牵张成骨联合正颌外科治疗成人严重小下颌畸形伴重度阻塞性睡眠呼吸暂停低通气综合征

目的:探讨牵张成骨术联合正颌外科的方法治疗小下颌畸形患者下颌骨严重发育不足伴重度睡眠呼吸暂停综合征(OSAHS)的效果。方法:对2例继发于颞下颌关节强直的小颌畸形患者首先采用牵张成骨技术进行治疗。手术在全麻下行双侧下颌角处截骨,安置牵引器,延长下颌升支及下颌体矫正小颌畸形及OSAHS。第二期在拆除牵引器的后行正畸治疗,继而采用正颌外科方法矫正颌面畸形及咬合关系,术后进一步正畸治疗矫正咬合关系排齐牙列。结果:2例患者均顺利完成治疗。下颌骨最小牵引距离25mm,最大牵引距离30mm,牵引区成骨良好。后气道间隙由治疗前的平均3.25mm增加到11.5mm;SNB角由术前平均67°增加到术后80°,OSAHS得以治愈。联合正颌外科及正畸治疗后小颌畸形得以矫治,面型及咬合功能均获得满意的效果。术后经过2年随访,未见复发。结论:牵张成骨技术联合正颌外科治疗成人严重小颌畸形伴重度OSAHS可以获得满意的效果。不仅可有效治疗伴发的OSAHS,而且能很好地矫治小下颌畸形引起的牙颌面畸形。     

小下颌畸形伴阻塞性睡眠呼吸暂停综合征的手术矫治

目的 观察下颌升支截骨下颌骨前徙术治疗小下颌畸形伴阻塞性睡眠呼吸暂停综合征(OSAS)的疗效。方法 1298年4月～2002年2月,对12例(女7例,男5例,年龄14～36岁)伴有严重OSAS症状及张口度0～3．0cm的小下颌畸形患者,7例采取下颌升支倒“L”形截骨、升支倒置颞下颌关节重建术的同时施行下颌体部前徙和颏成形术;3例在颞下颌关节重建术后进行下颌角部截骨、植骨下颌骨前徙术;2例施行下颌升支矢状劈开、下颌骨前徙术。其中8例施行了舌骨下肌群离断、舌骨悬吊术。截骨段以小钛板坚强内固定。结果 术后创口Ⅰ期愈合,经过6～48个月随访,12例患者张口度均恢复至3．0～3．8cm,面部外形明显改善。睡眠打鼾、憋醒、大汗症状消失或明显改善。睡眠时血氧饱和度由术前的82％～92％增加至术后的97％～99％。结论 下颌升支截骨下颌骨前徙术治疗小下颌畸形伴OSAS,对扩张口咽通气道、解除睡眠时呼吸阻塞症状可获得较满意的效果,并同时改善了面部容貌。     

牵引成骨技术在严重小颌畸形伴中重度阻塞性睡眠呼吸暂停低通气综合征治疗中的应用

目的 探讨应用牵引成骨技术治疗严重小颌畸形伴中、重度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea and hypopnea syndrome,OSAHS)的疗效。方法 采用下颌骨牵引成骨技术治疗严重小颌畸形伴中、重度OSAHS患者19例,分别于术前、后行多导睡眠监测仪监测及螺旋CT扫描,评价疗效并比较患者上气道三维结构的改变。结果 根据OSAHS疗效判定标准,19例中17例治愈,2例显效;手术后上气道各段的矢状径、矢状面积、横径和横截面积均较术前明显增加,气道容积从治疗前的(15 572.03±3 370.11) mm3变为治疗后的(21 182.69±4 533.15) mm3,变化主要发生在腭咽及舌咽,喉咽变化不明显。腭咽及舌咽区段气道各项检测指标与术前相比,差异均有统计学意义（P＜0.01或P＜0.05））。结论 下颌骨牵引成骨技术可明显扩张上气道腭咽段和舌咽段气道容积,从而有效治疗严重小颌畸形伴中、重度OSAHS。CT作为一种影像学手段,在该研究中有独到和重要的作用。     

内置式下颌骨牵引成骨术及其常见并发症的处理

目的 探讨内置式下颌骨牵引成骨术的常见术后并发症发生的原因及防治措施。方法 总结分析1997至2004年采用内置式下颌骨牵引成骨术治疗下颌骨畸形或缺损患者46例61侧，其中半侧颜面短小27例，下颌骨发育不足或小颌畸形双侧8例、单侧4例，电击伤或肿瘤术后缺损畸形3例，Treaeher Colins综合征2例，睡眠呼吸暂停综合征2例。结果 46例61侧发生并发症者9例，包括牵引机械装置故障3例，局部感染2例，前牙开骀2例，皮肤窦道2例。经积极处理后均达到预期治疗目的。结论 减少下颌骨牵引成骨术并发症的关键在于充分理解下颌骨牵引成骨术的机理，熟悉掌握下颌骨及邻近解剖结构，操作规范熟练，充分的术前准备和术后处理尤为重要。     

