牵引成骨术治疗唇腭裂继发颌骨畸形稳定性的研究进展

牵引成骨术（distraction osteogenesis,DO）在口腔颌面外科的应用越来越广,为唇腭裂继发颌骨畸形治疗提供了新的手段。DO按牵引类型主要分为内置式牵引（intraoral distraction osteogenesis, IDO）和外置式牵引（extraoral distraction osteogenesis, EDO）2种,在大距离前徙上颌骨时,唇腭裂牵引成骨术后的长期稳定性和复发的报道还很少。本文就牵引成骨治疗唇腭裂继发颌骨畸形术后的长期稳定性的临床研究进展作一综述。     

唇腭裂术后患者牵引成骨术X线头影测量分析

目的:通过对唇腭裂术后继发上颌骨发育不足患者进行口外支架式前牵引治疗术后6～24个月随访,探讨术后复发程度及可能存在的复发因素,并提出初步预防复发的办法。方法:1998～2002年我院进行牵引成骨治疗的39例唇腭裂患者中选出14例资料齐全者进行术后随访分析,随访期分别为术后3月、6月、1年、2年,分别将其头颅定位侧位片用CASSOS系统描迹、定点,进行矢状向和垂直向分析。结果:14例患者在牵引成骨术后6月内均有不同程度的复发,尤其是牵引器拆除后未进行正畸治疗者。而6月以后患者上颌骨在垂直向及矢状向基本无明显改变。结论:(1)唇腭裂术后上颌骨发育不足患者进行牵引成骨治疗后6月内较不稳定,尤其是未进行正畸治疗者;(2)6月后上颌骨矢状向和垂直向基本稳定。复发因素可能与局部疤痕、肌肉牵拉、软组织张力及适应性改建有关。     

唇腭裂患者正颌术后上颌骨短期稳定性的三维分析

目的:建立一种可同时反映上颌骨位置及姿势的三维测量方法,对唇腭裂患者上颌骨正颌术后的短期稳定性进行三维评估.方法:选取因唇腭裂继发上颌骨发育不足而行正颌手术的25例患者,按照患侧分为左侧唇腭裂组10例、右侧唇腭裂组8例、双侧唇腭裂组7例;收集术前6周(T0)、术后4天(T1)、术后3个月(T2)、6个月(T3)的全头颅螺旋CT资料,利用计算机辅助设计软件ProPlan建立三维坐标系,设定22个描述上颌骨空间位置的指标,并定义3个姿势角∠ PP-CP、∠RP-CP、∠YP-CP,分别表示上颌骨在空间内俯仰、侧滚、摆尾.利用SPSS16.0软件包对T2、T3时的测量结果进行配对t检验.结果:成功建立了较为完整反映上颌骨空间位置及姿势的测量方法.在垂直向上,颌骨前部牙骨段向上的总体复发率为7.46％;在矢状向上,各组复发率分别为30.95％、8.01％和34.76％,无显著差异;在水平向上,单侧完全性唇腭裂组均出现整体向健侧平移,且前部偏向健侧、而后部偏向患侧偏转的复发趋势.结论:腭裂患者正颌术后上颌骨在三维方向内存在复发趋势,本研究建立的三维测量比二维研究能更有效地从平移和旋转的角度进行评估.     

三维测量法分析上颌骨垂直向发育不足患者正颌术后稳定性

目的: 采用三维重建方法评价上颌骨垂直向发育不足患者正颌术后上颌骨位置变化,以探讨该类患者术后颌骨的稳定性及其影响因素。方法: 选取2016 年1月—2016年9月上海交通大学医学院附属第九人民医院口腔颅颌面科应用Le Fort I型截骨术矫治上颌骨垂直向发育不足的患者50例,收集术前2个月（T0）、术后3 d（T1）、术后6个月（T2）的三维CT图像,分别利用Proplan CMF 3.0软件对前鼻嵴点（ANS）、腭大孔点（GPL/R）进行测量,采用SPSS 13.0软件包对上述测量值进行样本均数t检验,比较该类患者术后上颌骨的稳定性;并对具有明显复发倾向者进行回归分析以及工作特征曲线分析,以探索其影响因素。结果: 统计学分析发现,ANS-FH（T2-T1）出现显著变化,平均上移1.11 mm（P<0.05）。术后垂直向复发现象主要与上颌骨术中的垂直向移动距离以及上颌骨后部的术中垂直向移动有关。结论: 应用Le Fort I 型截骨术矫治上颌骨垂直向发育不足患者具有一定复发倾向,其稳定性受到上颌骨术中位移距离及术后随访时间的影响。     

