口腔頜面外科學(xué)課件：顳下頜關(guān)節(jié)疾病

顳下頜關(guān)節(jié)疾病

口腔頜面外科學(xué)TMJconsistsofthe:MandibularcondyleTemporalbone(fossa)ArticulardiscJointcapsule(linedbythesynovialmembrane)LigamentsBloodandnervesupplyTMJistechnically

consideredaginglymoarthrodialjoint

不動(dòng)關(guān)節(jié)，微動(dòng)關(guān)節(jié)，活動(dòng)關(guān)節(jié)（滑膜關(guān)節(jié)）Hingingmovementinoneplane(ginglymoidjoint，屈戌關(guān)節(jié),絞鏈關(guān)節(jié),滑車關(guān)節(jié))Glidingmovement(arthrodialjoint，滑動(dòng)關(guān)節(jié),平面關(guān)節(jié))Unlikemostsynovialjoints,

ThearticularsurfaceofTMJsarelinedwithdensefibrousconnectivetissue,nothyalinecartilageThisisanimportantfeaturesincefibrousconnectivetissuehasagreaterabilitytorepairitselfthandoeshyalinecartilageMuscleprovidesmandibularmovement

Masticatorymusclesincludemasseter,medialpterygoidmuscle,temporalmuscle,andlateralpterygoidmuscleanddigastricmuscle.Associatedmusclesoftheheadandneckfurnishsecondarysupportduringmastication.顳下頜關(guān)節(jié)紊亂病

Temporomandibulardisorders顳下頜關(guān)節(jié)脫位

Dislocationoftemporomandibularjoint

顳下頜關(guān)節(jié)強(qiáng)直

Ankylosisoftemporomandibularjoint顳下頜關(guān)節(jié)紊亂病

顳下頜關(guān)節(jié)紊亂病的致病因素？顳下頜關(guān)節(jié)紊亂病的分類與診斷？Temporomandibulardisorders(TMD)Costen-syndrome(1934)TMJdisturbances,TMJdysfunctionsyndrome(Shore1959,Lupton1969,etal)Occluso-mandibulardisturbance(Gerber1971)Pain-dysfunctionsyndrome(Voss1964,Laskin1969)Myofacialpaindysfunctionsyndrome(Schwartz1959)Craniomandibulardisorders(CMD)Temporomandibulardisorders(TMD)顳下頜關(guān)節(jié)紊亂病(定義)

TMDsisacollectivetermembracinganumberofclinicalproblems(thathavemanycommonsymptoms)thatinvolvethemasticatorymusculature,theTMJandassociatedstructures,orboth.

指累及咀嚼肌系統(tǒng)和/或顳下頜關(guān)節(jié)，具有相關(guān)臨床問題（如疼痛、彈響、張口受限等）的一組疾病的總稱。TMDsinclude:MasticatorymuscledisordersDiscderangementdisordersInflammatorydisordersOsteoarthritis(Osteoarthrosis)不要把顳下頜關(guān)節(jié)紊亂病看作單純一個(gè)病!顳下頜關(guān)節(jié)紊亂病

顳頜關(guān)節(jié)功能紊亂癥-----

張、曾,1973年顳下頜關(guān)節(jié)紊亂綜合征------張、馬,1983顳下頜關(guān)節(jié)紊亂病------馬，張,1997年臨床診斷不宜使用TMD這個(gè)籠統(tǒng)的稱呼

TMD的臨床表現(xiàn)

下頜運(yùn)動(dòng)異常(開口度、開口型、絞鎖、前伸運(yùn)動(dòng)、側(cè)向運(yùn)動(dòng)）疼痛彈響和雜音

single/multiple,early/late,soft/loud,painful/notpainful,crepitusEpidemiologyofTMDPercentageofpopulationwithsigns

