骨性Ⅲ类患者双颌正颌手术后上气道形态变化与颌骨移动量的相关性研究

doi:10.13591/j.cnki.kqyx.2024.07.006

摘要/Abstract

摘要：

目的通过锥形束计算机断层扫描(cone beam computer tomography,CBCT)探究骨性Ⅲ类错𬌗畸形患者双颌手术后上气道形态变化,以及颌骨移动与气道变化的关系。方法本研究纳入44例Ⅲ类双颌手术患者(男性21例,女性23例)。采集患者术前及术后3~6个月内CBCT数据,使用Dophin3D 11.95软件行测量分析。采用配对t检验、非参数Wilcoxon秩和检验分析上气道手术前后变化。采用Pearson相关系数分析气道变化与颌骨移动量的相关性。结果术后患者的上气道容积、正中矢状面纵截面积、最小横截面积明显减少(P<0.01)。口咽区容积变化量与B点的变化量相关(P<0.05)。随B点后退量的增加,上气道容积降低的显著性增加,当B点后退量>7 mm时,上气道各区域容积均显著降低(P<0.01),同时患者气道最小横截面积的危险程度显著升高(P<0.01)。结论骨性Ⅲ类双颌手术可降低患者的上气道容积。术后上气道容积减少量与B点后退量相关。当行大量下颌后退(>7 mm)时,可造成上气道容积的显著减低,增加OSAHS患病风险。对上气道有狭窄倾向的患者,应适当调整方案以减少气道风险。

关键词: 骨性Ⅲ类错𬌗畸形, 双颌手术, 上气道, CBCT

Abstract:

Objective To investigate the morphological changes in the upper airway after bimaxillary surgery in patients with skeletal Class Ⅲ malocclusion and the relationship between jaw movement and airway changes using CBCT. Methods This study involved 44 individuals(21 males and 23 females)receiving Class Ⅲ bimaxillary surgery. Preoperative and 3-6-month postoperative CBCT data were examined using Dophin3D 11.95 software. The alterations before and after upper airway surgery were analysed using paired t-test and non-parametric Wilcoxon rank sum test. The association between airway alterations and jaw movement was examined using Pearson’s correlation coefficient. Results Patients who underwent Class Ⅲ bimaxillary surgery had significantly reduced upper airway volume, sagittal cross-sectional area, and minimum cross-sectional area(P<0.01). A correlation exists between oropharyngeal volume change and point B change(P<0.05). When B point recession was >7 mm, the decrease in upper airway volume increased significantly(P<0.01), as did the risk of minimum cross-sectional area of the patient’s airway(P<0.01). Conclusion Class Ⅲ bimaxillary surgery reduces upper airway capacity. Postoperative reduction in upper airway capacity coincides with mandibular recession. Mandibular recession(>7 mm)may reduce postoperative upper airway capacity and increase the risk of OSAHS. Patients at risk of upper airway stenosis should have their protocol modified to reduce airway risk.

Key words: skeletal Class Ⅲ malocclusion, bimaxillary orthognathic surgery, pharyngeal airway, cone-beam computed tomography

中图分类号:

R782.23

李根, 郭松松, 蔡观慧, 孙莲, 孙雯, 王华. 骨性Ⅲ类患者双颌正颌手术后上气道形态变化与颌骨移动量的相关性研究[J]. 口腔医学, 2024, 44(7): 515-521.

LI Gen, GUO Songsong, CAI Guanhui, SUN Lian, SUN Wen, WANG Hua. Correlation between upper airway morphological changes and jaw movement after bimaxillary orthognathic surgery in patients with skeletal Class Ⅲ malocclusion[J]. Stomatology, 2024, 44(7): 515-521.

