牵张成骨序列治疗颞下颌关节强直及继发畸形

目的:回顾我院应用牵张成骨序列治疗颞下颌关节强直及继发颌面部畸形的效果.方法:40例关节强直患者,平均年龄24.5岁(9～53岁),其中单侧强直11例,双侧29例,伴发OSAHS者27例.所有患者一期手术牵张成骨,二期手术拆除牵张器并同期行颞下颌关节成形术,同期或三期行正颌手术改善面部外形.通过术前术后最大张口度、面型及打鼾症状改善情况评估治疗效果.结果:关节成形术后40例患者张口度基本恢复正常,面型均得到显著改善,打鼾症状全部消失.经过4～72个月(平均20.5个月)的随访,4例患者关节强直复发.结论:应用一期牵张成骨二期关节成形治疗颞下颌关节强直及继发畸形能够精确控制面型和气道的改变.     

Gap arthroplasty combined with distraction osteogenesis in the treatment of unilateral ankylosis of the temporomandibular joint and micrognathia

Our aim was to evaluate the efficacy of simultaneous gap arthroplasty and distraction osteogenesis (DO) in the treatment of unilateral ankylosis of the temporomandibular joint (TMJ) in patients with micrognathia. During the period January 2000-December 2006, 11 patients with unilateral ankylosis of the TMJ and micrognathia were treated with simultaneous gap arthroplasty, mandibular osteotomy, and implantation of a distractor. Mouth opening exercises were started on the first postoperative day and distraction on the fifth postoperative day. All patients had satisfactory mouth opening at follow-up, the mean (range) being 32.4 (28-37) mm in 13 to 58 months' follow-up. Mean length (range) of the mandibular body increased by DO was 12.4 (7-15) mm. Facial asymmetry was corrected and satisfactory occlusions achieved with the help of postoperative orthodontic treatment. We conclude that DO and gap arthroplasty can be used simultaneously in the treatment of patients with ankylosis of the TMJ and micrognathia.     

人工颞下颌关节治疗关节强直的效果分析

目的 应用并评价Biomet标准型人工颞下颌关节假体治疗关节强直的效果。方法 回顾2013—2015年收治的颞下颌关节强直患者,采用计算机辅助设计和制作技术,设计并制作强直骨球切除和Biomet标准型人工颞下颌关节假体安放导板,术中应用下颌下切口取出的皮下游离脂肪移植于髁突假体周围,预防异位成骨。对于合并严重颌骨畸形的患者,采用人工关节假体延长前徙下颌支及Le Fort I型截骨术,数字化板辅助固定的方法同期矫正颌骨畸形。术后进行1年以上的临床和CT随访,评价开口度、咬合稳定性,以及假体周围有无异位成骨和假体与骨的结合情况。结果 11例患者15侧关节纳入研究,其中4例患者行下颌骨延长及颏后缩畸形纠正术。术后平均随访22.9个月（12~31个月）,无假体感染、断裂和松动。患者开口度显著改善（术前平均5.5 mm,术后31.5 mm,P<0.05）。4例患者气道显著增宽。CT显示假体固定螺钉周围无骨吸收,人工髁突头周围无异位成骨。结论 人工颞下颌关节假体是治疗关节强直,特别是复发性强直的可靠方法,可同时纠正颌骨畸形,效果稳定。     

Evaluating the remodeling of condyles reconstructed by transport distraction osteogenesis in the treatment of temporomandibular joint ankylosis