Le Fort Ⅰ型截骨术在唇腭裂正颌外科中的应用与评价

目的:观察分析Le Fort Ⅰ型截骨术在唇腭裂正颌外科中的应用效果.方法:回顾2004年3月至2006年12月武汉大学口腔医学院口腔颌面外科收治的唇腭裂患者的临床资料,并进行总结与分析,所有患者均进行了以Le Fort Ⅰ型截骨术为主的正颌外科治疗.结果:共收集相关病例16例,其中男9例,女7例,平均年龄22.4岁.术前∠SNA平均73.2°,术后LSNA平均79.5°;上颌前移距离平均8.13mm.平均随访时间7.3个月.所有患者术后面容改善明显,经正畸治疗后咬合关系满意.结论:以Le Fort Ⅰ型截骨术为主的正颌外科治疗,可以显著改善唇腭裂患者的颌骨与面容畸形.     

唇腭裂术后上颌骨发育不良骨牵引矫治的临床研究

目的:探讨口内入路牵引成骨技术在唇腭裂术后继发上颌骨发育不良患者成年之前矫治中的作用。方法:对12例9～12岁唇腭裂术后继发上颌骨明显发育不良者,采用高位LeFortI型截骨术,将上颌骨完全断离,安装口内牵引器,按一定的速度和频率牵引上颌骨向前,对术前、术后头颅定位X线侧位片进行颅颌面软硬组织的测量分析,数据以SPSS10.0统计软件包进行t检验。结果:本组病例上颌骨牵引前移明显,SNA角增加7°～11°,软组织鼻尖点、鼻底点及上唇最突点明显前移,面部外形得到明显改善,上下前牙获得正常覆牙合、覆盖关系。随访3～36个月,咬合关系保持稳定。结论:骨牵引成骨技术可以很好地用于矫治唇腭裂术后继发上颌骨发育不良,早期解除上颌骨畸形,使面部软组织得到适应性改变,面型更为协调,避免或减轻口颌系统继发畸形和功能障碍,不失为唇腭裂术后继发上颌骨发育不良的有效治疗方法。     

上颌骨前徙对唇腭裂患者腭咽闭合功能的影响

唇腭裂是口腔颌面部较为常见的先天发育畸形，约有25％的患者唇腭裂修复术后有不同程度的上颌骨发育不良。20世纪70年代人们开始采用上颌骨Le Fort Ⅰ、Ⅱ型截骨术后前徙上颌牙骨段矫治上颌骨发育不良。但传统正颌外科术中上颌骨前徙距离大于8mm时，术后复发率显著增高；同时由于腭裂修复所导致的腭部瘢痕使上颌骨前徙量受到限制。     

唇腭裂继发上颌骨发育不足牵引成骨后颌骨变化

目的　比较唇腭裂术后继发上颌骨发育不足患者颅外支架式牵引成骨术 (RigidExternalDistraction ,RED)前后上下颌骨前后向和垂直向位置及牙颌关系变化 ,评价RED治疗上颌发育不足效果。方法　唇腭裂术后继发上颌骨发育不足患者 2 2名 ,其中男性 1 4名 ,女性 8名 ,平均年龄为 1 5 3岁。所有患者在改良高位LeFortⅠ型截骨术基础上行颅外支架式上颌骨牵引成骨术。测量RED前后头颅定位侧位片上下颌骨位置及牙颌关系各项指标 ,用配对t检验比较RED术前术后变化。　结果　RED前后SNA角、NA与FH夹角、Ptm至S距离、Ptm至A距离、上中切牙至腭平面距离、上颌第一磨牙至腭平面距离、SNB角、面角、颌凸角、下颌平面角、ANB角、Y轴角、NA与AMe比、覆牙合和覆盖变化具高度显著性差异。　结论　RED用于唇腭裂术后继发上颌骨发育不足患者 ,可有效地延长上颌骨长度和高度并使之前移 ;下颌骨则顺时针旋转 ,上下颌骨间位置和比例更为协调 ,下颌骨的生长发育方向更趋于正常     