图/表 8

图1

图2

图3

表1

表2

表3

气道变化量与颌骨移动变化量相关性分析"

测量项目	统计值	A点矢状向变化量	A点垂直向变化量	B点矢状向变化量	B点垂直向变化量	PNS点矢状向变化量	PNS点垂直向变化量	H0点矢状向变化量	H0点垂直向变化量
总气道体积	r_s	0.099	-0.061	0.461	0.163	-0.067	0.120	-0.187	-0.041
	P	0.524	0.693	0.002^*	0.290	0.667	0.437	0.225	0.792
口咽体积	r_s	0.111	-0.043	0.431	0.231	-0.066	0.128	-0.221	-0.050
	P	0.474	0.783	0.004^*	0.132	0.670	0.407	0.150	0.747
上口咽体积	r_s	0.229	0.005	0.303	0.171	0.072	0.246	-0.135	-0.098
	P	0.135	0.973	0.046^*	0.268	0.641	0.107	0.382	0.525
下口咽体积	r_s	-0.027	-0.203	0.356	0.103	-0.108	0.058	-0.221	0.048
	P	0.861	0.187	0.018^*	0.505	0.487	0.709	0.149	0.758
咽下体积	r_s	-0.180	-0.004	0.283	0.066	-0.240	0.107	-0.066	-0.197
	P	0.241	0.979	0.063	0.668	0.116	0.488	0.669	0.200
总气道纵截面积	r_s	0.148	-0.083	0.379	0.105	0.047	0.153	-0.054	-0.087
	P	0.336	0.593	0.011^*	0.499	0.763	0.321	0.727	0.576
口咽纵截面积	r_s	0.241	-0.071	0.392	0.159	0.062	0.158	-0.131	0.03
	P	0.115	0.646	0.009^*	0.302	0.690	0.306	0.396	0.848
上口咽纵截面积	r_s	0.249	0.051	0.201	0.095	0.213	0.305	-0.144	-0.085
	P	0.103	0.744	0.191	0.540	0.165	0.044^*	0.351	0.583
下口咽纵截面积	r_s	0.022	-0.102	0.313	0.136	-0.145	0.028	-0.231	-0.013
	P	0.887	0.509	0.039	0.380	0.348	0.856	0.131	0.932
咽下纵截面积	r_s	-0.049	-0.216	0.068	-0.142	-0.102	0.057	-0.023	-0.086
	P	0.751	0.158	0.661	0.356	0.512	0.713	0.882	0.579
总气道横截面积	r_s	0.193	0.040	0.413	0.093	0.165	0.132	-0.082	0.080
	P	0.209	0.797	0.005^*	0.547	0.284	0.393	0.598	0.607
口咽横截面积	r_s	0.091	0.066	0.399	0.200	0.079	0.043	-0.190	0.061
	P	0.558	0.672	0.007^*	0.194	0.610	0.781	0.216	0.696
上口咽横截面积	r_s	0.199	0.000	0.434	0.219	0.112	0.157	-0.102	0.023
	P	0.194	0.998	0.003^*	0.153	0.468	0.308	0.509	0.882
下口咽横截面积	r_s	0.003	-0.189	0.279	0.131	-0.159	0.034	-0.212	0.072
	P	0.983	0.220	0.067	0.395	0.304	0.826	0.167	0.641
咽下横截面积	r_s	-0.057	-0.026	0.319	-0.026	-0.080	-0.011	-0.205	-0.092
	P	0.713	0.866	0.035^*	0.866	0.606	0.943	0.181	0.552

