3种截骨方式辅助上颌骨快速扩弓的应力分布

目的：研究牙支持式外科辅助上颌骨快速扩弓（SARME）技术中应用3种不同截骨方式的颅面部骨骼应力分布情况。方法：建立牙支持式SARME系统的三维有限元模型,根据不同截骨方式,将模型分为3组,即Ⅰ型—单独的腭中缝截骨术,Ⅱ型—腭中缝＋侧方皮质骨切开术,Ⅲ型—腭中缝截骨术＋侧方皮质骨切开术＋双侧翼颌连接截骨术。在模型上选取11个解剖结构,加载4种不同的扩弓量,比较分析颅面部各个部位骨骼的应力（von-Mises应力）分布情况。结果：SARME手术截骨程度越大,颅面部应力释放越多,最大应力值只出现在模型Ⅰ中;翼板处Ⅱ型手术应力比Ⅰ型明显增加;Ⅲ型截骨松解翼颌连接后,翼板的应力大大降低,同时面中部多数骨骼的应力也有所下降;Ⅲ型手术后面上部的解剖结构出现明显的应力回升。结论：手术辅助对于减小术后快速扩弓对颅面部产生的应力效果良好;翼板处应力集中,可能会增加颅底骨折的危险;离断翼颌连接后,面上份的应力集中可能是颅面部应力传导途径改变所致。     

超声骨刀劈开腭中缝辅助MSE对上颌宽度不足扩弓效果的研究

目的:评价超声骨刀劈开腭中缝辅助上颌骨骨性扩弓器(MSE)对上颌宽度不足成人患者的扩弓效果.方法:纳入21例反(牙合)偏颌下颌后缩等同时伴有上颌宽度发育不足的成年患者,男6例,女15例,先行超声骨刀腭中缝劈开术,然后安装MSE进行上颌骨扩弓,分别于扩弓前、扩弓后拍摄CBCT,利用Planmeca Romexis软件进行...     

超声骨刀在上颌骨陈旧性骨折治疗中的应用:附12例临床分析

目的：利用超声骨刀切开、钛板／钛网固定，采用正颌外科手段治疗12例伴错位愈合的上颌骨陈旧性骨折，评价其临床效果。方法：对12例上颌骨陈旧性骨折患者，采用LeFortⅠ型截骨术进行治疗。术中应用意大利Mectron的超声骨刀代替摇摆据进行切开，微型钛板／钛网固定，随访6～12个月，评价术后功能和美观效果。结果：利用超声骨刀切骨，切割高度精确，并且上颌骨没有发生任何振动损伤。手术所需时间比常规钻所用时间稍长。骨愈合良好，无任何神经血管异常。伤口一期愈合，咬合关系及外观满意或基本满意。结论：超声骨刀可用于颌骨陈旧性骨折的切开，精确度高，损伤小。     

上颌骨牵引成骨术矫治上颌牙弓狭窄

目的 观察上颌骨牵引成骨术矫治上颌牙弓狭窄的疗效。方法 对１０例成年患者行上颌Ｌｅ Ｆｏｒｔ Ｉ型截骨术（不移动骨块）,并手术截开腭中缝骨联结。以上颌快速扩弓装置（６４１４６带环）,每日打开螺旋４次,共１．０ｍｍ。其中２例行单侧扩大牙弓,矫正上颌单侧牙弓宽度不足。利用计算机图形数据分析系统对扩弓前后的后前位头颅定位片进行测量（上颌骨、上颌牙弓基骨、上颌后牙间的宽度）并通过上颌前部咬合片观察腭中缝的     

超声骨刀颊侧开窗法拔除下颌低位骨埋伏第三磨牙

目的 :探讨应用超声骨刀颊侧截骨开窗法拔除下颌低位骨埋伏第三磨牙中的应用效果。方法 :收集2016-05-01日—2018-05-01期间,在同济大学附属口腔医院颌面外科病房收治的下颌低位骨埋伏第三磨牙患者24例,采用超声骨刀颊侧截骨开窗法拔除。记录手术时间及围手术期并发症,评价应用效果。结果:所有阻生齿均顺利拔除,平均用时25.1 min(15～42 min)。2例(8.3%)术后1个月出现感染伴局部肿胀,经冲洗换药后均愈合。结论:使用超声骨刀颊侧骨开窗法拔除下颌低位骨埋伏第三磨牙成功率高,并发症发生率低。     

