下颌骨牵引成骨配合正颌手术矫治成人半侧颜面短小畸形

目的 探讨下颌骨牵引成骨配合正颌手术治疗成人严重半侧颜面短小畸形的方法.方法 将患者三维CT重建数据导入Mimics软件进行手术模拟设计,确定截骨线的位置、牵引向量以及拟牵引的长度并制作手术导板.一期手术行口外入路内置式牵引器置入术,术后5～7d开始骨牵引,延长速度为1 mm/d,牵引结束后,牵引器保留3～6个月.二期手术采用上颌骨Le Fort Ⅰ型截骨,将上颌骨旋转、下降,关闭患侧开颌,采用下颌骨外板植入到上颌截骨下降后的间隙并妥善固定,以保证骨质愈合、维持上颌截骨下降后的稳定性、增加患侧上颌骨的骨体积以增加患侧的丰满度.颏部仍遗留偏斜或形态位置不佳者,同时行颏成形术予以调整.结果 2009年9月至2012年3月,采用上述方法矫治9例半侧颜面短小畸形患者,术后面部对称性、咬合关系趋近正常,效果满意.8例未出现任何并发症,1例上颌切口感染,经清创换药后延迟愈合,未影响面部形态及咬合关系.结论 下颌骨牵引成骨配合正颌手术是矫治成人半侧颜面短小畸形的有效方法.     

双颌手术同期植骨矫治唇腭裂术后严重双颌畸形

目的:总结分析高位Le Fort Ⅰ型截骨术与下颌升支矢状劈开截骨术联合应用,配合牙槽嵴裂植骨术矫治唇腭裂术后严重双颌畸形的手术设计与效果.方法:2002年1月～2006年4月,共收治18例唇腭裂术后严重双颌畸形患者,男8例,女10例.年龄16～33岁,平均24.5岁.单侧唇腭裂15例,双侧3例.影像学检查均有继发严重双颌畸形的主要表现.均联合应用高位Le Fort Ⅰ型截骨术和下颌升支矢状劈开截骨术,同期行牙槽嵴裂自体髂骨游离移植Ⅰ期手术矫正.结果:术后伤口均Ⅰ期愈合.复查头部X线片,所有患者上、下颌骨位置均得到明显改善.随访6个月～3年,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.18例均获得满意面容及良好的<牙合>关系. 结论:高位Le Fort Ⅰ型截骨术与下颌升支矢状劈开截骨术联合应用,配合牙槽嵴裂植骨术可以Ⅰ期矫治唇腭裂术后严重双颌畸形,并可以获得满意的手术效果.不但可以减少手术次数,而且还降低了手术费用,是矫治唇腭裂术后严重双颌畸形的一种有效方法.     

唇腭裂上颌复合体在不同类型上颌截骨内置式牵引下生物力学研究

目的 探讨唇腭裂继发上颌发育不全应用不同类型截骨内置式牵引的生物力学变化特点.方法 采用三维有限元方法,建立唇腭裂上颌复合体Le Fort Ⅰ、Ⅱ、Ⅲ型截骨骨块及相应软组织有限元模型,分别模拟临床上新型内置牵引方式,使截骨块上牵引器固位点沿牵引方向前移10mm,比较分析其生物力学变化情况.结果 唇腭裂上颌复合体不同类型截骨内置式牵引下,Le FortⅠ型截骨腭部出现压缩现象,而Le Fort Ⅱ、Ⅲ型截骨腭部压缩现象不明显.矢向位移比较,Le FortⅢ型截骨内置式牵引可以整体前移截骨体,Le Fort Ⅰ、Ⅱ型截骨存在不同程度的旋转.垂直向位移比较Le FortⅡ型截骨出现较多的逆向旋转.结论 三维有限元仿真研究应用于内置式牵引成骨手术,可以较好地反映颌骨位移情况,为手术计划提供理论依据.     

