颞下颌关节三维动态磁共振成像研究及生物力学分析

目的通过在多层面二维动态MR成像上获取颞下颌关节组织的运动数据,构建颞下颌关节的三维动态模型,并进行初步生物力学分析。方法 MRI检查采用GE Signa 1.5T TwinSpeed超导型磁共振扫描仪。选取2例无症状男性志愿者行颞下颌关节MRI检查,将图像数据导入Mimics软件,构建颞下颌关节的三维模型,动态分析张口幅度和关节盘横径的量化关系。结果建立的颞下颌关节三维动态模型清晰显示三维动态盘髁关系及关节盘在动态过程中的形态变化;志愿者1张口/关节盘横径拟合直线为:y=-0.03x+14.44,相关系数R2=0.591,志愿者2相关拟合直线为:y=-0.061x+13.48,相关系数R2=0.306,志愿者张口位置与关节盘横径变化具有直线趋势,关节盘横径随着张口幅度的加大而呈现减小的趋势,颞下颌关节盘对于髁突的包绕程度与张口幅度呈反比。颞下颌关节盘纵径厚度在张口活动中后带外份及中带内份的变化幅度最大。结论通过颞下颌关节二维动态MR成像数据可构建三维动态模型立体动态地观察颞下颌关节运动,可直观、准确显示颞下颌关节盘髁关系,可作为颞下颌关节二维静态MR成像的有益补充,弥补常规MRI检查的局限。     

青少年颞下颌关节骨关节病患者髁突在关节窝内间隙变化与骨质破坏位置的相关性

背景：国内外对于青少年颞下颌关节骨关节病患者的相关研究甚少,以往采用传统X射线平片检查方法,近年来通过口腔锥形束CT手段获取图像资料分析优势显著,不仅可以了解髁突影像学变化特征,而且可为青少年颞下颌关节骨关节病患者在临床诊断及治疗中提供参考。目的：对青少年颞下颌关节骨关节病患者进行锥形束CT测量分析,评价在影像学成像方面的异常形态及影响因素。方法：选择80例颞下颌关节骨关节病的青少年（试验组）和80例无症状青少年（对照组）,均于牙尖交错位进行锥形束CT扫描,使用Invivo 5.2软件对两组患者进行颞下颌关节三维重建影像测量研究：（1）矢状位测量：包括颞下颌关节上间隙、前间隙、后间隙;（2）轴位测量：包括颞下颌关节髁突前后径、内外径;（3）三维立体成像：下颌升支的高度;（4）试验组颞下颌关节骨关节病各病理改变类型的百分比。结果与结论（1）据统计试验组中男27例,女53例,男、女比例约为1∶2;（2）组内比较：试验组双侧颞下颌关节关节上间隙、后间隙差异有显著性意义（P <0.05）;对照组双侧颞下颌关节的关节测量值相比差异均无显著性意义（P> 0.05）;（3）组间比较：试验...     

改良切口锚固术在颞下颌关节盘不可复性前移位中的近期疗效

目的 探究改良切口锚固术在颞下颌关节盘不可复性前移位（ADDWoR）中的近期疗效。方法 选取本院收治的80例ADDWoR患者为研究对象,均行改良切口锚固术。术后随访3个月,根据MRI影像学表现评估关节盘复位效果,并于术前、术后1个月、术后3个月记录患者最大张口度（MMO）、右侧偏动距离（RLE）、左侧偏动距离（LLE）、下颌前伸距离（PE）等下颌运动功能指标,颞下颌关节紊乱指数（CMI）及疼痛视觉模拟量表（VAS）评分,并统计患者术后的满意度。结果 80例患者中,45例患者复位效果为优,31例为良,优良率为95.00%。术前、术后1个月、术后3个月患者MMO、PE、RLE、LLE逐渐升高（P<0.05）,VAS评分、CMI逐渐降低（P<0.05）。80例患者中,45例患者为非常满意,33例患者为基本满意,总满意度为97.50%。结论 改良切口锚固术治疗ADDWoR可有效减轻患者术后疼痛,改善下颌运动功能,提高满意度,近期疗效较好。     