超声骨刀在口腔种植中应用效果的初步探讨

【摘要】 目的 本研究通过观察、比较超声骨刀和传统球钻在Onlay植骨、上颌窦提升、骨劈开等手术中的临床应用效果,探讨超声骨刀在种植手术中的优越性及操作要点。方法 2006—2012年在常州市口腔医院种植科就诊,需要进行植骨手术的78例患者,总计80个术区,分别使用超声骨刀和传统球钻在Onlay植骨、上颌窦提升、骨劈开等手术中进行切骨操作;超声骨刀组42例,传统球钻组38例。分别于术后6 h、24 h、3 d进行复查,采用 VAS记录术后疼痛水平,利用SPSS11.5统计软件将临床数据采用等级资料秩和检验进行统计学分析。结果 超声骨刀组在术后6 h VAS均值为（3.98±2.16）、24 h VAS均值（2.35±1.86）,传统球钻组在术后6 h VAS均值为（4.79±1.95）、24 h VAS均值（3.21±1.76）,术后6小时、术后24小时两组间疼痛反应差异有统计学意义（p＜0.05）。结论 与传统球钻相比,采用超声骨刀进行种植植骨手术可以降低植骨术后短期疼痛发生率。     

骨性Ⅱ类伴重度阻塞性睡眠呼吸暂停综合征的综合治疗效果评价

目的:评价手术辅助上颌快速扩弓(SARME)联合下颌骨牵张成骨术(DO)矫治年轻骨性Ⅱ类伴重度阻塞性睡眠呼吸暂停综合征(OSAHS)患者的疗效。方法:4例上颌牙弓狭窄及下颌骨发育不足的骨性Ⅱ类患者(其中男2例,女2例,18～23岁,平均20.3岁),经多导睡眠检测为重度OSAHS。采取SARME联合下颌骨DO术矫治骨性Ⅱ类畸形,术后正畸治疗排齐拥挤牙列及咬合精细调整。分别采用CT、鼻声反射检查及多导睡眠检测,比较治疗前、后(T0、T1)上颌骨宽度、鼻腔体积、鼻阻力以及PSG参数的改变。结果:矫治后患者的上颌骨宽度呈"V"形扩大,鼻腔体积增大,鼻阻力减小。多导睡眠检测结果显示,治疗后睡眠呼吸暂停紊乱指数(AHI)显著减小并恢复正常,患者的OSAHS症状得到显著改善。结论:SARME联合下颌骨DO术对治疗严重骨性Ⅱ类伴OSAHS的年轻患者具有较好疗效。     

超声骨刀法与凿骨劈冠法拔除下颌低位阻生智齿的比较研究

目的：对比超声骨刀法与传统凿骨劈冠法拔除下颌低位阻生智齿的临床效果。方法：下颌低位阻生智齿126例随机分为两组,超声骨刀组采用超声骨刀法拔除智齿63例,68个牙,凿骨劈冠组采用传统凿骨劈冠法拔除智齿63例,79个牙）,比较两组病例的拔牙时间,术中与术后疼痛评分,术后患者面部肿胀、张口受限情况,以及下唇麻木、伤口感染等并发症发生情况。结果：超声骨刀组平均拔牙时间为（33．3±9．4）min,明显短于凿骨劈冠组平均拔牙时间（47．6±11．3）min,差异有统计学意义（P〈0．05）。凿骨劈冠组术中、术后疼痛评分明显高于同期超声骨刀拔除者,各时间点差异均有统计学意义（P〈0．05）。同组各时间点疼痛评分比较,术后第2d评分均高于术中评分（P〈0．05）,术后第7d评分均低于术中评分（P〈0．05）。凿骨劈冠组术后第2d面部肿胀、术后第7d张口受限程度明显高于超声骨刀组（P〈0．05）。两组病例均未出现下唇麻木、伤口感染病例。结论;采用超声骨刀法拔除下颌低位阻生智齿手术时间短,能明显减少患者术中、术后疼痛,减轻术后面部疼痛与肿胀程度,术后并发症发生率大大降低,优于传统的凿骨劈冠法。     

