创伤性颞下颌关节强直的机理研究
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摘要
颞下颌关节强直是一种严重影响患者开口受限、咬合错乱的疾病，当TMJ强直发生在儿童的话，还会影响到下颌骨的发育，致小下颌畸形、面前突、咬合关系错乱以及心理健康。临床上TMJ强直的治疗非常困难，尽管其治疗方法有许多，但治疗结果仍不理想，复发是其最常见的并发症，国内外报道其治疗的复发率在4%-31%之间。TMJ强直发生的机理仍不清楚，使其治疗更加困难。本研究对大量颞下颌关节强直病例的回顾性研究的基础上，找出颞下颌关节强直发生的临床特点，得出结论：颞下颌关节强直病因中，创伤为关节强直的主要致病因素，其次是感染；对创伤引起的颞下颌关节强直病例进一步统计研究发现，创伤性颞下颌关节强直中大多数又由髁突骨折引起，骨折类型以髁突矢状骨折为主。其他动物实验及临床观察也发现髁突矢状骨折（B型囊内骨折）较髁突其它类型骨折更易发生TMJ强直。但损伤性关节强直发生机理仍然不明。其中一种观点认为，关节损伤后造成囊内出血、机化继而发生强直。但我们对山羊下颌骨撞击，损伤其颞下颌关节的实验中发现，单纯的TMJ损伤，囊内出血并不会引起TMJ强直的发生。我们在总结前人并结合自己研究的基础上提出翼外肌牵张成骨是导致髁突矢状骨折易于发展成TMJ强直的重要原因。本研究利用绵羊为动物实验，造成标准的髁突矢状骨折后，随即分为两组，一组切断翼外肌阻断其功能，另一组保留翼外肌功能，比较两组髁突愈合过程中的形态变化，观察翼外肌是否对髁突矢状骨折愈合过程中对髁突形态有影响，为进一步研究创伤性颞下颌关节强直的机理打下基础，从而对创伤性颞下颌关节强直的预防提供理论依据。
实验一颞下颌关节强直临床病例回顾性研究
对第四军医大学口腔医学院1990年1月～2009年12月20年间收治的294例真性颞下颌关节强直病例进行回顾性研究,对每份病例资料的发生年龄、性别、诱因、强直类型进行详细统计分析。通过统计研究，初步确定了颞下颌关节强直的发生特点和影响因素，创伤为关节强直的主要致病因素，其次是感染；对创伤引起的颞下颌关节强直病例进一步统计研究发现，创伤性颞下颌关节强直中大多数又是由髁突失状骨折引起。为进一步对颞下颌关节强直机理的研究打下基础。
实验二翼外肌在髁突矢状骨折愈合过程对髁突形态的影响----动物模型的建立
将20只健康成年绵羊随机分为两组，人为手术造成髁突矢状骨折后，实验组保留翼外肌功能，对照组阻断翼外肌功能，术后行MRI检查，确定翼外肌是否离断，术后一周行双侧颞下颌关节（TMJ）螺旋CT扫描，三维重建和多平面重建，观察和测量髁突骨折块的最大移位距离。结果发现，术后一周，保留翼外肌组手术侧髁突骨折块向前、下、内移位明显，而阻断翼外肌功能组，髁突骨折块移位不明显，证实翼外肌对髁突内极有牵拉作用。结论此动物模型的建立为进一步对“翼外肌在髁突矢状骨折愈合过程对髁突形态改建的影响研究”提供平台。
实验三螺旋CT扫描多平面重建辅助测量髁突矢状骨折后髁突形态
将实验二已制备的两组实验动物（每组各10只），分别在4周、12周、24周行螺旋CT检查，多平面重建，在矫正平面上（即：左右髁突处于同一水平面上），对左右髁突各层面的最大前后径、最大内外径以及该平面髁突的面积进行测量，并根据面积计算髁突的体积，求手术侧与正常侧各数值的差，对两组各差值进行比较。结果发现，实验组即保留翼外肌功能组，左右髁突形态差异较阻断翼外肌功能组髁突形态差异大。初步确定，翼外肌对髁突矢状骨折愈合过程中对髁突的形态改建有影响。
实验四结合解剖及螺旋CT扫描三维重建判断翼外肌对髁突矢状骨折愈合过程中髁突形态改建的影响
对实验三制备的两组动物，其中实验组动物保留翼外肌功能（10只），对照组动物切断翼外肌（10只）。每组动物分别在术后4周（各2只）、12周（各4只）、24周（各4只）处死。处死后行CT检查，骨性CT值测量，CT三维重建观察髁突形态，并解剖TMJ以观察髁突形态。结果：实验组组较对照组髁突有更多新骨形成，髁突形态改变更严重。进一步证实翼外肌在髁突矢状骨折愈合过程中对髁突形态改建的影响起非常重要作用。
实验五Micro-CT测量髁突矢状骨折愈合过程中骨折区新生骨各参数
对实验四解剖出来的髁突，修整成一定形态后行Micro-CT检查，观察骨折区相对骨体积或骨体积分数（Bone Volume to Tissue Volume，BV/TV）；骨小梁厚度（Trabecular Thickness，Tb.Th）；骨小梁数量（Trabecular Number，Tb.N）；骨小梁分离度（Trabecular Separation，Tb.Sp），结果对两组动物手术侧髁突形态参数的比较发现，实验组骨折区Tb.N(/mm)、Tb.Th(mm)、BV/TV(%)均比对照组低，而Tb.Sp(mm)比对照组高，两组比较均有统计学意义。对照组的值更接近于正常侧。说明实验组骨折区有大量的新生不成熟骨形成。
结论：
通过对临床颞下颌关节强直病例的回顾性研究发现，颞下颌关节强直主要是由于髁突骨折引起，髁突矢状骨折是最主要的骨折类型。通过动物实验研究发现，对绵羊髁突手术造成矢状骨折后，保留翼外肌功能组，在骨折愈合工程中，髁突形态变化较明显，并引起更多的新骨形成。而切断翼外肌组，骨折愈合过程中，髁突形态变化相对较小，因此可以明确翼外肌在髁突矢状骨折愈合过程中对髁突形态改建有影响。为进一步对创伤性TMJ强直的机理研究打下了基础。
