口腔颌面外科学课件：颞下颌关节疾病

颞下颌关节疾病

口腔颌面外科学TMJconsistsofthe:MandibularcondyleTemporalbone(fossa)ArticulardiscJointcapsule(linedbythesynovialmembrane)LigamentsBloodandnervesupplyTMJistechnically

consideredaginglymoarthrodialjoint

不动关节，微动关节，活动关节（滑膜关节）Hingingmovementinoneplane(ginglymoidjoint，屈戌关节,绞链关节,滑车关节)Glidingmovement(arthrodialjoint，滑动关节,平面关节)Unlikemostsynovialjoints,

ThearticularsurfaceofTMJsarelinedwithdensefibrousconnectivetissue,nothyalinecartilageThisisanimportantfeaturesincefibrousconnectivetissuehasagreaterabilitytorepairitselfthandoeshyalinecartilageMuscleprovidesmandibularmovement

Masticatorymusclesincludemasseter,medialpterygoidmuscle,temporalmuscle,andlateralpterygoidmuscleanddigastricmuscle.Associatedmusclesoftheheadandneckfurnishsecondarysupportduringmastication.颞下颌关节紊乱病

Temporomandibulardisorders颞下颌关节脱位

Dislocationoftemporomandibularjoint

颞下颌关节强直

Ankylosisoftemporomandibularjoint颞下颌关节紊乱病

颞下颌关节紊乱病的致病因素？颞下颌关节紊乱病的分类与诊断？Temporomandibulardisorders(TMD)Costen-syndrome(1934)TMJdisturbances,TMJdysfunctionsyndrome(Shore1959,Lupton1969,etal)Occluso-mandibulardisturbance(Gerber1971)Pain-dysfunctionsyndrome(Voss1964,Laskin1969)Myofacialpaindysfunctionsyndrome(Schwartz1959)Craniomandibulardisorders(CMD)Temporomandibulardisorders(TMD)颞下颌关节紊乱病(定义)

TMDsisacollectivetermembracinganumberofclinicalproblems(thathavemanycommonsymptoms)thatinvolvethemasticatorymusculature,theTMJandassociatedstructures,orboth.

指累及咀嚼肌系统和/或颞下颌关节，具有相关临床问题（如疼痛、弹响、张口受限等）的一组疾病的总称。TMDsinclude:MasticatorymuscledisordersDiscderangementdisordersInflammatorydisordersOsteoarthritis(Osteoarthrosis)不要把颞下颌关节紊乱病看作单纯一个病!颞下颌关节紊乱病

颞颌关节功能紊乱症-----

张、曾,1973年颞下颌关节紊乱综合征------张、马,1983颞下颌关节紊乱病------马，张,1997年临床诊断不宜使用TMD这个笼统的称呼

TMD的临床表现

下颌运动异常(开口度、开口型、绞锁、前伸运动、侧向运动）疼痛弹响和杂音

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

50-75%Percentageofpopulationwithsymptoms

20-25%Percentageofpopulationwhoseektreatment3-4%

对3050位四川省成都市郊区2～84岁居民进行的断面研究显示（史宗道，2008）30%的人群出现过TMD的某些症状，9.9%较重65%调查人群具有颞下颌关节紊乱病的症状体征，较重和严重者10.3%症状年发病率为8.9%，体征年发病率为17.5%每年6.7‰的自然人群新发病并伴有严重的症状体征，其学习、生活和工作受到影响来自中国，2008EpidemiologyofTMDOverallsymptomlevels(eg,Helkimoindex)innonpatientsurveysofadultswasalmostequalinmenandwomen.Awomen-to-menratioof3:1to9:1inpersonsseekingcareforTMD.(???)颞下颌关节紊乱病的致病因素BrJDent2007TMD的咬合因素

TMD的咬合因素

RCP与ICP不协调；平衡侧合干扰多个（多象限）后牙缺失；某些类型的错合

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)这两个研究结论应对我们临床有很大的指导意义！！！TMD的咬合因素

TMD的精神因素

焦虑(anxiety)抑郁(depression)应激(stress)生活事件(lifeevents)个性或人格(personality)其他：口腔习惯夜间磨牙等

明尼苏达多项人格测验Minnesotamultiphasepersonalityinventory(MMPI),症状自评量表Symptomchecklist90(SCL-90),医院焦虑抑郁量表Hospitalanxietyanddepressionscale(HADS),

