38例下颌骨髁突囊内骨折的手术治疗及疗效评价

doi:10.19438/j.cjoms.2018.03.010

摘要/Abstract

摘要： 目的： 介绍一种改良的下颌骨髁突囊内骨折（diacapitular condylar fractures, DCF）手术治疗方法，并评价其疗效。方法： 2015年1月—2016年12月期间，对38例（50侧）DCF患者进行骨折内固定联合颞下颌关节盘锚固术治疗。采用改良耳前入路，复位骨折髁突并用1颗长14~16 mm的螺钉固定，然后复位向前内侧移位的关节盘，并用1颗锚固钉锚固于髁突后斜面下缘中份。所有患者进行手术前、后颌面部CT、颞下颌关节 (temporomandibular joint, TMJ) MRI 检查，对伴有下颌骨其他部位的骨折，同期进行解剖复位、固定。利用SimPlant Pro 11.04软件 CMF模块进行术前、术后，健侧、患侧下颌支高度测量，并进行配对t检验，评价骨折固定效果。利用术前、术后MRI中关节盘与髁突顶点相对位置的变化，评价关节盘锚固术的准确性。术后对所有患者进行随访，对开口度、开口型、关节弹响、面神经损伤症状等进行比较。采用SPSS 17.0软件包对数据进行统计学处理。结果： 手术后颌面部CT显示，37例（48侧）囊内骨折达到解剖复位（有效率96%）。所有患者患侧下颌支高度较术前显著增加（P<0.05）；19例单侧囊内骨折患者术后健、患侧下颌支高度无显著差异（P>0.05）。术后MRI图像显示，35例（46侧）关节盘回到原有的解剖位置，有效率为92.0%（46/50）。术后远期随访显示，38例患者咬合关系稳定，平均开口度35.67 mm，最大侧方咬合平均值为4.45 mm，最大前伸咬合平均值为5.63 mm；开口型偏斜2例（5.3%），关节弹响2例2侧（4.0%）；4例患者出现不同程度的暂时性面神经功能不全，其中3例在术后3个月逐渐恢复，另外1例（2.6%）随访3个月后仍出现患侧抬眉困难，口服甲钴胺片后症状缓解。结论： 下颌骨髁突囊内骨折常伴发TMJ关节盘移位，且方向与移位的骨折片一致。骨折开放复位内固定术联合颞下颌关节盘锚固术是治疗该类型骨折的有效方法。

关键词: 髁突囊内骨折, 开放复位内固定术, 关节盘锚固术, 手术治疗

Abstract: PURPOSE: To introduce a modified surgical method for diacapitular condylar fractures. METHODS: Thirty-eight patients (50 TMJs) diagnosed as diacapitular condylar fracture through clinical examinations(CT and MRI) were treated with a modified surgical technique from January 2015 to December 2016. The technique was mainly proposed for diacapitular fractures. A minimized preauricular incision and transparotid access was used. Then reduction and fixation of diacapitular condylar fractures were performed. After confirming that the fracture was fixed rigidly, the articular disc was repositioned and anchored by a special anchorage nail. All patients were estimated by CT and MRI pre- or post-surgery, and followed up for 1 year at least. For patients who had other fractures of the mandible, open and internal fixation were conducted simultaneously. Radiologic, anatomic and objective functional parameters (axiography and MRI) were used to assess the vertical height, disk mobility, protrusive and translatory movement as well as potential physical complaints. All results were statistically analyzed with SPSS 17.0 software package. RESULTS: Spiral CT revealed that 96.0% (48/50 TMJs) of DCFs were correctly reduced and fixed. All patients showed significant difference in the vertical height between preoperation and postoperation (P<0.05) and there was no significant difference between the uninjured side and the postoperative affected side (P>0.05) in19 unilateral DCFs. Postoperative MRI showed that the displaced discs were reduced to its normal position in 46 of 50 TMJs(92.0%). Long-term follow-up of 38 patients included mouth opening(35.67 mm), maximum lateral occlusion (4.45 mm), maximum protrusive occlusion (5.63 mm), mouth open with deviation in 2 cases (5.3%), TMJ click in 2 cases(4.0%), facial nerve injury in 4 cases (3 cases were recovered spontaneously 3 months after surgery, another relieved by taking mecobalamin orally) and all occlusion was stable. CONCLUSIONS: This modified technique was proposed for DCF, clinical results were very good and should be popularized in clinic, but further evaluation was necessary.

Key words: Diacapitular condylar fracture, Open reduction and internal fixation, Temporomandibular joint disc anchorage;

中图分类号:

R318.08

任荣，蔡卜磊，支音，司家文，张剑飞，史俊. 38例下颌骨髁突囊内骨折的手术治疗及疗效评价[J]. 中国口腔颌面外科杂志, 2018, 16(3): 242-247.

REN Rong, CAI Bo-lei, ZHI Yin, SI Jia-wen, ZHANG Jian-fei, SHI Jun.. Modified surgical method for diacapitular condylar fractures in 38 consecutive patients[J]. China J Oral Maxillofac Surg, 2018, 16(3): 242-247.