50-75%Percentageofpopulationwithsymptoms

20-25%Percentageofpopulationwhoseektreatment3-4%

對(duì)3050位四川省成都市郊區(qū)2～84歲居民進(jìn)行的斷面研究顯示（史宗道，2008）30%的人群出現(xiàn)過TMD的某些癥狀，9.9%較重65%調(diào)查人群具有顳下頜關(guān)節(jié)紊亂病的癥狀體征，較重和嚴(yán)重者10.3%癥狀年發(fā)病率為8.9%，體征年發(fā)病率為17.5%每年6.7‰的自然人群新發(fā)病并伴有嚴(yán)重的癥狀體征，其學(xué)習(xí)、生活和工作受到影響來(lái)自中國(guó)，2008EpidemiologyofTMDOverallsymptomlevels(eg,Helkimoindex)innonpatientsurveysofadultswasalmostequalinmenandwomen.Awomen-to-menratioof3:1to9:1inpersonsseekingcareforTMD.(???)顳下頜關(guān)節(jié)紊亂病的致病因素BrJDent2007TMD的咬合因素

TMD的咬合因素

RCP與ICP不協(xié)調(diào)；平衡側(cè)合干擾多個(gè)（多象限）后牙缺失；某些類型的錯(cuò)合

CaoY,XieQF,LiK,LightAR,FuKY.Experimentalocclusalinterferenceinduceslong-termmasticatorymusclehyperalgesiainrats.Pain2009;144(3):287-93SubjectswithaTMDhistoryshowedmoreclinicalsignsandsubjectivesymptomsandadaptedlesswelltotheartificialinterferences.(LeBelletal.,ActaOdontolScand2006;64(1):59-63)SomepersonalitycharacteristicsinsubjectswithanearlierTMDhistorytendedtoassociatewithhighersymptomreportingdespitethetypeofintervention.

(NiemiPM,LeBellY,etal.,ActaOdontolScand2006;64(5):300-5)這兩個(gè)研究結(jié)論應(yīng)對(duì)我們臨床有很大的指導(dǎo)意義?。?！TMD的咬合因素

TMD的精神因素

焦慮(anxiety)抑郁(depression)應(yīng)激(stress)生活事件(lifeevents)個(gè)性或人格(personality)其他：口腔習(xí)慣夜間磨牙等

明尼蘇達(dá)多項(xiàng)人格測(cè)驗(yàn)Minnesotamultiphasepersonalityinventory(MMPI),癥狀自評(píng)量表Symptomchecklist90(SCL-90),醫(yī)院焦慮抑郁量表Hospitalanxietyanddepressionscale(HADS),

TMD的免疫因素

軟骨細(xì)胞膠原蛋白多糖

具有抗原性

TMD的免疫因素

TMD關(guān)節(jié)液中檢測(cè)到抗II型膠原抗體髁狀突軟骨內(nèi)免疫復(fù)合物沉積TMD關(guān)節(jié)液IL－1、TNF、IL－6含量升高滑膜組織過度表達(dá)HLA－DR抗原FuK,MaX,ZhangZ,andChenW.Tumornecrosisfactorinsynovialfluidofpatientswithtemporomandibulardisorders.JOralMaxillofacSurg1995;53:424-426FuK,MaX,ZhangZ,PangX,andChenW.Interleukin6insynovialfluidandHLA-DRexpressioninsynoviumfrompatientswithtemporomandibulardisorders.JOrofacialPain1995;9(2):131-139創(chuàng)傷炎癥膠原或蛋白多糖的降解抗原暴露抗原識(shí)別Blymphocyte抗體抗原抗體反應(yīng)TsynoviocytemacrophageneutrophilImmunocomplex,IL-1,IL-2,IL-6,TNF蛋白酶的釋放IL-1TMD的免疫反應(yīng)

TMD的解剖因素

現(xiàn)代人上下頜骨變小;現(xiàn)代人關(guān)節(jié)結(jié)節(jié)低,關(guān)節(jié)窩淺;現(xiàn)代人髁狀突變小，關(guān)節(jié)窩相對(duì)大;進(jìn)化使得關(guān)節(jié)和頜骨更為靈巧，以適應(yīng)更為復(fù)雜的語(yǔ)言和表情等下頜運(yùn)動(dòng)。但另一方面，關(guān)節(jié)結(jié)構(gòu)變得脆弱，易受到損傷和發(fā)生組織退行性變。健康志愿者髁突位置