上颌前徙术后腭咽闭合功能的临床观察

目的　临床观察评价上颌前徙术后腭咽闭合功能变化。方法　对 7例上颌发育不全患者及 3例唇腭裂继发上颌发育不全患者行LeFortI型截骨术前移上颌骨 ,术前术后行鼻咽纤维镜及发“i”音时的头颅侧位片检查 ,结合术前术后语音的评价 ,对上颌前徙术后腭咽闭合及发音的改变进行观察分析。结果　经统计学分析 ,软腭动度、腭咽闭合程度、语音清晰度等指标术前术后比较差异均无显著性。结论　患者术前腭咽闭合功能良好时 ,上颌前徙术后腭咽闭合功能无明显变化     

经上颌截骨术的唇腭裂患者使用加固板后上颌横向稳定性的研究

目的　对 2 1例唇腭裂患者接受 L e Fort 型手术后使用加固板维持上颌横向的稳定进行探讨。方法　 2 1例中单侧唇腭裂 14例 ,双侧唇腭裂 7例 ,L e Fort 型手术及制作加固板时采取过矫正设计。取术前石膏研究模型 ,模型外科拼对后的石膏模型和最后一次随访所取的模型。平均随访 14个月。分别测量每个模型两侧尖牙和第一磨牙近中腭面外形高点连线距离。结果　加固板使用在单侧唇腭裂较双侧唇腭裂明显限制术后横向复发。结论　加固板的运用可提高唇腭裂患者 L e Fort 型手术后上颌骨横向的稳定性。复发的原因是唇腭裂整复手术留下的疤痕组织和颊肌运动造成的压力以及颌骨周围的肌肉张力的改变     

Skeletal stability in patients with clefts after large maxillary advancements using intraoral distraction

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10 mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3 mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years’ follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.     

Factors related to relapse after Le Fort I maxillary advancement osteotomy in patients with cleft lip and palate.

OBJECTIVE: To identify factors associated with relapse after maxillary advancement in cleft lip and palate patient. SUBJECTS: Seventy-one cleft lip and palate patients underwent Le Fort I maxillary advancement osteotomy between 1988 and 1998, and 58 patients (42 unilateral cleft and 16 bilateral cleft) with complete data were investigated for relapse by clinical and cephalometric analysis. The clinical follow-up period ranged from 1.5 to 8.5 years (mean 2.5 years). RESULTS: Horizontal advancement averaged 6.9 mm. There was a significant correlation between surgical movement and postoperative relapse in both the horizontal and vertical planes. In vertical repositioning, 15 patients had maxillary intrusion and 31 had inferior repositioning. There was a significant difference between the intrusion group and the inferior repositioning group. There was a significant correlation between surgical and postoperative rotation regardless of the direction. Other factors were evaluated by the horizontal relapse rate. Type of cleft and the rate of relapse were statistically associated. A relapse was more likely to occur in patients with bilateral cleft. There were no significant associations with the rate of relapse in type of operations or previous alveolar bone grafting. There was no significant correlation between the rate of relapse and the number of missing anterior teeth, postoperative overbite and overjet, and age at operation. Four of 71 patients experienced major relapse, and 3 of them underwent jaw surgery again. CONCLUSIONS: Based on clinical and cephalometric analysis, two-jaw surgery should be performed in cases of severe maxillary hypoplasia, and overcorrection may be useful in inferior repositioning or surgical rotation. Special attention should be paid to the patient with bilateral cleft, multiple missing teeth, or shallow postoperative overbite.     

Comparison of treatment outcome and stability between distraction osteogenesis and LeFort I osteotomy in cleft patients with maxillary hypoplasia

The purpose of this study was to compare treatment outcome and relapse between maxillary advancement surgery with LeFort I osteotomy and maxillary distraction osteogenesis in patients with cleft lip and palate with maxillary hypoplasia. The sample consisted of a maxillary advancement surgery with LeFort I osteotomy group (group 1, N= 14, mean age, 21.7 years) and a maxillary distraction osteogenesis group (group 2, N = 11, mean age, 16.3 years). Lateral cephalograms were taken and traced at presurgery (T0), postsurgery (T1), and postretention (T2). Nine hard and four soft tissue cephalometric variables were measured. Differences in measurements at each stage, treatment outcome (T1-T0), and relapse (T2-T1) were compared between groups with independent t test. Because the amount of surgical movement could affect the amount of relapse, a difference in relapse between two groups was compared by analysis of covariance with the amount of surgical movement as a covariant. Although the amounts of forward movements of A point (P < 0.01), upper incisor (P < 0.001), and upper lip (P < 0.001) during T1-T0 were greater in group 2, there were no significant differences in the amounts of relapse (T2-T1) between the two groups. During T1-T0, counterclockwise rotation of the palatal plane was observed in group 2 as a result of downward movement of posterior nasal spine (PNS) at T1, whereas group 1 had clockwise rotation of palatal plane at T1 because of downward movement of anterior nasal spine (ANS). The amounts of relapse (T2-T1) in vertical movements of PNS and upper incisor were significantly different between the two groups (P < 0.05). The amount of required maxillary advancement, vector control of palatal plane, and vertical position of upper incisor would be important factors when planning a surgical treatment in patients with cleft lip and palate with midface hypoplasia.     

