联合运用牵张成骨及颏成形术矫治颞下颌关节强直继发小下颌畸形伴OSAHS

目的:探讨联合运用牵张成骨及颏成形术配合正畸治疗矫治颞下颌关节强直继发小下颌畸形伴阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的可行性.方法:9例双侧关节强直继发小下颌畸形伴OSAHS患者,一期通过关节成形术解除关节强直,完成正畸治疗后,二期运用牵张成骨及颏成形术矫治小下颌畸形伴OSAHS,随访8～36月,评价其治疗效果.结果:患者平均张口度由术前3.1mm提高到术后36.5 mm,小下颌畸形得到有效治疗,OSAHS得到同期治愈.结论:联合运用牵张成骨及颏成形术并配合正畸治疗,是矫治关节强直继发小下颌畸形伴OSAHS的有效治疗方案.     

罕见右侧颞下颌关节骨性强直伴同侧颌面部广泛异位骨化1例及文献复习

目的:回顾分析颞下颌关节骨性强直伴颌面部异位骨化的发病原因、临床表现及诊治方法。方法:回顾性分析2017-04就诊于遵义医科大学附属口腔医院的1例右侧颞下颌关节骨性强直伴颌面部广泛异位骨化的病例资料,并结合文献复习分析其发病原因,总结其特征临床表现、诊断及治疗原则。结果:根据临床表现及影像学检查结果,该患者被确诊为右颞下颌关节骨性强直伴颌面部异位骨化,无明确外伤史。采用“右关节成形术+牵张成骨+异位骨化部分切除术”治疗,术后张口度恢复正常,面型稍有改善。出院时主动张口约2.0 cm,被动张口可达3.0 cm。嘱患者使用开口器积极张口训练并同期进行下颌骨牵张成骨,但患者配合度较差。患者于术后4个月再次出现进行性张口受限,颌面部异位骨化增多;于术后5个月取出牵张器,同时行关节强直松解术,术中可被动张口2.5 cm;但术后再次出现进行性张口受限,颌面部异位骨化继续增多,患者放弃治疗。结论:颞下颌关节骨性强直伴颌面部广泛异位骨化在临床上较为罕见,可能的病因有外伤、遗传等。依据影像学检查可明确诊断,治疗以手术为主。如何在行关节成形的同时治疗颌面部的广泛异位骨化是临床上的难题。     

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。     

同期关节重建及下颌体牵张成骨治疗颞下颌关节强直3例报道

目的:对伴有严重牙颌面畸形的颞下颌关节强直患者,采用自体肋骨软骨移植重建关节,同期运用牵张成骨术行下颌骨牵张成骨延长下颌体长度,治疗下颌后缩和阻塞性睡眠呼吸暂停低通气综合征(OSAHS),评价治疗计划的可行性及短期效果。方法:3例颞下颌关节强直患者,平均年龄17.5岁,发生关节强直的平均年龄为3.6岁,病程平均为13.9a,开口度均为0,均伴有严重牙颌面畸形和OSAHS。根据头影测量结果,预先设计患侧下颌支下降的长度和下颌体延长长度;采用关节成形术加双侧冠突切除,术中取模制备板,进行同期自体肋骨软骨移植重建颞下颌关节和双侧下颌体牵张成骨术。术后第7天开始牵引,每天2次,牵引速率为0.8mm/d。结果:3例患者均顺利完成手术,术后未出现感染等严重并发症。顺利完成牵张成骨。下颌骨牵引长度平均为22.5mm(20.5～25mm)。术后3个月开口度平均为28mm(26～32mm),患者面形及OSAHS获得良好改善。结论:肋骨软骨移植关节重建同期进行下颌体牵张成骨具有良好的稳定性,该设计有利于缩短治疗周期和治疗费用,在短期内可同时解决开口、面形和OSAHS等问题,为后续矫正咬合关系奠定了基础。     

