外科矫正骨型下颌下后缩畸形的术前术后正畸治疗

以近期连续收治的１７例骨型严重下颌后缩的患者为例，重点介绍对该类畸形患者的术前准备，特别是术瓣术后正畸治疗及Ｈｅ导板的应用。正畸治疗内容包括；去代偿扩大上牙弓，排齐牙齿，平整Ｈｅ曲线，使上下牙弓形态协调，恢复Ｈｅ平衡重建良好的咬合关系。     

外科矫正骨型下颌后缩畸形的术前术后正畸治疗

以近期连续收治的 17例骨型严重下颌后缩 (已作正颌手术 )的患者为例 ,重点介绍对该类畸形患者的术前准备 ,特别是术前术后正畸治疗及导板的应用。正畸治疗内容包括 :去代偿扩大上牙弓 ,排齐牙齿 ,平整曲线 ,使上下牙弓形态协调 ,恢复平衡重建良好的咬合关系。作者的经验表明 ,对严重骨型下颌后缩患者 ,要获得形态和功能完美结合的理想治疗目标 ,外科和正畸联合治疗 ,特别是术前、术后的正畸准备 ,是保证手术成功的必须和必要的条件。     

Use of three-dimensional medical modeling methods for precise planning of orthognathic surgery

Stereolithographic (medical rapid prototyping) biomodeling allows three-dimensional computed tomography to be used to generate solid plastic replicas of anatomic structures. Reports in the literature suggest that such biomodels may have a use in maxillofacial surgery, craniofacial surgery, orthopedics, neurosurgery, otology, vascular, and nasal research. A prospective trial to assess the usefulness of biomodeling in orthognathic surgery has been performed. In 12 patients with mandibular prognathism and/or maxillary retrusion, in addition to routine preoperative cephalometric analysis, preoperative high-resolution (cutting slice thickness of 1 mm) three-dimensional computed tomography scan of the patients was obtained. Raw data obtained from computed tomography scanning was processed with a Mimics 9.22 Software (Materialise's Interactive Medical Image Control System, Belgium). Fabrication of three-dimensional medical models was obtained through a process called powder depositional modeling by use of a Spectrum Z 510 3D Color Printer (Z Corporation, Burlington, MA). Alveolar arches of the maxilla and mandibula of the models were replaced with orthodontic dental cast models. Temporomandibular joints of the models were fixed with Kirschner wire. Maxillary and mandibular bony segments were mobilized according to preoperative orthodontic planning done by analysis of cephalometric plain radiographs. The relation between proximal and distal mandibular segments after bilateral sagittal split osteotomies were evaluated on models preoperatively. The same surgeon had a role in both model cutting preoperatively and as an instructor preoperatively. The same bony relation was observed both in preoperative modelsand in the perioperative surgical field in all patients. Condylar malpositioning was not observed in any of the patients. Studying preoperative planned movements of osteotomized bone segments and observing relations of osteotomized segments of mandibula and maxilla in orthognathic surgery increased the intraoperative accuracy. Limitations of this technology were manufacturing time and cost.     

Surgery-first approach in class III open-bite

Recently, surgical-orthodontic treatment without preoperative orthodontic treatment (known as the surgery-first approach or SFA) has been proposed to improve facial aesthetics from the beginning of treatment, to shorten the entire treatment period, and to take advantage of the regional accelerated phenomenon for orthodontic tooth movement. The SFA concept involves the prediction and simulation of dental alignment, incisor decompensation, and arch coordination using manual setup models. Based on this, decisions regarding the surgical movement of the maxilla and mandible can be made to correct skeletal discrepancies through manual model surgery (MMS). Although several three-dimensional (3D) virtual model surgery (VMS) programs have been introduced to reduce time-consuming manual laboratory procedures and potential errors, these programs still require three-dimensional-computed tomography data and involve complex computerized maneuvers. Because it is difficult to acquire 3D-computed tomographic scans in all cases, a 2.5-dimensional VMS program using two-dimensional lateral and posteroanterior cephalograms and 3D virtual dental models (3Txer version 2.5; Orapix, Seoul, Korea) has been introduced. In addition, because accurate prediction of postoperative orthodontic treatment is crucial for controlling dental alignment, incisor decompensation, arch coordination, and occlusal settling, a new 3D virtual orthodontic treatment system that can construct 3D virtual models, execute a 3D virtual setup, place virtual brackets at predetermined positions, and fabricate transfer jigs with customized bracket base for indirect bonding using a stereolithographic technique has also been developed. The purpose of this article was to introduce the methodology of 2.5-dimensional VMS and 3D virtual postoperative orthodontic treatment using a stereolithographic technique in SFA for a class III open-bite case.     