Stability of maxillary surgical movement in unilateral cleft lip and palate with preceding alveolar bone grafting.

OBJECTIVE: To evaluate the long-term three-dimensional stability of Le Fort I maxillary osteotomy in patients with unilateral cleft lip and palate (CLP) who had preceding alveolar bone grafting. DESIGN: Analysis of prospectively collected data. Setting: University teaching hospital and postgraduate training center. SUBJECTS: Thirty consecutive patients with unilateral cleft lip and palate, who underwent the procedure between 1990 and 1999, satisfied the inclusion criteria and had complete records. There were 9 males and 21 females, with an age range of 14 to 28 years (mean, 18 years), and follow-up range of 12 to 66 months (mean, 62 months). METHODS: Cephalometric and study cast analyses using pre- and postoperative records (3, 6, 12, 24, and 36 months). Evaluation of surgical movement and postsurgical change at all above time intervals was carried out to determine stability of surgical maxillary movement in the horizontal and vertical planes and to identify rotational and transverse relapse. RESULTS: Total relapse of surgical movement was 31% in the horizontal plane and 52% in the vertical plane, as well as 30% rotational. Relapse correlated with extent of surgical movement, and most relapse occurred in the first 6 months after surgery. No significant transverse relapse was documented. CONCLUSION: Alveolar bone grafting prior to osteotomy stabilizes the transverse dimension of the dental arch, but does not improve horizontal, vertical, or rotational relapse, which remains significant. Correlation of relapse with extent of surgical movement does suggest that planned over-correction is a reasonable option.     

正畸治疗对恒牙晚期单侧完全性唇腭裂患者鼻部形态影响的研究

目的　研究恒牙晚期单侧完全性唇腭裂患者正畸治疗后的鼻部形态变化。方法　21例恒牙晚期单侧完全性唇腭裂患者在正畸治疗前、治疗后分别拍摄X线头颅侧位定位片,通过12个测量参数进行治疗前后的比较分析。数据资料用SPSS 13.0软件作统计学处理,治疗前后比较用t检验。结果　患者经上颌扩弓和正畸治疗后,鼻背长由（37.0±2.3）mm增加到（41.5±4.2）mm,P<0.05;鼻背深度1由（16.1±1.3）mm增加到（18.3±1.5）mm,P<0.05;鼻背深度2由(18.5±1.9)mm增加到(20.4±2.3)mm,P<0.05;鼻唇角由(66.9±5.6)°增大到(72.2±6.6)°,P<0.05;面型角由(-5.0±2.1)°变为(4.6±3.4)°,P<0.01。结论　恒牙晚期单侧完全性唇腭裂患者经过正畸治疗后,患者的鼻部长度及深度增加,鼻部形态改善,患者侧貌更加美观。     

唇腭裂正颌手术中应用微型钢板固定后上颌骨稳定性研究

２１例唇腭裂继发畸形患者接受ＬｅＦｏｒｔⅠ型手术并采用微型钢板固定，术后平均随访时间１４个月．采用标准头影侧位片测量比较．标志点Ａ在单侧唇腭裂组中，术后平均仅后移１．２ｍｍ，上移０．８ｍｍ，ＳＮＡ角减少１．３°．双侧唇腭裂组中，前移０．１ｍｍ，上移０．３ｍｍ．ＳＮＡ角增加０．３°．两组之间移动情况无显著性差异．微型钢板固定技术显著地改善了唇腭裂患者正颌手术后截骨段的稳定，但不能完全消除移动，原因主要是唇腭裂整复术遗留下的疤痕组织．     

Speech resonance in orthognathic surgery in subjects with cleft lip and palate

The main purpose of this study was to investigate the impact of maxillary advancement on speech resonance in subjects with cleft lip and palate. The study sample was composed of 42 subjects aged 16 to 41 years old with operated cleft palate ± lip submitted to maxillary advancement. Resonance was evaluated before and 3 to 12 months after surgery by perceptual analysis and graduated from absent to severe. It was observed that 47.5% of the subjects presented impairment of resonance after orthognathic surgery, with a confidence interval (at 95%) from 31.5% to 63.9%. These results suggest that orthognathic surgery in individuals with cleft palate may interfere in resonance, causing, or increasing the degree of hypernasality. Therefore, this highlights the importance of the orientation about the risks and benefits of maxillary advancement surgery and follow-up of these patients.     

