高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形

目的 探讨联合应用高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形的可行性。方法2002年1月～2005年1月，共收治10例唇腭裂术后面中部畸形患者，男4例，女6例。年龄16～32岁。单侧唇腭裂8例，双侧2例。影像学检查均有继发面中部畸形的主要表现。均采用高位Le Fort Ⅰ型截骨和牙槽嵴裂自体髂骨游离移植一期手术矫正。高位Le Fort Ⅰ型截骨的截骨线在上颌骨前壁比常规Le Fort Ⅰ型截骨线高，最高可达眶下孔下5mm左右，水平截开至颧牙槽嵴处再弧形转向下后方。结果术后伤口均I期愈合。复查头部X线片，所有患者上颌骨位置均得到明显改善。随访6～24个月，牙弓外形良好，X线片示无明显骨质吸收，植骨区密度与周围接近。10例均获得满意面容，其中9例获得良好的牙骀关系。结论高位Le Fort Ⅰ型截骨术不仅可前移上颌骨，还可前移部分眶下区及整个鼻旁区和鼻底，更明显地改善畸形。同期行牙槽嵴裂自体髂骨游离移植，可减少手术次数、降低费用、获得理想效果，是矫治唇腭裂术后面中部继发畸形的一种有效方法。     

A Follow-Up Study of Cleft Children Treated with Primary Bone Grafting: I. Orthodontic Aspects

The effect of primary bone grafting in the treatment of complete clefts has been studied with roentgenologic and biometric methods. The material, operated on during 1958–64, consisted of 16 patients with complete bilateral cleft lip and palate and 37 cases with complete unilateral cleft lip and palate. All of the studied bone grafts (= 69) healed well, but this did not lead to the expected normalisation of the growth of the middle face. On the contrary, our patients developed a pronounced maxillary retrognathia, which seemed to increase with age. This resulted in a concave facial skeletal profile for both the bilateral and unilateral cases. The occlusal analysis also indicated a maxillary growth retardation. Thus, our patients revealed a much higher frequency of anterior as well as lateral crossbites, when compared with other studies on not-bone-grafted clefts. Also, our patients had increased frequency of Class III molar relations while fewer had Class I and Class II relations. The growth aberration in many cases reached such a degree that the primary bone grafting of further cleft patients was discontinued.     

New orthodontic and orthopaedic managements on the premaxillary deformities in patients with bilateral cleft before alveolar bone grafting

At the age of mixed dentition, a downward or laterally displaced premaxilla with a wide alveolar cleft in patients with bilateral cleft lip and palate remains a dilemma both for orthodontists and surgeons. These premaxillary deformities not only make the alveolar bone grafting difficult but also aesthetically and functionally unacceptable. The purpose of the present article is to introduce three new orthodontic and orthopaedic techniques for solving these premaxillary deformities and facilitating alveolar bone graft through a non‐surgical approach. These techniques are the premaxillary orthopaedic intrusion for correcting a downward displaced premaxilla, the premaxillary orthopaedic repositioning for correcting a laterally displaced premaxilla, and maxillary orthopaedic protraction by alternate rapid maxillary expansions and constrictions for minimizing a wide alveolar cleft. They were evaluated clinically and cephalometrically for their treatment effects. The results revealed that the premaxillary and cleft deformities were corrected in a short period of time and therefore the alveolar bone grafting could be carried out without difficulty in all of the patients who received the treatment. The treatment effects were mostly orthopaedic and partly orthodontic. No growth disturbance on the maxilla was observed throughout the treatment. These new orthodontic and orthopaedic techniques are very effective for solving the difficult‐to‐treat premaxillary deformities and facilitating the alveolar bone grafting in the patients with bilateral cleft.      

