下颌骨缺损修复后颞下颌关节位置变化的临床分析

doi:10.7518/hxkq.2025.2024337

华西口腔医学杂志 ›› 2025, Vol. 43 ›› Issue (3): 422-430.doi: 10.7518/hxkq.2025.2024337

下颌骨缺损修复后颞下颌关节位置变化的临床分析

李审绥¹(), 田旭东¹, 吴亚东¹, 王伟丽²(), 唐正龙¹()

^1.贵州医科大学附属口腔医院口腔颌面外科，贵阳 550004
^2.贵州医科大学附属医院血液科，贵阳 550004

收稿日期:2024-09-10 修回日期:2025-02-27 出版日期:2025-06-01 发布日期:2025-06-10
通讯作者: 王伟丽,唐正龙 E-mail:lishensui@gmc.edu.cn;weili533@163.com;tangzhenglong@hotmail.com
作者简介:李审绥，主治医师，硕士，E-mail：lishensui@gmc.edu.cn
基金资助:
贵州省卫生健康委科学技术基金项目(gzwkj2024-195);贵州医科大学附属口腔医院横向课题(GYKQ2022HXZD05);贵州医科大学附属口腔医院科研基金(GYKQKY202305);贵州省教育厅高等院校教学改革项目(2023143);贵州医科大学本科教学内容和课程体系改革重点课题(JG2023017)

Clinical analysis of changes in the position of the condyle and temporomandibular joint after repair of mandibular defects

Li Shensui¹(), Tian Xudong¹, Wu Yadong¹, Wang Weili²(), Tang Zhenglong¹()

^1.Dept. of Oral and Maxillofacial Surgery, Affiliated Stomatological Hospital of Guizhou Medical University, Guiyang 550004, China
^2.Dept. of Hematology, Affiliated Hos-pital of Guizhou Medical University, Guiyang 550004, China

Received:2024-09-10 Revised:2025-02-27 Online:2025-06-01 Published:2025-06-10
Contact: Wang Weili,Tang Zhenglong E-mail:lishensui@gmc.edu.cn;weili533@163.com;tangzhenglong@hotmail.com
Supported by:
Science-Technology Fund of Health Commission of Guizhou Province(gzwkj2024-195);Horizontal Research Project of the Affiliated Stomatological Hospital of Guizhou Medical University(GYKQ2022-HXZD05);Scientific Research Fund of the Affiliated Stomatological Hospital of Guizhou Medical University(GYKQKY202305);Teaching Reform Program of Higher Education Institutions of Guizhou Provincial Department of Education(2023143);Key Project of Undergraduate Teaching Reform Research at Guizhou Medical University(JG-2023017)

摘要/Abstract

摘要：

目的通过回顾性分析探讨下颌骨缺损修复术后髁突及颞下颌关节位置改变的影响因素，并评估骨瓣重建后对髁突及颞下颌关节位置的影响，以期为确定下颌骨缺损修复方案和颞下颌关节重建提供临床参考。方法本研究选取贵州医科大学附属口腔医院2019年6月—2024年5月收治的90例下颌骨截断切除并同期行骨瓣修复术的患者作为研究对象。经严格筛选后，最终纳入50例完整病例进行回顾性分析。收集患者基本资料、骨缺损大小、位置及修复方式等临床信息，并获取术前（T0）、术后7~10 d（T1）、术后3月（T2）及术后6月（T3）4个时间节点的颌面部CT数据。运用Mimics 20软件进行三维重建后，通过Kamelchuk法测量颞下颌关节前间隙、后间隙及上间隙，根据Pullinger公式计算Ln值（后间隙/前间隙）大小以确定髁突在关节窝中的位置。同时Vitral法和Krisjane法测量下颌骨线距（下颌升支长度、髁突内外极点到矢状面的距离及角度）和关节窝形态指标，并使用SPSS 21.0进行统计分析。结果下颌骨缺损大小和位置是术后髁突位置变化的重要因素（P<0.05）。与术前相比，术后髁突前间隙、后间隙及上间隙均显著增加（P<0.001）。在术后7~10 d内，髁突位置前移现象最为显著，差异有统计学意义（P<0.05）。对于切除髁突的患者，术后关节间隙和角度显著增大；而保留髁突的患者，仅关节上间隙及前间隙变化差异有统计学意义（P<0.05）。此外，在T1~T2时间段内，髁突内极点到矢状面的距离、关节上间隙、前间隙的变化量与术前髁突位置呈负相关（P<0.05）；在T0~T1时间段内，髁突内极点到矢状面的距离、关节后间隙、关节结节角的变化量呈显著负相关（P<0.05）；值得注意的是，髁突长轴与冠状轴的夹角的变化量从T1至T3时间段内持续表现出负向变化趋势（P<0.05）。结论下颌骨缺损骨瓣修复术后，髁突位置的改变与骨缺损的大小和位置相关，同时术后颞下颌关节间隙发生适应性改建。术后早期（7~10 d）髁突前移现象随随访时间延长呈现复位趋势，需进一步扩大样本量研究。