正畸减数患者后牙前移对颞下颌关节应力影响的三维有限元分析

背景：颞下颌关节紊乱病与颞下颌关节内有高应力密切相关。减数拔牙后伴随着磨牙位置的改变,建立新的咬合关系往往会导致颞下颌关节内应力环境发生改变。目的：在牙尖交错位时,利用三维有限元模型分析正畸减数拔牙后不同程度磨牙前移下颞下颌关节的应力分布。方法：选择在山东青岛市市立医院口腔正畸科就诊的正常牙合患者1例,收集其锥形束CT和MRI数据,分别建立减数前、减数后上下磨牙前移1/3拔牙间隙(拔除4颗第二前磨牙)及减数后上下磨牙前移2/3拔牙间隙(拔除4颗第二前磨牙)的有限元模型,通过建模软件分析牙尖交错位时颞下颌关节各部位的应力分布。结果与结论：(1)减数前后模型中髁突、关节盘、骨关节窝的受力分布基本一致,髁突的应力主要分布于髁突的前部及顶部,关节盘的应力主要分布于关节盘的中带及外侧,颞骨关节窝的应力主要集中分布在关节窝的前部及顶部。与减数前相比,减数后模型中髁突、关节盘及关节窝的等效应力值减小;正畸减数拔牙后,上下磨牙前移1/3拔牙间隙模型中髁突及关节盘的等效应力值小于上下磨牙前移2/3拔牙间隙模型。(2)从生物力学角度上讲,正畸减数拔牙可以降低颞下颌关节的应力,进而提供良好的生物力学环境。     

无症状颞下颌关节盘前移位个体的动态磁共振及髁突运动轨迹特点

目的 颞下颌关节盘早期的前移位临床上可无弹响症状,了解无症状颞下颌关节盘的早期移位个体的髁突运动中心轨迹特点,将有助于早期发现隐匿性颞下颌关节结构内紊乱疾病。 方法 动态磁共振(Cine-MRI) 和ARCUSdigma系统检查30例无症状个体开闭口过程中髁状突-关节盘运动特点和下颌运动范围。 结果 Cine-MRI显示30例无症状人群中,20例健康颞下颌关节、10例单侧可复性关节盘前移位,闭口位关节盘本体部仍呈双凹形、盘后区均有轻度增厚和前移位,盘-突关系在小开口（<2 cm）期恢复正常;无症状可复性关节盘的运动中心轨迹出现弹跳切迹和偏摆,光滑性、重复性及双侧运动中心轨迹的对称性不及健康人,但是切点运动轨迹平滑,与健康人的切点运动轨迹基本一致;运动轴在髁突轨迹弹跳时出现偏斜,然后保持平行,呈现开闭口初、末时密度比开闭口中时大;髁突运动中心运动距离（13.6±3.7）mm,下颌切点运动距离（40.5±3.4）mm。 结论 髁突运动轨迹能间接反映髁突-关节盘复合体在开闭口运动中的位置变化,为下一步临床使用下颌运动轨迹仪作为早期关节盘移位的诊断提供一定的理论参考。     

血清CRP在小儿支原体肺炎诊治中的价值

目的 探讨血清CRP在小儿支原体肺炎诊治中的应用价值。方法 选择2017年1月~2018年12月我院收治的200例肺炎患儿作为观察组,根据疾病严重程度进一步分为轻症组和重症组,各100例,同期纳入健康体检儿童100例作为对照组,比较三组血清CRP水平,分析血清CRP与疾病严重程度的关系。结果 观察组血清CRP为（22.96±1.86）mg/L,高于对照组的（2.19±0.42）mg/L,差异有统计学意义（P＜0.05）;治疗后,轻症组与重症组血清CRP均低于治疗前,差异有统计学意义（P＜0.05）;重症组血清CRP水平为（9.03±1.12）mg/L,高于轻症组的（5.02±0.47）mg/L,但差异无统计学意义（P＞0.05）。结论 支原体肺炎患儿在接受治疗过程中进行检测血清CRP对评估病情严重程度有一定的意义,可用于指导临床制定治疗措施。     