Temporomandibular joint (TMJ) ankylosis is a serious disease that limits themovements of mandible, leading to limitation of mouth opening and masticatorydifficulty. When TMJ ankylosis occurs in Childhood, it can retard mandibulardevelopment, and will lead to maxillofacial deformity such as facial asymmetry,micrognathia, bird face deformity, create malocclusion and aggravatepsychological disorders. It is very difficult to treat TMJ ankylosis in clinicalconditioin. Although various techniques have been described, the treatmentresults remain unsatisfied. Re-ankylosis is one of the most frequently seencomplications. The incidence of re-ankylosis vary from4%to31%. And themechanisms of TMJ ankylosis development is unclear, thus making the treatmentof TMJ ankylosis more difficult. Retrospective study of temporomandibular jointankylosis cases.We found trauma was the most common cause of TMJ ankylosis.And most of the post-traumatic TMJ ankylosis occurred in patients who hadsagital condyar fracture. Other animal experiments and clinical observations haveshown that the sagittal fracture (or type-B intracapsular fracture) of mandibularcondyle (SFMC) has more risk of developing ankylosis than other condylarfractures. The mechanisms of how traumatic TMJ ankylosis develops aftertrauma are still unclear. One hypothesis is that the genesis of traumatic TMJankylosis is the organization and ossification of an intracapsular hematoma following TMJ injury. However, our animal experiments showed thatintra-reticular hematoma alone is not a causative factor for TMJ ankylosis. Weconsider the distraction osteogenesis (DO) caused by the traction of the lateralpterygoid muscle leads to new bone overgrowth, and then plays an important rolein the genesis of traumatic TMJ ankylosis.We used sheep in our study, anoblique vertical osteotomy was made from the lateral pole of the condyle to themedial side of the condylar neck by ultrasound osteotome. The lateral pterygoidmuscles of ten sheep were cut in group2. The lateral pterygoid muscles of tensheep in the other group were not cut. The capsuls were not sutured, and thewound was closed layer by layer. The aim of this study was to determine whetherthe lateral pterygoid muscle will affect the condylar shape in the healing processof sagittal fracture of mandibular condyle (SFMC). This study will help us tofurther study the mechanisms of TMJ ankylosis development.
