上颌前徙术对上颌发育不足患者腭咽部结构影响的临床探讨

目的：探讨上颌前移术对上颌发育不足患者腭咽部结构的影响。方法：选择2011-2013年行上颌Le FortI型截骨前移术的上颌发育不足患者12例,男7例,女5例,其中唇腭裂患者5例,非唇腭裂患者7例,平均年龄22．21岁,所有患者在术前、术后1月拍摄头颅定位侧位片,并对腭咽部结构指标进行测量分析。结果：上颌骨最大前移幅度8mill,最小3mm,平均前移（5．28±2．32）mm,术后咽腔深度明显增大（P〈0．05）;同时软腭长度及软硬腭夹角较术前11月显增大（P〈0．05）,软腭厚度减小。结论：上颌骨前移术造成患者咽腔深度显著增加,对腭咽闭合功能可能有不利影响：术后腭叫部软组织发生适应性变化,这种代偿性改变会在一定程度上减轻腭咽闭合不全。     

上颌骨LeFort Ⅰ型截骨前移术对腭咽闭合功能的影响

目的:探讨上颌骨LeFort Ⅰ型截骨前移术对腭咽闭合功能的影响.方法:应用该术矫治18例上颌骨发育不足患者,术前后分别拍摄正中(牙合)位及发[i]位头颅侧位定位片,通过头影测量分析腭咽部组织的变化;同时采用吹气试验及语音清晰度测听比较术前后腭咽闭合功能的变化.结果:上颌骨平均前移6.53±0.76 mm.结论:上颌骨LeFort Ⅰ型截骨前移对患者腭咽闭合功能有一定的潜在不良影响,但术前腭咽闭合功能良好者前移在一定距离范围内不会引起患者腭咽闭合不全,术后腭咽部软组织具有一定的适应性变化;术前腭咽闭合不全者,手术可加重腭咽闭合不全程度.     

无阻塞性睡眠呼吸暂停低通气综合征的31名老年男性上气道及周围组织形态观察

目的研究无阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）的70岁以上男性上气道及周围组织的结构特征,为深入认识OSAHS的病因及治疗手段提供依据。方法从182名70岁以上男性中,通过问卷和整夜多道睡眠监测（polysomnography,PSG）检测筛选出无OSAHS者31名,睡眠呼吸暂停低通气指数（apnea and hypopnea index,AHI）〈10次／h,年龄70～84岁,平均（74．5±3．7）岁。对31名研究对象行头颈部MRI扫描。对上气道及周围组织的93项指标进行测量。结果①上气道各段平均横截面积、最小横截面积均以腭咽最小,分别为（190．9±67．1）mm^2,（112．1±47．7）mm^2;②上气道各段横截面的前后径与左右径之比在0．22～0．89之间,各段横截面形状均为左右径长、前后径短的椭圆。其中腭咽段比值最小（0．22～0．71）;③上气道各段最小横截面积与最大横截面积之比在0．38～0．62之间,气道立体形状均为“漏斗形”,其中腭咽的“锥度”最大。结论根据上气道横截面大小和形状,无OSAHS老年男性上气道的腭咽段易塌陷。     

三维头模设计及个体化模板引导技术在OSAHS患者下颌骨牵引成骨术中的应用

目的 探索术前三维头模设计及个体化模板引导在下颌骨牵引成骨术中的应用,并且评估手术的治疗效果.方法 选择原发或继发小颌畸形患者10例,均伴有中度或者重度的阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea-hypopnea syndrome,OSAHS）.根据三维螺旋CT的数据制作三维头模,在三维头模上模拟手术截骨以及牵引器的安放,制作个体化模板.术中应用个体化模板指导截骨线的位置以及牵引器的安放.术后5～7 d的间歇期后,开始以每天1 mm的速度行骨牵引至牵引结束.术后3～6个月二次手术去除牵引器.结果 10例患者顺利完成下颌骨牵引成骨治疗,第一次手术平均手术时间为（1.6±1.3）h.10例患者的20侧下颌骨平均牵引长度为（23.6±7.5） mm.术前睡眠呼吸暂停低通气指数（apnea and hypopnea index,AHI）为（37.1±13.7）次/h,睡眠时最低血氧饱和度（lowest oxygen desaturation,LSAT）为75.2％±18.4％;术后AHI为（2.7±4.8）次/h,LSAT为92.1％±5.3％.所有患者的牵引成骨区成骨良好,均未出现成骨不良、下牙槽神经损伤及牵引故障等严重并发症.结论 术前三维头模设计可以很好的模拟牵引成骨术中的截骨位置及牵引器的安放,避免损伤重要解剖结构;应用个体化模板引导可以提高下颌骨牵引成骨术截骨及牵引器安放的精确性,缩短手术时间,降低手术难度及风险.     