Relapse patterns of two-jaw surgical correction in patients with skeletal Class III malocclusion and different vertical facial types

The aim of this study was to evaluate postoperative relapse after the surgical correction of skeletal Class III deformities of various facial patterns as a guide to surgical planning. A retrospective cohort study of 90 consecutive patients with skeletal Class III malocclusion who underwent bimaxillary surgery was performed. The surgical outcomes and postoperative stability were compared. The primary predictor variable was vertical facial type, which was classified into three groups according to the Frankfort mandibular plane angle (FMA). The primary outcome of angular and linear measurements was obtained using serial cone beam computed tomography scans obtained at time points of preoperative, 1 week after surgery, and orthodontic debonding. No significant difference in skeletal relapse was observed in patients with the different vertical facial types. The mandible displayed a forward and upward relapse in all three groups postoperatively. The patients with a low FMA exhibited a more consistent mandibular relapse pattern than those with a normal or high FMA. These findings suggest that bimaxillary surgery is clinically stable for mandibular prognathism regardless of the vertical facial pattern. However, 1–1.5 mm of overcorrection in the mandible setback should be considered in patients with a low FMA, because of the greater facial depth and consistent forward and upward mandibular relapse pattern.     

Orthognathic surgical planning on three-dimensional stereolithographic biomodel

The aim of this report was to present the orthognathic surgical planning of a patient with maxillary retrusion, mandibular prognathism, and midline shift on a three-dimensional stereolithographic biomodel. A patient who complained about facial deformity and difficulty in chewing was referred to our department. After a short-term presurgical orthodontic treatment, Le Fort I osteotomy and bilateral sagittal split ramus osteotomy were performed. Triangular axial gaps occurred anteriorly and posteriorly between the proximal and distal segments of the osteotomized mandible. These gaps were filled with bone grafts in accordance with templates that were constructed on a three-dimensional stereolithographic biomodel. Rotational movement of the distal mandibular segment around the y axis caused axial triangular gapping between the proximal and distal mandibular segments. In the presented case, orthognathic surgical planning was performed on the three-dimensional solid models, and templates were reconstructed according to these gaps. These templates were used to determine the size of the bone grafts during the surgical approach. The patient was diagnosed with lateral cephalometric and posteroanterior cephalometric analysis in postretention for 2 years, and it was determined that long-term results were perfect and skeletal relapse did not occur after 2.5 years of surgery. Movement at the site of the osteotomy is usually the main cause of relapse after orthognathic surgery. In the presented case, a three-dimensional stereolithographic biomodel was used to plan the orthognathic surgery and to reconstruct the templates to determine the size and shape of the bone grafts. Using bone grafts established close contact between proximal and distal osteotomized bone segments, enhanced bone healing, and diminished relapse risk.     

The frequency and distribution of skeletal and dental components in Class II orthognathic surgery patients

In an effort to identify the skeletal and dental relationships of Class II malocclusion, lateral cephalograms of 253 adult orthognathic surgery patients (76 male, 177 female) who had a Class II molar and cuspid relationship were traced. One hundred and four of the subjects had had presurgical orthodontic treatment and 148 had not. The most common combination of variables found in this study population was a retrusive maxilla, protrusive maxillary incisors, protrusive mandibular incisors, a retrusive mandible, and a long lower facial height.     