无痛口腔麻醉仪联合超声骨刀在埋伏上前牙正畸牵引治疗的临床应用

目的 探讨对需要正畸牵引的埋伏上前牙进行开窗手术时,应用无痛口腔麻醉仪联合超声骨刀对比卡式注射器联合涡轮快机的临床效果.方法 选取因埋伏上前牙需要正畸牵引,实行开窗术的病例128例,随机分为无痛口腔麻醉仪联合超声骨刀组(麻醉仪联合超声骨刀组)和卡式注射器联合涡轮快机组(常规组),每组64例;对比2组患者开窗术中的配合情况以及术后的肿胀和疼痛情况.结果 开窗术术中的配合程度比较,麻醉仪联合超声骨刀组0级和Ⅰ级占比分别为45.3%和31.3%,常规组0级和Ⅰ级分别为32.8%和20.3%,麻醉仪联合超声骨刀组术中配合优于常规组,差异有统计学意义(Z=-2.676,P<0.05).术后24 h疼痛和术后48 h肿胀程度比较,麻醉仪联合超声骨刀组疼痛Ⅰ级为81.2%,常规组疼痛Ⅰ级为59.4%,麻醉仪联合超声骨刀组术后疼痛轻于常规组,差异有统计学意义(Z=-2.777,P<0.05);麻醉仪联合超声骨刀组术后肿胀Ⅰ级为81.2%,常规组肿胀Ⅰ级为71.9%,麻醉仪联合超声骨刀组术后肿胀轻于常规组,差异有统计学意义(Z=-2.097,P<0.05).结论 在埋伏上前牙需要正畸牵引作开窗术时,使用无痛口腔麻醉仪联合超声骨刀,患者更加容易配合且术后反应较小.     

4种超声骨刀去骨法在高难度下颌阻生第三磨牙拔除术中的应用

目的：探讨应用超声骨刀进行4种去骨拔牙法在高难度下颌阻生第三磨牙拔除术中的应用效果。方法：根据改良的纳入标准将55例患者的74颗牙定为高难度下颌阻生第三磨牙。以X线平片和锥形束CT（CBCT）为依据,按不同的阻生牙情况,设计4种超声骨刀去骨拔除方法：术式1为整体去骨拔除,术式2为分块去骨拔除,术式3为去骨分牙拔除,术式4为牙骨一并拔除。记录去骨方式、手术时间以及围术期并发症,评价应用效果。结果：所有阻生牙均顺利拔除,4种去骨拔除术中,术式1为38颗牙（51.4%）,术式2为18颗牙（24.3%）,术式3为12颗牙（16.2%）,术式4为6颗牙（8.1%）。平均用时为15 min（8-26 min）。所有病例随访1个月,仅2例（2.7%）出现术后局部感染,予以引流、抗感染治疗,1周内痊愈。结论：本研究创立的4种超声骨刀去骨拔牙方法能顺利拔除所有类型的高难度下颌阻生第三磨牙,且用时较短,并发症较少。     

Ultrasound bone cutting for surgically assisted rapid maxillary expansion under local anesthesia. Preliminary results

Surgically assisted rapid maxillary expansion (SARME) is a well-established therapy for correction of maxillary transverse deficiency in adults, when consolidation of sutures has just been completed. It can be performed either under general or under local anesthesia and it can be accomplished with many surgical techniques. One of the most critical steps of SARME is the detachment of the pterygo-maxillary junction, due to the risks connected to such procedure. When required to obtain specific expansion patterns, the pterygo-maxillary separation has been suggested until now only for interventions under general anesthesia, due to the dangerousness and the rawness of this surgical step in awake patients. The authors introduce the use of an ultrasonic bone-cutting device to perform all osteotomic steps of SARME under local anesthesia on an outpatient basis, including pterygo-maxillary detachment. This ultrasonic device is unique in that the osteotomic action occurs only when the tool is employed on mineralized tissues, while it stops on soft tissues. It works in a linear pattern of vibration and it allows precise osteotomies without producing any heat damage to osteotomic surfaces and without any dangerous hammer-related stroke. Due to its precision and safety, this device named Piezosurgery, allows patients to undergo all the steps of SARME under local anesthesia, also without hospitalization.     

Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia

Ultrasonic bone-cutting surgery has been recently introduced as a feasible alternative to the conventional tools of cranio-maxillo-facial surgery, due to its technical characteristics of precision and safety. The device used is unique in that the cutting action occurs when the tool is employed on mineralized tissues, but stops on soft tissues. This technical note illustrates the use of Piezosurgery for all osteotomies of surgically assisted rapid maxillary expansion (SARME). The procedure, including pterygo-maxillary detachment, can be completed under local anaesthesia. Other advantages include minimal risk of jeopardizing critical anatomic structures (e.g. palatine artery), minimal intraoperative bleeding and postoperative swelling, and minimal thermal damage to bone surfaces. Narrow and rectilinear osteotomies can be easily performed with varying vibrating scalpels, at the cost of a longer operative time.     

Feasibility and long-term stability of surgically assisted rapid maxillary expansion with lateral osteotomy

Surgically assisted rapid maxillary expansion (SARME) has become a widely used and acceptable means to expand the maxilla in adolescents and adult patients. The method takes advantage of bone formation at the maxillary edges of the midline, while they are separated by an external force. The purpose of the present retrospective investigation was to evaluate the feasibility and long-term stability of maxillary expansion in patients in whom lateral pre-expansion osteotomy had been performed. The subjects were 20 patients (14 females, six males, mean age 30.6 years, range 16.2-44.2 years) whose malocclusions were treated solely or partly with SARME during 1988-1996. Two orthodontists carried out the post-orthodontic expansion treatment. The surgical technique followed a minimally invasive osteotomy on the lateral maxillary walls. Study models were obtained before surgery (T1), once expansion and the following orthodontic treatment were completed, before possible second-stage osteotomy (T2), and at long-term follow-up (T3). Using the study models, the width of the dental arch was measured with a digital sliding calliper. In addition, transverse occlusal relationships were examined at each time point. The results indicated that (1) SARME is possible when the minimally invasive operation technique is used, (2) long-term stability of maxillary expansion following the present technique compares favourably with the widening and stability achieved with other, more invasive, osteotomies. With age, several possible uncertainties are introduced to affect the course of SARME adversely. Therefore, more extensive osteotomies can be recommended in older patients.     

The effect of surgically assisted rapid maxillary expansion on sleep architecture: an exploratory risk study in healthy young adults

Maxillary transverse deficiencies (MTD) cause malocclusions. Rapid maxillary expansion treatment is commonly used treatment for correcting such deficiencies and has been found to be effective in improving respiration and sleep architecture in children with obstructive sleep apnoea (OSA). However, thus far, the effect of surgically assisted rapid maxillary expansion (SARME) treatment on sleep architecture and breathing of normal subjects has not been assessed. We hypothesised that sleep quality will improve after maxillary expansion treatment. The objective of this study is to access the effect of maxillary expansion treatment on sleep structure and respiratory functions in healthy young adults with severe MTD. This is a prospective and exploratory clinical study. Twenty‐eight consecutive young adult patients (15 males and 13 females, mean age 20·6 ± 5·8 years) presenting with severe MTD at the orthodontic examination were recruited into the study. All the participants underwent a standardised SARME procedure (mean expansion 6·5 ± 1·8 and 8·2 ± 1·8 mm, intercanine and intermolar distance, respectively) to correct malocclusion caused by MTD. An overnight in‐laboratory polysomnography, before and after the treatment, was performed. The mean follow‐up time was 9 months. The main outcome parameters were the changes in sleep architecture, including sleep stages, arousals, slow‐wave activity (SWA) and respiratory variables. Before surgery, young adult patients with MTD presented no evidence of sleep breathing problems. At baseline sleep recording, 7 of 28 (25%) had apnoea‐hypopnoea index (AHI) ≥ 5 events per hour. No negative effect of the SARME was observed in questionnaires or sleep laboratory parameters. In the patients with a higher baseline AHI (AHI ≥ 5 h of sleep), we observed a reduction in AHI after surgical treatment (P = 0·028). SARME did not have a negative effect on any sleep or respiration parameters in healthy young individuals with MTD. It normalised the breathing index in the patients with a mild AHI index.     