阻塞性睡眠呼吸暂停低通气综合征患者手术选择的初步探讨

目的通过不同手术方法对上气道结构的影响,为阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)手术适应症的选择提供有关依据.方法 12例经夜间睡眠监测(polysomnography,PSG)确诊的OSAHS患者全部行悬雍垂腭咽成型术(uvulopalatopharyngoplasty,UPPP),其中7例行UPPP 颏前徙术 舌骨悬吊术,1例行UPPP 舌骨悬吊术,1例行UPPP 舌根组织部分切除前移悬吊术,手术前后对患者行头影测量分析评估.结果 UPPP可以扩大腭咽气道,颏前徙术及舌骨悬吊术有助于扩大舌咽气道及下咽气道.结论术前应对OSAHS患者上气道做全面评估,根据上气道的阻塞状态选择适当的手术方法.     

肥胖伴OSAHS患者计算机辅助设计的手术治疗

目的对肥胖伴OSAHS患者,手术可能造成颅颌面形态异常,为获得理想双颌前移后颅颌面形态,进行计算机辅助设计、模拟的定量手术研究。方法(1)采用自行建立的上呼吸道测量、分析系统,进行阻塞部位和程度检查;同时摄发/i/音时的头颅定位侧位片,测量腭咽闭合点,按一定比例切除多余的软腭。(2)采用计算机手术模拟系统,对肥胖伴严重OSAHS患者进行手术模拟,以在双颌足够前移的前提下保证患者有一个美观的颅颌面外形。34例患者接受术前和术后PSG监测和头影测量分析及语音评价。结果手术成功率为85.29%,29例患者术后睡眠呼吸暂停-低通气指数降低50%以上或降至20%以下,睡眠质量和睡眠低氧状态得到显著改善。头影测量分析显示:34例患者腭咽闭合功能良好;语音检测显示:患者手术前后语音功能无显著差异(P>0.05)。结论不同阻塞部位、程度的患者,需要不同的手术方式或组合。UPPP手术成功的关键在于:严格掌握手术适应证,精确计算软腭切除量。计算机辅助的定量UPPP显著提高了手术成功率。对于肥胖伴严重OSAHS患者进行双颌前移手术治疗时,在保证颌骨足够前移的同时,需注意颅面形态的变化。     

唇腭裂术后牙颌面畸形的正颌外科治疗

作者对10例唇腭裂术后继发上颌骨发育障碍的成年患者行正颌外科治疗，并提出一种改良的Le Fort Ⅰ型分块截骨前移术。即在不影响腭咽闭合功能和不产生口鼻瘘的条件下前移上颌，通过术前、术后的正颌外科电脑模拟系境预测，牙髓活力的测定、腭咽闭合功能评价，面貌外形的对比，作者认为采用该术式是可行的，术后可获得功能与形态兼顾的满意效果。     

