韓思源， 賀佳妮， 冷 冰， 郭家妍， 李 怒， 左 娜， 劉海燕， 胡 楓

作者單位：110001 遼寧 沈陽，中國醫(yī)科大學(xué)附屬第一醫(yī)院 整形外科

頜面整形

下頜部畸形26例治療體會(huì)

韓思源， 賀佳妮， 冷 冰， 郭家妍， 李 怒， 左 娜， 劉海燕， 胡 楓

作者單位：110001 遼寧 沈陽，中國醫(yī)科大學(xué)附屬第一醫(yī)院 整形外科

目的 總結(jié)近5年我科收治下頜部畸形的治療經(jīng)驗(yàn)，以指導(dǎo)臨床工作。方法 收集26例下頜部畸形的病歷資料，對(duì)其進(jìn)行回顧性分析總結(jié)。安氏骨性Ⅲ類畸形、下頜前突、偏突頜畸形12例，其中，11例行下頜支矢狀骨劈開術(shù)，1例行經(jīng)口內(nèi)入路下頜支垂直骨切開術(shù)，3例同期行頦成形術(shù)；下頜角肥大9例，其中，7例行下頜角外板劈開截除術(shù)，2例行下頜角磨骨術(shù)；小頦畸形5例，其中，3例行膨體隆頦術(shù)，2例行硅膠假體隆頦術(shù)。結(jié)果 所有患者術(shù)后效果滿意，并發(fā)癥發(fā)生率為7.69%。結(jié)論 下頜支矢狀骨劈開術(shù)可以通過向前、向后移動(dòng)或旋轉(zhuǎn)遠(yuǎn)心骨段來完成下頜后縮、前突及偏突畸形的矯正，效果確切；下頜角磨骨術(shù)對(duì)于外翻型下頜角肥大治療效果較好，對(duì)于下頜角肥大向外側(cè)與后方較明顯突出的患者應(yīng)選用下頜角外板劈開截除術(shù)；填充頦成形術(shù)僅適用于輕、中度的小頦畸形，其他類型的畸形應(yīng)考慮頦成形術(shù)。

下頜支矢狀骨劈開術(shù)； 下頜前突； 偏突頜畸形； 下頜角肥大

1 臨床資料

本組患者共26例。男性5例，女性21例；年齡17～39歲，平均22.7歲。10例患者存在顳下頜關(guān)節(jié)彈響。安氏骨性Ⅲ類畸形、下頜前突、偏突頜畸形12例，其中11例行下頜支矢狀骨劈開術(shù)(sagittal split ramus osteotomy, SSRO)，1例行經(jīng)口內(nèi)入路下頜支垂直骨切開術(shù)(intraoral vertical ramus osteotomy, IVRO)，12例中3例同期行頦成形術(shù)；下頜角肥大9例，其中7例行下頜角外板劈開截除術(shù)，2例行下頜角磨骨術(shù)；小頦畸形5例，3例行膨體隆頦術(shù)；2例行硅膠假體隆頦術(shù)。

2 手術(shù)方法

2.1 安氏骨性Ⅲ類畸形、下頜前突、偏突頜畸形 治療程序均按照術(shù)前正畸、模型外科、正頜手術(shù)、術(shù)后正畸與康復(fù)治療[5]進(jìn)行。術(shù)前頜面部三維CT重建按正頜手術(shù)要求精確測量。經(jīng)鼻氣管插管全身麻醉。11例患者行SSRO，遠(yuǎn)心骨段移動(dòng)距離為3.00～13.00 mm，平均6.72 mm，以鈦板與單皮質(zhì)骨螺釘固定，其中2例患者同時(shí)行上頜Lefort Ⅰ型骨切開術(shù)，前徙距離分別為5.00 mm、7.00 mm，平均6.00 mm;前徙7.00 mm者，顴牙槽嵴處骨缺損用下頜骨截除外板進(jìn)行植骨，鉆孔后絲線縫合固定，其中3例患者同時(shí)行頦成形術(shù)。1例患者行IVRO，術(shù)后4周解除頜間橡皮圈固定。術(shù)后1個(gè)月左右開始術(shù)后正畸治療，同時(shí)進(jìn)行恢復(fù)頜周肌肉及顳頜關(guān)節(jié)功能的康復(fù)訓(xùn)練。

2.2 下頜角肥大 7例患者行下頜角外板劈開截除術(shù)(mandibular angle splitting ostectomy, MASO)，按設(shè)計(jì)線截骨后至欲截除下頜角部分后，將下頜角部分骨質(zhì)全層截?cái)?，并將截除的骨外板及下頜角部全層骨組織一并取出，打磨骨質(zhì)邊緣。2例下頜角外翻患者行下頜角磨骨術(shù)。

2.3 小頦畸形 經(jīng)口內(nèi)橫切口行硅膠假體或膨體置入術(shù)，3例行膨體隆頦術(shù)，2例行硅膠假體隆頦術(shù)。

3 結(jié)果

4 典型病例

圖1 下頜過度前突治療前后對(duì)比 a.術(shù)前正位 b.術(shù)后1個(gè)月正位 c.術(shù)前斜位 d.術(shù)后1個(gè)月斜位 e. 術(shù)前側(cè)位f. 術(shù)后1個(gè)月側(cè)位

Fig 1 Comparison between preview and postview of the treatment of lower mandible with excessive protraction. a. frontal preview.b. frontal postview at 1 month. c. oblique preview. d. oblique postview at 1 month. e. lateral preview. f. lateral postview at 1 month.

