两种术式矫治唇腭裂患者上颌发育不足的比较研究

doi:10.13591/j.cnki.kqyx.2024.12.003

摘要/Abstract

摘要：

目的比较上颌前段牵张成骨术及Le Fort Ⅰ型截骨术矫治唇腭裂继发上颌发育不足的临床疗效。方法选取南京医科大学附属口腔医院颌面外科唇腭裂上颌发育不足患者25例,其中利用牙支持式牵张器的上颌前段牵张成骨术10例,Le Fort Ⅰ型截骨术15例。术前1周及术后1个月拍摄锥形束CT、正侧貌相,语音评估及鼻咽纤维镜检查,分析两种术式的临床疗效。结果两种术式均有效前徙上颌骨并明显改善患者侧貌,上颌前段牵张成骨术微创、经济,更有利于前移上颌骨;而Le Fort Ⅰ型截骨术后患者的侧貌更佳,差异有统计学意义(P<0.05)。两种术式对发音无显著影响,Le Fort Ⅰ型截骨术对腭咽部解剖影响更大,表现为软腭长度增加(2.01±1.71)mm、厚度减小(0.98±0.50)mm,咽腔深度增加(3.06±1.35)mm,差异有统计学意义(P<0.05)。结论上颌前段牵张成骨从经济效益以及对软腭结构的影响上较Le Fort Ⅰ型截骨有优势。

关键词: 牵张成骨术, 正颌外科, 唇裂, 腭裂, 语音评估

Abstract:

Objective To evaluate the clinical efficacy of anterior maxillary segmental distraction osteogenesis and Le Fort Ⅰ Osteotomy on secondary maxillary hypoplasia in patients with cleft lip and palate. Methods Twenty-five patients with maxillary hypoplasia secondary to cleft lip and palate underwent surgery in maxillofacial surgical department of the Affiliated Stomatological Hospital of Nanjing Medical University were selected. Ten cases were treated using tooth-borne distractors for anterior maxillary distraction osteogenesis, and fifteen cases underwent Le Fort Ⅰ Osteotomy. Cone-beam CT, positive and lateral features, speech recording and nasopharyngeal fibroscope were taken one week before operation and one month after surgery. The clinical outcomes of the two methods and their influence on patients’ speech function were measured and compared using t-test. Results Both techniques effectively advanced the maxilla and significantly improved the patients’ profiles. Anterior maxillary segmental distraction osteogenesis, which was economical and minimally invasive, greater advanced the maxilla. However, the postoperative profile was better in patients undergoing Le Fort I osteotomy, with statistically significant differences (P<0.05). Neither technique significantly affected speech, but Le Fort Ⅰ osteotomy had a greater impact on palatopharyngeal anatomy, indicated by increased soft palate length (2.01±1.71)mm, reduced thickness (0.98±0.50) mm, and increased pharyngeal depth (3.06±1.35) mm, with statistically significant differences (P<0.05). Conclusion Anterior maxillary segmental distraction osteogenesis and orthognathic surgery are both effective methods for the treatment of secondary maxillary hypoplasia in cleft lip and palate patients. Anterior maxillary distraction osteogenesis has advantages over Le Fort I osteotomy in terms of economic benefits and its impact on the soft palate structure.

Key words: distraction osteogenesis, orthognathic surgery, cleft lip, cleft palate, speech evaluation

中图分类号:

R782.22

郭松松, 章振兴, 张平, 姜成惠, 程杰, 江宏兵, 李盛. 两种术式矫治唇腭裂患者上颌发育不足的比较研究[J]. 口腔医学, 2024, 44(12): 892-898.

GUO Songsong, ZHANG Zhenxing, ZHANG Ping, JIANG Chenghui, CHENG Jie, JIANG Hongbing, LI Sheng. Evaluation of two surgical methods for maxillary hypoplasia in patients with cleft lip and palate[J]. Stomatology, 2024, 44(12): 892-898.