应用牵引成骨技术治疗颞下颌关节强直继发的小颌畸形

目的 探讨应用牵引成骨技术治疗颞下颌关节强直继发的小颌畸形的临床疗效.方法 应用牵引成骨技术治疗颞下颌关节强直继发的小颌畸形患者43例,10例应用颅骨支持式牵引器行双侧下颌骨体延长;33例应用内置式牵引器行单侧(6例)或双侧(27例)下颌骨体延长,3～6个月的稳定期后,手术拆除牵引器.结果 43例患者80侧下颌骨体部平均牵引长度23.2 mm(14 ～ 35 mm),X线头影测量结果显示后气道间隙由术前的平均4.9 mm增加到术后的10.4 mm,代表下颌突度的SNB角由术前的平均64.2°增加到术后的74.5°,小颌畸形得到了有效治疗,牵引间隙内成骨良好.术后平均复查20.3个月,无不良并发症发生.结论 牵引成骨技术可有效矫治关节强直导致的小颌畸形.颅骨支持式牵引器是治疗儿童青少年小颌畸形的有效手段,手术方法简便、风险小,治疗效果稳定.     

牵引成骨技术治疗颌面畸形

目的 探讨应用口外颌骨牵引成骨装置治疗颌面畸形。方法 使用自行设计制作的口外颌骨牵引成骨装置和上颌杠杆式牵引支架分别水平延长下颌骨，水平快速前移上颌骨，垂直延长下颌骨升支，水平延长下颌骨颏部，用以矫正小下颌畸形，下颌骨颏部外伤性骨缺损，小颌偏颌畸形，半侧前面肥大畸形，咬合平面倾余和唇腭裂术后上颌后缩等，共11例。结果 4例不同类型下颌骨牵引成骨，其中有1例在牵引过程中1根克氏针发生松动，旋转，最终将克氏针取出。1例下颌升支垂直牵引4根克氏针发生轻度弯曲，7例唇腭裂上颌后缩行Le Fort Ⅰ型截骨快速牵引成骨中有1例固定期后1个月出现对刃合并有轻度开咬合。最终11例治疗效果满意。结论 口外颌骨牵引成骨装置治疗下颌骨复杂畸形。Le Fort Ⅰ型截骨快速牵引成骨治疗唇腭裂术后上颌后缩是一种安全简便效果可靠的有效方法。     

计算机辅助设计牵引成骨治疗小颌畸形

目的:探讨一种新的治疗小颌畸形的方法。方法:术前在计算机上进行手术模拟,设计截骨线的位置、牵引器的固定位置以及拟牵引的长度,并进行效果模拟,制作个性化手术导板。全麻下在导板指引下通过口外入路行内置式牵引器置入术。术后5~7d开始牵引,速度为1mm/d,牵引器保留3~8个月后行二期牵引器取出伴/不伴正颌手术。结果:随访6~24月,13例患者(年龄14.9±9.5岁)均无感染及其他并发症发生。下颌骨牵引成骨牵引距离为(23.8±4.6)mm。∠SNB术后较术前平均增加4.3°。咬合关系均由AngleⅡ错牙合趋近正常,面型改善满意。结论:计算机辅助设计牵引成骨治疗小颌畸形可以大大提高手术精度、减少手术创伤及并发症、实现手术效果可预测性。     

面中部牵引成骨术矫正综合征性面中部后缩畸形

目的 探讨牵引成骨术治疗面中部后缩畸形的可行性。方法 2001至2002年对4例Crouzon、Apert和Marfan综合征，并伴面中部后缩畸形的患者，分别行Le Fort Ⅲ内置式延长器(2例)、Le Fort Ⅲ水平外置式延长器(1例)、monobloc水平内置式延长器(1例)治疗，于截骨后4d开始牵引延长，速度为每天1mm。结果 按计划完成牵引，面中部前移8～20mm。面中部后缩畸形明显减轻，双侧对称，尤其眶、鼻根部效果更佳，随访4个月至1年，效果稳定。结论 骨牵引成骨术具有传统的植骨加坚强内固定的方法所无法比拟的优点，能较大范围前移面中部，是矫正各种发育不良造成的严重面中部后缩畸形的有效而可行的方法。     

疑难牙颌面畸形的牵引成骨矫治(附112例临床经验与体会)

