牵张成骨术在腭裂中的研究进展

<正>牵张成骨术（distraction osteogenesis,DO）是一项通过对切开后仍保留骨膜及软组织附着和血供的骨段施加特定的牵张力,以延长或扩宽骨骼,达到矫治骨骼畸形或缺损的外科新技术,是目前矫治各种畸形的新方法。目前,DO已应用于矫治各种颅颌面畸形,特别是下颌骨的各种先天性或获得性畸形的矫治,但在腭裂患者中的应用相对较少。     

牵张成骨在颞下颌关节强直及其继发畸形矫治中的应用

儿童时期发生的颞下颌关节强直可以导致不同程度的颌面部骨骼发育障碍,并引起自卑、社交障碍等一系列心理问题,其矫治是口腔颌面外科医生面临的一大挑战. 牵张成骨( distraction osteogenesis,DO)一直被国内外学者用于颞下颌关节(temporomandibular joint,TMJ)强直及其继发畸形的矫治,并取得了良好的临床效果.笔者所在科室每年大概收治50~60例TMJ强直患者,对DO技术在TMJ强直及其继发畸形矫治中的应用积累了较为丰富的临床经验. 本文中,笔者对DO技术在TMJ强直及其继发畸形矫治中的优缺点及相关问题进行述评.     

牵引成骨区钙化、矿化程度加速的研究现状

牵张成骨术(distraction osteogenesis,DO)是一种通过机械装置渐进性牵引手术离断的骨段二端,引导牵引间隙新骨组织形成以矫治骨骼及周围软组织畸形与缺损的方法。该技术起源于整形外科对长骨畸形的矫治,随后被引入颌面外科领域治疗严重的颌面部骨畸形。Synder等于1973年应用DO牵引延长狗下颌骨获得成功,McCarthy等于1992年首次在临床使用DO治疗下颌骨畸形患者。经过十多年的基础研究与临床实践,DO已经被广泛应用于颌面部骨畸形的治疗。但是,DO需要较长的牵张固定期以让牵张间隙的新骨形成。矿化、钙化成熟。研究表明,牵张后的固定期约为40～50 d/cm。从而限制了DO在临床的推广应用。为了使牵张区快速生成新骨组织,学者们进行了各种实验研究,以期找到一种切实可行的方法,以缩短治疗时间。其中有物理学的     

牵张成骨技术在矫治腭裂术后面中份畸形的应用

牵张成骨(Distraction osteogenesis,DO)是对切断后仍保留骨膜、软组织及血供的两个骨段,通过固定于其上的牵张器施以特定大小的牵引或扩张力,使骨段间隙内再生新骨延长或拓宽骨骼,增加骨量的外科技术.近年来,DO术日益成熟,现就其在矫治腭裂术后面中份凹陷畸形的应用综述如下.     

牵张成骨术在腭裂畸形矫治中的应用和研究进展

牵张成骨是矫治骨骼畸形及缺损的一种新型外科技术,它对先天性腭裂的各种畸形进行整复和矫治已取得明显效果。本文阐述了腭裂术后继发性面中份发育畸形利用该技术矫治的优点、术期的选择、术中注意事项及如何提高矫治精度和质量,并对腭咽闭合不全、上颌骨横向发育不足、牙槽突裂及原发性腭裂等颌骨畸形及缺损的矫治方法、效果及相关机理进行了介绍。     

牵张成骨术在腭裂畸形矫治中的应用和研究进展

牵张成骨是矫治骨骼畸形及缺损的一种新型外科技术，它对先天性腭裂的各种畸形进行整复和矫治已取得明显效果。本文阐述了腭裂术后继发性面中份发育畸形利用该技术矫治的优点、术期的选择、术中注意事项及如何提高矫治精度和质量，并对腭咽闭合不全、上颌骨横向发育不足、牙槽突裂及原发性腭裂等颌骨畸形及缺损的矫治方法、效果及相关机理进行了介绍。     

颅面部牵张成骨的临床应用

牵张成骨(distraction osteogencsis,DO)已成为矫治各类先天性和获得性颅面部畸形的重要手段。本文以dis-traction、Iengthening、mandible、mdndibular、maxilla、maxillary、midface、midfacial、monobloc、cranial、craniafacisl及maxillofacial为关键词,通过PUBMED检索自1966年至1999年12月的109篇临床研究报告,依照牵张类型、适应征、患者年龄、手术类型、牵张速度与频率、延迟期与固定期等参数分类,对各家文献报告的不同DO治疗程序与结果进行归纳与分析研究,评估其临床适应征,并尝试建立颌面部DO术的治疗方案与成功标准。     