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参考文献 25

[1]	戴俊峰, 邢树林. 先天性唇腭裂病因学研究的新进展[J]. 中国优生与遗传杂志, 2008, 16(12):124-125.
[2]	Good PM, Mulliken JB, Padwa BL. Frequency of Le Fort I osteotomy after repaired cleft lip and palate or cleft palate[J]. Cleft Palate Craniofac J, 2007, 44(4):396-401.
[3]	Mossey PA, Little J, Munger RG, et al. Cleft lip and palate[J]. Lancet, 2009, 374(9703):1773-1785. doi: 10.1016/S0140-6736(09)60695-4 pmid: 19747722
[4]	Prada Madrid JR, Gómez Prada DC, Gutierrez Rodríguez EP, et al. Lefort I osteotomy with and without osteogenic distraction in cleft lip and palate patients: Experience at hospital universitario infantil de San josé[J]. J Craniofac Surg, 2024, 35(3):721-725.
[5]	Chang CS, Wallace CG, Hsiao YC, et al. Airway changes after cleft orthognathic surgery evaluated by three-dimensional computed tomography and overnight polysomnographic study[J]. Sci Rep, 2017, 7(1):12260.
[6]	Venkategowda PR, Prakash AT, Roy ET, et al. Stability of vertical, horizontal and angular parameters following superior repositioning of maxilla by le fort I osteotomy: A cephalometric study[J]. J Clin Diagn Res, 2017, 11(1):ZC10-ZC14.
[7]	Bengi O, Karaçay S, Akin E, et al. Cephalometric evaluation of patients treated by maxillary anterior segmental distraction: A preliminary report[J]. J Craniomaxillofac Surg, 2007, 35(6/7):302-310.
[8]	Gunaseelan R, Cheung LK, Krishnaswamy R, et al. Anterior maxillary distraction by tooth-borne palatal distractor[J]. J Oral Maxillofac Surg, 2007, 65(5):1044-1049.
[9]	Richardson S, Selvaraj D, Khandeparker RV, et al. Tooth-borne anterior maxillary distraction for cleft maxillary hypoplasia: Our experience with 147 patients[J]. J Oral Maxillofac Surg, 2016, 74(12):2504.e1-2504.e14.
[10]	Jia HC, Zhuang L, Zhang N, et al. Comparison of skeletal maxillary transverse deficiency treated by microimplant-assisted rapid palatal expansion and tooth-borne expansion during the post-pubertal growth spurt stage[J]. Angle Orthod, 2021, 91(1):36-45. doi: 10.2319/041920-332.1 pmid: 33289835
[11]	杨辛, 沈国芳, 张志愿, 等. 唇腭裂患者牵张成骨术后的侧貌变化[J]. 中国口腔颌面外科杂志, 2009, 7(2):97-101.
[12]	郭秀娟, 耿海霞, 郑海英, 等. 上颌骨Le Fort Ⅰ型截骨前徙术对唇腭裂患者腭咽结构及功能影响的临床探讨[J]. 临床口腔医学杂志, 2017, 33(11):664-667.
[13]	Jordan HN, Schenck GC, Ellis C, et al. Examining velopharyngeal closure patterns based on anatomic variables[J]. J Craniofac Surg, 2017, 28(1):270-274. doi: 10.1097/SCS.0000000000003284 pmid: 27941550
[14]	Li HL, Dai JW, Si JW, et al. Anterior maxillary segmental distraction in the treatment of severe maxillary hypoplasia secondary to cleft lip and palate[J]. Int J Clin Exp Med, 2015, 8(9):16022-16028. pmid: 26629107
[15]	Fariña R, Lolas J, Moreno E, et al. Cleft lip and palate midfacial hypoplasia: Criteria to choose the treatment[J]. J Craniofac Surg, 2022, 33(2):496-501.
[16]	Kim YK. Complications associated with orthognathic surgery[J]. J Korean Assoc Oral Maxillofac Surg, 2017, 43(1):3-15.
[17]	Jiang Y, Jiang CY, Shi B, et al. Efficacy of modified anterior maxillary segmental distraction osteogenesis based on 3D visualisation for the treatment of maxillary hypoplasia among adolescents with cleft lip and palate[J]. BMC Oral Health, 2024, 24(1):1032. doi: 10.1186/s12903-024-04828-z pmid: 39227941
[18]	Varidel A, Padwa BL, Britt MC, et al. Patient-specific le fort I osteotomy plates are more stable than stock plates in patients with cleft lip and palate[J/OL]. Plast Reconstr Surg, 2024[2024-08-22]. https://pubmed.ncbi.nlm.nih.gov/38546729/.
[19]	Chen Q, Li Y, Shi B, et al. Analysis of the correlative factors for velopharyngeal closure of patients with cleft palate after primary repair[J]. Oral Surg Oral Med Oral Pathol Oral Radiol, 2013, 116(6):e424-428
[20]	Kanzaki H, Imai Y, Nakajo T, et al. Midfacial changes through anterior maxillary distraction osteogenesis in patients with cleft lip and palate[J]. J Craniofac Surg, 2017, 28(4):1057-1062. doi: 10.1097/SCS.0000000000003506 pmid: 28141644
[21]	Yatabe-Ioshida MS, Campos LD, Yaedu RY, et al. Upper airway 3D changes of patients with cleft lip and palate after orthognathic surgery[J]. Cleft Palate Craniofac J, 2019, 56(3):314-320.
[22]	Shi B, Losee JE. The impact of cleft lip and palate repair on maxillofacial growth[J]. Int J Oral Sci, 2015, 7(1):14-17. doi: 10.1038/ijos.2014.59 pmid: 25394591
[23]	Jung J, Lee CH, Lee JW, et al. Three dimensional evaluation of soft tissue after orthognathic surgery[J]. Head Face Med, 2018, 14(1):21. doi: 10.1186/s13005-018-0179-z pmid: 30290762
[24]	Tanikawa C, Hirata K, Aikawa T, et al. Efficacy of maxillary anterior segmental distraction osteogenesis in patients with cleft lip and palate[J]. Cleft Palate Craniofac J, 2018, 55(10):1375-1381.
[25]	Gateno J, Engel ER, Teichgraeber JF, et al. A new Le Fort I internal distraction device in the treatment of severe maxillary hypoplasia[J]. J Oral Maxillofac Surg, 2005, 63(1):148-154.