选择常规正颌外科难以矫治的七类复杂牙颌面畸形112例，采用内置式颌骨牵引成骨矫治，其中22例采用德国生产的牵引器，其余均采用作研制的不同类型的国产牵引器，其截骨方式，牵引器选择与安放，牵引方式依不同患的畸形分类，畸形严重程度，不同颌骨部位而不同，上颌骨牵引距离7－20mm，下颌骨12－46mm，3例合并局部慢性感染，导致部分新骨吸收，另3例因牵引器故障，下颌骨下缘骨折等原因另行手术处理完成牵引，其余106例均按术前设计顺利完成牵引成骨，取得了良好的成骨及牙颌面畸形矫治效果。内置式颌骨牵引成骨技术为各类复杂疑难牙颌面畸形的矫治提供了新的有效手段，具有广泛的应用价值。     

下颌骨牵引术治疗成人半面短小畸形一例

牵引成骨技术（distraction osteogenesis,DO）是一项将骨切开后应用牵引装置缓慢牵拉，使牵引间隙中形成新骨，从而达到骨骼处长目的的技术。我们对1例成人复杂半面短小畸形患者进行上、下颌骨的同时牵引治疗，效果良好。     

Distraction osteogenesis and glossopexy for Robin sequence with airway obstruction

Background: We present six cases of infants with Robin sequence and severe obstructive sleep apnoea who failed treatment with nasal mask continuous positive airway pressure (CPAP). Surgical intervention with mandibular distraction osteoneogenesis with glossopexy meant tracheostomy was avoided. Polysomnography (PSG) was used to document the severity of the obstructive sleep apnoea. The aim of this report was to assess the value of mandibular distraction osteogenesis with glossopexy in children with Robin sequence using PSG preoperatively and post‐operatively. Methods: Retrospective review of medical records to assess details of preoperative clinical progress, CPAP therapy, endoscopy, PSG and respiratory parameters. Results: Between 2003 and 2008, 20 infants with Robin sequence were admitted to the neonatal intensive care unit of our tertiary paediatric hospital. Six infants (30%) failed a treatment trial of CPAP during that period, but were subsequently successfully managed with mandibular distraction osteoneogenesis and glossopexy. At endoscopy, all had associated airway problems which included congenitally hypoplastic epiglottis (n= 2), laryngomalacia (n= 2), unilateral choanal atresia (n= 1) and long‐segment tracheal stenosis (n= 1). Conclusion: Mandibular distraction osteogenesis with glossopexy provides relief of severe upper airway obstruction for infants with Robin sequence. Epiglottic maldevelopment was present in two infants (33%). Endoscopy and PSG assisted clinical management, but highlighted ongoing respiratory issues.     

Treatment of upper airway obstruction in infants with micrognathia using mandibular distraction osteogenesis

Mandibular distraction osteogenesis has become an accepted alternative treatment for infants and children with upper airway obstruction associated with micrognathia. Several reports exist that purport the efficacy of mandibular distraction in these patients, such as preventing tracheostomy or facilitating tracheostomy removal. However, the majority of these studies are retrospective reviews with small cohorts and relatively short-term follow-up. Consequently, the ideal indications, pre- and postoperative evaluation, timing, and treatment are subject to controversy and not currently well established. Significantly less attention has been given to short- and long-term complications of mandibular distraction, such as effects on the developing tooth buds, impact on future mandibular development, and temporomandibular joint abnormalities. This article reviews the basic principles of distraction osteogenesis, summarizes the outcomes of recent literature involving pediatric mandibular distraction including this author's experience, and discusses the known and potential adverse sequelae of mandibular distraction. Before a clearly defined role of mandibular distraction in the treatment of infants with micrognathia-associated upper airway obstruction can be established, additional prospective studies are necessary to delineate its benefits and limitations.     

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective

To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia.

Study Design

Case series with chart review.

Setting

Tertiary care children's hospital.

Subjects and Methods

The records of a pediatric otolaryngology practice and tertiary children's hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified.

Results

Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure.

Conclusion

Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.     

牵引成骨术治疗新生儿Pierre Robin综合征呼吸阻塞

目的 探讨应用牵引成骨术治疗新生儿Pierre Robin综合征呼吸阻塞的可行性.方法 2007至2009年,用骨牵引技术治疗8例新生儿Pierre Robin综合征.行双侧下颌骨斜行截骨,安置下颌骨牵张器,术后第1天开始牵引,每天3次,每次0.4 mm,每天牵引1.2 mm,直至延长到所需长度.结果 8例患儿均按设计要求顺利完成牵引,无感染发生,无口角歪斜等面神经损伤症状.骨牵引达到预期的长度,约12～20 mm,平均15 mm.Pierre Robin综合征患儿的阵发性青紫、吸气性呼吸困难及哺乳困难等症状均消失.结论 牵引成骨术是治疗新生儿Pierre Robin综合征严重呼吸阻塞比较理想的手术方法,是可行和安全的.     