TMD的其他因素（關(guān)節(jié)負(fù)荷過重）

單側(cè)咀嚼夜磨牙緊咬牙發(fā)育不對(duì)稱喜硬食物醫(yī)源性EtiologyofTMDTheidentificationofanunambiguousuniversalcauseofTMDislackingMostofthefactorsdiscussedarenotprovencausalfactors,butfactorshavingassociationswithTMD.FactorsthatincreasetheriskofTMDarecalledpredisposingfactors,thatcausetheonsetofTMDarecalledinitiatingfactors,thatinterferewithhealingorenhancetheprogressionofTMDarecalledperpetuatingfactors.mutansstreptococcisugar

TMD致病因素

TMD病因

易感因素(Predisposingfactors)促發(fā)因素(Initiatingfactors)持續(xù)因素(Perpetuatingfactors)病因?qū)W說(shuō)回顧機(jī)械移位學(xué)說(shuō)和因素學(xué)說(shuō)關(guān)節(jié)囊薄弱理論合

--神經(jīng)肌肉學(xué)說(shuō)肌肉學(xué)說(shuō)精神生理學(xué)說(shuō)心理病因?qū)W說(shuō)關(guān)節(jié)內(nèi)微小創(chuàng)傷理論多因素致病學(xué)說(shuō)顳下頜關(guān)節(jié)紊亂病診斷與分類

顳頜關(guān)節(jié)功能紊亂癥-------

張、曾,1973年功能紊亂期結(jié)構(gòu)紊亂期器質(zhì)性破壞期顳下頜關(guān)節(jié)紊亂病診斷與分類

顳下頜關(guān)節(jié)紊亂綜合征------張、馬,1983年第一類：咀嚼肌功能紊亂類第二類：關(guān)節(jié)結(jié)構(gòu)紊亂類第三類：器質(zhì)性改變類顳下頜關(guān)節(jié)紊亂病診斷與分類顳下頜關(guān)節(jié)紊亂病------馬，張,1997年Ⅰ：咀嚼肌紊亂疾?、颍航Y(jié)構(gòu)紊亂疾病----關(guān)節(jié)盤移位Ⅲ：炎癥性疾病----滑膜炎Ⅳ：骨關(guān)節(jié)病顳下頜關(guān)節(jié)紊亂病診斷與分類MasticatorymuscledisordersDiscderangementdisordersInflammatorydisordersOsteoarthritis(Osteoarthrosis)ResearchDiagnosticCriteriaforTemporomandibulardisorders(RDC/TMD)byDworkinSFandLeRescheRI)Musclediagnosesa:Myofacialpainb:MyofacialpainwithlimitedopeningII)Diskdisplacementsa:DDwithreductionb:DDwithoutreduction,withlimitedopeningc:DDwithoutreduction,withoutlimitedopeningIII)Arthralgia,Arthritis,Arthrosisa:Arthralgiab:OsteoarthritisofTMJc:OsteoarthrosisofTMJ傅開元.顳下頜關(guān)節(jié)紊亂病的RDC/TMD標(biāo)準(zhǔn)化診斷(講座).中國(guó)口腔醫(yī)學(xué)繼續(xù)教育雜志2009;12(2):55-57第I類 肌肉疾患肌筋膜疼痛肌筋膜疼痛伴開口受限第II類 關(guān)節(jié)盤移位可復(fù)性關(guān)節(jié)盤移位不可復(fù)性關(guān)節(jié)盤移位，開口受限不可復(fù)性關(guān)節(jié)盤移位，無(wú)開口受限第III類 關(guān)節(jié)痛、關(guān)節(jié)炎、關(guān)節(jié)病關(guān)節(jié)痛骨關(guān)節(jié)炎骨關(guān)節(jié)病ResearchDiagnosticCriteriaforTemporomandibulardisorders(RDC/TMD)byDworkinSFandLeRescheRMasticatorymuscledisordersMyofascialpainMyositisMyospasm..\kyfu_Clinic\Specialcases\翼肌咬肌痙攣\張榮_1-97157.MOVLocalmyalgia-UnclassifiedMyofibroticcontractureSystemic---FibromyalgiaMasticatorymuscledisordersMusclepainisacommoncomplaintOveruseorischemiaofanormallyworkingmusclemaycausepainPsychologicoremotionalstatesaltermuscletonePeripherallyNociceptiveendingssensitizedCentralsensitizationMasticatorymuscledisorders