Direct gingivoperiosteoplasty with palatoplasty

Gingivoperiosteoplasty creates a mucoperiosteal bridge across the alveolar cleft associated with cleft lip and palate. The subperiosteal tunnel allows for bone generation in the absence of bone grafting in young patients. The original procedure required wide maxillary subperiosteal dissection and flap rotation but has since evolved along with techniques to narrow the alveolar cleft toward limited dissection and direct closure. Multiple studies reveal superior facial growth parameters, particularly vertical maxillary growth, when compared with primary bone grafting typically performed within the first year of life and a reduced need for later secondary bone grafting. Most centers that perform gingivoperiosteoplasty do so in conjunction with primary lip closure after initial narrowing of the cleft with presurgical orthopedics. We present our method of direct gingivoperiosteoplasty performed simultaneously with palatoplasty after alveolar cleft narrowing without presurgical orthopedics via a two-stage lip repair. Preliminary data suggest bone growth capable of supporting tooth eruption without significant growth disturbances in a majority of patients treated with this protocol.     

齿槽裂修复方法的研究进展

目的探讨齿槽裂修复治疗的目的、方法以及治疗时机的选择。方法查阅1950年至2006年有关齿槽裂修复的文献,归纳文献中报道的不同方法,并评价其各自的优缺点。结果齿槽裂修复的主要目的:关闭口鼻瘘;建立稳定、连续的上颌骨牙弓;为牙齿萌出提供基础;为上唇和鼻底提供稳定支架。主要治疗方法:植骨术;牵引成骨技术;组织工程骨和生长因子应用;引导骨再生技术。患者最佳的手术治疗时机是9~11岁时混合牙列期。结论在9~11岁混合牙列期手术,以髂骨松质骨为移植材料被认为是修复齿槽裂的主要手段。牵引成骨技术、组织工程技术和引导骨再生技术,将是齿槽裂修复的新方向。     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract

This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16–19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16–19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16–19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

Orthopaedic growth guidance and stimulation for patients with cleft lip and palate

The growth potential of the craniofacial complex of a child with a congenital cleft is not at variance with that of the normal craniofacial complex. Early surgery including mucoperiosteal undermining and the formation of scar tissue generally results in considerable growth retardation. Primary bone grafting seriously inhibits maxillary growth. 15 years' experience with the treatment of cleft patients applying "growth stimulators" combined with postponing surgical corrections is reported, and the results of this treatment method are compared with those found in literature. As a criterion an accurately measurable and reliable parameter, namely the crossbite relation, was opted for. The frequency of crossbite occurrence is now only 16% for deciduous dentitions and 21% for mixed dentitions. In comparison with the most favourable treatment results found in the literature this constitutes a reduction of more than 50%. This implies that the development of maxillary morphology is normalised, leading to an improvement of the oro-nasal functions including speech development.     

A Multicentre Comparison of Treatment Regimens for Unilateral Cleft Lip and Palate Using a Multiple Regression Model

Abstract

The European Cleft Lip and Palate Research Group consists of specialists in orthodontics from six centres for the treatment of cleft palate in northern Europe. The purpose of this part of the multicentre study was to investigate whether differences in outcomes could be explained by specific treatment regimens. Three regimens that were assumed to influence the outcome of treatment were selected: Presurgical orthopaedics, closure of the palate, and primary bone grafting. The sample comprised 151 children with complete unilateral cleft lip and palate from the six centres. The result of multiple regression analysis showed that within that sample it was not possible to reach definite conclusions as to which factors exerted the most favourable influence on facial growth, but primary bone grafting was associated with reduced maxillary inclination and presurgical orthopedics with increased mandibular inclination.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16-19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16-19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16-19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

Evaluation of a combination of the Abbé flap and the Le Fort I osteotomy in CLP patients

The purpose of this paper is to present the experience with 4 adult CLP patients with severe maxillary hypoplasia and an unacceptable upper lip. This was corrected with a Le Fort I advancement osteotomy en bloc or in two segments, bone grafting the alveolar cleft if present and an Abbé flap. The combination of a Le Fort I osteotomy and an Abbé flap resulted in satisfactory functional and aesthetic improvement in all 4 adult CLP patients without complications. Received: 24 February 1997 Accepted: 10 December 1997     

Maxillary bone transportation in alveolar cleft-transport distraction osteogenesis for treatment of alveolar cleft repair.

Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, inappropriate patient age, or large clefts. For alveolar clefts, we developed a method consisting of alveolar bone transportation, closure of the alveolar cleft, and/or grafting of new bone. Transport distraction osteogenesis along the curve of the dental arch is ideal. Alveolar bone was transported in the planned direction using a ready-made bone-borne distractor in combination with an orthodontic arch wire for transport guidance. This method allows simultaneous correction of nasal septal deviation and also correction of maxillary arch deformities and malocclusion since, the dental arch is expanded without donor sacrifice. This method can be regarded as tissue engineering to expand bone tissue. This method can be safely performed not only in patients undergoing initial treatment for alveolar clefts but also in patients in whom bone grafting has failed. Since 1997, we have performed this method in 22 patients and obtained good results.     

Neonatal computed tomographic maxillary explorations in children with unilateral cleft lip and palate

The aim was to examine the bony maxillary structures by computed tomographic measurements in newborns with unilateral cleft lip and palate before cheiloplasty. Analysis of maxillary bone was performed and size parameters were measured by computed-tomographic analysis in 12 infants with unilateral cleft lip and palate. We compared the bony maxillary length and the bony maxillary width between the cleft side and the healthy side. For eight patients, the bony maxillary length was different between the cleft side and the healthy side. For three patients, the bony maxillary width was different between the incisor alveolar structure in the cleft side and the healthy side. For six patients, the bony maxillary width was different between the canine alveolar structure in the cleft side and the healthy side. We noted an asymmetry without hypoplasy in bony maxillary structure in newborns before cheiloplasty. The data can serve as the starting point for a control and later evaluation on the efficiency of different therapeutic approaches of alveolar and maxillary development in children with cleft lip and palate.     

扩弓后单侧完全性牙槽突裂的骨移植修复

目的:研究单侧完全性牙槽突裂畸形患者扩弓后骨移植修复的效果,为唇腭裂序列治疗后期正畸和正颌外科治疗提供临床基础。方法:对23例恒牙期单侧完全性唇腭裂术后伴发牙弓狭窄的牙槽突裂畸形患者进行快速扩弓并保持半年后,采用自体髂骨松质骨颗粒移植修复进行研究,对术后随访的X线片进行效果评价。结果:临床应用该方法治疗23例牙槽突裂患者,术后随诊3个月以上,临床观察牙槽突裂已修复,X线片显示骨密度接近正常骨质,移植骨块清晰可见,有较好的术后愈合效果。结论:正畸扩弓技术牙槽突裂骨移植修复术是唇腭裂序列治疗的重要组成部分,对于矫治伴有牙槽突裂的上牙弓缩窄畸形的唇腭裂患者,应在植骨手术前行扩弓治疗。     

Maxillary distraction in patients with cleft deformity using a rigid external distraction device: a pilot study on the distraction ratio of the maxilla to the device.

We examined the ratio between actual maxillary distraction and the distraction of the rigid external distraction device (Rigid external distraction (RED) system) used for maxillary distraction in patients with a cleft deformity. Twelve patients were examined. The amount of maxillary advancement was measured on lateral cephalograms and divided by the activation amount on the RED system. The value obtained was represented as the distraction ratio of the maxilla to the system. The mean ratio in 10 patients with complete cleft lip, palate, and alveolus (complete cleft) was 0.24. However, the ratios in two patients with cleft lip and alveolus or soft cleft palate (incomplete cleft) were considerably higher than the mean ratios in patients with complete cleft. When the maxilla is distracted in patients with complete cleft using the RED system, the amount of activation on the system needs to be about four times the amount of planned maxillary distraction. However, the distraction ratio may be affected by the type of cleft.     

