下颌和颞下颌关节运动影像和运动轨迹的建立及临床初步应用
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摘要
下颌运动是由下颌、咀嚼肌及颞下颌关节共同参与进行的一种复杂运动,对于我们行使并认识咀嚼、吞咽及语言等功能具有十分重要的意义。下颌运动是完成口腔功能的重要途径,在临床上下颌运动的异常改变是诊断下颌系统疾病和判断治疗效果的可靠客观指标。目前却无法真正客观、生动地再现下颌骨和颞下颌关节的运动状态。
320排CT由于大面积探测器实现的16公分覆盖,最少仅用0.35秒扫一圈就能将整个器官在瞬间内冻结成像；除了能够重现人体脏器的立体结构以外,还能反映其整个器官功能状态和血流运行的情况,是目前唯一能够实现真正动态容积成像的CT,即是对人体内部结构进行四维动态观察。本研究依据320排CT独特的功能,建立下颌和颞下颌关节运动影像和运动轨迹,为下颌骨/髁突骨折,颞下颌关节紊乱病等的诊断和治疗效果评价,建立起一个新的方法。
一、下颌和颞下颌关节运动影像的建立
目的：利用320CT (Toshiba, Aquilion one)建立下颌和颞下颌关节运动影像。方法：本研究共观察10名正常人群,通过非金属、阶梯状开口器,放置前牙正中位,控制每次开口度(0.5cm),采用Jiont-Move＆Shot序列进行动态扫描,每咬一个阶梯曝光一次,使用Dynamic重建方式,建立若干容积数据,在Aquilion one副台或Vitrea2.1工作站上进行后处理。结果：实现了静止和运动状态下下颌和颞下颌关节四维动态影像,并能做到多角度和各个断层的运动影像的观察。每次扫描有效吸收剂量仅为16层螺旋CT的1/6。结论：通过320排容积CT的动态扫描功能,建立起下颌和颞下颌关节四维动态影像,为临床下颌骨疾病,特别是颞下颌关节紊乱疾病的诊断,以及治疗后效果的评价提供了一个新的方法。
二、下颌和颞下颌关节运动轨迹的建立
目的：利用320CT和计算机软件建立正常下颌和颞下颌关节运动轨迹。方法：本研究共观察10名正常人群,通过放置前牙正中位阶梯状开口器,采用Jio nt-Move＆Shot序列进行动态扫描,每咬一个阶梯曝光一次,使用Dynamic重建方式,建立若干容积数据,在Aquilion one副台或Vitrea2.1工作站上进行后处理,形成下颌和颞下颌关节张闭口运动影像。利用Macromedia Flash8、Adobe Photoshop CS3软件,获得受试者下颌及颞下颌关节的运动轨迹DV影像。结果：10例观察对象下颌张闭口运动轨迹分离,开口型偏向左侧；双侧髁突呈现向前下方的平滑弧形曲线,张闭口轨迹基本吻合。结论：大多数无症状人群的下颌张口运动轨迹向左侧偏斜,闭口偏向右侧,开闭口轨迹不吻合；双侧髁突张闭口运动轨迹基本吻合,两侧基本对称。
三、运动影像和运动轨迹在临床的初步应用
1、骨折术后评价：
双侧髁突骨折术后：下颌张闭口运动轨迹呈‘8’字形,右侧髁突张闭口运动轨迹呈倒弧形,左侧髁突运动轨迹平滑,双侧髁突张闭口轨迹分离。主要考虑是左侧髁突未行手术治疗,髁突断段内侧移位,下颌升支缩短,两侧髁突左右侧解剖学上不对称；左侧髁突肌肉和韧带附着的丧失,导致张闭口过程中,牵拉力量的不平衡。
左侧髁突术后：右侧髁突运动轨迹呈‘L'形,最大张口位时仅至关节结节的后下,左侧髁突运动轨迹平滑,但是运动幅度小于右侧,下颌运动轨迹偏于左侧,三者的运动轨迹吻合。主要考虑术后2周行320CT检查,左侧髁突骨折未能愈合,张口时骨折段部分分离,不能够整体移动,髁突向前滑动受限,以转动为主。
2、颞下颌关节紊乱病诊断：下颌张闭口运动轨迹呈倒‘L’形,右侧髁突张闭口运动轨迹呈折线,左侧髁突运动轨迹呈不平滑的弧形曲线,张闭口轨迹基本吻合。通过运动影像和运动轨迹可以明确诊断为TMD。
3、关节盘前移位的诊断：将钆造影剂和碘造影剂按比例配制,行颞下颌关节上腔注射,先后行320CT和MRI造影检查,通过运动影像和运动轨迹同关节造影结合,明确关节盘前移位的诊断。
总结
本研究利用320CT建立下颌和颞下颌关节运动影像,通过计算机软件,将下颌及颞下颌关节运动影像和运动轨迹相结合,对临床下颌骨疾病,特别是颞下颌关节紊乱疾病的诊断,以及治疗后效果的评价提供了一个新的方法。
Mandibular movement is a complex phenomenon involving the mandible,masticatory muscles, and temporomandibular joint (TMJ). It is central to mastication,swallowing, and linguistic function. In clinical practice, abnormalities in mandibularmovement are reliable indicators of mandibular system disease and changes in motioncan be used to evaluate treatment effect. However, these techniques are limited toaccurately tracking mandible and temporomandibular joint movement.