Myofascialpainischaracterizedbyaregional,dull,achingmusclepainandthepresenceoflocalizedtendersites(triggerpoints)inmuscle,tendon,orfascia.Inactivationofthetrigger-pointswithinjectionoflocalanesthetics,ice,vapocoolantspray,ortranscutaneouselectricalnervestimulation(TENS)relievesthelargerareaofpain.Pathogenesisisnotwellunderstood.Masticatorymuscledisorders

Myofascialpain---diagnosticcriteriaregionaldull,achingpain;painaggravatedbymandibularfunctionhyperirritablesites(triggerpoint)frequentlypalpatedwithinatautbandofmuscletissueorfasciagreatthan50%reductionofpainwithvapocoolantsprayorlocalanestheticinjectionofthetriggerpoint

(sensationofmusclestiffness;sensationofacutemalocclusion;earsymptom;tension-typeheadache;decreasedmouthopening;hyperalgesiaintheregionofthereferredpain)Masticatorymuscledisorders

Myofascialpain局限性鈍痛，下頜運(yùn)動(dòng)時(shí)疼痛加重。局部肌肉或筋膜帶觸壓診痛（觸痛點(diǎn)或扳機(jī)點(diǎn)），觸壓扳機(jī)點(diǎn)可加重疼痛或引起相鄰部位的牽涉痛。使用冷凍噴霧或扳機(jī)點(diǎn)局部封閉可減輕疼痛達(dá)50％以上?？砂殡S以下癥狀或體征：1）肌肉僵硬感;2）臨床檢查難以發(fā)現(xiàn)的急性錯(cuò)合感;3）耳痛、耳鳴、眩暈、牙痛、緊張型頭痛;4）開口受限，但有被動(dòng)開口;5)牽涉痛或受累部位的痛覺敏感。Ia 肌筋膜疼痛

肌肉源性的疼痛，包括疼痛主訴及主訴相關(guān)的局部肌肉疼痛。

1)

主訴頜骨、顳面部、耳前區(qū)或耳內(nèi)靜息時(shí)或下頜功能運(yùn)動(dòng)時(shí)疼痛；加

2)

下述20處肌肉壓診有三處以上痛覺敏感，左右側(cè)獨(dú)自計(jì)數(shù)。顳肌前、中、后束、咬肌起始處、咬肌體部、咬肌終止部、頜后區(qū)、頜下區(qū)、翼外?。趦?nèi)）、顳肌肌腱（口內(nèi)）。至少有一處壓痛位于主訴疼痛側(cè)。傅開元.顳下頜關(guān)節(jié)紊亂病的RDC/TMD標(biāo)準(zhǔn)化診斷(講座).中國(guó)口腔醫(yī)學(xué)繼續(xù)教育雜志2009;12(2):55-57DiscderangementdisordersItischaracterizedbyanabnormalrelationormisalignmentofthearticulardiscandcondyletheusualdirectionfordisplacementisinananteriororanteromedialdirectionDiscderangementdisordersDiscdisplacementwithreductionDiscdisplacementwithoutreductionAcutevsChronicTMDdiskdisplacementwithreductionTMDdiskdisplacementwithoutreductionADDwRADDw/oRZhangRong(A018867,X125254),M/24.

CC:Openlimitedfor1month,clickinghistoryofbothTMJsfor3yearsandclose-lockedsometimesontherightside.

CF:Mouthopenwas30mm,openingpainontherightandopeningclickingontheleftside.

CD:AcuteADDw/oR(right),ADDwR(left)

Close-ROpen-LOpen-RClose-LDiscderangementdisorders---

discdisplacementwithreductionisdescribedasanabruptalterationorinterferenceofthedisc-condylestructuralrelationmisaligneddiscreducesorimprovesitsstructuralrelationwiththecondylewhenmouthopeningjointnoise(sound):clickingorpoppingDiscderangementdisorders---

discdisplacementwithreduction---diagnosticcriteriaReproduciblejointnoisethatoccursusuallyatvariablepositionsduringopeningandclosingmandibularmovementssofttissueimagingrevealingdisplaceddiscthatimprovesitspositionduringjawopening,andhardtissueimagingshowinganabsenceofextensivedegenerativebonechanges