正常及关节盘移位后颞下颌关节滑膜OPG/OPGL的表达及意义

目的： 观察正常及关节盘移位后颞下颌关节滑膜内护骨素OPG及其配体OPGL的表达及意义。方法： 32只日本大耳白兔，25只建立颞下颌关节盘前移位的动物模型，术后1、2、4、8、12周处死，5只行模拟手术作为假手术对照，另2只不行手术作为空白对照。取颞下颌关节标本，HE染色观察镜下结构， S-P免疫组化法检测滑膜中OPG和OPGL的表达与分布。结果： 各实验组动物术后体重无减轻，伤口愈合良好，大体及显微镜下观察关节盘明显前移位。对照组OPG主要表达于滑膜下层血管内皮细胞及部分滑膜衬里细胞，滑膜内 OPGL无表达或鲜有表达。关节盘移位后，仅1、2周各1个样本滑膜下层少量OPGL表达，其它样本未见明显OPGL阳性细胞；OPG表达强度无减弱。结论： 正常颞下颌关节滑膜内OPG表达明显强于OPGL，对正常状态骨软骨代谢平衡的维持有重要意义；关节盘移位后OPG和OPGL无明显变化，保证了关节盘移位后骨软骨代谢能维持平衡。     

轻症和重症甲型 H1 N1流感患者免疫学特征比较分析

目的对比分析轻症和重症甲型H1 N1流感患者的细胞免疫学特征,为该病的病情监测和治疗提供科学依据。方法收集2009年7月1日至2009年12月31日于宁波市第二医院及宁海县第一医院就诊并确诊为甲型H1N1流感的204名患者作为病例组,其中轻症组52例,重症组152例,选取同时期的26名健康志愿者作为对照组;采用流式细胞仪检测各组外周血淋巴细胞亚群,采用ELISA方法检测各组血清干扰素-γ（IFN-γ）及白细胞介素-4（IL-4）水平。结果 H1N1流感患者重症组外周血淋巴细胞计数降低显著,与健康对照组及轻症组患者比较差异均有统计学意义（P＜0．01）;重症组T淋巴细胞、NK细胞、CD4＋T及CD8＋T淋巴细胞计数、百分比均较轻症组显著降低（ P＜0．01）,B淋巴细胞及CD4＋T/CD8＋T比值虽然较轻症组降低,但差异无统计学意义（P＝0．11,0．175）;轻症组和重症组血清IFN-γ水平均较健康对照组降低,但是重症组降低更为显著（与健康对照组和轻症组比较,P＜0．01）;同样,轻症组和重症组血清IL-4水平均较健康对照组降低,但各组间比较统计学差异均无显著性意义（P＞0．05）。结论甲型H1N1流感患者免疫功能的异常与病情轻重有一定关系,尤其是细胞免疫功能,监测患者的免疫功能变化,对于判断患者的病情有较好的参考价值。     

可视化融合成像技术诊治腰关节突关节综合征的疗效分析*

目的探讨可视化融合成像技术诊治腰关节突关节综合征的临床效果。方法临床纳入2017年6月至2020年5月于深圳市龙岗中心医院住院和门诊收治的80例腰关节突关节综合征患者作为研究对象,按随机数字表法分为两组,各40例。其中40例患者采用可视化融合成像技术引导下诊断及介入治疗者作为研究组,仅采用X线透视引导下诊断及介入治疗者作为对照组。观察两组患者治疗前后疼痛情况,分析两组患者诊疗效果及不良反应情况。结果研究组治疗后1周、3个月、6个月、12个月的VAS评分明显低于对照组,两组比较差异有统计学意义(P<0.05);在不同治疗时期疼痛缓解方面,对照组患者总有效率明显低于研究组,差异有统计学意义(P<0.05);在术区血肿形成、术区疼痛、消化道症状及下肢疼痛等不良反应方面,对照组不良事件发生率为25%,研究组为7.5%,两组比较差异有统计学意义(P<0.05)。结论可视化融合成像技术诊治腰关节突关节综合征的临床效果明显、持久及安全性高,值得临床应用推广。     

小儿肺炎患者治疗前后心肌酶学指标的检测分析

目的:观察小儿肺炎患者心肌酶水平变化并分析其临床意义。方法:选择2009年8月～2011年8月住院治疗的小儿肺炎患者112例,其中重症组32例,轻症组80例,对照组为体检正常小儿68例。采用全自动生化分析仪检测各肺炎组治疗前后及对照组天冬氨酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、肌酸激酶(CK)及其同工酶(CK-MB)活性水平,并进行组间比较。结果:与对照组相比,轻症组及重症组治疗前AST、LDH、CK、CK-MB水平均明显升高,其差异有统计学意义(P均<0.05),且重症组水平明显高于轻症组(P<0.05);治疗后,重症组及轻症组心肌酶水平均明显低于治疗前水平(P<0.05),且与对照组接近(P>0.05)。结论:小儿肺炎患者病情越重,心肌酶升高越明显,针对性治疗可使其恢复正常。     