PurposeThis study aimed to evaluate the remodeling of condyles reconstructed by transport distraction osteogenesis (DO) in patients with temporomandibular joint (TMJ) ankylosis.Patients and methodsTwenty-one patients with 26 affected joints were followed up for 34.1 ± 13.3 months. Patients who had undergone gap arthroplasty and TMJ reconstruction by DO were included. Maximal mouth opening (MMO) and occlusion were recorded. Computed tomography images were obtained preoperatively (T0), upon completing distraction (T1), upon removal of the distraction device (T2), and >2 years postoperatively (T3). The following were measured: mandibular ramus height, distance between gonion and Frankfurt plane (Go–FN), condylar width, and condyle–ramus angulation.ResultsOf the 21 patients, one showed re-ankylosis, while five exhibited anterior open bite. From T1 to T3, the total amount of resorption of ramus height reached up to 8.2 ± 4.6 mm (p < 0.001), in comparison with a total distraction length of 13.8 ± 4.1 mm; the mean resorption rate was 59.4%. Similarly, Go–FN decreased by 6.2 ± 4.0 mm (p < 0.001).ConclusionOur findings indicated that DO combined with gap arthroplasty was an effective method for the treatment of TMJ ankylosis to improve MMO. The reconstructed condyle exhibited a high frequency of resorption in height.     

创伤性颞下颌关节外强直10例临床分析

总结分析10例创伤性颞下颌关节外强直患者的临床特点,如创伤及关节外强直类型、伴发颌面部骨折情况、病理、治疗方法及效果,为临床医师在诊断治疗上提供参考。     

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。     

创伤性颞下颌关节强直的分类和治疗-84例临床资料分析

目的:探讨创伤性颞下颌关节强直以冠状CT为基础的分类和治疗方法。方法:选择2001—2009年上海交通大学口腔颌面外科关节组收治的创伤所致颞下颌关节强直84例(124侧)患者作为研究对象,所有患者术前、术后均进行CT扫描,关节区冠状重建,据此提出创伤性关节强直的4型分类,即A1～A4型。根据分类进行相应的治疗。A1型,纤维组织松解或髁突切除+肋骨移植+颞肌筋膜瓣修复;A2和A3型,切除外侧融合骨球,保留内侧髁突和关节盘+颞肌瓣或咬肌瓣外侧间隙填塞(外侧成形术),如果内侧髁突残余较小不能负重,骨球切除后用肋骨移植+颞肌瓣或咬肌瓣修复;A4型,切除全部骨球,肋骨移植关节置换+颞肌瓣或咬肌瓣修复。对治疗结果进行CT和临床随访评价。结果:84例124侧创伤性关节强直中,A1型14侧,占11.3%;A2型43侧,占34.7%;A3型46侧,占37.1%;A4型21侧,占16.9%。其中部分A1型,全部A2和A3型有内侧移位的髁突残余,占75%(93/124)。根据分类采用的治疗方式包括外侧成形术82侧,占66.1%;肋骨移植重建33侧,占26.6%;其他9侧,占7.3%。48例68侧关节强直术后随访10个月～4a,占57%。其中,48侧行外侧成形术的关节中有7侧复发,占14.6%;17侧行肋骨移植的关节中有4侧复发,占23.5%。结论:基于冠状CT的关节强直新分类对于临床治疗有重要指导意义。外侧成形术+颞肌瓣修复是治疗A2和部分A3型关节强直(内侧有足够承重的髁突和关节盘残余)的理想方法,肋骨移植+颞肌瓣修复治疗完全骨性强直效果良好。     

Differential regulation of blood vessel formation between traumatic temporomandibular joint fibrous ankylosis and bony ankylosis in a sheep model

ObjectivesClinical and experimental studies show that the etiology of traumatic temporomandibular joint (TMJ) fibrous ankylosis and bony ankylosis are associated with the severity of trauma. However, how the injury severity affects the tissue differentiation is not clear. We tested the hypothesis that angiogenesis affects the outcomes of TMJ trauma, and that enhanced neovascularization after severe TMJ trauma would promote the development of bony ankylosis.MethodsBilateral condylar sagittal fracture and discectomy were performed for each sheep, with the glenoid fossa receiving either severe trauma to induce bony ankylosis or minor trauma to induce fibrous ankylosis. At days 7, 14, 28, and 56 after surgery, total RNA was extracted from the ankylosed callus. Temporal gene expressions of several molecules functionally important for blood vessel formation were studied by real-time PCR.ResultsHistological examination revealed a prolonged hematoma phase and a lack of cartilage formation in fibrous ankylosis. mRNA expression levels of HIF-1α, VEGF, VEGFR2, SDF1, Ang1, Tie2, vWF, CYR61, FGF2, TIMP1, MMP2, and MMP9 were distinctly lower in fibrous ankylosis compared with bony ankylosis at several time points.ConclusionsOur study indicates that inhibition of angiogenesis after TMJ trauma might be a promising strategy for preventing bony ankylosis in the future.     