Does the timing and method of rapid maxillary expansion have an effect on the changes in nasal dimensions?

The aim of this study was to assess the effects of rapid maxillary expansion (RME) and surgical assisted rapid maxillary expansion (SARME) on nasopharyngeal area. The study group consisted of 30 subjects in the permanent dentition who had both maxillary constriction and a posterior cross-bite. The patients were divided into two groups, RME and SARME. The subjects in the RME group consisted of 15 patients (eight girls, seven boys) whose average age was 12.1 +/- 1.1 years. The SARME group also consisted of 15 patients (eight boys, seven girls) whose mean age was 18.4 +/- 1.4 years. An acrylic bonded RME appliance was used in both groups. Surgery was performed using lateral cortical osteotomies in the SARME group. The nasopharyngeal and respiratory area was determined using a digital planimeter on lateral cephalometric radiographs taken before and after RME. Nasal cavity width was evaluated on postero-anterior radiographs. Nasal dimension was measured using planimeter measurements of the respiratory and nasopharyngeal areas before and after treatment. The data obtained were analyzed using SPSS. Comparisons within the groups were carried out with paired t-tests and comparisons between the groups were with a Student's t-test. In both groups, the respiratory area and the ratio of the respiratory area to nasopharyngeal (RA/NA) area increased following RME. There were no statistically significant differences between the groups. Nasal cavity width and maxillary width also increased, but the difference between the groups was not significant. Following RME, various differences in both the maxilla and surrounding bones occurred and nasal width increased with a decrease in nasal airway resistance. At the end of treatment there were increases in the width of the nasal floor near the midpalatal suture and nasal cavity. As the maxillary structures separated, the outer walls of the nasal cavity moved laterally resulting in an increase in internasal volume. Nasal resistance decreased and respiratory area increased in patients treated with RME.     

Surgically assisted rapid maxillary expansion compared with orthopedic rapid maxillary expansion

The objective of this study is to evaluate and compare the dental and skeletal changes occurring during orthopedic rapid maxillary expansion (RME) and surgically assisted RME during the active phase of treatment. The study was divided into two groups. The first group of 10 patients (six males, four females; mean age, 15.51 years) received orthopedic RME. The second group of 10 patients (seven males, three females; average age: 19.01 years) received surgically assisted RME (SARME). All patients underwent maxillary expansion with occlusal-coverage Hyrax-type expanders activated two turns a day (0.25 mm per turn). Preexpansion and postexpansion lateral and posteroanterior cephalograms were obtained for each patient. Statistically significant differences between the SARME and RME groups were found in the N-ANS, SN/ PP (P < .01) and SNA, SNB, mandibular dentoalveolar, and maxillary bony base (P < .05) measurements. Clinically, there is no difference in patient response between the RME and SARME groups. The only difference between the groups was their indication for RME or SARME, which is based on the age and skeletal maturation of the patient.     

Segment tilting associated with surgically assisted rapid maxillary expansion

This study aimed to evaluate, via computed tomography, the direction and magnitude of the segmental tilting that may occur after surgically assisted rapid maxillary expansion (SARME) in patients with a transverse maxillary deficiency. Thirty adult patients with a transverse maxillary deficiency greater than 5 mm were treated by SARME. The procedures consisted of bilateral zygomatic buttress and midpalatal osteotomies combined with the use of a tooth-borne orthopaedic device postoperatively. Axial and coronal images were obtained before and 6 months after SARME to evaluate the segment tilting. The greatest expansion occurred in the most inferior (5.4 ± 1.1 mm) and anterior (4.0 ± 1.3 mm) regions of the maxilla. The expanded segment tilted outward inferiorly and anteriorly in coronal and axial images, respectively. The segment tilting was 2.0 mm (2.3%) inferiorly and 3.1 mm (12.8%) anteriorly. It can be concluded that an outward tilting occurs in the most inferior and anterior portions of the maxilla during SARME procedures. Hence the direction and magnitude of such segmental tilting must be considered preoperatively when determining the surgical objectives.     