外置支架牵引成骨术治疗复杂面中部后缩畸形

目的 应用外支架牵引成骨治疗复杂面中部后缩畸形.方法 对1例继发性面中部凹陷畸形、2例Crouzon综合征和1例Parry Romberg综合征患者,采取Le Fort Ⅲ型截骨或同时行Le Fort Ⅰ型截骨,应用颅面外支架牵引装置对目标骨块进行牵引治疗.牵引开始于截骨后第7天,牵引速度为每天1 mm,牵引完成后,固定外支架牵引装置3个月.结果 所有病例按计划完成牵引,面中部前移10～14 mm,后缩畸形明显改善.结论 外支架牵引成骨技术是治疗各种复杂面中部后缩畸形的一种有效方法.     

正颌联合正畸矫治唇腭裂术后牙颌面畸形

目的以正颌外科手术联合正畸治疗的方法矫治唇腭裂术后牙颌面畸形。方法1996年以来共矫治此类畸形2l例，采用手术方法如下：Le FortⅠ型截骨术7例；多片段Le FortⅠ型截骨术5例；Le FortⅠ型截骨术加双侧下颌升支矢状劈开术（BSSRO）4例；BSSRO加颏成形术2例：Le FortⅠ型截骨术加下颌体部截骨术2例；BSSRO1例。结果2l例术后均达到模型外科设计要求，术后随访14例，平均25．6个月，九严重并发症及明显复发。12例行术前后正畸治疗者希关系及面部外形均满意，另2例个别牙齿矛台关系欠佳。结论以正颌外科手术联合正畸治疗的方法矫治成年期唇腭裂术后牙颌面畸形可取得满意结果。     

多片段LeFortI型截骨矫治严重牙颌面畸形

目的：采用多片段Le Fort I型截骨术矫治严重牙颌面畸形，并为克服术后骨段固位不良之缺点自制一种腭侧固定夹板。方法；以该手术方法联合双侧下颌升支矢状劈开术（BSSRO）矫治上颌宽度不足伴上下颌其它严重畸形的患者19例。采用单纯多片段Le Fort I型截骨6例，联合BSSRO13例。19例中上颌两片段Le Fort I型截骨12例，3片段7例。结果：术后随访6例，平均22.6m,6/6间距离平均扩宽7.3mm,3/3间平均扩宽3.9mm。无严重并发症及明显复发，咬合关系满意。结论：应用良好的腭侧固定夹板，采用多片段Le Fort I截骨联合BSSRO可一次满意矫治严重双颌畸形。     

重度进行性半侧颜面萎缩骨骼和软组织的轮廓重建

目的 总结治疗重度半侧颜面萎缩症的手术方法.方法 2004年1月至2012年5月,对25例重度半侧颜面萎缩的患者,综合应用自体脂肪游离移植、股前外侧筋膜脂肪瓣、自体真皮游离移植等方法进行软组织重建,应用下颌骨延长技术、正颌技术、自体组织移植或假体植入等方法进行骨骼轮廓重建.结果 25例患者中有24例接受了颧骨增高术和面部脂肪注射；17例接受了正颌手术:Le Fort Ⅰ型截骨3例,颏部截骨整形4例,下颌骨延长配合二期Le Fort Ⅰ型截骨3例,颏部截骨整形联合下颌骨Medpor贴附整形7例；股前外侧筋膜脂肪瓣10例；背阔肌肌瓣修复1例.术后随访6个月至5年,25例患者通过骨骼轮廓和软组织结构重建,倾斜的咬合平面和错颌畸形获得纠正,面部不对称和扭曲畸形得到明显改善.结论 对于重度半侧颜面萎缩患者,只有综合应用各种治疗手段进行软组织和骨骼轮廓重建,才能获得良好的治疗效果.     

下颌升支牵引成骨矫治半侧颜面发育不全

目的 探讨下颌升支牵引成骨在矫治半侧颜面发育不全中的应用价值.方法 1999至2006年采用下颌升支牵引成骨矫治半侧颜面发育不全畸形患者15例,其中幼儿及青少年患者12例,成年患者3例,部分患者一期或二期采用了上颌Le Fort Ⅰ型截骨术、健侧下颌升支矢状劈开截骨术、颏成形术及游离肩胛皮瓣移植修复术等.结果 所有患者术后均顺利完成牵引治疗,平均牵引距离21.25舢(15～40 mm).临床及影像学观察新骨形成良好后去除牵引器.术后患侧面部丰满度和面部对称性均得到明显提高,咬合关系均较术前明显改善,咬合平面基本摆正.无一例出现感染或成骨不良等并发症.未出现永久性下牙槽神经功能损伤症状.结论 下颌升支牵引成骨技术是矫治严重半侧颜面发育不全的较好方法,且矫治效果优于传统正颌外科.     