Experiment One was the retrospective study of TMJ ankylosis byclinical cases.294temporomandibular ankylosis cases managed by school ofStomatology, Fourth Military Medical University from1990to2009were used inthis retrospective study. Age, sex, aetiology, join(s) affected, types were evluated.Results: truma was the most common aetiology. The patient’s age range was0-66years. Most of the traumatic temporomandibular joint ankylosis were caused bycondylar fracture. And the Sagittal fracture of the mandibular condyle causingtemporomandibular joint ankylosis was the main type of condylar fracture. Theresults will help further study of temporomandibular joint ankylosis mechanisms.
Experiment Two was the created animal model the role of the lateralpterygoid muscle in the sagittal fracture of mandibular condyle (SFMC)healing process. Twenty adult healthy sheep were divided into two groups with10sheep in each group. An oblique vertical osteotomy was made from the lateralpole of the condyle to the medial side of the condylar neck by ultrasoundosteotome.The lateral pterygoid muscles of ten sheep were cut(we cut off0.5-1.0cm lateral pterygoid muscle off each sheep in this group) in group2. The lateral pterygoid muscle of ten sheep in the other group were not cut. Computedtomography(CT) were recorded before operation and1week after operation.Three-dimensional reconstruction and multiplanar reconstruction (MPR) CTimages were obtained to observe the displacement of the fragment. The fragmentdisplaced anteriorly, medially and inferiorly in the sheep of group1. However,the results was not found in the sheep of group2. This animal model can be usedto evaluate the role of the lateral pterygoid muscle in the sagittal fracture ofmandibular condyle (SFMC) healing process.
Experiment Three was that the shape of condyle were measured by CTscans. The sheep of two groups in experiment two were performed helical CT at4week,12week and24week after operation. The anteroposterior diameter,medial-lateral diameterand and area of the condylar were measured by CT scans.And the volume of the condylar were recived by area. All the sizes of theoperated condylar’s anteroposterior diameter, medial-lateral diameter, area andvolume were increased. But the size of the condylar in group1increasedremarkablely than that in group2. The results show the lateral pterygoid muscleaffected the condylar shape reconstructing during the sagittal fracture ofmandibular condyle (SFMC) healing process.
Experiment Four was used CT three-dimensional reconstruction andafter dissecting TMJ were evaluated the role of the lateral pterygoid musclein the sagittal fracture of mandibular condyle (SFMC) healing process. Thetwo groups of sheep in Experiment Three were killed at4week(2of eachgroup),12week (4of each group) and24week(4of each group) after operation.Computed tomography(CT) were recorded just after the sheep were killed. Themaximum anteroposterior diameter and medial-lateral diameter of the condylarwere measured by CT scans. The shape of the joints observed by CTthree-dimensional reconstruction and after dissecting. The result showed new bone formation occurred irregularly on the articular surfaces in both groups. Butthe joints in group1showed more severe than those in group2. So the lateralpterygoid muscle played a very important role in reconstructing the condylarshape during the sagittal fracture of mandibular condyle (SFMC) healing process.
Experiment Five was that we use Micro-CT measured the parametersof the new bone in the condylar sagittal fracture zone. We dissected the jointsand received the condyle. Micro-CT had been taken after the dissection. one thirdof medial-inside of the bilateral condylar was selective volume of interests.
We measured the centroid of the bilateral condylar of the sheep bymicro-CT and analysed the representative architectural parameters(BV/TV,TB.TH,TB.N,TB.SP) the selective volume of interests. The condylarsof the group in which the lateral peterygoid muscle had not been cut showedovergrowth of new bone.