参考文献

[1] Pereira MD, Marques A, Ishizuka M, et al. Surgical treatment of the fractured and dislocated condylar process of the mandible [J]. J Craniomaxillofac Surg, 1995, 23(6): 369-376.
[2] Eckelt U. Commentary regarding the publication "Fractures of the mandibular condyle-a review of 466 cases. Literature review, reflections on treatment and proposals" by N. Zachariades et al [J]. J Craniomaxillofac Surg, 2006, 34(7): 433-434.
[3] He D, Yang C, Chen M, et al. Intracapsular condylar fracture of the mandible: our classification and open treatment experience [J]. J Oral Maxillofac Surg, 2009, 67(8): 1672-1679.
[4] Ellis E 3rd, Reynolds ST, Park HS. A method to rigidly fix high condylar fractures[J]. Oral Surg Oral Med Oral Pathol, 1989, 68(4): 369-374.
[5] Kermer Ch, Undt G, Rasse M. Surgical reduction and fixation of intracapsular condylar fractures. A follow up study [J]. Int J Oral Maxillofac Surg, 1998, 27(3): 191-194.
[6] Landes CA, Lipphardt R. Prospective evaluation of a pragmatic treatment rationale: open reduction and internal fixation of displaced and dislocated condyle and condylar head fractures and closed reduction of non-displaced, non-dislocated fractures Part Ⅰ: high condylar and condy[J]. Int J Oral Maxillofac Surg, 2005, 34(8): 859-870.
[7] Pilling E, Schneider M, Mai R, et al. Minimally invasive fracture treatment with cannulated lag screws in intracapsular fractures of the condyle [J]. J Oral Maxillofac Surg, 2006, 64(5): 868-872.
[8] Vesnaver A. Open reduction and internal fixation of intra-articular fractures of the mandibular condyle: our first experiences[J]. J Oral Maxillofac Surg, 2008, 66(10): 2123-2129.
[9] Yang ML, Zhang B, Zhou Q, et al. Minimally-invasive open reduction of intracapsular condylar fractures with preoperative simulation using computer-aided design [J]. Br J Oral Maxillofac Surg, 2013, 51(3): e29-33.
[10] Collier J, Bridle C, Makdissi J, et al. The role of pre-operative 3-dimension CT evaluation of Type B intracapsular condylar fractures to determine the feasibility of lag screw osteosynthesis [J]. Br J Oral Maxillofac Surg, 2008, 46(7): e37-38.
[11] Xu X, Shi J, Xu B, et al. Treatment of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures [J]. J Craniofac Surg, 2015, 26(2): e181-185.
[12] Oki K, Hyakusoku H, Aoki R, et al. Fixation of intracapsular fractures of the condylar head with bioabsorbable screws [J]. Scand J Plast Reconstr Surg Hand Surg, 2009, 40(4): 244-248.
[13] Emshoff R, Rudisch A, Ennemoser T, et al. Magnetic resonance imaging findings of temporomandibular joint soft tissue changes in type V and VI condylar injuries [J]. J Oral Maxillofac Surg, 2007, 65(8): 1550-1554.
[14] Choi BH. Magnetic resonance imaging of the temporomandibular joint after functional treatment of bilateral condylar fractures in adults [J]. Int J Oral Maxillofac Surg, 1997, 26(5): 344-347.
[15] Gerhard S, Ennemoser T, Rudisch A, et al. Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes [J]. Int J Oral Maxillofac Surg, 2007, 36(3): 214-218.
[16] Chuong R, Piper MA. Open reduction of condylar fractions of the mandible in conjunction with repair of discal injury: a preliminary report [J]. J Oral Maxillofac Surg, 1988, 46(4): 257-263.
[17] Hlawitschka M, Loukota R, Eckelt U. Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible [J]. Int J Oral Maxillofac Surg, 2005, 34(6): 597-604.
[18] Neff A, Kolk A, Deppe H, et al. New aspects for indications of surgical management of intra-articular and high temporomandibular dislocation fractures[J]. Mund Kiefer Gesichtschir, 1999, 3(1): 24-29.
[19] Shi J, Jiao F, Xu B, et al. Transparotid approach in the treatment of intracapsular condylar fracture[J]. J Craniofac Surg, 2015, 26(2): 495-497.
[20] Yang C, Zhang SY, Wang XD, et al. Magnetic resonance arthrography applied to the diagnosis of intraarticular adhesions of the temporomandibular joint [J]. Int J Oral Maxillofac Surg, 2005, 34(7): 733-738.
[21] Holmlund AB. Surgery for TMJ internal derangement. Evaluation of treatment outcome and criteria for success [J]. Int J Oral Maxillofac Surg, 1993, 22(2): 75-77.
[22] 张善勇, 杨驰, 蔡协艺, 等. MRI评价颞下颌关节镜盘复位固定术的短期疗效 [J]. 口腔颌面外科杂志, 2008, 18(1): 31-34.
[23] Zhang Y, He DM. Clinical investigation of early post-traumatic temporomandibular joint ankylosis and the role of repositioning discs in treatment [J]. Int J Oral Maxillofac Surg, 2006, 35(12): 1096-1101.
[24] Laskin DM. Role of the meniscus in the etiology of post-traumatic temporomandibular joint ankylosis [J]. Int J Oral Surg, 1978, 7(4): 340-345.
[25] Iizuka T, Lindqvist C, Hallikainen D, et al. Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures. A clinical and radiologic study of thirteen patients [J]. Oral Surg Oral Med Oral Pathol, 1991, 72(4): 400-407.
[26] Chen M, Yang C, He D, et al. Soft tissue reduction during open treatment of intracapsular condylar fracture of the temporomandibular joint: our institution's experience [J]. J Oral Maxillofac Surg, 2010, 68(9): 2189-2195.
[27] Annandale T. On displacement of the inter-articular cartilage of the lower jaw, and its treatment by operation [J]. Lancet, 2004, 129(3313): 411-411.
[28] Wilkes CH. Arthrography of the temporomandibular joint in patients with the TMJ pain-dysfunction syndrome [J]. Minn Med, 1978, 61(11): 645-652.
[29] McCarty WL, Farrar WB. Surgery for internal derangements of the temporomandibular joint [J]. J Prosthet Dent, 1979, 42(2): 191-196.