牵引成骨术治疗儿童单侧颞下颌关节强直伴OSAHS 4例报道

目的:评价牵引成骨术治疗儿童单侧颞下颌关节强直伴阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的治疗效果。方法:4例儿童单侧颞下颌关节强直伴发OSAHS患者,男女各2例,年龄5～13岁(中位年龄6.5岁)。均采用颞下颌关节成形术以恢复开口功能,下颌体牵引成骨术治疗OSAHS;其中3例行同期手术,1例行分期手术;单侧和双侧下颌体牵引各2例。固定期约3个月时行呼吸监护仪监测(PSG)复查和牵引器拆除术。结果:4例患儿OSAHS症状均消失,平均AHI由术前的42.7降到4.9,平均最低血氧饱和度由术前的74.3%上升到89.8%;平均开口度由6.5mm增加至25.5mm;面部畸形得到满意矫正。经过平均38.1个月(13～58个月)的随访,无1例复发。结论:下颌骨牵引成骨术联合颞下颌关节成形术能够有效地治疗儿童单侧颞下颌关节强直及其伴发的OSAHS、面部不对称畸形,并且可以同期手术。     

颞下颌关节强直继发颌面畸形的外科矫治

为矫治颞下颌关节强直继发的颌面畸形，应用颞下关节成形术与正颌外科技术，对２２例该类患者（双侧关节强直９例，单侧关节强直１３例）进行了矫治。１３例患者关节成形术与正颌外科手术同期进行，９例患者分期进行，均达到满意的功能与畸形矫治效果。结论：颞下颌关节及继发颌面畸形的矫治，关键在于保证患者的开口功能，并在此基础上矫治继发畸形。同时对颞下颌关节强直伴有阻塞性睡眠呼吸暂停综合征的情况应予以高度重视。     

牵张成骨术治疗颞下颌关节强直后睡眠呼吸暂停综合征

目的 评估牵张成骨术(DO)治疗颞颌关节强直后睡眠呼吸暂停综合征(OSAS)的效果。方法 对8例患有颞颌关节强直后OSAS的患者采用DO技术进行治疗。手术在全麻下分两期进行。第一期行关节成形、下颌体部截骨,安置牵引器,前徙下颌矫正小颌畸形及OSAS;第二期在拆除第一期牵引器的同时,进行下颌升支后缘L型截骨,安置牵引器,通过牵引延长下颌升支。结果 8例患有颞颌关节强直后OSAS的患者的症状均有不同程度的改善。术后张口度可迭3cm～4cm,小颌畸形得以矫治,AHI指数由术前的20～40降至5以下,最低血氧饱和度由术前的68％提高至术后的96％,OSAS得以治愈。术后半年～两年随访,未见复发。结论 DO技术是治疗颞颌关节强直后OSAS理想方法。     

骨牵引技术治疗TMJ强直小下颌畸形伴阻塞性睡眠呼吸暂停低通气综合征

目的:探讨牵引成骨术(d istraction osteogenesis DO)在治疗小下颌畸形伴阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrom e,OSAHS)中的应用。方法:9例小下颌畸形伴OSAHS患者行下颌骨牵张成骨术,3个月后行颞下颌关节成形术,术前术后行头颅侧位测量和多导睡眠监测仪测试。结果:9例牵引完成后所有患者后气道间隙(posterior airway space,PAS)值扩大,睡眠呼吸暂停综合指数下降,血氧饱和度增加,OSAHS症状消失或减轻,面部畸形得到明显改善。结论:DO技术在矫治颞下颌关节强直导致的小下颌畸形伴OSAHS中具有重要的临床价值。     

关节盘复位在创伤性颞下颌关节强直治疗中的作用

目的　探讨创伤性颞下颌关节强直关节成形术中关节盘复位的手术方法及其临床效果。方法　 19例创伤性颞下颌关节强直患者接受关节成形术时进行了关节盘复位。术中在关节附近寻找分离出移位的关节盘并将其复位至髁突顶端的解剖位置 ,最后将关节盘的外侧端缝合固定至颧弓根部的软组织。结果　平均随访 2 3 7个月 ,患者的张口度为 2 4～ 4 3mm (平均为 32 6mm) ,所有的患者张口度均接近或达到正常 ,无关节疼痛及弹响症状 ,随访期内无一例患者复发。结论　在创伤性颞下颌关节强直的治疗中 ,关节盘复位可行有效 ,是重建关节结构、恢复关节功能和预防复发的好方法。     

牵张成骨在颞下颌关节强直及其继发畸形矫治中的应用

儿童时期发生的颞下颌关节强直可以导致不同程度的颌面部骨骼发育障碍,并引起自卑、社交障碍等一系列心理问题,其矫治是口腔颌面外科医生面临的一大挑战. 牵张成骨( distraction osteogenesis,DO)一直被国内外学者用于颞下颌关节(temporomandibular joint,TMJ)强直及其继发畸形的矫治,并取得了良好的临床效果.笔者所在科室每年大概收治50~60例TMJ强直患者,对DO技术在TMJ强直及其继发畸形矫治中的应用积累了较为丰富的临床经验. 本文中,笔者对DO技术在TMJ强直及其继发畸形矫治中的优缺点及相关问题进行述评.     