The secondary bone grafting in cleft lip and palate: technical notes and indications about 62 cases

INTRODUCTION: Secondary bone grafting of the maxilla has become a well-accepted procedure in the surgical protocol for rehabilitation of patients with cleft lip and palate (CLP). The aim of this study is to review the surgical procedure and the indication of the secondary bone graft. MATERIALS AND METHODS: Sixty-two secondary bone graft were retrospectively reviewed from 1993 to 2000. There were 50 unilateral CLP and 12 bilateral CLP. The age at the time of bone grafting ranged from 9 years to 25.5 years with a mean at 14.34 +/- 2.9 years. The same operator performed a Gingivoperiosteoplasty (GPO) in all cases and the graft material was cancellous iliac bone in all cases. RESULTS: There were three indications of the bone graft and in each case the objective is different. First the interceptive bone graft in mixed dentition (50%): it was performed prior to the orthodontic treatment 12.8 +/- 2.3 years. The graft provides a bone support for teeth adjacent to the cleft. Second the stabilisation bone graft in permanent dentition (33.8%): it stabilize the orthodontic treatment and/or plan orthognathic surgery (15.2 +/- 1.6 years). Third the consolidation bone graft (16.2%): it was a late secondary bone graft after the complete growth (17,3 +/- 3,6 years) to correct the sequellae. It restored the maxilla continuity, stabilised the clefting teeth and prepared a prosthetic rehabilitation. CONCLUSION: The benefice of the secondary bone graft with GPO are numerous and is a part of the protocol treatment in CLP patients. A multidisciplinary follow up is necessary for the indication and timing of secondary bone grafting. The indication is subject to the clefting teeth, to the occlusal status and to the maxillary growth.     

Secondary Bone Grafting of Alveolar Clefts: A Surgical/Orthodontic Treatment Enabling a Non-prosthodontic Rehabilitation in Cleft Lip and Palate Patients

A procedure combining grafting of cancellous bone to the residual cleft of the primary palate with subsequent orthodontic movement of teeth into the former cleft area is described. The preliminary results from the first 80 patients (89 clefts) are presented. The age of the patients at the bone grafting ranged from 8 to 18 years, and the observation time from 17 to 44 months. The results have been assessed 1) on the basis of dental radiographs and 2) clinically, by the response of the grafted area to the orthodontic movement of adjacent teeth. In 69 clefts in which the cleft side canine had been brought into its final position at the time of evaluation, the height of the interal-veolar septum was assessed to be approximately normal in 38% and slightly less than normal in 44%. A septum of insufficient height (less than 3/4 of the normal) had formed in 5 clefts (7%). Even in these cases, the main objects of the operation were fulfilled: The maxillary segments were stabilized, the teeth adjacent to the cleft had better bone support, and the gap in the dental arch could be closed orthodontically in four of the five clefts. Failures, i.e. no continuous bone bridge across the alveolar cleft, were recorded in 8 instances (9%) of the total material. When failures were disregarded, the gap in the dental arch was closed orthodontically in 90%, while prosthodontic closure was deemed necessary in 10% of the cases. Optimal results were obtained when bone grafting was performed prior to the full eruption of the cleft side canine. In this situation, the known potential of an erupting tooth to induce alveolar bone generation proved to be of great advantage. By deliberately guiding the erupting canine through the grafted area close to the incisor, a nearly normal interalveolar septum was formed, and the gap in the dental arch was closed orthodontically in 23 out of 26 clefts. When fissural teeth were present, they were in most cases integrated in the dental arch. Approximate incisor symmetry could thus be obtained. In the remaining 20 clefts, the ipsilateral canine had not reached its final position at the time of evaluation, and the end results could not be assessed. However, bone formation in the defect was good in 19 of the 20 clefts, and a fully satisfactory result is expected in the majority of these cases. Further advantages were obtained by this procedure: 1) The maxillary segments were stabilized, particularly important in bilateral clefts in which the premaxilla was movable. 2) Oronasal fistulae were effectively closed and mucosal recesses eliminated. 3) The grafted bone provided support for the receded alar base, reducing the nasal asymmetry and improving the facial contour. 4) The postoperative orthodontic treatment could be brought to an end at approximately the same age as for patients with a non-cleft malocclusion. The only significant complication in this series was infection of the grafted area, causing loss of the bone grafts in two cases, and possibly contributing to the failure in some other patients. The experience gained with this treatment permits the conclusion that a full osseous and dental rehabilitation can be achieved in the great majority of patients with cleft lip and palate without any prosthodontic reconstructive work.     