不同微型种植体稳定性比较的动物实验

目的评价自攻型和助攻型正畸微型种植体的稳定性，探讨两种种植体生物力学的差别。方法将自攻型组与助攻型组正畸微型种植体（每组各28枚）种植于两只狗的上下颌骨颊侧根间区，植入时测量最高植入转矩，即刻负载水平力约1．96N，持续9周后取出种植体，测量最高去除转矩。结果上、下颌自攻型组最高植入转矩[分别为（5．6±1．1）N·cm和（8．7±2．3）N·cm]均明显高于助攻型组[分别为（3．5±2．1）N·cm和（7．4±1．1）N·cm]，差异均有统计学意义（P〈0．05）。上、下颌自攻型组最高去除转矩[分别为（-6．5±2．2）N·cm和（-7．1±2．0）N·cm]均高于助攻型组[分别为（-5．7±2．3）N·cm和（-6．1±0．5）N·cm]，差异均无统计学意义（P〉0．05）。自攻型组成功率为92．9％，助攻型组成功率为86．7％。结论自攻型种植体有较高的初期稳定性，适于种植在上颌骨及下颌骨骨皮质较薄的部位。     

计算机辅助设计的定量UPPP手术及其评价

目的 评价计算机辅助设计的UPPP的手术效果。方法 采用我科自行建立的上呼吸道测量、分析系统．进行阻塞部位和程度检查；同时摄发／i／音头颅定位侧位片，测量腭咽闭合点，按一定的比例切除多余的软腭。对18例患者进行术前和术后PSG监测和头影测量分析及语音评价，检验本法的效果。结果 手术成功率为88．89％．18例患者术后睡眠呼吸暂停、睡眠质量和睡眠低氧状态得到显著改善。头影测量分析显示：18例患者腭咽闭合功能良好，患者术后进食无呛咳。语音检测显示：18例患者手术前后语音功能无显著差异。结论 UPPP手术成功的关键在于严格掌握手术适应证和精确计算软腭切除量。计算机辅助的定量UPPP，显著提高了手术成功率。     

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     

双颌前徙手术治疗黄种人群阻塞性睡眠呼吸暂停低通气综合征的初步研究

目的 初步探讨应用双颌前徙手术治疗黄种人群阻塞性睡眠呼吸暂停低通气综合征患者的术后效果及相关并发症.方法 选择北京大学口腔医院正颌外科中心2005年9月到2007年10月诊治的4名阻塞性睡眠呼吸暂停低通气综合征患者,均为男性.所有患者均进行双颌前徙手术治疗.术前和术后3-6个月分别进行多导睡眠图仪检查和拍摄头颅定位侧位片,于术后3-6个月期间进行主观问询.结果 术后所有患者的睡眠呼吸暂停低通气指数及睡眠时最低血氧饱和度均得到明显改善,SNA、SNB都有明显增大,术后后气道间隙得到了明显的扩大,舌骨到下颌骨的距离也有所缩短.通过主观调查问卷调查,本研究中所有4名患者术后睡眠打鼾及日问嗜睡症状消失,并且对术后面型的改善比较满意.3名患者术后出现短暂的下唇麻木及颞下颌关节不适,术后短期存在的下唇麻木及颞下颌关节不适的症状基本消失.结论 双颌前徙手术是一种治疗黄种人群OSAHS有效的方法.     

颏舌肌前移舌骨悬吊术联合UPPP治疗OSAHS的X线头影测量研究

目的：观察重度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者运用颏舌肌前移舌骨悬吊术（GAHM）联合悬雍垂腭咽成形术（UPPP）,对手术治疗前后的X线头影测量值变化的比较,验证联合手术治疗严重OSAHS的上气道改变和舌骨的位置变化,联合手术对阻塞部位的改善情况。方法：20例施行GAHM及UPPP术的OSAHS患者术前及术后摄取X线头颅定位侧位片,采用NemoCeph NX软件进行头影测量分析,测量指标为SNA、SNB、SN—MP、PNS—U、V—LPW、PUS、PAS、AH上MP、AH上C3Me、Ah—CC。结果：SNA术前和术后均为81．5°。术后SNB由术前的77．60增加到78．90°。SN—MP术后稍减小,无统计学意义。PNS—U由术前的39．4mm减小到术后的38．2mm,术后下咽通气道间隙V—LPW从15．7mm明显增加到19．6mm。GAHM术后上气道间隙PUS及最小后气道间隙PAS明显增加了1．1mm和3．7mm,达到6．2mm和11．8mm。具有显著性差异。舌骨到下颌平面的距离AH上MP从术前的23．8mm减小为16．7mm,AH⊥C3Me也减小,Ah—cc则从39．6mm增加到43．8mm。表明舌骨向前向上移位。手术前后舌骨测量值的差异具有统计学意义。结论：X线头影测量证实GAHM联合UPPP手术治疗OSAHS患者,能扩大上气道间隙,改变舌骨的位置,解除咽部平面的阻塞。     