牵张成骨联合正颌外科治疗成人严重小下颌畸形伴重度阻塞性睡眠呼吸暂停低通气综合征

目的:探讨牵张成骨术联合正颌外科的方法治疗小下颌畸形患者下颌骨严重发育不足伴重度睡眠呼吸暂停综合征(OSAHS)的效果。方法:对2例继发于颞下颌关节强直的小颌畸形患者首先采用牵张成骨技术进行治疗。手术在全麻下行双侧下颌角处截骨,安置牵引器,延长下颌升支及下颌体矫正小颌畸形及OSAHS。第二期在拆除牵引器的后行正畸治疗,继而采用正颌外科方法矫正颌面畸形及咬合关系,术后进一步正畸治疗矫正咬合关系排齐牙列。结果:2例患者均顺利完成治疗。下颌骨最小牵引距离25mm,最大牵引距离30mm,牵引区成骨良好。后气道间隙由治疗前的平均3.25mm增加到11.5mm;SNB角由术前平均67°增加到术后80°,OSAHS得以治愈。联合正颌外科及正畸治疗后小颌畸形得以矫治,面型及咬合功能均获得满意的效果。术后经过2年随访,未见复发。结论:牵张成骨技术联合正颌外科治疗成人严重小颌畸形伴重度OSAHS可以获得满意的效果。不仅可有效治疗伴发的OSAHS,而且能很好地矫治小下颌畸形引起的牙颌面畸形。     

进行性半面萎缩症的综合外科矫治术

目的 评价综合应用正颌外科、颌骨牵引成骨技术和去表皮肩胛游离皮瓣移植术矫治进行性半面萎缩畸形的疗效与可行性.方法 5例进行性半面萎缩畸形,轻度畸形的1例行去表皮肩胛游离皮瓣移植充填术及同期行颏成形术;中度畸形的2例,一期行上颌Le Fort I型截骨术,双侧下颌升支矢状劈开截骨术和颏成形术,3～6个月后行去表皮肩胛游离皮瓣移植充填术;重度畸形的2例,一期行患侧下颌升支和上颌牙骨段的同期牵引成骨术,3～4个月后取出牵引器的同时行去表皮肩胛游离皮瓣移植充填术.结果 5例患者正颌外科及牵引成骨均效果良好,去表皮肩胛游离皮瓣均成活,患者面部对称性得到明显改善.结论 ①进行性半面萎缩症的程度与发病年龄密切相关,发病年龄越小,畸形越严重.②综合应用正颌外科、颌骨牵引成骨技术和去表皮肩胛游离皮瓣移植充填术,可有效矫治进行性半面萎缩畸形的软、硬组织复合畸形.     

Incomplete mobilization of the maxilla resulting in failed maxillary distraction: a case report.

Maxillary distraction osteogenesis has become an accepted alternative method in the treatment of patients with severe maxillary hypoplasia in craniofacial syndromes and cleft-related deformities. Insufficient distraction, undesirable soft tissue changes, and occurrence of defective distraction vectors are among the potential complications of intraoral maxillary distraction osteogenesis. A 2-stage procedure combining maxillary advancement by distraction technique with genioplasty and mandibular setback surgery was planned to correct jaw deformities in a 22-year-old patient with severe maxillary retrusion, mandibular prognathism, and excessive lower facial height. In the first stage, osteotomies were performed and maxilla was lightly mobilized after down-fracture. Distractors were placed to the maxilla intraorally. During activation period, the maxilla rotated in a clockwise direction, producing a discrepancy between the planned and the actual vectors. Complete distraction was unsatisfactory and the complication was due to surgical technique. This case report presents the failure of maxillary distraction due to incomplete mobilization of the maxilla. Treatment of the case was achieved by the conventional osteotomy techniques at final operation. The maxilla was successfully advanced to the desired position producing good occlusion and an improved facial profile.     