In conclusion, retrospective study of TMJ ankylosis by clinical casesshowed truma was the commonest aetiology. Most of the traumatictemporomandibular joint ankylosis were caused by condylar fracture. And theSagittal fracture of the mandibular condyle was the main type of condylarfracture causing temporomandibular joint ankylosis. Twenty adult healthy sheepwere divided into two groups. Sagittal fracture of the mandibular condyle wasmade by ultrasound osteotome.The lateral pterygoid muscle were cut with tensheep in group2. The lateral pterygoid muscle of the sheep in the other groupwere not cut. Animal experiment study demonstrate there were more new bonesforming there were more new growing bones on the condyles of group1thanthose of group2. And the shape of condyles in group1were almost normal. Sothe lateral pterygoid muscle played a very important role in reconstructing thecondylar shape during the sagittal fracture of mandibular condyle (SFMC) healing process.The results will help us to further study the mechanisms oftemporomandibular joint ankylosis.
实验一颞下颌关节强直临床病例回顾性研究
对第四军医大学口腔医学院1990年1月～2009年12月20年间收治的294例真性颞下颌关节强直病例进行回顾性研究,对每份病例资料的发生年龄、性别、诱因、强直类型进行详细统计分析。通过统计研究，初步确定了颞下颌关节强直的发生特点和影响因素，创伤为关节强直的主要致病因素，其次是感染；对创伤引起的颞下颌关节强直病例进一步统计研究发现，创伤性颞下颌关节强直中大多数又是由髁突失状骨折引起。为进一步对颞下颌关节强直机理的研究打下基础。
实验二翼外肌在髁突矢状骨折愈合过程对髁突形态的影响----动物模型的建立
将20只健康成年绵羊随机分为两组，人为手术造成髁突矢状骨折后，实验组保留翼外肌功能，对照组阻断翼外肌功能，术后行MRI检查，确定翼外肌是否离断，术后一周行双侧颞下颌关节（TMJ）螺旋CT扫描，三维重建和多平面重建，观察和测量髁突骨折块的最大移位距离。结果发现，术后一周，保留翼外肌组手术侧髁突骨折块向前、下、内移位明显，而阻断翼外肌功能组，髁突骨折块移位不明显，证实翼外肌对髁突内极有牵拉作用。结论此动物模型的建立为进一步对“翼外肌在髁突矢状骨折愈合过程对髁突形态改建的影响研究”提供平台。
实验三螺旋CT扫描多平面重建辅助测量髁突矢状骨折后髁突形态
将实验二已制备的两组实验动物（每组各10只），分别在4周、12周、24周行螺旋CT检查，多平面重建，在矫正平面上（即：左右髁突处于同一水平面上），对左右髁突各层面的最大前后径、最大内外径以及该平面髁突的面积进行测量，并根据面积计算髁突的体积，求手术侧与正常侧各数值的差，对两组各差值进行比较。结果发现，实验组即保留翼外肌功能组，左右髁突形态差异较阻断翼外肌功能组髁突形态差异大。初步确定，翼外肌对髁突矢状骨折愈合过程中对髁突的形态改建有影响。
实验四结合解剖及螺旋CT扫描三维重建判断翼外肌对髁突矢状骨折愈合过程中髁突形态改建的影响
对实验三制备的两组动物，其中实验组动物保留翼外肌功能（10只），对照组动物切断翼外肌（10只）。每组动物分别在术后4周（各2只）、12周（各4只）、24周（各4只）处死。处死后行CT检查，骨性CT值测量，CT三维重建观察髁突形态，并解剖TMJ以观察髁突形态。结果：实验组组较对照组髁突有更多新骨形成，髁突形态改变更严重。进一步证实翼外肌在髁突矢状骨折愈合过程中对髁突形态改建的影响起非常重要作用。
实验五Micro-CT测量髁突矢状骨折愈合过程中骨折区新生骨各参数
对实验四解剖出来的髁突，修整成一定形态后行Micro-CT检查，观察骨折区相对骨体积或骨体积分数（Bone Volume to Tissue Volume，BV/TV）；骨小梁厚度（Trabecular Thickness，Tb.Th）；骨小梁数量（Trabecular Number，Tb.N）；骨小梁分离度（Trabecular Separation，Tb.Sp），结果对两组动物手术侧髁突形态参数的比较发现，实验组骨折区Tb.N(/mm)、Tb.Th(mm)、BV/TV(%)均比对照组低，而Tb.Sp(mm)比对照组高，两组比较均有统计学意义。对照组的值更接近于正常侧。说明实验组骨折区有大量的新生不成熟骨形成。
结论：
通过对临床颞下颌关节强直病例的回顾性研究发现，颞下颌关节强直主要是由于髁突骨折引起，髁突矢状骨折是最主要的骨折类型。通过动物实验研究发现，对绵羊髁突手术造成矢状骨折后，保留翼外肌功能组，在骨折愈合工程中，髁突形态变化较明显，并引起更多的新骨形成。而切断翼外肌组，骨折愈合过程中，髁突形态变化相对较小，因此可以明确翼外肌在髁突矢状骨折愈合过程中对髁突形态改建有影响。为进一步对创伤性TMJ强直的机理研究打下了基础。