(Painwhenpresentprecipitatedbyjointmovement;deviationduringmovementcoincidingwithaclick;……)Discderangementdisorders---

discdisplacementwithreduction---diagnosticcriteria開閉口下頜運(yùn)動(dòng)過程中，可重復(fù)的關(guān)節(jié)彈響影像學(xué)檢查證實(shí)閉口位關(guān)節(jié)盤處于前移位狀態(tài)，開口位時(shí)關(guān)節(jié)盤回復(fù)至正常狀態(tài)。硬組織X線影像無(wú)廣泛的骨關(guān)節(jié)退行性改變。

可伴有下列情況：關(guān)節(jié)區(qū)疼痛，下頜運(yùn)動(dòng)時(shí)疼痛加重，與彈響發(fā)生相關(guān)的開口偏斜。IIa可復(fù)性盤前移位符合a或ba． 往返性關(guān)節(jié)彈響（開閉口過程同一位置點(diǎn)出現(xiàn)彈響，下頜前伸位開閉口能消除彈響），連續(xù)檢查3次出現(xiàn)2次以上。b． 垂直向（開口或閉口）和側(cè)向或前伸運(yùn)動(dòng)均有關(guān)節(jié)彈響，連續(xù)檢查3次可出現(xiàn)2次以上。傅開元.顳下頜關(guān)節(jié)紊亂病的RDC/TMD標(biāo)準(zhǔn)化診斷(講座).中國(guó)口腔醫(yī)學(xué)繼續(xù)教育雜志2009;12(2):55-57Discderangementdisorders---

discdisplacementwithoutreductionisdescribedasanalteredormisaligneddisc-condylestructuralrelationthatismaintainedduringmandibulartranslationdiscisnonreducingor“permanently”displacedanddoesnotimproveitsrelationwiththecondyleontranslationsometimesreferredtoasa“closedlock”acuteandchronicAcutediscdisplacementwithoutreduction---

diagnosticcriteriaPersistentmarkedlimitedmouthopening(<35mm)withhistoryofsuddenonsetDeflectiontotheaffectedsideonmouthopeningMarkedlimitedlaterotrusiontothecontralateralside(ifunilateral)Sofetissueimagingrevealingdisplaceddiscwithoutreduction,andhardtissueimagingrevealingnoextensiveosteoarthriticchanges

(painprecipitatedbyforcedmouthopening;historyofclickingthatceasedwiththelocking;painwithpalpationoftheaffectedjoint;…..)Acutediscdisplacementwithoutreduction---

diagnosticcriteria持續(xù)性開口受限（≤35mm），突然發(fā)生如單側(cè)患病，開口時(shí)下頜偏向患側(cè)明顯的向?qū)?cè)側(cè)向運(yùn)動(dòng)受限影像學(xué)檢查可證實(shí)，關(guān)節(jié)盤前移位且開口位時(shí)關(guān)節(jié)盤仍位于髁突前方。硬組織X線檢查無(wú)廣泛的骨關(guān)節(jié)病改變。

可伴有以下情況：1）疼痛、用力開口時(shí)疼痛加重；2）關(guān)節(jié)彈響史，開口受限發(fā)生后彈響消失；3）局部關(guān)節(jié)區(qū)存在觸壓痛；4）患側(cè)咬合過緊；6）X線檢查中度的骨關(guān)節(jié)病改變IIb 不可復(fù)性盤前移位，伴開口受限

指的是關(guān)節(jié)盤在髁突和關(guān)節(jié)結(jié)節(jié)之間的正常位置上發(fā)生移位，向前和向內(nèi)或向外移位，且伴有下頜開口受限。1)突然開口受限的病史；加2)最大自由開口度35mm；加3)有一定的被動(dòng)開口，但一般僅增加4mm以內(nèi)；加4)對(duì)側(cè)側(cè)向運(yùn)動(dòng)受限（<7mm）和/或開口時(shí)下頜偏斜，偏向病變側(cè)；加5)無(wú)關(guān)節(jié)彈響或有關(guān)節(jié)彈響但完全不同于可復(fù)性前移位診斷的關(guān)節(jié)彈響。Chronicdiscdisplacementwithoutreduction---

diagnosticcriteriaHistoryofsuddenonsetoflimitedmouthopeningthatoccurredmorethan4monthsagoSofetissueimagingrevealingdisplaceddiscwithoutreduction,andhardtissueimagingrevealingnoextensiveosteoarthriticchanges