Reconstruction of segmental mandibular defects by distraction osteogenesis for mandibular reconstruction

BACKGROUND: Distraction osteogenesis is an established technique for the lengthening of long bones and correction of selected craniofacial deformities. Regenerate osteoid bone matrix formed during the distraction phase is malleable and can recreate the three-dimensional form of native bones. Animal experiments and early clinical experience have confirmed that distraction osteogenesis can be used for the reconstruction of segmental bony defects. Herein we discuss the principles of distraction osteogenesis in reference to reconstruction of segmental bony defects and report its clinical application of the mandible continuity defects. PATIENTS AND METHODS: Four patients (age, 7-83 years) with critical segmental mandibular defects (range, 3.5 cm-6.5 cm), resulting from ablative oncologic head and neck surgery underwent primary mandibular reconstruction by transport distraction osteogenesis. Two defects were at the angle and body region, one at the body, and the other at the parasymphysis and body region. Synthes Titanium Multi-vector and Leibinger Multi-guide distractors in bifocal (n = 2) and trifocal (n = 2) architecture were used after the stabilization of the segmental continuity defect using a defect-bridging mandibular reconstruction plate. Osteodistraction was carried out at a rate of 1 mm per day, with once or twice a day rhythm, after a 1-week latency period. The consolidation period was equal to the period of distraction. RESULTS: All patients tolerated the distraction procedure. Satisfactory bone formation was observed in two patients, and partial bone formation was seen in one patient. Treatment failure was encountered in one patient who had a second oral cavity primary tumor observed during the consolidation period, requiring interruption of the treatment sequence. CONCLUSIONS: Mandibular reconstruction with distraction osteogenesis is a potentially useful technique in selected patients with segmental mandibular continuity defects after ablative head and neck cancer surgery.     

定向两次牵引成骨术在下颌骨肿瘤术后缺损修复中的应用

目的 探讨定向两次牵引成骨术在下颌骨肿瘤术后缺损修复中的应用.方法 2002年1月至2006年12月,对6例因肿瘤术后致下颌骨缺损患者,先牵引下颌骨体部,再牵引下颌骨升支部.结果 手术过程顺利,外形恢复良好,局部成骨满意,无感染等并发症.下颌骨最大体部单侧牵引幅度为5.5 cm,平均5.2 cm,升支部最大4.2 cm,平均3.4 cm.咬合及张口度恢复良好.结论 定向两次牵引成骨术用于修复肿瘤术后下颌骨缺损,创伤小、手术时间短、操作简单,并可避免植骨及由此带来的供、受区并发症,效果稳定可靠;缺点是整个治疗时间长,需3次手术.     

Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography.

OBJECTIVE: The goal was to evaluate 3-dimensional airway CT for upper airway assessment in obstructive sleep apnea syndrome (OSAS). DESIGN: Airway CT was obtained and 3-dimensional airway models were constructed prospectively for 40 patients with OSAS and 10 controls. Airway dimensions were correlated with polysomnography, and comparison was made between patients with and without OSAS. RESULTS: OSAS patients had a mean respiratory distress index of 51.9 events per hour. The mean minimum cross-sectional area (XSA) in the neutral position was 67.1 mm(2). Minimum XSA decreased in both the inspiratory and expiratory phases to 16.3 mm(2) and 15.0 mm(2), respectively (P<0.001). Complete airway obstruction occurred in 1 or more phases of respiration in 28 patients. Neither airway XSA nor length of obstruction correlated with sleep apnea parameters. No statistically significant differences in airway dimensions were found between OSAS and control patients. CONCLUSIONS: Airway CT demonstrates dynamic airway obstruction in OSAS but does not correlate well with clinically important disease parameters.     

Maxillo-mandibular distraction osteogenesis for hemifacial microsomia in children

To obviate or lessen the long period of use of orthodontic appliances after distraction for hemifacial microsomia in the mixed dentition patients, simultaneous maxillo-mandibular distraction osteogenesis has been performed in 10 patients aged 7 to 12 years with hemifacial microsomia. In these patients, there were two cases of type I, five cases of type IIa, and three cases of type IIb. A uniplanar internal distraction device was used in all cases. After maxillary Le Fort I osteotomy and mandibular ramus osteotomy, a uniplanar internal distraction device was attached to the mandible. On days 5 to 6 after surgery, distraction of 1 mm per day was started. Rigid intermaxillary fixation (IMF) using soft wires was performed at the distraction and was retained for 1 hour. Except for this period, rigid IMF was released. Distraction length ranged from 10 to 21 mm. After the distraction, a slight lateral crossbite in one case and a slight occlusal change in two cases, which did not necessitate the particular orthodontic treatment, were noted. Postoperative follow-up ranged from 16 to 40 months. The postoperative clinical course was uneventful thereafter. Maxillary growth impairment after the osteotomy has been obscure because of the short postoperative period. This procedure is effective for obviating or lessening the long duration of use of orthodontic appliances in the mixed dentition period of 7 to 14 years of hemifacial microsomia.