TMD的免疫因素

软骨细胞胶原蛋白多糖

具有抗原性

TMD的免疫因素

TMD关节液中检测到抗II型胶原抗体髁状突软骨内免疫复合物沉积TMD关节液IL－1、TNF、IL－6含量升高滑膜组织过度表达HLA－DR抗原FuK,MaX,ZhangZ,andChenW.Tumornecrosisfactorinsynovialfluidofpatientswithtemporomandibulardisorders.JOralMaxillofacSurg1995;53:424-426FuK,MaX,ZhangZ,PangX,andChenW.Interleukin6insynovialfluidandHLA-DRexpressioninsynoviumfrompatientswithtemporomandibulardisorders.JOrofacialPain1995;9(2):131-139创伤炎症胶原或蛋白多糖的降解抗原暴露抗原识别Blymphocyte抗体抗原抗体反应TsynoviocytemacrophageneutrophilImmunocomplex,IL-1,IL-2,IL-6,TNF蛋白酶的释放IL-1TMD的免疫反应

TMD的解剖因素

现代人上下颌骨变小;现代人关节结节低,关节窝浅;现代人髁状突变小，关节窝相对大;进化使得关节和颌骨更为灵巧，以适应更为复杂的语言和表情等下颌运动。但另一方面，关节结构变得脆弱，易受到损伤和发生组织退行性变。健康志愿者髁突位置

TMD的其他因素（关节负荷过重）

单侧咀嚼夜磨牙紧咬牙发育不对称喜硬食物医源性EtiologyofTMDTheidentificationofanunambiguousuniversalcauseofTMDislackingMostofthefactorsdiscussedarenotprovencausalfactors,butfactorshavingassociationswithTMD.FactorsthatincreasetheriskofTMDarecalledpredisposingfactors,thatcausetheonsetofTMDarecalledinitiatingfactors,thatinterferewithhealingorenhancetheprogressionofTMDarecalledperpetuatingfactors.mutansstreptococcisugar

TMD致病因素

TMD病因

易感因素(Predisposingfactors)促发因素(Initiatingfactors)持续因素(Perpetuatingfactors)病因学说回顾机械移位学说和因素学说关节囊薄弱理论合

--神经肌肉学说肌肉学说精神生理学说心理病因学说关节内微小创伤理论多因素致病学说颞下颌关节紊乱病诊断与分类

颞颌关节功能紊乱症-------

张、曾,1973年功能紊乱期结构紊乱期器质性破坏期颞下颌关节紊乱病诊断与分类

颞下颌关节紊乱综合征------张、马,1983年第一类：咀嚼肌功能紊乱类第二类：关节结构紊乱类第三类：器质性改变类颞下颌关节紊乱病诊断与分类颞下颌关节紊乱病------马，张,1997年Ⅰ：咀嚼肌紊乱疾病Ⅱ：结构紊乱疾病----关节盘移位Ⅲ：炎症性疾病----滑膜炎Ⅳ：骨关节病颞下颌关节紊乱病诊断与分类MasticatorymuscledisordersDiscderangementdisordersInflammatorydisordersOsteoarthritis(Osteoarthrosis)ResearchDiagnosticCriteriaforTemporomandibulardisorders(RDC/TMD)byDworkinSFandLeRescheRI)Musclediagnosesa:Myofacialpainb:MyofacialpainwithlimitedopeningII)Diskdisplacementsa:DDwithreductionb:DDwithoutreduction,withlimitedopeningc:DDwithoutreduction,withoutlimitedopeningIII)Arthralgia,Arthritis,Arthrosisa:Arthralgiab:OsteoarthritisofTMJc:OsteoarthrosisofTMJ傅开元.颞下颌关节紊乱病的RDC/TMD标准化诊断(讲座).中国口腔医学继续教育杂志2009;12(2):55-57第I类 肌肉疾患肌筋膜疼痛肌筋膜疼痛伴开口受限第II类 关节盘移位可复性关节盘移位不可复性关节盘移位，开口受限不可复性关节盘移位，无开口受限第III类 关节痛、关节炎、关节病关节痛骨关节炎骨关节病ResearchDiagnosticCriteriaforTemporomandibulardisorders(RDC/TMD)byDworkinSFandLeRescheRMasticatorymuscledisordersMyofascialpainMyositisMyospasm..\kyfu_Clinic\Specialcases\翼肌咬肌痉挛\张荣_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局限性钝痛，下颌运动时疼痛加重。局部肌肉或筋膜带触压诊痛（触痛点或扳机点），触压扳机点可加重疼痛或引起相邻部位的牵涉痛。使用冷冻喷雾或扳机点局部封闭可减轻疼痛达50％以上。可伴随以下症状或体征：1）肌肉僵硬感;2）临床检查难以发现的急性错合感;3）耳痛、耳鸣、眩晕、牙痛、紧张型头痛;4）开口受限，但有被动开口;5)牵涉痛或受累部位的痛觉敏感。Ia 肌筋膜疼痛