An accurate simulation model of anteriorly displaced TMJ discs with and without reduction

Internal derangement of the temporomandibular joint (TMJ) is defined as an abnormal positional relationship of the disc relative to the mandibular condyle and the glenoid fossa. Among others, the anterior disc displacement is the most common disorder, however its origin and consequences are still unclear. Several finite element simulations of the TMJ have been developed, but none of them has reported dynamic simulations of the disc as a three-dimensional, fiber-reinforced biphasic material under finite deformations, during the opening movement of a pathologic joint affected of an anterior displacement of the disc with and without reduction, using a realistic geometry of the ligaments in the joint. The aim of the work presented here was to compare the stress distribution in the healthy joint and in two pathologic situations, one joint affected of an anterior disc displacement with reduction (ADDWR) and one without reduction (ADDWOR) during an opening movement of the mouth. It was found that, while in the healthy disc the highest compressive stresses were located in the intermediate zone, in the pathologic joints the maximum compressive stresses were located in the posterior band both in the ADDWOR case and in the ADDWR before the reduction. Moreover, although the final stress distribution in the ADDWR was similar to that in the healthy case, the collateral ligaments supported higher stresses, a fact that could lead to degeneration of these components and subsequently to the total anterior displacement of the disc. Finally, the results suggest that an anterior displacement of the disc would lead to higher compressive and tangential stresses in the posterior band of the disc than in the healthy one, and as a consequence, to possible perforations in that zone of the disc which would modify its geometry if no treatment is applied.     

Three-dimensional finite element analysis of human temporomandibular joint with and without disc displacement during jaw opening

The aim of this study was to evaluate the differences of stress distribution in the temporomandibular joint (TMJ) disc during jaw opening between the subjects with and without internal derangement of TMJ (TMJ-ID). Three symptom-free volunteers and three symptomatic patients with anterior disc displacement were selected as normal and TMJ-ID subjects, respectively. For each subject, magnetic resonance images (MRI) were taken in the axial, sagittal and coronal directions. Using MRI taken, six three-dimensional finite element models of TMJ were developed. For each subject, the condylar movements during jaw opening were recorded and used as the loading condition for stress analysis. By comparing the calculated disc displacement to the measured one from MRI, the frictional coefficients were mu = 0.001 for the normal subjects, but mu = 0.01-0.001 for the TMJ-ID subjects. For the normal subjects, relatively high stresses were found at the anterior and lateral portions of the disc throughout jaw opening. In the connective tissues, the stress level was higher in the TMJ-ID than in the normal subjects. It is suggested that the disc displacement induces the change of stress distribution in the disc and the increase of frictional coefficients between articular surfaces, resulting in the secondary tissue damage.     

Role of magnetic resonance imaging in the clinical diagnosis of the temporomandibular joint