Temporomandibular joint (TMJ) ankylosis is a serious disease that limits themovements of mandible, leading to limitation of mouth opening and masticatorydifficulty. When TMJ ankylosis occurs in Childhood, it can retard mandibulardevelopment, and will lead to maxillofacial deformity such as facial asymmetry,micrognathia, bird face deformity, create malocclusion and aggravatepsychological disorders. It is very difficult to treat TMJ ankylosis in clinicalconditioin. Although various techniques have been described, the treatmentresults remain unsatisfied. Re-ankylosis is one of the most frequently seencomplications. The incidence of re-ankylosis vary from4%to31%. And themechanisms of TMJ ankylosis development is unclear, thus making the treatmentof TMJ ankylosis more difficult. Retrospective study of temporomandibular jointankylosis cases.We found trauma was the most common cause of TMJ ankylosis.And most of the post-traumatic TMJ ankylosis occurred in patients who hadsagital condyar fracture. Other animal experiments and clinical observations haveshown that the sagittal fracture (or type-B intracapsular fracture) of mandibularcondyle (SFMC) has more risk of developing ankylosis than other condylarfractures. The mechanisms of how traumatic TMJ ankylosis develops aftertrauma are still unclear. One hypothesis is that the genesis of traumatic TMJankylosis is the organization and ossification of an intracapsular hematoma following TMJ injury. However, our animal experiments showed thatintra-reticular hematoma alone is not a causative factor for TMJ ankylosis. Weconsider the distraction osteogenesis (DO) caused by the traction of the lateralpterygoid muscle leads to new bone overgrowth, and then plays an important rolein the genesis of traumatic TMJ ankylosis.We used sheep in our study, anoblique vertical osteotomy was made from the lateral pole of the condyle to themedial side of the condylar neck by ultrasound osteotome. The lateral pterygoidmuscles of ten sheep were cut in group2. The lateral pterygoid muscles of tensheep in the other group were not cut. The capsuls were not sutured, and thewound was closed layer by layer. The aim of this study was to determine whetherthe lateral pterygoid muscle will affect the condylar shape in the healing processof sagittal fracture of mandibular condyle (SFMC). This study will help us tofurther study the mechanisms of TMJ ankylosis development.
Experiment One was the retrospective study of TMJ ankylosis byclinical cases.294temporomandibular ankylosis cases managed by school ofStomatology, Fourth Military Medical University from1990to2009were used inthis retrospective study. Age, sex, aetiology, join(s) affected, types were evluated.Results: truma was the most common aetiology. The patient’s age range was0-66years. Most of the traumatic temporomandibular joint ankylosis were caused bycondylar fracture. And the Sagittal fracture of the mandibular condyle causingtemporomandibular joint ankylosis was the main type of condylar fracture. Theresults will help further study of temporomandibular joint ankylosis mechanisms.