表3

表4

表5

参考文献 26

[1]	Abbasi S, Rahpeyma A, Shooshtari Z, et al. Bimaxillary orthognathic surgery does not induce obstructive sleep apnea in skeletal class Ⅲ patients[J]. J Oral Maxillofac Surg, 2022, 80(8):1340-1353.
[2]	Parappallil CJ, Parameswaran R, Vijayalakshmi D, et al. A comparative evaluation of changes in soft tissues after single-jaw surgery and bimaxillary surgery in skeletal class Ⅲ patients[J]. J Maxillofac Oral Surg, 2018, 17(4):538-546.
[3]	Tan SK, Tang ATH, Leung WK, et al. Three-dimensional pharyngeal airway changes after 2-jaw orthognathic surgery with segmentation in dento-skeletal class Ⅲ patients[J]. J Craniofac Surg, 2019, 30(5):1533-1538.
[4]	Park JH, Kim HS, Choi SH, et al. Changes in position of the hyoid bone and volume of the pharyngeal airway after mandibular setback: Three-dimensional analysis[J]. Br J Oral Maxillofac Surg, 2019, 57(1):29-35. doi: S0266-4356(18)30674-0 pmid: 30598316
[5]	Bin LR, Filho LI, Yamashita AL, et al. How does bimaxillary orthognathic surgery change dimensions of maxillary sinuses and pharyngeal airway space?[J]. Angle Orthod, 2020, 90(5):715-722. doi: 10.2319/120919-782.1 pmid: 33378484
[6]	Steegman R, Hogeveen F, Schoeman A, et al. Cone beam computed tomography volumetric airway changes after orthognathic surgery: A systematic review[J]. Int J Oral Maxillofac Surg, 2023, 52(1):60-71.
[7]	Irani SK, Oliver DR, Movahed R, et al. Pharyngeal airway evaluation after isolated mandibular setback surgery using cone-beam computed tomography[J]. Am J Orthod Dentofacial Orthop, 2018, 153(1):46-53.
[8]	AlQahtani F, George JM, Bishawi K, et al. Comparison of oropharyngeal airway dimensional changes in patients with skeletal Class Ⅱ and Class Ⅲ malocclusions after orthognathic surgery and functional appliance treatment: A systematic review[J]. Saudi Dent J, 2021, 33(8):860-868.
[9]	Rückschloß T, Ristow O, Jung A, et al. The relationship between bimaxillary orthognathic surgery and the extent of posterior airway space in class Ⅱ and Ⅲ patients-A retrospective three-dimensional cohort analysis[J]. J Oral Maxillofac Surg Med Pathol, 2021, 33(1):30-38.
[10]	Ngan P, Moon W. Evolution of Class Ⅲ treatment in orthodontics[J]. Am J Orthod Dentofacial Orthop, 2015, 148(1):22-36.
[11]	Karaaslan S, Tüz HH, El H, et al. Three-dimensional evaluation of upper airway changes after bimaxillary surgery of skeletal class 3 patients[J]. J Craniofac Surg, 2023, 34(3):996-1000.
[12]	聂萍, 陶丽, 朱妍菲, 等. 2种不同正颌术式对骨性Ⅲ类错𬌗畸形患者上气道形态的影响[J]. 上海口腔医学, 2018, 27(3):280-284.
[13]	Havron AG, Aronovich S, Shelgikar AV, et al. 3D Airway changes using CBCT in patients following mandibular setback surgery ± maxillary advancement[J]. Orthod Craniofac Res, 2019, 22(Suppl 1):30-35.
[14]	Guijarro-Martínez R, Swennen GRJ. Three-dimensional cone beam computed tomography definition of the anatomical subregions of the upper airway: A validation study[J]. Int J Oral Maxillofac Surg, 2013, 42(9):1140-1149.
[15]	Ding XF, Suzuki S, Shiga M, et al. Evaluation of tongue volume and oral cavity capacity using cone-beam computed tomography[J]. Odontology, 2018, 106(3):266-273. doi: 10.1007/s10266-017-0335-0 pmid: 29468332
[16]	Brito FC, Brunetto DP, Nojima MCG. Three-dimensional study of the upper airway in different skeletal Class Ⅱ malocclusion patterns[J]. Angle Orthod, 2019, 89(1):93-101.
[17]	Giralt-Hernando M, Valls-Ontañón A, Haas Junior OL, et al. What are the surgical movements in orthognathic surgery that most affect the upper airways? A three-dimensional analysis[J]. J Oral MaxillofacSurg, 2021, 79(2):450-462.
[18]	Souza Pinto GN, Iwaki Filho L, Previdelli ITDS, et al. Three-dimensional alterations in pharyngeal airspace, soft palate, and hyoid bone of Class Ⅱ and Class Ⅲ patients submitted to bimaxillary orthognathic surgery: A retrospective study[J]. J Craniomaxillofac Surg, 2019, 47(6):883-894.
[19]	Resnick CM, Middleton JK, Calabrese CE, et al. Retropalatal cross-sectional area is predictive of obstructive sleep apnea in patients with syndromic craniosynostosis[J]. Cleft Palate Craniofac J, 2020, 57(5):560-565.
[20]	Deyoung PN, Bakker JP, Sands SA, et al. Acoustic pharyngometry measurement of minimal cross-sectional airway area is a significant independent predictor of moderate-to-severe obstructive sleep apnea[J]. J Clin Sleep Med, 2013, 9(11):1161-1164. doi: 10.5664/jcsm.3158 pmid: 24235897
[21]	Marcussen L, Stokbro K, Aagaard E, et al. Changes in upper airway volume following orthognathic surgery[J]. J Craniofac Surg, 2017, 28(1):66-70. doi: 10.1097/SCS.0000000000003206 pmid: 27893557
[22]	Zhao YL, Li XY, Ma JG. Combined application of pharyngeal volume and minimal cross-sectional area may be helpful in screening persons suspected of obstructive sleep apnea (OSA)[J]. Sleep Breath, 2022, 26(1):243-250.
[23]	Zhang ZQ, Wang SZ, Li J, et al. Quantification of pharyngeal airway space changes after two-jaw orthognathic surgery in skeletal Class Ⅲ patients[J]. BMC Oral Health, 2023, 23(1):345. doi: 10.1186/s12903-023-03075-y pmid: 37264397
[24]	龚依玲, 樊蓉, 常新. 骨性Ⅲ类患者正颌手术后上气道变化预测方法的研究现状[J]. 口腔医学, 2023, 43(10):955-960.
[25]	Ghosh A, Ray A. “Converting a bi-jaw surgery to a single-jaw surgery:” Posterior maxillary dentoalveolar intrusion with microimplants to avoid the need of a maxillary surgery in the surgical management of skeletal Class Ⅲ vertical malocclusion[J]. APOS Trends Orthod, 2016, 6: 218-227.
[26]	罗世逸, 羊书勇, 吴坡, 等. 双颌前徙术配合颏成形术对OSAHS患者气道容积的影响[J]. 西南国防医药, 2020, 30(1):38-40.