唇腭裂术后成人颌面部畸形的序列治疗：附4例分析

目的：通过研究因唇腭裂手术导致颌面部畸形的治疗，探讨序列治疗的方式及效果。方法：4例唇腭裂患者在幼儿时进行唇腭裂治疗，成人后出现颌面部畸形。通过术前正畸、正颌手术、牙槽突裂植骨、术后正畸治疗、义齿修复以及软组织矫正等6个阶段，对畸形进行序列治疗。通过面型分析、头影测量分析．探讨颌面部畸形的矫治效果。结果：所有患者的猞关系良好，猞关系稳定，未出现复发。面部容貌和软组织形态得到较大改善。结论：通过序列治疗．唇腭裂手术所致的成人颌面部畸形可得到良好的矫治。     

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骨性畸形在牙颌面畸形中占有相当高的比例,许多患者要通过正颌手术治疗.通常患者首诊到正畸科、颌面外科(整形外科、正颌外科).是否要行正颌手术治疗往往要取决于正畸科是否能通过代偿正畸治疗解决问题.若代偿矫治的结果能使患者和医生都满意,则患者可以避免更复杂、风险更大的正颌手术治疗;若患者的要求很高(可能是美观方面)或畸形非常严重,单纯正畸治疗已不能很好地解决患者对颌面部美观和功能恢复的要求,正颌手术就是惟一正确的选择、目前,在正畸和手术联合治疗开展比较好的医疗单位,是否手术以及手术如何设计几乎是由正畸医生主导.所以,这就要求正畸医生除了要全面掌握骨性牙颌面畸形术前、术后正畸治疗的理论和临床技能外,还要比较透彻地了解各种正颌手术术式、手术的最大限度、术前术后正畸、(牙合)板制作等方面知识.本文将结合临床实际,就几个正畸和手术联合治疗的重要问题进行讨论,重点在各种畸形正颌手术的术式选择策略,正畸和手术联合治疗的术前、术后正畸治疗原则等.     

正颌外科和正畸联合治疗下颌前突畸形

目的：总结分析下颌升支部和下颌体部截骨矫正下颌前突畸形的手术和正畸治疗特点。方法：根据手术设计需要，将125例下颌前突畸形患者分下颌升支部截骨和下颌骨体部截骨两组，并分别进行内容不同的术前术后的正畸治疗。结果：两种术式均获得满意的治疗效果。下颌升支部截骨和下颌骨体部截骨满意率分别为88.3%和83.3%。2例下颌体部截骨术后2年复发，行二次手术予以矫正。结论；必需根据不同的术工，设计不同的术前术后正畸方案。一方面保证下颌前突畸形患者获得满意的美学改善，同时在新建的颌位上应具有良好的he关系。     

Relationship between transverse dental anomalies and skeletal asymmetry.

The recognition and elimination of dental compensation is essential in presurgical orthodontic treatment to achieve successful stabilization of the occlusion after surgery. However, the relationship between a transverse dental anomaly and skeletal asymmetry is not fully understood. To evaluate this relationship, frontal cephalometric and 3-dimensional dental model analyses were carried out on 44 adult Japanese Class III patients (mean age 21 years 11 months) who required surgical orthodontic treatment. The patients were divided into 2 groups: a facial asymmetry group in which the mandibular transverse deviation exceeded +/- 1 SD from the norm, and a control group in which the mandibular transverse deviation was within +/- 1 SD of the norm. Statistical comparison with a control group showed characteristic dental anomalies in the facial asymmetry group, including asymmetry of the curve of Spee, molar inclination, dental arch form, lateral overjet, and slanting of the occlusal plane. Stepwise linear regression analysis showed that transverse and vertical skeletal asymmetry variables including the mandible and the maxilla were effective parameters for characteristic dental anomaly variables, and a significant high correlation between dental anomalies and skeletal asymmetry was found.     