颅面部牵张成骨的临床应用

牵张成骨（distraction osteogenesis,DO)已成为矫治各类先天性和获得性颅面部畸形的重要手段。本文以distraction、lengthening、mandible、mandibular、maxilla、maxillary、midface、midfacial、monobloc、cranial、craniofacial及maxillofacial为关键词，通过PUBMED检索自1966年至1999年12月的109篇临床研究报告，依照牵张类型、适应征、患者年龄、手术类型、牵张速度与频率、延迟期与固定期等参数分类，对各家文献报告的不同DO治疗程序与结果进行归纳与分析研究，评估其临床适应征，并尝试建立颌面部DO术的治疗方案与成功标准。     

牵张成骨术治疗腭裂术后严重上颌骨后缩畸形

目的：观察应用牵张成骨技术治疗腭裂术后继发的严重上颌骨后缩畸形的效果。方法：对10例腭裂术后继发严重上颌骨后缩畸形的患者，术前常规行头影测量和模型外科设计；手术采用上颌骨Le Fort Ⅰ型截骨术，4例使用颅骨支抗外置式牵张器，其余患者采用内置式牵张器进行骨牵张术；术后延迟期为7d，牵张节律为0．8—1mm／d，2—4次／d，牵张结束后固定8-12周。结果：术后伤口一期愈合，牵张过程顺利，最大牵张距离为22mm，最小距离为15mm；患者的面形得到明显改善，未出现畸形愈合或骨不连接等并发症。结论：牵张成骨技术应用于腭裂术后继发的严重上颌骨后缩畸形，不需要植骨，可有效地达到上颌骨前徙、明显改善面形的目的。     

颌骨牵张成骨术的影响因素

<正> 牵张成骨(distraction osteogenesis,DO)是通过特殊牵张装置,对切开后仍保留骨膜、软组织附着与血供的骨段施加特定的牵张力,使骨段和相应软组织延长,以达到矫治骨畸形或缺损的外科技术。它广泛应用于颅骨、上下颌骨、牙槽嵴等的扩张延长。DO的成功应用受牵张器械、牵张参数、手术方案、机体状况等多种内外因素影响。现综述如下。     

腭裂实验动物模型的建立及缝牵张成骨的实验研究

目的 探讨手术建立腭裂实验动物模型及应用NiTiSMA牵张器行缝牵张成骨治疗发育期实验动物腭裂的可行性。方法 12只杂种犬被随机分为实验组和对照组，每组6只。采用自行设计、制作的表面处理的NiTiSMA牵张器，对发育期的腭裂实验动物（杂种犬）模型进行腭上颌缝牵张成骨，修复腭部裂隙区的全层组织缺损。观察裂隙关闭的过程。通过石膏模型，观察缝牵张成骨对上颌牙弓宽度发育的影响。结果 实验组动物腭部裂隙于牵张器植入14d后在腭中线处闭合。缝牵张成骨过程未对实验组动物牙弓宽度的发育造成明显影响。结论 表面处理的NiTiSMA牵张器运用牵张成骨原理，能有效地修复杂种犬腭裂动物模型的腭裂骨质缺损。     

硬腭两维牵张器的研制及体外实验研究

目的：探讨腭骨外固定两维牵张器在腭裂修复中关闭骨裂隙和后退腭骨的可行性。方法：设计并制作两维硬腭骨牵张器，在离体犬颅骨模型上制造人工腭裂模型，根据机械移动原理和牵张成骨原理，在硬腭后部设计2块可相对移动的转移盘，在一定范围内使骨块向内和向后移动，进行两维牵张成骨，并进行了手术模拟。结果：研制的两维缝牵张器可将转移盘前后方向移动16mm，近中方向左右各移动4mm，牵张器固定牢靠，转运盘稳定，牵张控制准确，在离体模型上可实现关闭裂隙、后退硬腭的设计要求。结论：设计的外固定两维牵张器可以向后、内牵张腭骨，从而达到关闭裂隙和硬腭后退的目的。     

Treatment of osseous cleft palate defects: a preliminary evaluation of novel treatment modalities.