骨牵张技术治疗下颌骨获得性畸形

目的：探讨用骨牵张成骨技术治疗下颌骨获得性畸形的方法和经验，方法：7例因下颌骨创伤或肿瘤切除后遗留下颌骨畸形患者，采用新型内置式骨牵开器进行骨牵开术，术后潜伏期为7天，牵引节律为1mm／天，2次／天，牵引结束后固定6—8周。结果：7例患者的咬合关系和面形均得到理想恢复，最大牵张距离为3cm，最小距离为9mm，伤口无并发症。结论：骨牵引延长技术可以很好地适用于下颌骨骨折错位愈合或骨缺损患者，尤其适用于软组织不足，不易覆盖植骨的患者，此外，不需要另取自体骨移植。     

Correction of airway obstruction in congenital micrognathia by mandibular distraction osteogenesis

Varying degrees of upper airway obstruction is almost universally present in patients of congenital micrognathia which needs to be corrected as early as possible. This allows appropriate feeding and growth and prevents long-term complications such as pulmonary hypertension and cor pulmonale. We report the case of a tracheostomy-dependent, 4-year-old child with congenital micrognathia who was treated with mandibular distraction osteogenesis. This is the treatment of choice for surgical correction of mandibular hypoplasia and for the challenging airway management in infants. Once a bone length of 2 cm was achieved through distraction osteogenesis, the child was completely relieved of respiratory obstruction and tracheostomy tube was removed through the process of decannulation.     

Mandibular elongation and remodeling by gradual distraction. An experience of 277 cases]

Distraction osteogenesis at the craniofacial skeleton offers superior results than using standard osteotomies and other surgical techniques when treating mandibular hypoplasia. After ten years, we have performed 221 patients with hemifacial microsomia and 56 patients with micrognathia using external mandibular distraction. For every single patient the distraction vector is different according to the degree of bone hypoplasia. The bone elongation ranged from 12 to 49 mm, and the results were excellent: facial symmetry was reestablished, the menton became horizontal and the long term result controls shows stability clinically and occlusally.     

Vertical distraction osteogenesis of fibular bone flap in reconstructed mandible

Excellent functional and aesthetic results can be achieved in mandibular reconstructions with using free fibular bone flap. However, the vertical deficiency between the reconstructed segment and the occlusal plane made dental rehabilitation impossible in some cases. We encountered this problem in our 3 patients who had mandibular reconstruction with fibular flap due to extensive bone defect result from gunshot injury. To overcome this segmental vertical distraction of the reconstructed mandible was performed. Fibular bone segments (40-70 mm) were distracted with using extraoral distraction device after a latency period of 5-7 days. The rate of distraction was 1 mm/day, and the rhythm was 4 times (4 x 0.25 mm). Distraction was continued until the desired height was achieved, and the distractor left in place for 12 weeks for bony consolidation. No minor or major complications were encountered. The increase of vertical height was between 9 and 13 mm, and it was stable during the follow-up period (7-22 months). Following the vertical distraction and vestibuloplasty operations, the dental restoration of the patients was performed with mandibular removable partial dentures.     

Maxillo-mandibular distraction osteogenesis for hemifacial microsomia in children

To obviate or lessen the long period of use of orthodontic appliances after distraction for hemifacial microsomia in the mixed dentition patients, simultaneous maxillo-mandibular distraction osteogenesis has been performed in 10 patients aged 7 to 12 years with hemifacial microsomia. In these patients, there were two cases of type I, five cases of type IIa, and three cases of type IIb. A uniplanar internal distraction device was used in all cases. After maxillary Le Fort I osteotomy and mandibular ramus osteotomy, a uniplanar internal distraction device was attached to the mandible. On days 5 to 6 after surgery, distraction of 1 mm per day was started. Rigid intermaxillary fixation (IMF) using soft wires was performed at the distraction and was retained for 1 hour. Except for this period, rigid IMF was released. Distraction length ranged from 10 to 21 mm. After the distraction, a slight lateral crossbite in one case and a slight occlusal change in two cases, which did not necessitate the particular orthodontic treatment, were noted. Postoperative follow-up ranged from 16 to 40 months. The postoperative clinical course was uneventful thereafter. Maxillary growth impairment after the osteotomy has been obscure because of the short postoperative period. This procedure is effective for obviating or lessening the long duration of use of orthodontic appliances in the mixed dentition period of 7 to 14 years of hemifacial microsomia.     