测量项目	术前		术后		术后-术前		P
测量项目	平均值	标准差	平均值	标准差	平均值	标准差	P
ANB/(°)	-4.03	2.64	0.77	1.96	4.80	2.12	0.000^*
wits值/mm	-12.13	3.65	-3.98	2.97	8.16	2.82	0.000^*
A-Y轴/mm	1.59	3.23	3.16	3.70	1.57	1.65	0.000^*
A-X轴/mm	-61.64	4.27	-62.38	5.05	-0.74	2.23	0.033^*
B-Y轴/mm	8.88	5.68	3.39	5.29	-5.49	3.24	0.000^*
B-X轴/mm	-101.14	8.02	-99.98	6.99	1.17	3.02	0.014^*
PNS-Y轴/mm	-42.72	4.05	-39.93	3.99	2.79	1.67	0.000^*
PNS-X轴/mm	-53.41	4.06	-53.42	4.41	-0.01	1.52	0.953
H0-Y轴/mm	-37.28	7.63	-38.6	7.60	-1.33	3.68	0.021^*
H0-X轴/mm	-113.35	8.51	-115.73	9.57	2.38	4.69	0.002^*

测量项目	术前		术后		术后-术前		变化率	P
测量项目	平均值	标准差	平均值	标准差	平均值	标准差	变化率	P
气道体积/mm³
总气道	2 1381.1	8 275.5	17 442.3	6 002.7	-3 938.9	4 732.6	-16.39%	0.000^*
口咽区	15 745.0	6 576.9	12 525.2	4 745.4	-3 219.8	3 845.9	-17.88%	0.000^*
上口咽区	8 307.7	4 039.5	6 585.0	2 902.3	-1 722.8	2 475.0	-17.24%	0.000^*
下口咽区	7 539.2	3 274.5	5 837.0	2 509.8	-1 702.2	2 240.4	-19.15%	0.000^*
咽下区	5 629.3	2 168.8	4 914.7	1 891.1	-714.6	1 274.2	-10.61%	0.001^*
正中矢状面纵截面积/mm²
总气道	943.6	208.2	842.7	180.4	-100.9	130.8	-9.87%	0.000^*
口咽区	705.4	160.8	627.9	137.7	-77.5	95.0	-10.13%	0.000^*
上口咽区	385.3	93.6	345.1	68.5	-40.3	64.1	-8.78%	0.000^*
下口咽区	326.6	100.2	286.1	93.1	-40.5	64.9	-10.89%	0.000^*
咽下区	236.5	71.3	218.4	61.5	-18.0	53.9	-3.53%	0.032^*
最小横截面积/mm²
总气道	171.6	79.1	121.5	59.1	-50.1	57.5	-23.32%	0.000^*
口咽区	181.1	89.6	126.5	63.1	-54.6	63.4	-26.95%	0.000^*
上口咽区	191.9	102.8	146.0	81.3	-45.9	58.4	-20.99%	0.000^*
下口咽区	221.1	94.8	156.9	67.8	-64.3	78.0	-25.07%	0.000^*
咽下区	229.3	113.6	202.3	95.7	-27.1	92.9	-0.65%	0.060