OBJECTIVE: To compare the use of autogenous iliac bone graft (ABG) alone with nonresorbable expanded polytetrafluoroethylene Gore-Tex TR membrane (GTM) and with ABG plus resorbable Resolut XT membrane barriers for the secondary closure of alveolar cleft defects. STUDY DESIGN: Fifteen patients aged 9 to 17 years with unilateral cleft palate were included in this study. All patients had primary closure of the soft tissues at infancy. Presurgical orthodontics and scaling preceded the surgery. The patients were randomized to one of three surgical treatment groups: (1) ABG, (2) GTM, or (3) autogenous bone plus resorbable membrane (ABM). Periapical radiographs were taken pretreatment and 2 to 6 years later and were used to measure changes in size (linear and area) of the osseous defect. RESULTS: Significant decreases were observed in mean initial defect width (9.8 to 6.7 mm; p = .0263), mean initial defect height (20.7 to 15.1 mm), and overall mean defect size (223.6 to 143.9 mm2). Greater improvement in mean defect width was observed for the ABM group (6.42 mm) compared with the ABG (1.22 mm) and GTM (1.38 mm) groups. The reduction in overall mean defect size was significantly greater in the ABM group (177 mm2) compared with the GTM (20.51 mm2) and ABG (41.69 mm2) groups. CONCLUSION: Guided bone regeneration was found potentially useful for the treatment of osseous cleft palate defects. The combined approach yielded significantly greater defect fill. If further substantiated in larger independent studies, the adjunctive use of barrier membranes could improve the management of secondary closure of cleft palate defects.     

牵张成骨矫治腭裂新骨生成区超微结构特征的研究

目的:观察不同时间间期牵张生成的新骨组织的超微结构特征,探讨新骨生成的规律。方法:建立12只动物的人工腭裂实验模型,实验组动物10只:应用牵张成骨术,以每日2次,每次014 mm的速度和恒定的方向整复其腭部软硬组织缺损,至裂隙完全封闭。于术后固定期第2、4、6、8及12周分别安乐处死2只实验动物,切取标本后于扫描电镜下观察,并与实验对照组及空白对照组(动物各2只)观察结果对比。结果:第2周时,牵张区以大量沿牵张方向排列的胶原纤维束为主,成纤维细胞大量增殖,新生骨小梁钙化程度低。第4~6周时,成骨活动极其活跃,骨小梁较致密,其表面密集排列成骨细胞。新骨呈/蜂巢样0结构。第8~12周时,骨小梁结构逐渐钙化成熟。实验对照组裂隙创缘处无明显新骨形成。结论:应用牵张成骨术矫治腭裂骨质缺损,以原位产生新骨,增加骨量的方式推移骨运送盘封闭腭裂裂隙。术后早期即有膜内成骨的新骨形成,并最终改建成熟为适应正常生理功能需要的骨质结构。     

牵张成骨矫治腭裂的激光共聚焦荧光定量分析

目的：利用激光共聚焦显微镜与计算机辅助荧光定量分析，研究牵张成骨术矫治腭裂新骨生成随时间间期不同的动态变化趋势，为临床矫治腭裂应用提供理论与实验依据。方法：以家猫20只为实验对象。其中18只动物建立人工腭裂实验模型。实验组（动物15只）：应用牵张成骨术，以0．4mm×2次／d的速率牵张整复封闭其腭部组织缺损。术后第2、4、6、8及12周前6d以四环素肌注标记（30mg／kg）后各取材3只动物，标本制片后激光共聚焦显微镜观察荧光沉积并进行计算机定量分析，结果与实验对照组（动物3只）及空白对照组（动物2只）对比。结果：实验组不同时间间期标本的荧光强度平均值及其总量，显示出明确的动态变化规律，自2周组起，成骨活动明显活跃，到4周组达到顶峰，至8、12周组逐渐减弱，但仍显著高出无明显荧光沉积的空白和试验对照组。结论：应用牵张成骨术移动骨运送盘封闭组织缺损，牵张间隙逐渐被膜内成骨新骨生成修复，恢复了骨连续性。随时间间期的延长，新骨逐渐改建成熟。成骨活动呈现短期达到高峰后，逐步减弱的动态变化规律。     

Segment distraction to reduce a wide alveolar cleft before alveolar bone grafting.