Longitudinal changes in electromyographic activity of masseter and anterior temporalis muscles before and after alloplastic total joint replacement in patients with temporomandibular ankylosis: a prospective study

The purpose of the study was to evaluate the longitudinal changes in electromyographic (EMG) activity of the masseter and temporalis muscles before and after temporomandibular joint (TMJ) total joint replacement (TJR) in ankylosis patients. A prospective longitudinal study was designed on patients undergoing unilateral or bilateral TMJ-TJR. EMG activity at rest and maximal voluntary contraction (MVC) was recorded for the muscles preoperatively (T0), and at one-week (T1) and six-month (T2) follow up. The study sample was composed of 10 (male: female 2.3:1) patients undergoing TMJ-TJR. The number of unilateral and bilateral cases was three and seven, respectively. In both unilateral and bilateral cases a statistically significant reduction in EMG activity of the masseter and anterior temporalis muscles was observed at T1. At T2, EMG activity of the muscles was found to be approaching the preoperative value. In unilateral cases, when the affected side at T0, T1, and T2 was compared with T0 for the unaffected side, statistically significant differences were seen for the masseter. In the case of the temporalis, similar results were seen except at T2 for the postural rest position. The results indicate that re-attachment of the masseter and temporalis muscles occurs progressively post TMJ-TJR.     

Hydroxyapatite/collagen block with platelet rich plasma in temporomandibular joint ankylosis: a pilot study in children and adolescents

The aim of this study was to evaluate the feasibility of using preshaped hydroxyapatite/collagen condyles as carriers for platelet-rich plasma after gap arthroplasty in patients with temporomandibular ankylosis, to assess the aesthetic and functional outcomes, and to find out if neocondylar regeneration was possible. We studied 19 patients with temporomandibular joint ankylosis (25 joints), in whom preshaped hydroxyapatite/collagen condyles with platelet-rich plasma were fixed to the ramus with a titanium miniplate, and temporal fascia was placed in between. We evaluated the type of ankylosis, mouth opening before and after operation, deviation on mouth opening, lateral excursion, protrusion, postoperative anterior open bite, radiographic assessment, and complications. All patients showed appreciable improvements in mouth opening and excursion of the jaw. There were a few complications such as mild fever, and temporary involvement of the facial nerve, which improved with time. No open bite or recurrence was reported during the 18 months’ follow up. Radiographic evaluation at 3 months showed a less opaque condyle, but the opacity at 18 months was more defined, suggesting a newly formed condyle. A preshaped hydroxyapatite/collagen condyle with platelet-rich plasma improves both aesthetics and function. However, a long term study is required to follow the growth patterns to see if the patients develop any facial deformity as they grow.     

Changes in pain and mouth opening at 1 year following temporomandibular joint replacement—a prospective study

We describe the outcome of 46 patients 12 months after partial or total replacement of the temporomandibular joint (TMJ) using the Christensen implant system (TMJ Implants Inc, Golden, CO, USA). The study group comprised 35 women and 11 men; the women were slightly older than the men at the time of operation. We studied three diagnostic groups in detail: patients who had ankylosis, internal derangement, and osteoarthritis. Those with ankylosis were slightly older than the others. Pain decreased over time in all three groups. There was a significant reduction between preoperative pain and that recorded 1 month postoperatively. After this point the pain decreased slowly, and by year 1 it had decreased significantly with respect to preoperative scores. Women reported worse preoperative pain than men, but not significantly so.     