下颌骨牵引成骨术治疗儿童小下颌畸形伴阻塞性睡眠呼吸暂停综合征

目的 探讨和评价下颌骨牵引成骨技术在治疗儿童小下颌畸形伴阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome，OSAS)中的应用价值。方法 6例先天性小下颌发育不全畸形伴重度OSAS，年龄4个月至9岁。每例患者术前术后均行X射线头影测量及睡眠多导图仪检查。用牵引成骨技术牵引双侧下颌骨，带动舌和口底肌肉组织前移，使口咽腔通畅，达到治疗小下颌畸形患者OSAS的目的。结果 6例12侧下颌骨牵引成骨，最大牵引延长距离为25mm，最小15mm，平均19．2mm。后气道间隙由平均4．5mm增至10．1mm。牵引时间最短10d，最长20d，平均14．5d。所有病例在截骨、牵引器固定过程中均未损伤下牙槽神经血管束。牵引过程顺利，牵引区成骨良好。随访2至11个月。1例需要进行继续治疗，5例均恢复正常呼吸，去除鼻咽导气管和气管切开导管。结论 下颌骨牵引成骨术是治疗OSAS重要的有效治疗手段，能够有效地矫正口咽腔气道狭窄，改善呼吸，可在年幼儿童应用。随着应用例数的增多会更详尽阐明其所发挥的作用。     

Difficult tracheal intubation induced by maxillary distraction devices in craniosynostosis syndromes

BACKGROUND: Difficult intubation occurred during anaesthesia for removal of maxillary distraction devices in five of seven children with syndromal craniosynostoses (four with Apert, two with Pfeiffer and one with Crouzon syndrome). METHODS: Intubation was assessed in terms of laryngeal view and an established intubation difficulty score and had been straightforward before device insertion. Difficulty was induced by trismus due to device insertion and by increased maxillary prominence. This was compounded by preexisting mandibular hypoplasia. Cephalometric analysis, with each child acting as their own control, demonstrated anterior displacement of the maxilla and increased maxillary vertical height, as well as increased protuberance of the maxillary incisors. RESULTS: All five difficult tracheal intubations were associated with preoperative Mallampati scores of 3 or 4 and the nine straightforward intubations with scores of 1 or 2. Maximal interincisor distance was less than the lower 95% confidence limit for age in all five children who were difficult to intubate at the time of device removal. No child had a failed intubation, but all had significantly increased intubation difficulty. CONCLUSIONS: In view of the risks of trauma, hypoxia and aspiration associated with difficult direct laryngoscopy, we recommend elective fibreoptic intubation at anaesthesia for removal of maxillary distraction osteogenesis devices in these children.     

内置式下颌骨牵引成骨术及其常见并发症的处理

目的 探讨内置式下颌骨牵引成骨术的常见术后并发症发生的原因及防治措施。方法 总结分析1997至2004年采用内置式下颌骨牵引成骨术治疗下颌骨畸形或缺损患者46例61侧，其中半侧颜面短小27例，下颌骨发育不足或小颌畸形双侧8例、单侧4例，电击伤或肿瘤术后缺损畸形3例，Treaeher Colins综合征2例，睡眠呼吸暂停综合征2例。结果 46例61侧发生并发症者9例，包括牵引机械装置故障3例，局部感染2例，前牙开骀2例，皮肤窦道2例。经积极处理后均达到预期治疗目的。结论 减少下颌骨牵引成骨术并发症的关键在于充分理解下颌骨牵引成骨术的机理，熟悉掌握下颌骨及邻近解剖结构，操作规范熟练，充分的术前准备和术后处理尤为重要。