下颌前移矫治器辅助腭咽成形术治疗睡眠呼吸暂停低通气综合征

目的:对经腭咽成形术(UPPP)后的睡眠呼吸暂停低通气综合征(OSAHS)患者辅以下颌前移器治疗,探讨UPPP手术后口腔矫治器前移下颌辅助治疗的作用机制。方法:10例OSAHS患者接受UPPP手术后,辅以下颌前移矫治器治疗。所有患者在戴用矫治器后1个月再次进行多导睡眠监测(PSG)。同时,按标准头颅定位片拍摄方法分别拍摄戴用口腔矫治器前、后的头颅定位侧位片,由作者应用正颌外科模拟预测系统(CASSOS 2001)进行头影测量分析。头影测量数据应用SPSS10.0软件包进行配对t检验,各个测量项目的差值分别与呼吸暂停低通气指数(AHI)的差值作相关分析。结果:戴用矫治器后,X线头影测量显示颅中窝和上颌骨后部的相对位置(MCF)有显著改变(P<0.05),而舌骨的上、下位置(∠C3-Rgn-H)以及前颌间高度(Ant In Mx.Ht)有非常显著的变化。各个测量项目的差值分别与AHI的差值作相关分析,结果显示AHI值的变化与前颌间高度(Ant In Mx.Ht)以及正中矢状面上舌面积和颌间面积的比例(T/In Mx.Area)的变化有显著相关性(P<0.05)。结论:经UPPP手术后戴用口腔矫治器的患者,其下颌前移的作用机制主要不是发生在口咽腔,而是由于下颌骨本身的位置改变而产生的一系列效应,从而导致AHI的改变。     

A protocol for uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibular advancement in patients with obstructive sleep apnea: an analysis of 40 cases.

PURPOSE: This study evaluated the effectiveness of uvulopalatopharyngoplasty (UPPP) with mortised genioplasty and maxillomandibular advancement (MMA) for the treatment of patients with obstructive sleep apnea not controllable with appliances or continuous positive airway pressure. METHODS: Forty patients with obstructive sleep apnea were evaluated retrospectively. Thirty-three patients underwent combined UPPP and a modified mortised genioglossus advancement. Patients who had specific indications for MMA underwent combined procedures, eliminating staging of multiple surgeries. Seven patients were in this group. All patients were evaluated preoperatively and postoperatively with polysomnography to evaluate the efficacy of the treatment. RESULTS: Mean respiratory distress indices (RDI) and nadir oxyhemoglobin desaturation values were significantly improved with each of the therapies despite many patients having body mass indices significantly greater than the average quoted in other studies. Patients with moderate sleep apnea (RDI, 21 to 40) who underwent UPPP/genioglossus advancement did very well, with 86% of patients achieving success. Patients who underwent MMA all decreased their RDI by at least 56% and had an average improvement of 86%. CONCLUSIONS: The UPPP/mortised genioglossus advancement is effective for the treatment of obstructive sleep apnea. Maxillomandibular advancement is effective for treating severe sleep apnea and may, in some cases, be indicated in combination with UPPP/mortised genioglossus advancement to avoid multiple procedures. Surgical reconstruction of the upper airway is a reasonable approach to the treatment of patients with obstructive sleep apnea, and can be approached more directly to minimize repeated surgical intervention.     