单侧完全性唇腭裂前方牵引治疗后的稳定性研究

目的 通过对唇腭裂术后反（牙合）患者前方牵引治疗患者的纵向研究,探讨唇腭裂患者前方牵引治疗的稳定性.方法 单侧完全性唇腭裂术后前牙反（牙合）患者,下颌不能后退至切牙对刃、凹面型;骨龄显示患者处于生长发育高峰前期的患者18例,平均年龄（9.63±1.24）岁.进行前方牵引治疗,建立前牙正常覆盖关系,治疗时间平均（1.07±0.23）年.12名患者于（2.71±0.77）年之内完成了随访,患者分别于治疗前、前方牵引治疗后及治疗完成2年后进行头颅侧位X线片检查,手工描图并进行9项角度和15项线距测量.不同时点的（牙合）颌面特征进行配对t检验,并对影响前牙覆盖的因素进行了逐步回归分析.结果 前方牵引治疗后,经过平均（2.71±0.77）年的随访,NA-PA减小了2.92°±3.52°（P＜0.05）、OJ减小了（2.83±3.83） mm（P＜0.05）;L1-TL、B-TL、Po-TL、分别增加了（1.38±4.22） mm,（1.29±4.85） mm,（1.79±5.18） mm差异均有显著性（P＜0.05）;随访期间前面高N-ME、前下面高ANS-Me及后面高S-Go分别增加了（5.33±3.11） mm（P＜0.01）、（5.42±2.61）mm（P＜0.01）和（5.25±3.79） mm（P＜0.01）;治疗结束两年后患者SNA、ANB、NA-PA、U1-Sn、Y轴角、下颌平面角仍较治疗前增加;L1-MP及OP-SN、UL-U1保持较治疗前减小水平;U1-TL、A-TL、OJ与治疗前相比分别增加了5.38±2.79（P＜0.01）、3.13±1.60（P＜0.01）、4.78±2.96（P＜0.01）;而L1-TL、B-TL、PO-TL、UL-EL在治疗后的随访期与治疗前无显著性差异.以随访时前牙覆盖的复发量（T2-T1）为因变量对前方牵引治疗前及治疗后变化量的（牙合）颌面形态测量值做自变量进行逐步回归分析,得出回归方程：OJ（T2-T1）＝20.43-1.172OJT1-T0—0.548 L1-T1T1-T0—0.229U6-PPT1-T0 （R2=0.969）.结论 唇腭裂术后反（牙合）患者前方牵引治疗后的复发主要来自下颌的继续生长,前方牵引产生的上颌变化基本稳定.     

Stability after Le Fort I osteotomy in cleft lip and palate patients

Le Fort I osteotomies were performed in 20 patients with cleft lip and palate as a one-segment movement, and the fragments were fixed with miniplates without bone grafting. Tracings of preoperative and serial postoperative lateral cephalograms were used to determine changes in maxillary position. The posterior nasal spine, not subjected to extensive changes during surgical procedures and remodeling, was found to be the most reliable landmark for measuring maxillary advancement and stability. The mean maxillary advancement was 5.96 mm. Analysis did not reveal significant changes in linear and angular measurements from immediately postoperative to 6 months postoperative. A modest maxillary advancement by Le Fort I osteotomy, along with alleviation of palatal scar tissue tension and miniplate fixation, is a stable surgical method in patients with cleft lip and palate.     

Maxillary advancement using distraction osteogenesis with intraoral device

This article describes the surgical orthodontic treatment of maxillary hypoplasia in a patient with cleft lip and palate using maxillary distraction osteogenesis with internal maxillary distractors. Maxillary advancement was performed to correct the retrusive maxillary facial profile and Class III malocclusion. Rotational movement of the distraction segment was made to correct the upper dental midline. Although maxillary advancement was insufficient because of unexpected breakage of the intraoral distractor after completion of the distraction, skeletal traction with a face mask compensated for the shortage. Successful esthetic improvement and posttreatment occlusal stability were achieved with no discernible relapse after 2 years of retention.