手术辅助快速扩弓矫治上颌横向发育不足的临床疗效分析

目的:评价手术辅助快速扩弓矫治成人上颌横向发育不足病例牙齿和基骨的变化。方法:上颌发育不足患者20例(男13例,女7例)按年龄分为扩弓组和手术组,扩弓组(平均年龄12.51±0.82岁)行矫形快速扩弓治疗;手术组(平均年龄19.07±2.54岁)行手术协助快速扩弓治疗。所有患者治疗前后摄头颅定位正侧位片和咬合片,头影测量分析、比较。结果:两组病例均有明显的扩弓效果,手术组牙弓宽度增加更为显著,扩弓组牙弓长度增加明显,但组间均无显著性差异;治疗前后,手术组B点显著后移,而扩弓组B点前移,组间有显著性差异(P<0.05);治疗前后,手术组腭平面后旋,扩弓组腭平面前旋,组间有显著性差异(P<0.01);治疗前后,两组病例上颌切牙均内倾,组间无显著性差异。结论:手术协助快速扩弓治疗成人上颌横向发育不足,可取得良好的扩弓效果;对上下颌骨、上颌切牙在矢状面的改变更有利于III类错畸形的矫正;在病例的选择上,更适用于低角病例。     

3种手术方式下牙支持式外科辅助上颌骨快速扩弓位移分布的三维有限元分析

目的:研究3种不同截骨方式下牙支持式外科辅助上颌骨快速扩弓中颅颌面部各解剖部位的位移情况。方法:建立3种不同截骨方式的牙支持式外科辅助上颌骨快速扩弓系统的三维有限元模型,模型上选取21个解剖结构,加载横向7mm扩弓量,比较分析颅面部各个解剖部位在X(矢状向)、Y(水平向)、Z(垂直向)方向的位移分布情况。结果:矢状向:上颌骨各解剖结构都有明显向前位移的趋势,而且随着手术范围的增大,颅颌面部各解剖结构向前移动的趋势越来越明显。水平向正面观,颅颌面复合体呈金字塔样打开,鼻腔底部有明显扩大;面观,支抗牙颊尖的位移最大,牙的位移大于相应区域牙槽骨的位移,手术范围的增大可以使上颌骨后部有明显的扩展。垂直向观,上颌骨正中区域的腭板有向下移动的趋势,上颌骨的侧方结构如支抗牙和牙槽骨都向上移动。结论:牙支持式扩弓器行横向扩弓时会出现牙的代偿和骨骼的倾斜和旋转。随着手术范围的增大,支抗牙和牙槽骨区域水平向的位移也随之增大。     

Evaluation of stress by finite element analysis of the midface and skull base at the time of midpalatal osteotomy in models with or without pterygomaxillary dysjunction

Surgically-assisted rapid maxillary expansion (SARME) is commonly used to treat skeletally mature patients with transverse discrepancies. Some osteotomies are made in areas that resist expansion, but there is no clear consensus about the sequence in which the osteotomies are made. Some clinicians do the pterygomaxillary osteotomy last, while others do it before the midpalatal osteotomy. We used the finite element method to measure the stresses on the midface, cranial base and pterygoid plates at the time of midpalatal osteotomy in two models, one with and one without pterygomaxillary dysjunction (PMD). In both, SARME consisted of maxillary bilateral osteotomy from the piriform rim to the pterygoid plate. Midpalatal osteotomy was also done in both. In the PMD model, minimum principal stresses increased on the midface, and maximum principal and von Mises stresses increased at the cranial base and on the pterygoid plates. Our results suggest that the stresses on the midface and cranial base can be reduced during midpalatal osteotomy in adults if the pterygomaxillary osteotomy is done last.