on the same dates were assessed for reduction in the height of the ramus. Other variables were age, sex, segmentation of the maxilla, and additional genioplasty. Changes in the symptoms of dysfunction were investigated with the McNemar test. Measurements of the maximum mandibular movements taken preoperatively and postoperatively were compared using the paired t test. Multivariate logistic regression was used to assess the influence of the variables on symptoms preoperatively and postoperatively. The effect of occlusal stability (overjet and overbite) on postoperative symptoms in the TMJ was investigated with the unpaired t test. Women and class II patients had significantly more pain on palpation preoperatively, and a significant reduction in pain on palpation and clicking after operation. Predictive factors were preoperative crepitus for postoperative pain, and preoperative clicking for postoperative clicking. Patients with and without symptoms showed no significant differences in overjet and overbite postoperatively. Condylar resorption was found in 29 patients (5.8 %), and only 14 of them had symptoms in the TMJ. In patients with no preoperative symptoms or radiological abnormalities of the condyle, condylar resorption was rare (0.8 %). Orthognathic surgery has a beneficial effect on dysfunction of the TMJ as it reduces pain and clicking considerably. Patients should be informed, however, that TMJ disorders could still develop even if they had no symptoms preoperatively.     

Evaluation of condylar resorption rates after orthognathic surgery in class II and III dentofacial deformities: A systematic review

The purpose of this study was to perform a systematic review of morphological alterations in the condyles after orthographic surgery involving a sagittal split ramus osteotomy (SSRO), with or without surgery on the maxilla. Searches were performed on three databases and registered in the PROSPERO. The selected studies fulfilled the criteria established by the following PICO model: (1) population: individuals with skeletal dentofacial deformities (class II or III facial patterns), without asymmetry; (2) intervention: orthognathic surgery for mandibular setback using an SSRO, with or without a Le Fort I osteotomy, and fixed with bicortical screws or plates and screws; (3) comparison: orthognathic surgery for mandibular advancement using an SSRO, with or without a Le Fort I osteotomy, and fixed with plates and screws or bicortical screws; and (4) outcome: condylar resorption rate and relapse. Initially, 1,371 articles were identified and 636 articles were screened after elimination of duplicates, and 6 articles were selected for qualitative analysis based on the inclusion and exclusion criteria. Five studies had data regarding the rate of condylar resorption, varying from 0.0% to 4.2%. In conclusion, condylar resorption and relapses were present in a small percentage of patients studied.     

国际颞下颌关节外科发展史

随着人类的进化,颌骨的形态不断发生变化,颞下颌关节的问题一直伴随人类左右。作为口腔颌面外科的常见病和多发病,颞下颌关节疾病是口腔颌面外科的重要内容之一。从早期的文字记载开始,颞下颌关节外科经历了漫长的发展历程。如今,颞下颌关节外科取得的长足进步,离不开无数前人的尝试和努力。本文总结梳理了国际上颞下颌关节外科的发展历程,追溯其中具有里程碑意义的事件,以为广大读者提供参考。     

数字化导板在标准型人工颞下颌关节置换术中的应用

目的 设计并制作数字化导板（digital template）,指导标准型人工颞下颌关节置换术中的骨修整和假体定位并评价其应用效果。方法 选择2013年11月—2014年3月间收治的人工关节置换病例6例,术前将Biomet标准型人工关节假体激光扫描后导入ProPlan CMF 1.4软件,模拟假体摆放位置并据此确定骨修整范围,设计、制作多块数字化导板,分别用于术中指示骨修整范围、方向及深度,并定位假体安放位置。术后进行CT扫描,评价假体植入准确性及其与术前设计的吻合情况。结果 导板术中就位顺利,与骨面贴合,引导截骨及骨修整准确,未伤及颅底及下牙槽神经血管束等重要解剖结构。术后CT拟合结果显示,假体植入位置与术前设计的平均误差为（1.139±0.183）mm。结论 数字化导板可以准确指导标准型人工颞下颌关节置换术中的骨修整和假体定位,有利于确保假体植入的稳定性,避免了颅底及下牙槽神经血管束的损伤。     

颌间弹性牵引技术在颞下颌关节外科中的应用

颌间弹性牵引是一种常用的调整及重建咬合关系的方法,利用颌间交互支抗的原理,通过持续的弹性牵引力来建立良好稳定的(牙合)关系。颞下颌关节与(牙合)之间存在密切联系,关节局部结构的改变可能造成咬合关系的改变,这种(牙合)关系的矫正,可以考虑采用颌间弹性牵引技术。本文就颌间弹性牵引技术的原理、与颞下颌关节的关系,及其在颞下颌关节外科中的应用进行综述。