(painwhenpresentmarkedlyreducedfromacutestage;historyofclickingthatresolvedwithsuddenonsetofthelocking;moderateosteoarthriticchangeswithimagingofhardtissue;gradualresolutionoflimitedmouthopening.)Chronicdiscdisplacementwithoutreduction---

diagnosticcriteria至少4個(gè)月前有突然發(fā)生的開口受限史影像學(xué)檢查證實(shí)有不可復(fù)性盤前移位。X線檢查無(wú)廣泛的骨關(guān)節(jié)病改變

可伴有以下情況：1）疼痛，明顯的比急性期輕或僅有輕度僵硬感；2）關(guān)節(jié)彈響史、隨開口突然受限而彈響消失；3）X線檢查可存在中度的骨關(guān)節(jié)病改變；4）開口度可漸漸的改善。IIc不可復(fù)性盤前移位，無(wú)開口受限1．突然的開口受限病史；加2．最大自由開口度>35mm；加3．有被動(dòng)開口，且開口度可增加5mm以上；加4．對(duì)側(cè)側(cè)向運(yùn)動(dòng)>7mm；加5．出現(xiàn)關(guān)節(jié)彈響但不符合可復(fù)性前移位的診斷標(biāo)準(zhǔn)。6．如果接受影像學(xué)檢查，則應(yīng)符合不可復(fù)性盤前移位診斷。作出IIc診斷應(yīng)明確說(shuō)明是基于臨床檢查和病史還是基于影像學(xué)檢查結(jié)果。Li(李潤(rùn)亮,X129776),male,35yearsold.CC:LeftTMJsoundsforyears.CF:Maximalincisalopening45mm,reciprocalclickingintheleftside.MRI:ADDwRoftheleftside

Chronic

ADDw/oRoftherightsideLLRRInflammatorydisordersInflammatoryconditionssuchassynovitisorcapsulitisfrequentlyoccursecondarytotrauma,irritation,orinfectionandoftenaccompanyotherTMDsSynovitisandcapsulitisPolyarthritidesInflammatorydisorders

SynovitisandcapsulitisisdescribedasaninflammationofthesynovialliningoftheTMJthatcanbeduetoinfection,animmunologicconditionsecondarytocartilagedegeneration,ortrauma.ischaracterizedbylocalizedpainthatisexacerbatedbyjointfunctiononoccasiontherewillbeaswelling(effusion)thatdecreasestheabilitytooccludeontheipsilateralposteriorteethInflammatorydisorders

Synovitisandcapsulitis---

diagnosticcriteriaLocalizedTMJpainexacerbatedbyfunction,especiallywithsuperiororposteriorjointloadingandpalpationNoextensiveosteoarthriticchangeswithhardtissueimaging

(localizedTMJpainatrest;limitedrangeofmotionsecondarytopain;swelling(duetoeffusion)thatdecreasesabilitytooccludeonipsilateralposteriorteeth;abrightMRIsignalwhenfluidispresent;earpain.)Inflammatorydisorders

Synovitisandcapsulitis---

diagnosticcriteria關(guān)節(jié)區(qū)疼痛，下頜運(yùn)動(dòng)時(shí)疼痛加重，特別是向關(guān)節(jié)上或后方的用力或觸壓疼痛明顯X線無(wú)明確的骨關(guān)節(jié)病改變可伴有以下情況：1）下頜靜止時(shí)關(guān)節(jié)區(qū)疼痛；2）因疼痛而下頜運(yùn)動(dòng)受限；3）關(guān)節(jié)區(qū)腫脹（關(guān)節(jié)內(nèi)滲液），病變側(cè)后牙不能緊咬；4）MRIT2圖像可見關(guān)節(jié)滲液的強(qiáng)信號(hào)；5）耳部疼痛Osteoarthrosis(Osteoarthritis)isconsideredtobeanoninflammatoryarthritisconditionthatiscommonlyfoundinavarietyofsynovialjointsisclassifiedaseitherprimaryorsecondaryaccordingtotheetiologydiscperforationOsteoarthrosis(Osteoarthritis)

SecondaryOAOAisdefined