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牵张成骨术作为一种有效颌骨延长手术被越来越多应用于严重的颅颌面畸形治疗中。相比传统的颌骨延长术(如下颌矢状劈开术),牵张成骨术具有更强的颌骨延长能力和更理想的术后稳定性。由于牵张成骨术中受神经肌肉作用和咬合干扰等因素的影响,颌骨牵张效果与预期可能存在一定偏差。为实现面型改善和理想咬合的统一,需要对颌骨牵引方向进行正畸辅助调控和术后精细咬合调整。本文通过介绍1例牵张成骨术治疗安氏Ⅱ类单侧颜面不对称畸形患者的矫治过程,探讨牵张成骨术联合正畸治疗单侧颜面不对称畸形的应用要点,为今后临床应用提供借鉴。     

Planning orthognathic surgery with three-dimensional models

Computerized imaging to provide the perspective of the third dimension is helpful for preoperative evaluation and has been introduced for a variety of indications. Calculated from original computerized tomographic scans, deformities in skeletal and soft tissue profiles can be visualized on a television monitor. A method of fabricating three-dimensional skeletal models that can be used for planning orthognathic surgery has been developed. Mandibular and maxillary surgical movements can be simulated exactly, and osteosynthesis materials can be chosen, adapted, and prepared to save time intraoperatively.     

Orthodontic-surgical treatment of Class III malocclusion with mandibular asymmetry

Class III skeletal malocclusion may present several etiologies, among which maxillary deficiency is the most frequent. Bone discrepancy may have an unfavorable impact on esthetics, which is frequently aggravated by the presence of accentuated facial asymmetries. This type of malocclusion is usually treated with association of Orthodontics and orthognathic surgery for correction of occlusion and facial esthetics. This report presents the treatment of a patient aged 15 years and 1 month with Class III skeletal malocclusion, having narrow maxilla, posterior open bite on the left side, anterior crossbite and unilateral posterior crossbite, accentuated negative dentoalveolar discrepancy in the maxillary arch, and maxillary and mandibular midline shift. Clinical examination also revealed maxillary hypoplasia, increased lower one third of the face, concave bone and facial profiles and facial asymmetry with mandibular deviation to the left side. The treatment was performed in three phases: presurgical orthodontic preparation, orthognathic surgery and orthodontic finishing. In reviewing the patient's final records, the major goals set at the beginning of treatment were successfully achieved, providing the patient with adequate masticatory function and pleasant facial esthetics.     

Use of intraoral miniplates to control postoperative occlusion after high condylectomy for the treatment of condylar hyperplasia

Mandibular condylar hyperplasia is a rare disorder, characterized by unilateral mandibular overgrowth with overeruption of the dentition on the affected side. Although the etiology is unclear, multiple surgical techniques have been described to correct the associated mandibular bone, occlusal, and soft tissue deformities. Often a condylectomy, to arrest mandibular growth, is combined with various orthognathic procedures to restore occlusion and facial harmony. Here we report our technique of isolated high condylectomy with simultaneous intraoral placement of maxillary and mandibular miniplates. Each plate has an intraoral extension that allows our orthodontists to develop vertical force vectors to intrude the maxillary and mandibular molar segments. Using this combined surgical and orthodontic technique, we were able to postoperatively control the occlusal cant, restore the dental midline, improve facial aesthetics, and resolve the patient's contralateral temporomandibular joint dysfunction without concomitant orthognathic surgery. As a result of our findings, we are currently using, and would recommend, this technique for patients requiring surgical-orthodontic intervention for other conditions.     

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目的预测骨性安氏Ⅲ类错患者正颌外科手术术后的面部软组织侧貌,分析侧貌美观评价的差异,为正畸治疗和正颌外科手术方案的设计提供参考。方法选择中国医科大学口腔医学院正畸科2005年2月收治的骨性安氏Ⅲ类错患者1例。模拟正颌外科手术的设计方案,对术前正畸去代偿后的侧貌照片及头颅定位侧位片进行图片叠合处理,上颌硬组织以术前影像为基准,分别前移0、2、4、6、8mm,软组织按相应比例移动,下颌后退至正常覆、覆盖关系,生成5张面部侧貌图片。选择3组评分者:医生组(正畸及正颌外科医生,41名)、口腔本科生组(中国医科大学口腔医学专业本科生,44名)和患者组(骨性Ⅲ类错畸形患者,20例)。对术前及预测的共6张图片(图2a、2b、2c、2d、2e、2f)进行随机排序,由高到低评分,比较所有图片的评分差异以及评分者性别对评分结果的影响。结果 6张图片的得分差异均具有统计学意义(P<0.05),评分由高到低的顺序为:图2c、2d、2a、2f、2b、2e。3组间及不同性别评分者的评分结果比较,差异均无统计学意义(P>0.05)。结论比较评分者对术后预测图片的评价结果,直面型满意度最高,凸面型其次,凹面型最低;评价结果不受性别影响。     