双颌前徙术治疗阻塞性睡眠呼吸暂停低通气综合征及长期稳定性的研究

目的采用双颌前徙术治疗中度到重度的中国阻塞性睡眠呼吸暂停低通气综合征（obstructivesleepapnea-hypopneasyndrome,OSAHS）患者,评估术后效果、治病机理及长期稳定性。方法应用双颌前徙术治疗的中度到重度OSAHS患者共9人。患者分别于T1（术前3个月内）、T2（术后3～6个月）及T3（术后最长随访期,至少1年以上）分别进行多导睡眠图仪检查、拍摄头颅定位侧位x线片进行x线头影测量及三维螺旋CT上气道重建。结果9名患者睡眠呼吸暂停低通气指数（apneaandhypopneaindex,AHI）在T1为49．5次／／l,时,T2为7．8次／小时,T3为8．5次／11,时;睡眠时最低血氧饱和度（10westoxygensaturation,I。SAT）在T1为70．2％,T2为91．8％,T3为90．3％。通过术后长期随访,患者颌骨的位置及上气道各层面的测量值相对稳定,主观症状的改善也表现出很好的稳定性。结论双颌前徙术非常适用于治疗上下颌骨发育不足的OSAHS患者,术后长期随访显示双颔前徘术治疗OSAHS具有较好的长期稳宁件．     

Oral appliances and maxillomandibular advancement surgery: an alternative treatment protocol for the obstructive sleep apnea-hypopnea syndrome.

PURPOSE: The present study comprises a retrospective evaluation of the potential application of mandibular repositioning appliance (MRA) therapy preceding maxillomandibular advancement (MMA) surgery in the treatment of the Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). Our initial experiences with a new surgical protocol, in which MRA therapy serves as a predictor for success of MMA surgery, are reported. PATIENTS AND METHODS: Forty-three consecutive patients with OSAHS treated with MRA therapy were considered for inclusion (mean+/-SD; Apnea-Hypopnea Index [AHI]=27+/-20; age=53+/-9 years). All patients displaying a substantial improvement in their AHI with MRA therapy (ie,>50% reduction) who preferred surgical rather than "prosthetic" advancement of the mandible were offered MMA surgery. Accordingly, 4 out of 43 patients were treated with MMA surgery. The AHI was used as the primary outcome measure, with MMA surgery being considered successful in case of a postoperative AHI <5. RESULTS: All 4 patients included displayed substantial improvement in their AHI following MRA therapy. Moreover, in 3 patients MRA therapy resulted in a post-treatment AHI 相似文献   

Fiberoptic nasopharyngolaryngoscopy for airway monitoring after obstructive sleep apnea surgery.

PURPOSE: This study evaluated the upper airway characteristics in the early postoperative period after reconstructive surgery for obstructive sleep apnea (OSA). METHODS: During a 24-month period, the upper airway of patients who underwent uvulopalatopharyngoplasty (UPPP) with genioglossus advancement (GA) or hyoid myotomy (HM) or maxillomandibular advancement (MMA) were evaluated with fiberoptic nasopharyngolaryngoscopy (NPG) preoperatively and 24 to 72 hours postoperatively. RESULTS: NPG was performed on 271 patients. One hundred seventy-three patients had UPPP with GA or HM, and the remainder had MMA. All of the patients who underwent UPPP with GA or HM were found to have varying degrees of soft tissue edema involving the soft palate and the tongue base. The patients who underwent tonsillectomies and UPPP with GA or HM had greater soft palate/pharyngeal wall edema. In contrast, patients who underwent MMA had minimal edema involving the soft palate and the base of tongue, but diffuse lateral pharyngeal wall edema throughout the upper airway was identified. Eighteen of the MMA patients had ecchymosis and edema involving the pyriform sinus and aryepiglottic fold; 4 of these patients also had a hypopharyngeal hematoma involving the pyriform sinus, aryepiglottic fold, arytenoid, and false vocal cord, which partially obstructed the airway. These 4 patients were closely monitored for 1 to 2 additional days, and all were discharged without problems. None of the patients in the study had postoperative airway obstruction. CONCLUSION: NPG may be useful in postoperative airway monitoring and assist in discharge planning after upper airway reconstruction in the OSA patients.     