Experiment Two was the created animal model the role of the lateralpterygoid muscle in the sagittal fracture of mandibular condyle (SFMC)healing process. Twenty adult healthy sheep were divided into two groups with10sheep in each group. An oblique vertical osteotomy was made from the lateralpole of the condyle to the medial side of the condylar neck by ultrasoundosteotome.The lateral pterygoid muscles of ten sheep were cut(we cut off0.5-1.0cm lateral pterygoid muscle off each sheep in this group) in group2. The lateral pterygoid muscle of ten sheep in the other group were not cut. Computedtomography(CT) were recorded before operation and1week after operation.Three-dimensional reconstruction and multiplanar reconstruction (MPR) CTimages were obtained to observe the displacement of the fragment. The fragmentdisplaced anteriorly, medially and inferiorly in the sheep of group1. However,the results was not found in the sheep of group2. This animal model can be usedto evaluate the role of the lateral pterygoid muscle in the sagittal fracture ofmandibular condyle (SFMC) healing process.
Experiment Three was that the shape of condyle were measured by CTscans. The sheep of two groups in experiment two were performed helical CT at4week,12week and24week after operation. The anteroposterior diameter,medial-lateral diameterand and area of the condylar were measured by CT scans.And the volume of the condylar were recived by area. All the sizes of theoperated condylar’s anteroposterior diameter, medial-lateral diameter, area andvolume were increased. But the size of the condylar in group1increasedremarkablely than that in group2. The results show the lateral pterygoid muscleaffected the condylar shape reconstructing during the sagittal fracture ofmandibular condyle (SFMC) healing process.
Experiment Four was used CT three-dimensional reconstruction andafter dissecting TMJ were evaluated the role of the lateral pterygoid musclein the sagittal fracture of mandibular condyle (SFMC) healing process. Thetwo groups of sheep in Experiment Three were killed at4week(2of eachgroup),12week (4of each group) and24week(4of each group) after operation.Computed tomography(CT) were recorded just after the sheep were killed. Themaximum anteroposterior diameter and medial-lateral diameter of the condylarwere measured by CT scans. The shape of the joints observed by CTthree-dimensional reconstruction and after dissecting. The result showed new bone formation occurred irregularly on the articular surfaces in both groups. Butthe joints in group1showed more severe than those in group2. So the lateralpterygoid muscle played a very important role in reconstructing the condylarshape during the sagittal fracture of mandibular condyle (SFMC) healing process.
Experiment Five was that we use Micro-CT measured the parametersof the new bone in the condylar sagittal fracture zone. We dissected the jointsand received the condyle. Micro-CT had been taken after the dissection. one thirdof medial-inside of the bilateral condylar was selective volume of interests.
We measured the centroid of the bilateral condylar of the sheep bymicro-CT and analysed the representative architectural parameters(BV/TV,TB.TH,TB.N,TB.SP) the selective volume of interests. The condylarsof the group in which the lateral peterygoid muscle had not been cut showedovergrowth of new bone.
In conclusion, retrospective study of TMJ ankylosis by clinical casesshowed truma was the commonest aetiology. Most of the traumatictemporomandibular joint ankylosis were caused by condylar fracture. And theSagittal fracture of the mandibular condyle was the main type of condylarfracture causing temporomandibular joint ankylosis. Twenty adult healthy sheepwere divided into two groups. Sagittal fracture of the mandibular condyle wasmade by ultrasound osteotome.The lateral pterygoid muscle were cut with tensheep in group2. The lateral pterygoid muscle of the sheep in the other groupwere not cut. Animal experiment study demonstrate there were more new bonesforming there were more new growing bones on the condyles of group1thanthose of group2. And the shape of condyles in group1were almost normal. Sothe lateral pterygoid muscle played a very important role in reconstructing thecondylar shape during the sagittal fracture of mandibular condyle (SFMC) healing process.The results will help us to further study the mechanisms oftemporomandibular joint ankylosis.
引文
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