Temporomandibular joint (TMJ) abnormalities cannot be reliably assessed by a clinical examination. Magnetic resonance imaging (MRI) may depict joint abnormalities not seen with any other imaging method and thus is the best method to make a diagnostic assessment of the TMJ status. In patients with temporomandibular joint disorder (TMD) referred for diagnostic imaging the predominant TMJ finding is internal derangement related to disc displacement. This finding is significantly more frequent than in asymptomatic volunteers, and occurs in up to 80% of patients consecutively referred for TMJ imaging. Moreover, certain types of disc displacement seem to occur almost exclusively in TMD patients, namely complete disc displacements that do not reduce on mouth opening. Other intra-articular abnormalities may additionally be associated with the disc displacement, predominantly joint effusion (which means more fluid than seen in any asymptomatic volunteer) and mandibular condyle marrow abnormalities (which are not seen in volunteers). These conditions seem to be closely related. Nearly 15% of TMD patients consecutively referred for TMJ MRI will have joint effusion, of whom about 30% will show bone marrow abnormalities. In a surgically selected material of joints with histologically documented bone marrow abnormalities nearly 40% showed joint effusion. Disc displacement is mostly bilateral, but joint effusion seems to be unilateral or with a lesser amount of fluid in the contralateral joint. Abnormal bone marrow is also mostly unilateral. Many patients have unilateral pain or more pain on one side. In a regression analysis the self-reported in-patient TMJ pain side difference was positively dependent on TMJ effusion and condyle marrow abnormalities, but negatively dependent on cortical bone abnormalities. Of the joints with effusion only one fourth showed osteoarthritis. Thus, there seems to be a subgroup of TMD patients showing more severe intra-articular pathology than disc displacement alone, and mostly without osteoarthritis. It should, however, be emphasized that patients with TMJ effusion and/or abnormal bone marrow in the mandibular condyle seem to constitute only a minor portion (less than one fourth) of consecutive TMD patients referred for diagnostic TMJ imaging. The majority of patients have internal derangement related to disc displacement, but without accompanying joint abnormalities. In patients with rheumatoid arthritis and other arthritides TMJ involvement may mimick the more common TMDs. Using MRI it is possible, in most cases, to distinguish these patients from those without synovial proliferation.     

关节盘移位对颞下颌关节内应力分布的影响

目的 通过对不同关节盘移位的数值模拟,探究各种移位情况下颞下颌关节（temporomandibular joint,TMJ）内各结构的应力分布规律。方法 依据CT图像,建立包含下颌骨、全牙列、关节盘和关节软骨的正常TMJ三维有限元模型;参考关节盘前、后、外、内移位的临床特征,建立对应的4个模型。关节盘与关节软骨间考虑接触,用缆索元模拟下颌韧带和关节盘附着,施加正中咬合荷载。结果 前移位将导致关节盘中带产生过高的压应力,达到3.23 MPa;后、内、外移位时关节盘的整体应力水平比前移位和正常TMJ高;各种移位都使关节结节后斜面的应力值大幅度增加,但对髁突关节面的影响却不大。结论 各种移位都将导致关节盘和关节结节后斜面产生过高的应力,且后、内、外移位更为危险,更容易造成关节结构和功能的损伤。     

不同牙 合 位时翼外肌对颞下颌关节盘的生物力学影响

目的　研究在牙尖交错位和最大张口位时可复性关节盘前移位中翼外肌对关节盘的生物力学影响及两牙合 位之间的差异。 方法　对已经建立的可复性关节盘前移位的颞下颌关节数字化仿真模型,在不同牙合 位时进行翼外肌加载,通过三维有限元的方法进行生物力学分析。 结果　最大张口位时,关节盘应力集中区较牙尖交错位时向前外侧移动,集中于关节盘中间带偏外侧区;关节盘中间带与关节盘后带之间存在明显位移差,形成位移撕裂带,而在牙尖交错位时则无类似位移差现象。 结论　在可复性关节盘前移位中,最大张口位时翼外肌可导致关节盘中间带偏外侧区的应力集中,在关节盘中间带形成位移撕裂带,导致此区域变薄、穿孔甚至撕裂。     

不同稳定咬合板厚度对可复性前移位患者颞下颌关节应力分布影响

目的 利用三维有限元方法比较双侧颞下颌关节(temporomandibular joint, TMJ)可复性前移位(anterior disc displacement with reduction, ADDwR)患者在佩戴两种不同厚度稳定性咬合板后紧咬时TMJ应力分布改变。方法 根据患者CT、MRI影像数据,依次构建ADDwR患者牙尖交错位(工况1)与戴3、5 mm稳定咬合板咬合(工况2、3)时共3个TMJ有限元模型。分别给予3种工况中的下颌骨施加最大肌力60 s,之后对各工况中关节窝和髁突软骨表面、关节盘表面及双板区的最大等效应力进行评估。结果 各工况左侧TMJ内各结构等效应力均大于右侧。戴3 mm咬合板后,双侧关节盘均未发生复位,关节盘应力仍旧集中在后带及双板区,双侧关节软骨表面应力显著增加;戴5 mm咬合板后,右侧关节盘复位,关节盘最大应力位于中间带,关节软骨和双板区等效应力降低约40%,左侧关节盘未复位,关节窝软骨和双板区等效应力下降约6%。结论 ADDwR患者佩戴不同厚度咬合板,TMJ内应力及其分布模式均发生改变;5 mm稳定性咬合板可以减小ADDwR患者关节窝软骨及双板区...     