With its width16centimeters (cm) of anatomic coverage,320-row CT can scan themandibular system in a single gantry rotation. It can also construct the stereoscopicstructure of human organs, and disclose the functional status and blood flow of thewhole organ. Currently, it is the only CT that can truly achieve dynamic volumeimaging (i.e. four-dimensional dynamic observation of internal structure of humanbody). In this study, we established the dynamic images and movement traces ofmandible and TMJ with the specific merit of320-row CT, with the aiming at developinga new approach to diagnose the diseases such as mandible/condylar fracture andtemporomandibular joint disorder and evaluate the treatment effectiveness.I. Dynamic images of mandible and TMJ
Objective: To establish dynamic images of mandible and TMJ using320-rowcomputed tomography (CT)(Toshiba, Aquilion One). Methods: A non-metallic,stepwise mouth gag was placed between mandibular and maxillary incisors to controlmouth opening (0.5-cm increments) in10normal volunteers. A320-row CT Joint-Move&Shot sequence was used to dynamic scanning with an exposure taken after eachincrement. Dynamic reconstruction was used to establish volume data. Results:Dynamic images of mandible and TMJ in a rest state and in a state of mandibularmovement from multi angles and in different planes demonstrated differences on healthy subjects. The effective dose per scan was approximately17%of the16-slicespiral CT. Conclusions: Dynamic images of mandible and TMJ can be achievedthrough320-row volume CT scanning, which may provide a new approach fordiagnosis of TMD and other conditions, and assessment of treatment effects.II. Movement traces of mandible and TMJ
Objective: To establish movement traces of mandible and TMJ using320CT and soft.Methods: A non-metallic, stepwise mouth gag was placed between mandibular andmaxillary incisors to control mouth opening (0.5-cm increments) in10normalvolunteers. A320-row CT Joint-Move&Shot sequence was used to dynamic scanningwith an exposure taken after each increment. Dynamic reconstruction was used toestablish volume data. Movement traces of mandible and TMJ can be achieved through320CT scanning and soft of Macromedia Flash8、Adobe Photoshop CS3. Results:The movement traces of madibular opening and closing were separated in10normalvolunteers, which were deflected to left when opening. The movement traces of twocondylaris presented as smooth arc curve pointing to anterior inferior, and themovement traces of opening and closing were inosculated. Conclusions: Mandibulartraces separated and deflected to left and right when opening and closing. Themovement traces of opening and closing of bilateral condylaris were inosculated andbilateral symmetry.III. The clinical application of dynamic images and movement traces
1. Post-operative evaluation of bone fracture
Bilateral condylaris fracture after operation: The movement traces of the opening andclosing of mandible showed a8shaped curve. The movement traces of right condylarshowed inverted arc shaped curve, and movement traces of left condylar was smooth.The movement traces of bilateral condylaris opening and closing were separated. Themain reasons were as follow: The left condylar didn‘t undergo operation, the rupturedcondylar shifted inward, the mandibular ramus was shorten, and the bilateral condylariswere asymmerty on anatomy; The loss of adhesion of muscle and ligament of left condylar induced the unbalance of pulling strength during the opening and closingprocess.
Left condylar fracture after operation: The movement traces of right condylar showedL shaped curve, and the maximum opening only reached posterior inferior point ofarticular tubercle. The movement traces of left condylar was smooth, but the motionamplitude was less than right side. The movement traces of mandible shifted to left side.The three movement traces were inosculated. The320-row CT examination wasperformed after two weeks of operation. The main reasons were as follow: The fractureof left condylar didn‘t heal at that time, the ruptured condylar was partly separated andcould not move as a whole bone, and the forward gliding of condylar was limited.
2. The diagnosis of temporomandibular joint disorder: The movement traces ofmandible opening and closing showed inverted L shaped curve. The movement traces ofright condylar presented as curving line, left condylaris presented as smoothness arccurve, and the movement traces of opening and closing were inosculated. Theconfirmed diagnosis of TMD could be achieved by dynamic images and movementtraces.
3. The diagnosis of anterior disc displacement: The mixture of gadolinium contrastagent and diodone was injected into the superior cavity of temporomandibular joint, andthen320-row CT and MRI were performed. The diagnosis of anterior disc displacementwas establised by dynamic images, movement traces and arthrography.Conclusions Dynamic images and movement traces of mandible and temporo-mandibular joint can be achieved through320-row volume CT scanning, which mightprovide a new approach for diagnosis of temporo mandibular joint disorder and otherconditions and can be used to evaluate of treatment effects.
