关节镜辅助下改良耳屏切口颞下颌关节盘复位缝合术的疗效评价

Effectiveness of modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy

目的探讨关节镜辅助下改良耳屏切口颞下颌关节盘复位缝合术治疗颞下颌关节盘前移位(anterior disc displacement,ADD)的疗效。方法回顾性分析2022年9月—2024年2月收治且符合选择标准的30例(45侧)颞下颌关节ADD患者临床资料。其中,15例(23侧)接受小切口颞下颌关节盘复位缝合术(全开放组),15例(22侧)接受关节镜辅助下改良耳屏切口颞下颌关节盘复位缝合术(关节镜组)。两组患者性别、年龄、病程、侧别、Wilkes-Bronstein分期以及术前疼痛视觉模拟评分(VAS)、最大开口度(maximal interincisal opening,MIO)、颞下颌关节功能障碍指数(dysfunction index,DI)、颞下颌关节紊乱指数(craniomandibular index,CMI)、肌肉压痛指数(palpation index,PI)等基线资料比较,差异均无统计学意义(P>0.05)。术后3个月记录患者疼痛VAS评分、MIO以及颞下颌关节功能指标(PI、DI、CMI),计算上述指标手术前后差值(变化值)进行组间比较。术后1周行MRI检查,与术前图像比较评价关节盘复位情况,分为优、良、差,其中优及良判定为有效复位;术后3个月行锥形束CT(cone beam CT,CBCT)检查观察髁突骨质修复情况。结果两组术后切口均Ⅰ期愈合。患者均获随访,随访时间3~18个月,平均8.2个月。全开放组3例、关节镜组1例出现面神经损伤症状,均经理疗及药物治疗后恢复正常。两组术后3个月MIO、VAS评分均较术前改善,颞下颌关节功能指标(PI、DI、CMI)均降低,差异有统计学意义(P<0.05)。关节镜组MIO变化值、颞下颌关节功能指标变化值高于全开放组,差异有统计学意义(P<0.05);VAS变化值组间差异无统计学意义(P>0.05)。随访期间未见复发病例。术后MRI复查示全开放组关节盘有效复位率95.65%(22/23)、关节镜组为95.45%(21/22),组间差异无统计学意义(P>0.05);CBCT检查示早期及时有效复位关节盘有利于髁突修复重建。结论关节镜辅助下改良耳屏切口颞下颌关节盘复位缝合术治疗ADD创伤小、术后并发症少,患者恢复快,可获得较好早期疗效。

Objective To investigate the effectiveness of modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy for temporomandibular joint anterior disc displacement(ADD).Methods A clinical data of 30 patients(45 sides)with temporomandibular joint ADD,who met selective criteria and were admitted between September 2022 and February 2024,was retrospectively analyzed.Among them,15 patients(23 sides)were treated with temporomandibular joint disc reduction and suture via small incision(open operation group),and 15 patients(22 sides)with modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy(arthroscopy group).There was no significant difference in gender,age,disease duration,affected side,Wilkes-Bronstein stage,preoperative visual analogue scale(VAS)score,maximal interincisal opening(MIO),and temporomandibular joint dysfunction index(DI),craniomandibular index(CMI),palpation index(PI),and other baseline data between groups(P>0.05).VAS score,MIO,and temporomandibular joint function indicators(PI,DI,CMI)of patients were recorded at 3 months after operation,and the difference(change value)of the above indicators between pre-and post-operation was calculated.At 1 week after operation,MRI was performed to evaluate the reduction of the articular disc compared to the preoperative image.The results were classified as excellent,good,and poor,with excellent and good being considered effective reduction.The condition of condyle process repair was observed by cone beam CT(CBCT)at 3 months after operation.Results All incisions healed by first intention in the two groups.All patients were followed up 3-18 months(mean,8.2 months).Facial nerve injury occurred in 3 cases in the open operation group and 1 case in the arthroscopy group,all of which returned to normal after physiotherapy and drug treatment.At 3 months after operation,MIO and VAS scores of both groups significantly improved when compared with those before operation(P<0.05),and temporomandibular joint function indicators(PI,DI,CMI)significantly decreased(P<0.05).The change values of MIO and temporomandibular joint function indicators in arthroscopy group were significantly higher than those in open operation group(P<0.05).There was no significant difference in the change value of VAS score between groups(P>0.05).There was no recurrence during follow-up.Postoperative MRI review showed that the effective reduction rate of joint disc was 95.65%(22/23)in the open operation group and 95.45%(21/22)in the arthroscopy group,with no significant difference between groups(P>0.05).Postoperative CBCT found that early and timely effective reduction of joint disc was conducive to condyle process repair and reconstruction.Conclusion Modified temporomandibular joint disc reduction and suture with tragus incision assisted by arthroscopy has a clear effect in the treatment of ADD,with less trauma,fewer postoperative complications,and good early effectiveness.