肌肉源性的疼痛，包括疼痛主诉及主诉相关的局部肌肉疼痛。

1)

主诉颌骨、颞面部、耳前区或耳内静息时或下颌功能运动时疼痛；加

2)

下述20处肌肉压诊有三处以上痛觉敏感，左右侧独自计数。颞肌前、中、后束、咬肌起始处、咬肌体部、咬肌终止部、颌后区、颌下区、翼外肌（口内）、颞肌肌腱（口内）。至少有一处压痛位于主诉疼痛侧。傅开元.颞下颌关节紊乱病的RDC/TMD标准化诊断(讲座).中国口腔医学继续教育杂志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开闭口下颌运动过程中，可重复的关节弹响影像学检查证实闭口位关节盘处于前移位状态，开口位时关节盘回复至正常状态。硬组织X线影像无广泛的骨关节退行性改变。

可伴有下列情况：关节区疼痛，下颌运动时疼痛加重，与弹响发生相关的开口偏斜。IIa可复性盘前移位符合a或ba． 往返性关节弹响（开闭口过程同一位置点出现弹响，下颌前伸位开闭口能消除弹响），连续检查3次出现2次以上。b． 垂直向（开口或闭口）和侧向或前伸运动均有关节弹响，连续检查3次可出现2次以上。傅开元.颞下颌关节紊乱病的RDC/TMD标准化诊断(讲座).中国口腔医学继续教育杂志2009;12(2):55-57Discderangementdisorders---

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

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

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

diagnosticcriteria持续性开口受限（≤35mm），突然发生如单侧患病，开口时下颌偏向患侧明显的向对侧侧向运动受限影像学检查可证实，关节盘前移位且开口位时关节盘仍位于髁突前方。硬组织X线检查无广泛的骨关节病改变。

可伴有以下情况：1）疼痛、用力开口时疼痛加重；2）关节弹响史，开口受限发生后弹响消失；3）局部关节区存在触压痛；4）患侧咬合过紧；6）X线检查中度的骨关节病改变IIb 不可复性盘前移位，伴开口受限

指的是关节盘在髁突和关节结节之间的正常位置上发生移位，向前和向内或向外移位，且伴有下颌开口受限。1)突然开口受限的病史；加2)最大自由开口度35mm；加3)有一定的被动开口，但一般仅增加4mm以内；加4)对侧侧向运动受限（<7mm）和/或开口时下颌偏斜，偏向病变侧；加5)无关节弹响或有关节弹响但完全不同于可复性前移位诊断的关节弹响。Chronicdiscdisplacementwithoutreduction---

diagnosticcriteriaHistoryofsuddenonsetoflimitedmouthopeningthatoccurredmorethan4monthsagoSofetissueimagingrevealingdisplaceddiscwithoutreduction,andhardtissueimagingrevealingnoextensiveosteoarthriticchanges

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

diagnosticcriteria至少4个月前有突然发生的开口受限史影像学检查证实有不可复性盘前移位。X线检查无广泛的骨关节病改变

可伴有以下情况：1）疼痛，明显的比急性期轻或仅有轻度僵硬感；2）关节弹响史、随开口突然受限而弹响消失；3）X线检查可存在中度的骨关节病改变；4）开口度可渐渐的改善。IIc不可复性盘前移位，无开口受限1．突然的开口受限病史；加2．最大自由开口度>35mm；加3．有被动开口，且开口度可增加5mm以上；加4．对侧侧向运动>7mm；加5．出现关节弹响但不符合可复性前移位的诊断标准。6．如果接受影像学检查，则应符合不可复性盘前移位诊断。作出IIc诊断应明确说明是基于临床检查和病史还是基于影像学检查结果。Li(李润亮,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关节区疼痛，下颌运动时疼痛加重，特别是向关节上或后方的用力或触压疼痛明显X线无明确的骨关节病改变可伴有以下情况：1）下颌静止时关节区疼痛；2）因疼痛而下颌运动受限；3）关节区肿胀（关节内渗液），病变侧后牙不能紧咬；4）MRIT2图像可见关节渗液的强信号；5）耳部疼痛Osteoarthrosis(Osteoarthritis)isconsideredtobeanoninflammatoryarthritisconditionthatiscommonlyfoundinavarietyofsynovialjointsisclassifiedaseitherprimaryorsecondaryaccordingtotheetiologydiscperforationOsteoarthrosis(Osteoarthritis)

SecondaryOAOAisdefined