320排CT由于大面积探测器实现的16公分覆盖,最少仅用0.35秒扫一圈就能将整个器官在瞬间内冻结成像；除了能够重现人体脏器的立体结构以外,还能反映其整个器官功能状态和血流运行的情况,是目前唯一能够实现真正动态容积成像的CT,即是对人体内部结构进行四维动态观察。本研究依据320排CT独特的功能,建立下颌和颞下颌关节运动影像和运动轨迹,为下颌骨/髁突骨折,颞下颌关节紊乱病等的诊断和治疗效果评价,建立起一个新的方法。
一、下颌和颞下颌关节运动影像的建立
目的：利用320CT (Toshiba, Aquilion one)建立下颌和颞下颌关节运动影像。方法：本研究共观察10名正常人群,通过非金属、阶梯状开口器,放置前牙正中位,控制每次开口度(0.5cm),采用Jiont-Move＆Shot序列进行动态扫描,每咬一个阶梯曝光一次,使用Dynamic重建方式,建立若干容积数据,在Aquilion one副台或Vitrea2.1工作站上进行后处理。结果：实现了静止和运动状态下下颌和颞下颌关节四维动态影像,并能做到多角度和各个断层的运动影像的观察。每次扫描有效吸收剂量仅为16层螺旋CT的1/6。结论：通过320排容积CT的动态扫描功能,建立起下颌和颞下颌关节四维动态影像,为临床下颌骨疾病,特别是颞下颌关节紊乱疾病的诊断,以及治疗后效果的评价提供了一个新的方法。
二、下颌和颞下颌关节运动轨迹的建立
目的：利用320CT和计算机软件建立正常下颌和颞下颌关节运动轨迹。方法：本研究共观察10名正常人群,通过放置前牙正中位阶梯状开口器,采用Jio nt-Move＆Shot序列进行动态扫描,每咬一个阶梯曝光一次,使用Dynamic重建方式,建立若干容积数据,在Aquilion one副台或Vitrea2.1工作站上进行后处理,形成下颌和颞下颌关节张闭口运动影像。利用Macromedia Flash8、Adobe Photoshop CS3软件,获得受试者下颌及颞下颌关节的运动轨迹DV影像。结果：10例观察对象下颌张闭口运动轨迹分离,开口型偏向左侧；双侧髁突呈现向前下方的平滑弧形曲线,张闭口轨迹基本吻合。结论：大多数无症状人群的下颌张口运动轨迹向左侧偏斜,闭口偏向右侧,开闭口轨迹不吻合；双侧髁突张闭口运动轨迹基本吻合,两侧基本对称。
三、运动影像和运动轨迹在临床的初步应用
1、骨折术后评价：
双侧髁突骨折术后：下颌张闭口运动轨迹呈‘8’字形,右侧髁突张闭口运动轨迹呈倒弧形,左侧髁突运动轨迹平滑,双侧髁突张闭口轨迹分离。主要考虑是左侧髁突未行手术治疗,髁突断段内侧移位,下颌升支缩短,两侧髁突左右侧解剖学上不对称；左侧髁突肌肉和韧带附着的丧失,导致张闭口过程中,牵拉力量的不平衡。
左侧髁突术后：右侧髁突运动轨迹呈‘L'形,最大张口位时仅至关节结节的后下,左侧髁突运动轨迹平滑,但是运动幅度小于右侧,下颌运动轨迹偏于左侧,三者的运动轨迹吻合。主要考虑术后2周行320CT检查,左侧髁突骨折未能愈合,张口时骨折段部分分离,不能够整体移动,髁突向前滑动受限,以转动为主。
2、颞下颌关节紊乱病诊断：下颌张闭口运动轨迹呈倒‘L’形,右侧髁突张闭口运动轨迹呈折线,左侧髁突运动轨迹呈不平滑的弧形曲线,张闭口轨迹基本吻合。通过运动影像和运动轨迹可以明确诊断为TMD。
3、关节盘前移位的诊断：将钆造影剂和碘造影剂按比例配制,行颞下颌关节上腔注射,先后行320CT和MRI造影检查,通过运动影像和运动轨迹同关节造影结合,明确关节盘前移位的诊断。
总结
本研究利用320CT建立下颌和颞下颌关节运动影像,通过计算机软件,将下颌及颞下颌关节运动影像和运动轨迹相结合,对临床下颌骨疾病,特别是颞下颌关节紊乱疾病的诊断,以及治疗后效果的评价提供了一个新的方法。
Mandibular movement is a complex phenomenon involving the mandible,masticatory muscles, and temporomandibular joint (TMJ). It is central to mastication,swallowing, and linguistic function. In clinical practice, abnormalities in mandibularmovement are reliable indicators of mandibular system disease and changes in motioncan be used to evaluate treatment effect. However, these techniques are limited toaccurately tracking mandible and temporomandibular joint movement.