关键词: 下颌骨缺损, 骨瓣修复, 髁突位置, 颞下颌关节位置改变, 颌面部CT

Abstract:

Objective This retrospective study aimed to investigate factors influencing positional changes of the condyle and temporomandibular joint (TMJ) following mandibular defect reconstruction with bone flaps, and to evaluate the biomechanical impacts of flap reconstruction on condylar positioning, thereby providing evidence for optimizing surgical protocols and TMJ functional rehabilitation. Methods A retrospective study was conducted on 90 patients undergoing mandibular segmental resection with immediate bone flap reconstruction at Guizhou Medical University Affiliated Stomatological Hospital (June 2019 to May 2024). After strict screening, 50 cases with complete data were analyzed. Clinical parameters (defect size, location, reconstruction method) and craniofacial CT scans at four timepoints [preoperative (T0), 7-10 days (T1), 3 months (T2), and 6 months (T3) postoperatively] were collected. Mimics 20 software facilitated 3D reconstruction for measuring TMJ anterior/posterior/superior joint spaces (Kamelchuk method) and calculating condylar position via the Pullinger index [Ln (posterior/anterior space)]. Vitral and Krisjane methods quantified mandibular linear parameters (ramus length, condylar pole distances to the sagittal plane, angulation) and glenoid fossa morphology. Statistical analyses were performed using SPSS 21.0. Results Mandibular defect size and location were significant factors influencing postoperative condylar position changes (P<0.05). Compared to preoperative measurements, postoperative condylar anterior, posterior, and superior joint spaces were significantly increased (P<0.001). The most pronounced anterior condylar displacement occurred within 7-10 days postoperatively (P<0.05). In patients with condyle resection, postoperative joint space and angle changes were significant; in patients with condyle preservation, only superior and anterior joint space changes were statistically significant (P<0.05). Additionally, from T1 to T2, the changes in condylar medial-lateral distance, superior joint space, and anterior joint space were negatively correlated with the preoperative condylar position. Compared with preoperative,in the T0-T1 period, condylar medial-lateral distance, posterior joint space, and articular tubercle angle changes were significantly negatively correlated with time (P<0.05). Notably, the angle between the condylar long axis and the coronal axis showed a sustained negative trend from T1 to T3 (P<0.05). Conclusion Condylar position changes after mandibular defect repair with bone flap reconstruction are associated with the size and location of the defect. Additionally, adaptive remodeling of the temporomandibular joint (TMJ) joint space occurs postoperatively. The phenomenon of anterior displacement of the condyle in the early postoperative period (7-10 days) shows a trend of reduction with prolonged follow-up time, and further sample size research is needed.