类型	测量项目	含义
上颌骨改变	Ax/mm	A点在X轴上的坐标
	SNA/(°)	S-N-A形成的角度
	ANS-Ptm/mm	ANS与Ptm点在X轴上投影点间的距离
	SNPP/(°)	ANS-PNS平面与SN平面的交角
	UI-SN/(°)	上切牙长轴与SN平面的交角
硬组织侧貌	SNB/(°)	S-N-B形成的角度
	ANB/(°)	SNA与SNB角的差值
	NA-PA/(°)	NA连线与PA连线的交角
	覆盖/mm	UI点与LI点在X轴上的投影点间的差值
软组织侧貌	Ns-Prn-Pgs/(°)	Ns-Prn-Pgs形成的角度
	As-Ns-Bs/(°)	As-Ns-Bs形成的角度
	Ns-Sn-Pgs/(°)	Ns-Sn-Pgs形成的角度,反映面型的凸度
腭咽部结构	软腭长度/mm	PNS与U的距离
	软腭厚度/mm	PNS-U的垂线与软腭最宽处两点相交形成的距离
	软硬腭交角/(°)	ANS-PNS平面与PNS-U平面的交角
	咽腔深度/mm	PNS与PPW的距离
	腭咽间隙/mm	Ve与Pe的距离
	骨性腭咽间隙/mm	Ve与Te的距离

测量项目	AMSDO(T2-T1)	Le FortⅠ型截骨术(T2-T1)	P
Ax/mm	6.91±1.73	2.82±0.69	0.00^a
SNA/(°)	7.74±1.65	5.01±0.98	0.00^a
ANS-Ptm/mm)	10.68±2.13	3.02±0.69	0.00^a
SNPP/(°)	-(3.11±1.64)	3.23±2.82	0.00^a
UI-SN/(°)	3.62±3.23	0.82±0.91	0.00^a

测量项目	AMSDO(T2-T1)	Le FortⅠ型截骨术(T2-T1)	P
覆盖/mm	11.02±1.82	8.21±1.39	0.00^a
SNB/(°)	-(0.41±0.65)	-(4.82±1.75)	0.00^a
ANB/(°)	7.32±1.86	9.61±2.02	0.00^a
NA-PA/(°)	13.82±1.94	14.81±3.66	0.22
Ns-Prn-Pgs/(°)	10.35±4.85	7.15±2.82	0.02^b
As-Ns-Bs/(°)	6.21±2.28	8.89±2.06	0.00^a
Ns-Sn-Pgs/(°)	2.25±1.60	6.65±2.08	0.00^a

测量项目	AMSDO组	Le FortⅠ组	P
软腭长度/mm	0.65±0.69	2.01±1.71	0.01^b
咽腔深度/mm	0.89±0.92	3.06±1.35	0.00^a
软硬腭交角/(°)	5.62±2.23	10.23±3.11	0.00^a
软腭厚度/mm	-(0.15±0.14)	-(0.98±0.50)	0.03^b
腭咽间隙/mm	0.06±0.10	0.39±0.33	0.00^a
骨性腭咽间隙/mm	0.12±0.16	0.58±0.62	0.02^b

测量项目	AMSDO组			Le FortⅠ组
测量项目	术前1周	术后1个月	P	术前1周	术后1个月	P
鼻音	1.60±0.22	1.70±0.21	0.75	2.07±0.18	2.00±0.20	0.80
语音可理解性	1.80±0.25	1.70±0.26	0.78	2.47±0.19	2.40±0.19	0.80
腭咽闭合功能	1.90±0.18	1.90±0.18	1.00	1.87±0.13	1.80±0.14	0.73
呼吸习惯	1.80±0.13	1.80±0.13	1.00	1.87±0.09	1.87±0.09	1.00