OBJECTIVE: To demonstrate a method for reduction of wide alveolar clefts prior to bone grafting. This method aims to facilitate bone grafting and achieve adequate soft tissue coverage of the graft with attached gingiva. CASE REPORT: Treatment of a patient with bilateral cleft lip and palate with a severe alveolar defect on the left side is illustrated. Distraction osteogenesis was used to mesialize the left segment so that the alveolar cleft was reduced to a minimum. After a 10-week retention period, bone grafting of the reduced alveolar defect was successfully performed. After consolidation of the bone graft, the alveolar cleft was found to have an osseous closure with adequate soft tissue coverage. CONCLUSION: In patients with a wide alveolar cleft, soft tissue coverage with keratinized mucosa can be more readily assured by reducing the alveolar cleft by callus distraction to mesialize the lateral segment prior to bone grafting.     

Mid Versus Late Secondary Alveolar Cleft Grafting Using Iliac Crest Corticocancellous Bone Graft

Background

Mid-secondary alveolar cleft repair performed at ages 9–12, in the mixed dentition stage, prior to eruption of the permanent canine, is generally accepted as the ideal time for residual alveolar cleft closure in cleft lip and palate cases with a cleft alveolus.

Methods

In our study, four cases of mid-secondary and five cases of late–secondary alveolar cleft grafting were carried out using iliac crest corticocancellous bone graft. Clinical defect closure and radiographic bone fill were compared.

Results

All the nine cases performed in the two different age groups showed excellent results, clinically, with complete closure of the cleft defect and achievement of continuity of the dental arches. One case was planned for a two-stage procedure owing to the large bilateral maxillary defects. Good bone fill was visualized radiographically in all nine cases.

Conclusion

Precise timing for undertaking alveolar cleft repair may not be all that crucial for a successful alveolar cleft grafting procedure.     

Comparative study of maxillary growth and occlusal outcome after autogenous rib grafting in complete cleft palate defect

Cleft palate is a congenital deformity with soft tissue and hard tissue defects. Normal cleft palate repairing surgery only repairs soft tissue defects, whereas bone defects in the hard palate still exist. Therefore, we conducted this study in beagles to observe the influence of bone grafting at primary surgery on craniofacial growth and occlusal relationships in individuals with complete cleft palate and to provide experimental evidence for optimal surgical procedures for cleft palate.Using 60 beagle puppies as subjects, we tested the effects of bone grafting in surgically induced palatal defect. The animals were randomly and equally divided into four groups: (1) unoperated controls; (2) surgically induced unilateral cleft palate, not repaired; (3) two-flap palatoplasty used to close the soft defect of the surgically induced cleft palate; (4) autogenous bone (a piece of rib bone) implanted into the palatal defect before two-flap palatoplasty was performed.Cephalometric roentgenography and plaster casts of the maxillary were taken preoperatively and every 4 weeks after surgery. Sixty metric cranial variables were measured directly from the cleaned skulls after the animals were killed the 34th week postoperatively.The measurement results indicated that bone grafting may reduce the disturbance of maxillary growth caused by the cleft palate and the denuded bone, but it may cause other maxillary deformities. This finding suggests that surgeons should be careful in choosing the method of primary bone grafting in repairing complete cleft palate.     

Prosthetic treatment by pushing back part of the hard palate in third-degree cleft palate

In the third degree of cleft palate, the palate bones are short, the cleft is wide, the degree of palatal tissue atrophy and the anterior displacement of the muscles are great. It is difficult to repair satisfactorily. We carried out a treatment plan by pushing the soft palate and posterior part of the palatal bone fully back to the physiological closure position by surgical means without cutting through the palatal aponeurosis. By using a palatal plate with pharyngeal prong immediately after operation to fix the composite flap posteriorly and restore the defect of the hard palate. The palatal palate is changed with a silicon obturator or performed secondary operation to repair the perforation of the hard palate after the primary wound is well healed. 24 cases have been performed by this means since 1984. The outcomes are good. It is well conditioned for surgical orthodontics of severe crossbite which results from undeveloped maxilla also.     

Use of distraction osteogenesis in cleft palate patients

Distraction osteogenesis (DO) has been used recently to correct maxillary hypoplasia with predictable and stable results. In patients with clefts of the secondary palate, DO can also be used to aid in vertical alveolus augmentation and rapid orthodontic tooth movement. If an osteotomized dental arch can be transported to a new position without complications, it would reduce or eliminate the need for a secondary bone graft to the cleft alveolus in cleft patients and help prevent dentoalveolar defects by approximating the native alveolar bone and gingiva. Mobilizing a segment in the dentoalveolar region also results in the creation of new bone and attached gingiva. This report shows that the application of DO for skeletal expansion and rapid movement of tooth-bone segments should receive more careful consideration in the treatment of patients with clefts of the palate.