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.     

Two-stage treatment of TMJ ankylosis by early surgical approach and distraction osteogenesis

Temporomandibular joint (TMJ) ankylosis is characterized by the formation of bone or fibrous adhesion of the anatomic joint components, which replaces the normal articulation and limitation of mouth opening. Early surgical intervention is considered as a treatment procedure to release the joint ankylosis and to maintain the function of the joint. Longstanding temporomandibular joint ankylosis which starts during the active growth period in early childhood resulting in facial asymmetry. Thus, the importance of the evaluation for the facial asymmetries and unfavorable remodeling of the mandible has to be considered during the initial treatment planning. Further operations, either osteotomies or distraction osteogenesis, are required for the treatment of maxillofacial deformities. The present study reports a case of unilateral TMJ ankylosis treated by interpositional arthroplasty prior to distraction osteogenesis for the treatment of mandibular secondary deformity. Various treatment procedures and timing protocols are reviewed and discussed.     

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.     

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颞下颌关节强直继发畸形临床表现复杂多样,是口腔颌面整复外科领域内颇具挑战的一类疾病。近年来,运用多种矫治方法来恢复关节功能,改善容貌缺陷,矫正咬合紊乱以期获得形态与功能俱佳的治疗效果是诊治此类严重畸形的终极目标。目前,临床上综合运用关节成形术、正颌外科与正畸联合、牵张成骨、轮廓整形外科、骨或骨替代材料移植等技术来矫治此类继发畸形,获得了较为满意的治疗效果。     

The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children.

INTRODUCTION: Temporo-mandibular joint ankylosis is a common cause of acquired deformity in children. PURPOSE: Surgical correction of the ankylosis only leaves the patient with an uncorrected mandibular deformity. This study was to evaluate the use of distraction osteogenesis for simultaneous correction of the mandibular deformity. MATERIAL: This study was done on six children with temporo-mandibular joint ankylosis and mandibular deformity. Uniaxial double pin distractors with Schanz pins were used in this study. METHODS: The patients underwent simultaneous gap arthroplasty and mandibular osteotomy (retromolar) with distractor insertion. Distraction was started on the fifth post-operative day. The patients were put on dynamic temporo-mandibular joint exercises on the first post-operative day. RESULTS: All patients had a satisfactory mouth opening on follow-up. Satisfactory cosmetic correction of the mandibular deformity was also achieved in all these patients. Some degree of malocclusion resulted from treatment due to which the patients were placed on orthodontic treatment.CONCLUSIONS: Distraction osteogenesis can be used simultaneously with gap arthroplasty in patients with temporo-mandibular ankylosis, for the correction of the mandibular deformity.     

Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction osteogenesis technique

Transport distraction technique is a good treatment modality for unilateral temporomandibular joint ankylosis. However, with a unidirectional distraction, it is not possible to correct facial asymmetry that results from mandibular hypoplasia associated with early-onset unilateral temporomandibular joint ankylosis. For this purpose, gap arthroplasty and simultaneous bidirectional transport distraction was used to correct these deformities. Although vertical distraction corrects vertical deficiency of the ramus and creates a neocondyle, the simultaneous anteroposterior distraction of the transport segment corrects facial asymmetry resulting from horizontal shortness of mandible. Three patients, whose mean mouth opening was 8.6 mm, were successfully treated with this technique. Mean advancements in vertical and anteroposterior direction were 14.7 and 7.7 mm, respectively. Mean maximal mouth opening was 29.7 mm postoperatively. The average follow-up period was 13 months (range, 12-15 mo). During this period, reankylosis was not observed, and the interincisal distance did not decrease. Gap arthroplasty and bidirectional transport distraction of the mandibular ramus is a good and effective therapeutic option in treatment.