肋骨移植治疗生长期患者单侧颞下颌关节强直合并颌骨畸形效果评价

目的 评价肋骨移植治疗生长期患者单侧颞下颌关节强直合并颌骨畸形的效果。方法 对2010年1月—2014年12月采用肋骨移植同期治疗单侧颞下颌关节强直合并颌骨畸形的生长期患者进行CT影像学分析,采用ProPlan CMF 1.4软件对术前、术后1周和随访1年以上的下颌支高度、肋骨长度和颏点偏斜程度进行测量和比较。采用SPSS 17.0软件包对数据进行配对t检验。结果 6例患者纳入研究,年龄3~7岁,平均5岁。肋骨术后平均延长下颌支高度6.2 mm,颏点偏斜平均矫正5.3 mm;术后平均随访2.7 a,肋骨平均生长6.9 mm,健侧下颌支平均生长4.4 mm,患侧4.3 mm（P>0.05）。结论 肋骨移植可以同期治疗颞下颌关节强直及合并的颌骨畸形,具有生长潜能,但是长期效果有待于进一步观察。     

The sequential treatment of temporomandibular joint ankylosis with secondary deformities by distraction osteogenesis and arthroplasty or TMJ reconstruction

The purpose of this study was to evaluate the sequential treatment of patients with temporomandibular joint (TMJ) ankylosis and secondary deformities by distraction osteogenesis and subsequent arthroplasty or TMJ reconstruction. This study included 40 patients treated at a stomatological hospital in China; they ranged in age from 9 to 53 years (mean age 24.5 years). Ten of these patients were diagnosed with unilateral TMJ ankylosis and 30 with bilateral TMJ ankylosis. Twenty-seven patients also presented obstructive sleep apnoea–hypopnoea syndrome (OSAHS). All patients underwent distraction osteogenesis as the initial surgery, followed by arthroplasty or TMJ reconstruction. Some patients underwent orthognathic surgery to improve occlusion and face shape along with or after arthroplasty or TMJ reconstruction. The therapeutic effects were evaluated in terms of the improvements in maximum inter-incisal opening (MIO), appearance, and respiratory function. After the completion of treatment, all patients showed improvements in MIO and appearance, and the symptom of snoring disappeared. The airway space was significantly increased. Patient follow-up ranged from 6 to 85 months (mean 28.3 months), and four patients experienced relapse. This study suggests that treating TMJ ankylosis with secondary deformities by distraction osteogenesis as the initial surgery and arthroplasty or TMJ reconstruction as the second-stage treatment may achieve favourable outcomes, especially for patients with OSAHS; however, some patients may require orthognathic surgery.     

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.     

颞颌关节强直续发OSAS软组织关影测量特征

该研究对12例成年男性颞颌关节强直续发阻塞性睡眠呼吸暂停综合征（OSAS）患者和18名成年男性正常人作对照的头影进行测量分析研究，结果发现：颞颌关节强直续发OSAS患者头影软组织测量特征是（1）最小矢状咽径（posteriorairwayspace；PAS）减小（P〈0．001）；（2）舌和软腭占口咽腔矢状面积比显著地增加P＜0．001）。指出：上述两项参数对诊断和治疗均有重要意义。     

颞肌筋膜瓣联合冠突移植治疗颞下颌关节强直

目的:应用带蒂颞肌筋膜瓣联合冠突移植治疗颞下颌关节真性强直,评价其重建颞下颌关节的效果。方法:对6例颞下颌关节真性强直患者切除病变区骨质,形成骨间隙,采用带蒂颞肌筋膜瓣转移充填骨间隙和冠突切取植入构造新的“髁突”,重建颞下颌关节。手术后常规随访,评价其疗效。结果:全部病例术后随访4～28个月,开口度3.1～3.8cm,平均开口度3.5cm,效果满意。结论:带蒂颞肌筋膜瓣联合冠突移植治疗颞下颌关节真性强直具有多方面优势,是防止颞下颌关节术后复发的有效手术治疗方法。     