正畸正颌联合治疗唇腭裂术后牙颌面畸形的疗效观察

目的:探讨正畸、正颌外科联合治疗唇腭裂术后牙颌面畸形的临床疗效。方法:选择2001—2012年,我院收治的唇腭裂术后牙颌面畸形患者56例,采用正颌联合正畸的方法进行治疗。随访6²4个月,观察牙颌面畸形改善情况。结果:56例患者面形改善明显,咬合关系良好,随访无复发。比较手术前后的头影测量值进行分析,差异具有统计学意义(P<0.05)。结论:正颌外科联合术前、术后正畸,可明显改善面部畸形,减少术后复发,是治疗唇腭裂术后牙颌面畸形的理想手术方式。     

The role of mandibular stabilization in orthognathic surgery

Stability of the temporomandibular joint (TMJ) structure is a critical requirement for treatment that includes orthognathic surgery. If the condyles are not positioned properly in the articular fossae during the manual positioning of the condyle or the intermaxillary fixation, postoperative relapse can result. However, it is difficult for the orthognathic surgeon to control the positioning of the mandibular condyles during orthognathic surgery due to muscle relaxation and the harsh intraoperative environment. Well-managed presurgical orthodontic treatment does not always guarantee the proper positioning of the proximal segment either, especially if the TMJ structures are not stable in their functional area. Therefore, the mandible should be stabilized with a presurgical stabilization splint to provide proper stimulation that forms a pseudodisc in the TMJ structures before surgical procedures.     

Extraoral vertical ramus osteotomy combined with internal fixation for the treatment of mandibular deformities

Extraoral vertical ramus osteotomy (EVRO) is used in orthognathic surgery for the treatment of mandibular deformities. Originally, EVRO required postoperative intermaxillary fixation (IMF). EVRO has been developed using rigid fixation, omitting postoperative IMF. We examined retrospectively the long-term stability and postoperative complications for patients with mandibular deformities who underwent EVRO with internal rigid fixation. Patients who were treated with EVRO for a mandibular deformity in the period 2008–2017 at the Clinic of Oral and Maxillofacial Surgery, Mölndal, Sweden were included (N = 26). Overjet and overbite were calculated digitally and cephalometric analyses were performed preoperatively, and at three days, six months, and 18 months postoperatively. There was a general setback of the mandible, decreased gonial angle and reduced degree of skeletal opening. Excellent dental and vertical skeletal stabilities were seen up to 18 months postoperatively, although relapse was seen sagitally up to six months postoperatively. Since the overjet did not show any significant change over time, the sagittal skeletal changes have been attributed to dental compensation. There was no permanent damage to the facial nerve and 5.8% neurosensory damage to the inferior alveolar nerve was observed.     

Surgical treatment of a skeletal Class III patient using customized brackets based on the CAD/CAM virtual orthodontic system

The computer-aided design/computer-aided manufacturing (CAD/CAM) virtual orthodontic system produces customized brackets, indirect bonding jigs, and archwires based on a three-dimensional virtual setup. In surgical cases, this system helps to visualize the final occlusion during diagnosis and to efficiently plan individualized presurgical orthodontic treatments. A 20-year-old female patient with a skeletal Class III malocclusion, maxillary protrusion, and lip protrusion was successfully treated with orthognathic surgery and orthodontic treatment with maxillary first premolar extractions. The CAD/CAM system was applied for efficient treatment, with a total active treatment time of 16 months. In this case report, the applicability of the CAD/CAM virtual orthodontic system for orthognathic surgery cases is demonstrated. Suggestions are also made to overcome the limitations and to maximize the advantages of this system during orthodontic treatment of patients undergoing orthognathic surgery.