口腔颌面外科学：颞下颌关节疾病

TMJ is technically considered a ginglymoarthrodial joint
不动关节，微动关节，活动关节（滑膜关节） Hinging movement in one plane (ginglymoid joint，屈戌 关节,绞链关节,滑车关节) Gliding movement (arthrodial joint， 滑动关节,平面关节)
Fu K, Ma X, Zhang Z, Pang X, and Chen W. Interleukin 6 in synovial fluid and HLADR expression in synovium from patients with temporomandibular disorders. J Orofacial Pain 1995;9(2):131-139
(Nia Odontol Scand 2006; 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的精神因素
焦虑 (anxiety) 抑郁 (depression) 应激 (stress) 生活事件 (life events) 个性或人格 (personality) 其他：口腔习惯 夜间磨牙等
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
Fu K, Ma X, Zhang Z, and Chen W. Tumor necrosis factor in synovial fluid of patients with temporomandibular disorders. J Oral Maxillofac Surg 1995;53:424-426
Muscle provides mandibular movement
Masticatory muscles include masseter, medial pterygoid muscle, temporal muscle, and lateral pterygoid muscle and digastric muscle. Associated muscles of the head and neck furnish secondary support during mastication.
颞下颌关节紊乱病的致病因素
Br J Dent 2007
TMD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
Cao Y, Xie QF, Li K, Light AR, Fu KY. Experimental occlusal interference induces long-term masticatory muscle hyperalgesia in rats. Pain 2009; 144(3): 287-93
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
Etiology of TMD
The identification of an unambiguous universal cause of TMD is lacking Most of the factors discussed are not proven causal factors, but factors having associations with TMD. Factors that increase the risk of TMD are called predisposing factors, that cause the onset of TMD are called initiating factors, that interfere with healing or enhance the progression of TMD are called perpetuating factors.
来自中国，2008
Epidemiology of TMD
Overall symptom levels (eg, Helkimo index) in nonpatient surveys of adults was almost equal in men and women. A women-to-men ratio of 3:1 to 9:1 in persons seeking care for TMD. (???)
明尼苏达多项人格测验Minnesota multiphase personality inventory (MMPI), 症状自评量表Symptom checklist 90 (SCL-90), 医院焦虑抑 郁量表Hospital anxiety and depression scale (HADS),
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
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。
TMDs include:
Masticatory muscle disorders Disc derangement disorders Inflammatory disorders Osteoarthritis (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）
Temporomandibular disorders (TMD)
Costen-syndrome (1934) TMJ disturbances, TMJ dysfunction syndrome
(Shore 1959, Lupton 1969, et al) Occluso-mandibular disturbance (Gerber 1971) Pain-dysfunction syndrome (Voss 1964, Laskin 1969) Myofacial pain dysfunction syndrome (Schwartz 1959) Craniomandibular disorders (CMD)
➢ 颞下颌关节紊乱病
Temporomandibular disorders
➢ 颞下颌关节脱位
Dislocation of temporomandibular joint
➢ 颞下颌关节强直
Ankylosis of temporomandibular joint
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？
疼痛
弹响和杂音
single/multiple,
early/late,
soft/loud,
painful/not painful,
crepitus
Epidemiology of TMD
Percentage of population with signs 50-75%
Percentage of population with symptoms 20-25%
Percentage of population who seek treatment 3-4%
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
口腔颌面外科学
颞下颌关节疾病
TMJ consists of the:
➢ Mandibular condyle ➢ Temporal bone (fossa) ➢ Articular disc ➢ Joint capsule (lined by the synovial membrane) ➢ Ligaments ➢ Blood and nerve supply
TMD的咬合因素
Subjects with a TMD history showed more clinical signs and subjective symptoms and adapted less well to the artificial interferences. (Le Bell et al., Acta Odontol Scand 2006; 64(1):59-63) Some personality characteristics in subjects with an earlier TMD history tended to associate with higher symptom reporting despite the type of intervention.
Temporomandibular disorders (TMD)
颞下颌关节紊乱病 (定义)
TMDs is a collective term embracing a number of clinical problems (that have many common symptoms) that involve the masticatory musculature, the TMJ and associated structures, or both.
TMD致病因素
TMD病因
易感因素 (Predisposing factors)
促发因素 (Initiating factors)
持续因素 (Perpetuating factors)
mutans streptococci
sugar
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
TMD的免疫反应
创伤
炎症
胶原或蛋白多糖的降解
蛋白酶的释放
IL-1
抗原暴露
Immunocomplex, IL-1, IL-2, IL-6, TNF
抗原识别
B lymphocyte
T
抗体
synoviocyte macrophage neutrophil
抗原抗体反应
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
Unlike most synovial joints,
The articular surface of TMJs are lined with dense fibrous connective tissue, not hyaline cartilage This is an important feature since fibrous connective tissue has a greater ability to repair itself than does hyaline cartilage