小儿颞下颌关节强直手术的麻醉处理

目的: 探讨小儿颞下颌关节强直手术的麻醉和困难气道管理。方法: 回顾性分析43例小儿颞下颌关节强直开口受限,困难气道病例资料,在保留自主呼吸的情况下,分为氯胺酮组（K1组）和氯胺酮复合右美托咪定组（K2组）。K1组和K2组均静脉给予氯胺酮1~2 mg/kg,K2组则追加静注右美托咪定1 μg/kg。患者意识消失后,辅以气管内和咽喉区表面麻醉。采用纤维支气管镜经鼻腔气管插管。插管过程中,根据患者反应小剂量滴定氯胺酮,维持麻醉深度。采用GraphPad Prism 6.0软件对数据进行统计学分析。结果: 所有患儿均在纤维支气管镜下经鼻腔成功气管插管。插管过程中,氧饱和度<95%发生率K2组略低于K1组,差异无统计学意义（P>0.05）。插管过程中追加氯胺酮次数和氯胺酮总剂量K2组显著低于K1组（P<0.05）,插管时心率变化和插管用时K2组显著低于K1组（P<0.05）。结论: 氯胺酮麻醉辅以良好的气管内和咽喉区表面麻醉,可完成小儿颞下颌关节强直开口受限的困难气道纤维支气管镜插管,氯胺酮复合右美托咪定可使小儿困难气道的插管过程更短、更平稳。     

Management of recurrent ankylosis in arthrogryposis: new solutions to a rare problem

Arthrogryposis is a rare condition that comprises contracture of the joints, muscular weakness, and fibrosis. Restricted mouth opening caused by coronoid hyperplasia has been reported but to our knowledge, ankylosis of the temporomandibular joint (TMJ) has not. Standard management of ankylosis includes creation of a gap arthroplasty and possible reconstruction with autogenous or alloplastic materials. We describe management of a patient with arthrogryposis who developed ankylosis for a second time after satisfactory gap arthroplasty and total replacement of the TMJ with a custom-made prosthesis. The original prosthesis was removed, the ankylosis resected, and the prosthesis replaced. This has given an excellent outcome at 12 months.     

数字化耠板在儿童颞下颌关节强直合并颌骨畸形同期治疗中的应用：附2例报告

目的：探讨数字化验板在儿童颞下颌关节强直合并颌骨畸形同期治疗中的应用效果。方法：2例儿童单侧颞下颌关节强直合并颌骨畸形患者,术前采用SurgiCaseCMF5．0软件进行颌骨畸形的三维测量．模拟骨球截除后摆正下颌骨,制作数字化袷板,术中应用,行肋骨一软骨移植关节重建。术后进行CT扫描二三维测量,评价应用效果。结果：2例患者术中袷板戴入顺利,术后CT三维测量与术前设计吻合度高。结论：数字化袷板在儿童颞下颌关节强直合并颌骨畸形的同期治疗中节省了手术时间,提高了手术的准确性,具有较好的临床应用前景。     

Distraction osteogenesis for management of obstructive sleep apnoea in temporomandibular joint ankylosis patients before the release of joint

AimTo evaluate the effects of distraction osteogenesis in management of obstructive sleep apnoea patients secondary to temporomandibular joints ankylosis.MethodsFifteen patients were included in study. Preoperatively the patients were worked up for polysomnography and CT scans. Only those patients with Apnoea–hypopnoea index >15 events/h denoting moderate to severe obstructive sleep apnoea were included in the study. Distraction osteogenesis was followed with 5 days latency period in adult patients and 0 days for children. Rate of distraction was 1 mm/day for adults and 2 mm/day for children till the mandibular incisors were in reverse overjet. After 3 months post distraction assessment was done using polysomnography and CT scan.TMJ ankylosis was released by doing gap arthroplasty after distraction osteogenesis.ResultsPost distraction improvement was seen in clinical features of OSA like daytime sleepiness and snoring. Epworth sleepiness scale improved from a mean of 10.25 to 2.25. Polysomnographic analysis also showed improvement in all cases with apnoea–hypopnoea index from 57.03 to 6.67 per hour. Lowest oxygen saturation improved from 64.47% to 81.20% and average minimum oxygen saturation improved from 92.17% to 98.19%. Body mass index improved from a mean of 18.26 to 21.39 kg/m².ConclusionDistraction osteogenesis is a stable and beneficial treatment option for temporomandibular joint ankylosis patients with obstructive sleep apnoea.