With its width16centimeters (cm) of anatomic coverage,320-row CT can scan themandibular system in a single gantry rotation. It can also construct the stereoscopicstructure of human organs, and disclose the functional status and blood flow of thewhole organ. Currently, it is the only CT that can truly achieve dynamic volumeimaging (i.e. four-dimensional dynamic observation of internal structure of humanbody). In this study, we established the dynamic images and movement traces ofmandible and TMJ with the specific merit of320-row CT, with the aiming at developinga new approach to diagnose the diseases such as mandible/condylar fracture andtemporomandibular joint disorder and evaluate the treatment effectiveness.I. Dynamic images of mandible and TMJ
Objective: To establish dynamic images of mandible and TMJ using320-rowcomputed tomography (CT)(Toshiba, Aquilion One). Methods: A non-metallic,stepwise mouth gag was placed between mandibular and maxillary incisors to controlmouth opening (0.5-cm increments) in10normal volunteers. A320-row CT Joint-Move&Shot sequence was used to dynamic scanning with an exposure taken after eachincrement. Dynamic reconstruction was used to establish volume data. Results:Dynamic images of mandible and TMJ in a rest state and in a state of mandibularmovement from multi angles and in different planes demonstrated differences on healthy subjects. The effective dose per scan was approximately17%of the16-slicespiral CT. Conclusions: Dynamic images of mandible and TMJ can be achievedthrough320-row volume CT scanning, which may provide a new approach fordiagnosis of TMD and other conditions, and assessment of treatment effects.II. Movement traces of mandible and TMJ
Objective: To establish movement traces of mandible and TMJ using320CT and soft.Methods: A non-metallic, stepwise mouth gag was placed between mandibular andmaxillary incisors to control mouth opening (0.5-cm increments) in10normalvolunteers. A320-row CT Joint-Move&Shot sequence was used to dynamic scanningwith an exposure taken after each increment. Dynamic reconstruction was used toestablish volume data. Movement traces of mandible and TMJ can be achieved through320CT scanning and soft of Macromedia Flash8、Adobe Photoshop CS3. Results:The movement traces of madibular opening and closing were separated in10normalvolunteers, which were deflected to left when opening. The movement traces of twocondylaris presented as smooth arc curve pointing to anterior inferior, and themovement traces of opening and closing were inosculated. Conclusions: Mandibulartraces separated and deflected to left and right when opening and closing. Themovement traces of opening and closing of bilateral condylaris were inosculated andbilateral symmetry.III. The clinical application of dynamic images and movement traces
1. Post-operative evaluation of bone fracture
Bilateral condylaris fracture after operation: The movement traces of the opening andclosing of mandible showed a8shaped curve. The movement traces of right condylarshowed inverted arc shaped curve, and movement traces of left condylar was smooth.The movement traces of bilateral condylaris opening and closing were separated. Themain reasons were as follow: The left condylar didn‘t undergo operation, the rupturedcondylar shifted inward, the mandibular ramus was shorten, and the bilateral condylariswere asymmerty on anatomy; The loss of adhesion of muscle and ligament of left condylar induced the unbalance of pulling strength during the opening and closingprocess.
Left condylar fracture after operation: The movement traces of right condylar showedL shaped curve, and the maximum opening only reached posterior inferior point ofarticular tubercle. The movement traces of left condylar was smooth, but the motionamplitude was less than right side. The movement traces of mandible shifted to left side.The three movement traces were inosculated. The320-row CT examination wasperformed after two weeks of operation. The main reasons were as follow: The fractureof left condylar didn‘t heal at that time, the ruptured condylar was partly separated andcould not move as a whole bone, and the forward gliding of condylar was limited.
2. The diagnosis of temporomandibular joint disorder: The movement traces ofmandible opening and closing showed inverted L shaped curve. The movement traces ofright condylar presented as curving line, left condylaris presented as smoothness arccurve, and the movement traces of opening and closing were inosculated. Theconfirmed diagnosis of TMD could be achieved by dynamic images and movementtraces.
3. The diagnosis of anterior disc displacement: The mixture of gadolinium contrastagent and diodone was injected into the superior cavity of temporomandibular joint, andthen320-row CT and MRI were performed. The diagnosis of anterior disc displacementwas establised by dynamic images, movement traces and arthrography.Conclusions Dynamic images and movement traces of mandible and temporo-mandibular joint can be achieved through320-row volume CT scanning, which mightprovide a new approach for diagnosis of temporo mandibular joint disorder and otherconditions and can be used to evaluate of treatment effects.
引文
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