Secondary bone grafting and orthodontic treatment in patients with bilateral complete clefts of the lip and palate

The results of secondary bone grafting and orthodontic treatment in 41 patients with bilateral complete clefts of the lip and palate are reported. Good bone formation was found in 98% of the cleft sites grafted before the eruption of the canines, and in 80% of the clefts grafted later. Closure of both cleft spaces by orthodontic means was achieved in 20 of the 21 patients in the first group, and in 14 of the 20 patients in the second group. The bone grafts failed in one cleft site in 4 patients, all of which were regrafted with satisfactory results. In 2 patients one of the canines was later affected by external root resorption, necessitating endodontic treatment. Both the failures and the root resorptions occurred in patients bone grafted at an older age than was considered optimal for bilateral clefts: 10 to 11 years. Seven patients needed a bridge prosthesis, 3 of these over one cleft space only. Even these patients benefited greatly from bone grafting.     

计算机辅助外科在腭裂手术中的应用

选取2021年1月-2022年12月于徐州市第一人民医院行腭裂手术的54例患者作为研究对象,分析 在腭裂手术中计算机辅助外科的应用价值。所有患者均实施计算机辅助外科,对手术治疗效果、平均手术 时间、术中平均出血量、术后感染发生情况、两侧上颌结节连线至悬雍垂的垂直距离术后的延长长度等进 行评估。结果显示,54例患者在计算机辅助外科实施下,均得到治愈,有效率为100.00%;平均手术时间为 （69.35±15.05）min;术中平均出血量（44.20±6.70）ml;术后1例患者出现轻度感染（1.85%）;术后患 者两侧上颌结节连线至悬雍垂的垂直距离术后的延长长度为（5.76±1.12）mm。可见,计算机辅助外科的 应用价值、可行性较高,可以使手术趋于更加精确、微创,能够为腭裂患者提供更佳的治疗效果。     

Maxillofacial osteotomies for patients with cleft lip and palate

A variety of dental malocclusions may be found in the patient with cleft lip and palate. These range from trivial dental rotation to major dentoskeletal disharmonies. Some of these deformities are intrinsic to the cleft malformation whereas others are secondary deformations resultant from specific management options taken in childhood. In most cases, a combination of orthodontics and orthognathic surgery is necessary to correct the deformity, that is, normalize the dentition, the facial skeleton, and the facial appearance. The timing of intervention, dependent upon the specific problem, is chosen to minimize negative secondary effects. Stability of mobilized and repositioned maxillary segments remains a problem in spite of the use of rigid internal fixation miniplates. The role of bone grafting when miniplates are used is unclear. While it is clear that movement of the maxilla, segmentally or in toto, can correct major dentoskeletal deformities in cleft patients, much remains to be learned regarding the best means of executing such operations.     

不同年龄腭裂患者手术后上颌骨发育状况的比较研究

目的：分析腭裂手术早晚是否会对患者上颌骨发育造成不同的影响。方法：采用X线头影测量方法，对50名不同年龄时期接受腭裂手术的患者上颌骨特征进行比较分析。结果：腭裂患者手术后都会出现不同程度上颌骨长度、高度及深度的发育不足，但早期手术的患者上颌骨发育状况并不明显差于晚期手术患者。结论：腭裂患者手术后上颌骨发育状况与手术年龄早晚无显著联系，早期手术对患者正常的语音发育起着关键的作用。