Key words: mandibular defect, bone flap repair, condylar position, temporomandibular joint position change, maxillofacial CT

中图分类号:

R782.6

李审绥, 田旭东, 吴亚东, 王伟丽, 唐正龙. 下颌骨缺损修复后颞下颌关节位置变化的临床分析[J]. 华西口腔医学杂志, 2025, 43(3): 422-430.

Li Shensui, Tian Xudong, Wu Yadong, Wang Weili, Tang Zhenglong. Clinical analysis of changes in the position of the condyle and temporomandibular joint after repair of mandibular defects[J]. West China Journal of Stomatology, 2025, 43(3): 422-430.

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参考文献 23

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指标	定义
下颌升支长度（Co-Go）	髁顶点到下颌角点的距离
关节上间隙（super articular space，SS）	关节窝顶点至髁突顶点的距离
关节前间隙（anterior articular space，AS）	过关节窝顶点作髁突前缘切线，切点与关节窝前缘的最短距离
关节后间隙（retroarticular space，PS）	过关节窝顶点作髁突后缘切线，切点与关节窝后缘的最短距离
关节窝宽度（articular fossa width，FS）	外耳道与关节结节最低点间距离
关节窝深度（articular fossa depth，FD）	关节窝顶点至外耳道与关节结节最低点间连线的最短距离
关节结节角（articular nodular angle，NA）	关节窝顶点与关节结节最低点间连线与眶耳平面的夹角
a	髁突外极点到正中矢状面的垂直距离
b	髁突内极点到正中矢状面的垂直距离
r	髁突中心点到正中矢状面的垂直距离
α	髁突长轴与冠状轴的夹角
正中矢状面（median sagittal plane，MSP）	鼻尖-鼻中隔-枕骨大孔中点连线，作为矢状面基线

变量	术后随访时间
变量	T1	T2	T3
钛板外露	0	2（4%）	2（4%）
TMJ疼痛	0	2（4%）	2（4%）
TMJ弹响	0	0	0
咬合紊乱	0	1（2%）	1（2%）
张口受限	0	0	0

满意度	术后随访时间
满意度	T1	T2	T3
满意率	100%	100%	100%
满意	44	43	40
比较满意	6	7	10
不满意	0	0	0

变量	T3/n			P值
变量	髁突前移	中间	髁突后移	P值
骨缺损/cm	0.030
<8.44	13	8	3
≥8.44	13	10	3
下颌骨缺损修复方式	0.700
腓骨瓣	25	15	6
髂骨瓣	1	3	0
肿瘤类型	0.400
良性肿瘤	18	15	3
恶性肿瘤	8	3	1
是否行数字化技术	0.400
是	18	15	3
否	8	3	3
下颌骨Brown分类	0.020
BrownⅠ类缺损	7	4	0
BrownⅠc类缺损	4	2	1
BrownⅡ类缺损	6	4	0
BrownⅡc类缺损	3	2	3
Brown Ⅲ类缺损	3	3	1
Brown Ⅳ类缺损	3	3	0
Brown Ⅳc类缺损	0	0	1

指标	T0	T1	T2	T3	4组间比较P值
Co-Go/cm	6.96±0.99	6.12±1.00^**	6.36±0.73	6.86±0.73	0.003
SS/cm	0.20±0.10	0.44±0.29^****	0.25±0.14	0.32±0.26	<0.000 1
AS/cm	0.08±0.04	0.21±0.20^****	0.15±0.13	0.09±0.06	0.000 1
PS/cm	0.15±0.10	0.30±0.22^***	0.25±0.16	0.22±0.16	0.001
FS/cm	2.79±0.25	2.81±0.32	2.72±0.22	2.81±0.18	0.130
FD/cm	0.88±0.22	0.86±0.21	0.84±0.12	0.99±0.34	0.060
NA/°	38.21±7.27	37.34±6.89	32.81±5.95^*	41.19±6.64	0.006
a/cm	6.08±0.38	6.12±0.58	5.96±0.56	5.93±0.51	0.300
b/cm	4.54±0.35	4.85±0.63^*	4.75±0.59	4.62±0.58	0.030
r/cm	5.31±0.36	5.50±0.56	5.37±0.52	5.27±0.49	0.160
α/°	25.85±8.07	31.64±9.09^**	30.33±8.31	28.99±10.64	0.013