阻塞性睡眠呼吸暂停低通气综合征的手术治疗：137例临床分析

目的：观察不同手术术式治疗阻塞性睡眠呼吸暂停低通气综合征的疗效。方法：对137例（男109例,女28例,年龄6～54岁）阻塞性睡眠呼吸暂停低通气综合征患者,69例采用腭垂腭咽成形术,10例采用腭垂腭咽成形术＋舌骨悬吊术,6例采用腭垂腭咽成形术＋颏前徙＋舌骨悬吊术,9例采用颏前徙＋舌骨悬吊术,32例采用正颌手术,11例采用牵张成骨方法进行治疗。结果：术后随访6～60个月,所有患者睡眠打鼾、憋醒、大汗淋漓症状消失或明显改善;129例患者AHI指数由术前51±13降为术后11以下,59例患者AHI指数降为5以下;睡眠时最低血氧饱和度由术前的63%±15%增加至术后的97%±6%,平均血氧饱和度由术前的74%±9%增加至术后的95%±7%,有效率为95%,治愈率为43%。结论：对阻塞性睡眠呼吸暂停低通气综合征患者根据其阻塞部位设计个体化的手术术式,可达到最佳的手术效果。     

Case Control Study in the Treatment of Obstructive Sleep-Disordered Breathing with a Mandibular Protrusive Appliance

BACKGROUND: Mandibular protrusive appliances have long been used to treat obstructive sleep apnea/hypopnea syndrome (OSAHS). Their efficacy regarding respiration during sleep varies greatly and remains difficult to predict. In this study the efficacy of a two-splint appliance on nocturnal breathing disorders, sleep profile, and daytime sleepiness were evaluated according to a specially-designed treatment process. PATIENTS AND METHODS: In this study 42 consecutive OSAHS patients who had been fitted with a mandibular protrusive appliance according to a preset treatment regimen were included in a follow-up analysis. The diagnosis and the degree of severity of OSHAS were determined by polysomnography in the sleep laboratory. The treatment regimen was established with the sleep laboratory physician. Treatment regimen included the diagnostic procedure in the sleep laboratory, each patient's dental requirements, the fabrication of the appliance used, and the titration of the mandibular protrusion. After having grown accustomed to the appliance for 24.5 +/- 7.8 days, 34 patients underwent overnight polysomnography. RESULTS: The mean apnea/hypopnea index decreased significantly from 19.6 +/- 12.8 to 3.3 +/- 7.8 events per hour to 83%; the apnea index also improved significantly, as did minimal oxygen saturation and the desaturation index. Changes in sleep profile did not reach statistical significance; the arousal index (p < 0.02) and the subjectively-assessed daytime sleepiness (p < 0.02) decreased significantly. A therapeutically-required AHI of below 5 events per hour was achieved in 88.2% of the patients. CONCLUSION: A significant improvement in the respiratory situation of the vast majority of OSAHS patients, particularly in their AHI, can be achieved when one applies the procedural steps and employs the mandibular protrusive appliance we describe herein.     

Retrospective study of 18 patients treated by maxillomandibular advancement with adjunctive procedures for obstructive sleep apnea syndrome

A surgical protocol in the treatment of obstructive sleep apnea syndrome (OSAS) is presented. Eighteen patients with particular craniofacial characteristics consisting in maxillomandibular retroposition or retromandibulism underwent bimaxillary advancement by way of Lefort I and bilateral sagittal ramus osteotomies. Adjunctive procedures (genioplasty, uvuloplasty, and glossoplasty) were performed in the same surgical procedure. In all cases, the patients were evaluated before and 6 months after surgery by a physical examination, Delaire cephalometric analysis, and polysomnography. Surgery was considered successful when the postoperative apnea/hypopnea index (AHI) was less than 15/h and with at least a 50% reduction of the initial index. The surgical success rate was 84%. AHI decreased from 54/h (+/-20.7) to 9.66/h (+/-6.67). The results of this study indicate that successful surgical treatment by maxillomandibular advancement with adjunctive procedures at the same operative time is efficient with a high percentage of success when patients are clearly selected.