颏成形术联合颞下颌关节盘复位锚固术对颞下颌关节内紊乱伴下颌偏缩畸形的治疗作用分析

doi:10.3877/cma.j.issn.1674-1366.2021.04.006

目的

探讨关节盘移位复位锚固术同期数字化颏成形术对成人颞下颌关节盘不可复性盘前移位（ADDwoR）伴下颌偏缩（MR/D）患者的治疗效果。

方法

2016—2019年于深圳大学附属深圳市口腔医院颌面外科就诊的成人ADDwoR伴MR/D患者35例，全部患者术前经磁共振成像（MRI）及计算机体层摄影术（CT）确诊，由同一医生行颞下颌关节盘前移位切开松解复位锚固术+数字化设计指导下颏成形术，术后1年复诊，将患者手术前后关节症状（疼痛、开口度、弹响）数据、面相及影像学检查资料进行对比分析，术后临床医生、患者和第三方对患者面形改善满意度进行打分。

结果

35例ADDwoR伴MR/D患者中20例为双侧、15例为单侧，共55侧关节。其中男4例、女31例；年龄18~33岁，平均24.08岁。（1）术前关节疼痛VAS评分2~9分，平均（5.7 ± 3.3）分，术后1年复诊关节区疼痛VAS评分0~3分，平均（1.2 ± 1.8）分，差异有统计学意义（t = 3.482，P<0.001）；术前开口度为16~33 mm，平均开口度（25.1 ± 7.8）mm，术后开口度为33~40 mm，平均开口度（36.4 ± 3.5）mm，差异有统计学意义（t = -3.14，P = 0.002）；术前34例（97.14%）患者均有关节区弹响病史，术后有1例（2.86%）仍然存在关节弹响；所有患者术前均经MRI检查确诊为颞下颌关节盘不可复性前移位，术后1年复查MRI，均显示关节盘复位稳定无复发，其中有14例患者髁突骨质表面新骨形成双轮廓表现，占40.00%。（2）术后临床医生对患者面形平均满意度92.23%，患者满意度93.94%，第三方满意度93.94%，平均满意度93.37%。

结论

对ADDwoR伴MR/D患者在行关节手术同期数字化设计指导下颏成形，复位关节盘改善关节症状同时改善面形，减少手术次数，术后效果稳定，安全可靠，术后三方满意度高，值得临床推广。

关键词: 颞下颌关节紊乱, 颏成形术, 下颌后缩, 下颌偏斜畸形, 不可复性关节盘前移位

Objective

Anterior Disc Displacement without Reduction (ADDwoR) in adolescence can result in condylar resorption which produces mandibular retrusion/deviation (MR/D) in adulthood. This study aims to analyze the therapeutic effect of simultaneous genioplasty and temporomandibular joint (TMJ) anchorage surgery on ADDwoR with MR/D patients.

Methods

During 2016-2019, 35 ADDwoR with MR/D cases were included and underwent TMJ anchorage surgery and genioplasty guided by digital design. Pre-/post-surgical clinical manifestations, facial photography, radiographic data, facial shape satisfaction of clinicians/patients/third-party were recorded and analyzed.

Results

A total of 35 cases (55 joints) were included, in which 20 cases were bilateral and 15 cases were unilateral. The average age was 24.08, ranged from 18 to 33 years old. Ratio of male/female was 4/31. (1) Visual analog pain scale (VAS) score pre-/post-surgical ranged from 2 to 9 and 0 to 3, with an average of (5.7 ± 3.3) and (1.2 ± 1.8) (t = 3.482, P<0.001) . Maximal mouth opening pre-/post-surgical ranged from 16 to 33 mm and 33 to 40 mm, with an average of (25.1 ± 7.8) mm and (36.4 ± 3.5) mm (t = -3.14, P = 0.002) . Before operation, 34 patients had a history of joint sound, accounting for 97.14%. After operation, one patient still had joint sound, accounting for 2.86%. MRI was completed and showed stable disc reduction without recurrence one year postoperatively. Among them, 14 patients (40.00%) showed double contour of new bone on condylar surface. (2) MR/D was corrected and a better face shape was obtained. The satisfaction rate of clinicians, patients and third-parties was 92.23%, 93.94% and 93.94%, with an average of 93.37%.

Conclusions

For ADDwoR with MR/D patients, simultaneous TMJ anchorage surgery and genioplasty can improve TMJ symptoms/functions, correct facial appearance, and enhance the degree of satisfaction. The postoperative effect is stable, safe and reliable, which is worthy of clinical promotion.

Key words: Temporomandibular joint disorders, Genioplasty, Retrognathia, Mandibular deviation, Disc displacement without reduction

图1 典型病例术前、术后正面及仰面照　A：术前患者正面照，右侧髁突吸收导致颏部右偏不对称畸形；B：术后1年患者正面照，显示颏部不对称畸形已纠正，面部对称；C：术前患者仰面照，显示右侧下颌升支较短导致右侧下颌角上移；D：术后1年患者仰面照，显示双侧下颌角高度一致

图2 典型病例术前、术后磁共振成像（MRI）图像资料　A：术前MRI显示颞下颌关节盘不可复性前移位；B：术后MRI显示颞下颌关节盘已稳定复位；箭头示关节盘

图3 典型病例术前、术后全颌曲面断层片图像资料　A：术前全颌曲面断层片显示右侧髁突吸收影像；B：术后全颌曲面断层片显示右侧髁突骨质修复影像；图中红色圆圈示髁突

图4 数字化设计导板引导下颏成型术

图5 右侧颞下颌关节盘复位锚固术　黄色箭头示已复位的关节盘；白色箭头示锚固钉

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Outcomes of treatment with genioplasty and temporomandibular joint anchorage surgery in temporomandibular joint internal derangement with mandibular deviation/retraction

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Outcomes of treatment with genioplasty and temporomandibular joint anchorage surgery in temporomandibular joint internal derangement with mandibular deviation/retraction