测量项目	B点后退量<4 mm(15例)				B点后退量4~7 mm(15例)				B点后退量>7 mm(14例)
测量项目	平均值	标准差	变化率	P	平均值	标准差	变化率	P	平均值	标准差	变化率	P
气道体积/mm³
总气道	-1 626.5	2 780.6	-8.28%	0.040^*	-2 371.8	3 482.3	-11.37%	0.008^*	-7 489.5	5 879.2	-26.93%	0.002^*
口咽区	-1 446.2	2 017.8	-10.19%	0.015^*	-1 782.4	3 200.1	-10.47%	0.012^*	-6 166.4	4 648.7	-29.86%	0.002^*
上口咽区	-1 356.0	1 773.7	-16.20%	0.010^*	-467.2	1 709.2	-4.73%	0.173	-3 150.1	3 285.8	-27.37%	0.004^*
下口咽区	-724.9	1 994.9	-7.88%	0.181	-1 261.9	1 825.1	-16.61%	0.017^*	-3 055.6	2 411.3	-30.93%	0.002^*
咽下区	-248.3	1 123.1	-3.13%	0.406	-483.7	778.1	-9.32%	0.023^*	-1301.4	1 662.4	-17.97%	0.012^*
正中矢状面纵截面积/mm²
总气道	-39.5	90.3	-4.58%	0.112	-60.8	100.9	-6.53%	0.010^*	-187.3	152.7	-16.55%	0.002^*
口咽区	-33.1	70.9	-5.58%	0.092	-39.1	77.0	-5.29%	0.011^*	-147.9	98.6	-17.55%	0.001^*
上口咽区	-36.2	52.0	-8.70%	0.017^*	-5.1	50.5	-0.57%	0.222	-70.1	81.2	-14.47%	0.005^*
下口咽区	-10.7	63.4	-3.49%	0.525	-31.4	51.5	-9.50%	0.030^*	-76.9	61.4	-19.03%	0.000^*
咽下区	-9.5	44.1	-1.28%	0.416	-17.7	44.9	-4.51%	0.114	-24.9	71.0	-3.54%	0.001^*
最小横截面积/mm²
总气道	-29.5	35.6	-16.93%	0.006^*	-23.1	50.2	-8.49%	0.031^*	-89.8	64.0	-39.97%	0.001^*
口咽区	-26.7	41.5	-14.37%	0.026^*	-32.4	40.8	-20.50%	0.001^*	-98.1	81.3	-40.78%	0.001^*
上口咽区	-22.6	42.8	-10.51%	0.060	-27.2	60.6	-13.25%	0.028^*	-89.9	65.4	-36.21%	0.002^*
下口咽区	-34.7	68.7	-11.47%	0.070	-42.4	51.4	-21.92%	0.001^*	-107.1	97.1	-36.06%	0.002^*
咽下区	5.5	104.4	12.14%	0.842	-13.9	68.7	10.39%	0.177	-62.2	91.7	-19.49%	0.025^*

B点后退量	术前最小横截面积危险度秩平均值	术后最小横截面积危险度秩平均值	Z	P
<4 mm	13.43	16.68	-1.383	0.167
4~7 mm	13.79	17.03	-1.119	0.263
>7 mm	11.00	18.00	-2.985	0.003^*