下颌骨缺损修复后颞下颌关节位置变化的临床分析

Clinical analysis of changes in the position of the condyle and temporomandibular joint after repair of mandibular defects

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指标	T0	T1	T2	T3	4组间比较P值
SS/cm	0.20±0.09	0.80±0.25^****	0.29±0.09	0.35±0.26	<0.000 1
AS/cm	0.08±0.08	0.46±0.25^****	0.25±0.17	0.24±0.16	0.003
PS/cm	0.13±0.04	0.51±0.16^****	0.44±0.06^****	0.47±0.10^****	<0.000 1
NA/°	35.39±5.28	34.28±5.20	28.79±3.91^*	30.5±5.82	0.040
a/cm	6.20±0.35	6.18±0.74	5.88±0.68	5.95±0.68	0.590
b/cm	4.57±0.58	5.40±0.67^**	5.15±0.72	5.29±0.88	0.010
r/cm	5.35±0.28	5.77±0.68	5.46±0.69	5.55±0.74	0.400
α/°	28.77±4.82	37.55±11.22	35.99±8.01	38.10±13.36	0.090

指标	T0	T1	T2	T3	4组间比较P值
SS/cm	0.20±0.10	0.30±0.16^****	0.22±0.15	0.28±0.15	<0.000 1
AS/cm	0.09±0.04	0.13±0.08^**	0.10±0.05	0.09±0.06	0.002
PS/cm	0.16±0.10	0.22±0.19	0.16±0.11	0.18±0.07	0.370
NA/°	39.36±7.57	38.92±6.46	34.83±5.77	40.97±7.32	0.140
a/cm	6.05±0.38	6.12±0.51	6.00±0.52	5.96±0.31	0.610
b/cm	4.52±0.36	4.60±0.45	4.55±0.40	4.52±0.24	0.410
r/cm	5.29±0.39	5.39±0.48	5.32±0.43	5.21±0.29	0.480
α/°	24.91±8.81	28.67±5.43	28.52±6.94	28.86±5.60	0.110

指标	T0-T1	T1-T2	T2-T3
Co-Go变化量/cm	-0.88±1.81	-1.68±2.32	-1.27±1.70
SS变化量/cm	0.22±0.27	0.02±0.16	0.04±0.22
AS变化量/cm	0.13±0.19	0.05±0.15	-0.005±0.07
PS变化量/cm	0.14±0.24	0.09±0.19	0.03±0.16
FS变化量/cm	-0.03±0.50	-2.66±0.22	0.59±1.20
FD变化量/cm	-0.04±0.19	-0.15±0.27	-0.10±0.67
NA变化量/°	-1.67±9.38	-7.77±12.86	-3.77±19.61
a变化量/cm	-0.07±1.06	-0.31±1.35	-1.32±2.35
b变化量/cm	0.22±1.03	-0.003±1.16	-1.02±1.82
r变化量/cm	0.09±1.02	-0.16±1.28	-1.24±2.1
α变化量/°	5.40±10.83	3.36±12.10	-3.20±16.34

组别	SS变化量		AS变化量		PS变化量		NA变化量		b变化量		α变化量
组别	r值	P值	r值	P值	r值	P值	r值	P值	r值	P值	r值	P值
T0-T1	-0.06	0.700	-0.07	0.640	-0.34	0.020	-0.49	0.001	-0.42	0.003	-0.47	0.001
T1-T2	-0.41	0.040	-0.54	0.007	-0.39	0.060	-0.15	0.300	-0.52	0.010	-0.69	0.001
T2-T3	0.14	0.680	-0.38	0.270	-0.14	0.690	-0.48	0.150	-0.28	0.430	-0.64	0.040

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