上颌扩弓对颞下颌关节应力影响的有限元分析

目的 通过三维有限元法对比扩弓前和放置扩弓器时颞下颌关节(temporomandibular joint, TMJ)内部各组织应力分布情况。方法 根据1名上颌牙弓狭窄患者CBCT影像资料,构建扩弓前和包含扩弓器的TMJ三维有限元模型,对模型加载相同的肌力和边界约束,观察TMJ髁突、关节盘、关节窝的等效应力、最大主应力和最小主应力。结果 扩弓前TMJ等效应力主要分布在下颌支前缘、髁突前斜面、关节盘中间带和后带以及关节窝顶部。放置扩弓器时,TMJ应力分布特征与扩弓前基本一致,应力虽然明显增加,但应力分布区域更加均匀;髁突和关节盘应力向前、向外侧移动,髁突后斜面表现出更加均匀的最大主应力分布范围。结论 上颌扩弓器产生的矫形力能够使TMJ应力增加,诱导髁突发生组织改建,协调髁突和关节盘的关系。临床上对于牙弓狭窄的患者应该采用合适的手段进行扩弓矫治。     

Sensitivity and specificity of a new MRI method evaluating temporo-mandibular joint disc–condyle relationships: an in vivo study

The aim of this study was to evaluate sensitivity and specificity of a new method to locate temporo-mandibular joint (TMJ) disc using magnetic resonance imaging (MRI) and analyze disc–condyle relationships, in asymptomatic subjects and patients with disc displacement. Twenty-nine sagittal MRI of 16 subjects, 8 asymptomatic volunteers and 8 subjects with anterior disc displacement, were carried out during controlled opening from intercuspal position up to a 25 mm opening. Selected sections were analyzed with a graphic computerized system of coordinates. The total surface area (TS) of disc section was separated into anterior surface area (AS) and posterior surface area. Areas were determined by computer. Two trained examiners drew images at random. The reliability of AS/TS ratio index was evaluated in a previous study. AS/TS ratio sensitivity (Se) and specificity (Sp) were calculated closed mouth, 5 mm open and 25 mm open mouth. Best sensitivity (Se=0.63) and specificity (Sp=0.81) were obtained when MRI was realized with closed mouth and 25 mm open mouth. Lower sensitivity was observed when MRI was performed either with closed mouth (Se=0.54) or 25 mm open mouth (Se=0.18). Lower specificity was observed with 5 mm open mouth (Sp=0.68). In conclusion, it was confirmed as well that MRI of anterior disc displacement should be performed with closed mouth and opened mouth. Thus, further studies are required to assess disc displacement and mechanical alterations and to evaluate the risk of direct damage on TMJ tissues.     

MMP-13 (collagenase 3) localization in human temporomandibular joint discs with internal derangement

The normal articular disc of the human temporomandibular joint (TMJ) consists of regularly arranged collagen fibers and fibroblast-like cells. Disc tissue is subjected to various types of loading. Adaptive remodelling entails microscopic changes in which different types of collagen and non-collagen proteins, as well as matrix metalloproteinases (MMPs), are involved. Collagenase-3 (MMP-13) seems to play a key role. The aim of the study was to evaluate its involvement in TMJ disc histopathology. We studied 10 discs from patients with arthropathy of the TMJ. Paraffin wax-embedded sections were processed for histological and immunohistochemical analysis. A well-characterized mouse monoclonal anti-MMP-13 antibody (anti-collagenase 3) was used. The results showed increased MMP-13 immunoreactivity in TMJ diseased disc tissue was correlated with the severity of the histopathological changes. The more severe the pathological changes, the greater the number of immunolabelled cells detected. Nearly all chondrocyte-like cells were immunopositive, whereas fibroblast-like cells and fibrochondrocytes were more rarely labelled. MMP-13 upregulation in disc tissue from patients with TMJ internal derangement suggests that MMP-13 is involved in disc histopathology, and that disc cells actively participate in the synthesis of extracellular matrix-degrading proteinases.