Fig 2 Comparison between preview and postview of the treatment of bilateral SSRO. a. preview. b. postview at 1 month. c. preview with occlusion. d. postview with occlusion at 1 month.

5 討論

5.1 安氏骨性Ⅲ類畸形、下頜前突、偏突頜畸形 目前，國際上公認(rèn)的矯治術(shù)式有SSRO和IVRO[6-7]。使用最普遍的矯正下頜前突畸形的手術(shù)方法是SSRO[8]，適用于矯正下頜發(fā)育不足和下頜發(fā)育過度，當(dāng)伴有上頜發(fā)育不足、小頦畸形時(shí)可同期行上頜Lefort Ⅰ型骨切開術(shù)、頦成形術(shù)，手術(shù)順序?yàn)樯项M手術(shù)、下頜手術(shù)、頦部手術(shù)。術(shù)中應(yīng)用鈦板堅(jiān)固內(nèi)固定。改良的SSRO有如下優(yōu)點(diǎn):⑴口內(nèi)切口，面部不留瘢痕；⑵矢狀截骨使牙槽神經(jīng)血管束得以完整保留，減少并發(fā)癥的發(fā)生；⑶近遠(yuǎn)心骨段有較大的骨接觸面，有利于骨段間愈合；⑷可以有很大的后退量, 有利于嚴(yán)重下頜前突的矯治[9]；⑸對(duì)面部側(cè)方形態(tài)影響不大，咀嚼肌適應(yīng)迅速。兩種截骨術(shù)改變了原來的頜骨形態(tài)和位置，也改變了顳下頜關(guān)節(jié)前、上、后間隙，從而導(dǎo)致髁突位置在術(shù)后也發(fā)生了改變。但因影響這種改變的因素復(fù)雜，移位方向也多種多樣，有向前移位[10]、向內(nèi)向后旋轉(zhuǎn)[11]，顳頜關(guān)節(jié)的各個(gè)間隙在術(shù)前術(shù)后也有明顯改變[12]。IVRO由于術(shù)后不需要進(jìn)行堅(jiān)固內(nèi)固定，術(shù)后近心端骨段可以發(fā)生旋轉(zhuǎn)移位。Bell等[13-14]報(bào)道IVRO后髁狀突向前向下移位，但是當(dāng)全身神經(jīng)肌肉恢復(fù)后，髁狀突有回到原來位置的傾向[15]。有報(bào)道稱，IVRO術(shù)后顳頜關(guān)節(jié)紊亂癥狀消失[16-18]。Lai等[19]建議應(yīng)用單側(cè)IVRO聯(lián)合對(duì)側(cè)SSRO的方法來改善下頜不對(duì)稱畸形，同時(shí)改善顳頜關(guān)節(jié)紊亂的癥狀。

5.2 下頜角肥大 下頜角縮小成形術(shù)主要包括磨骨術(shù)和MASO。MASO適用于向外側(cè)與后方較明顯突出者，對(duì)于正面觀下頜角骨質(zhì)外翻的患者尤其適合磨骨術(shù)，術(shù)中需注意預(yù)防出血[20]。該術(shù)式不會(huì)導(dǎo)致骨折和顳下頜關(guān)節(jié)損傷，創(chuàng)傷小。本研究中應(yīng)用MASO的下頜角肥大病例在操作中一次性將骨外板與下頜角截除，效果確切，值得推廣。

5.3 小頦畸形 隆頦術(shù)作為常見的美容整形手術(shù)，手術(shù)難度不大，但易出現(xiàn)下唇外翻、假體移位等并發(fā)癥。這些并發(fā)癥的產(chǎn)生與切口的選擇有關(guān)[21]。下唇及頦部有3對(duì)肌肉與口內(nèi)切口相關(guān)，即頦肌、下唇方肌和下唇三角肌，作用均為降下唇，上提頦部皮膚[22]。切口應(yīng)順應(yīng)頦肌、下唇方肌和下唇三角肌等肌肉的輻射狀走向，最大程度地保留下唇正常解剖結(jié)構(gòu)，可最大限度地減少術(shù)后并發(fā)癥的發(fā)生，可以選用雙側(cè)縱切口及口內(nèi)環(huán)系帶U形切口。

下頜部畸形的矯治術(shù)式多種多樣，但目前沒有一種術(shù)式適合所有的下頜部畸形患者[23]。應(yīng)根據(jù)畸形的類型，從下頜部整體輪廓考慮，制定最佳的手術(shù)方案，才能達(dá)到理想的美學(xué)效果。

[1] Lee ST, Mori Y, Minami K, et al. Does skeletal surgery for asymmetric mandibular prognathism influence the soft tissue contour and thickness[J]? J Oral Maxillofac Surg, 2013,71(9):1577-1587.

[2] Guglielmi M, Schneider KM, Iannetti G, et al. Orthognathic surgery for correction of patients with mandibular excess: don′t forget to assess the gonial angle [J]. J Oral Maxillofac Surg, 2013,71(6):1063-1072.

[3] Haraguchi S, Takada K, Yasuda Y. Facial asymmetry in subjects with skeletal Class Ⅲ deformity [J]. Angle Orthod, 2002,72(1):28-35.

[5] 張志愿. 口腔頜面外科學(xué)[M]. 7版. 北京:人民衛(wèi)生出版社, 2014:502.

[6] Huseyin AB, Cenk K, Altan V, et al. A morphometric study of the maxillary artery and lingula in relation to mandibular ramus osteotomies and TMJ surgery[J]. Eur J Dent, 2010,4(2):166-170.

[7] Yazdani J, Talesh KT, Motamedi MH, et al. Changes in the gonial angle following bilateral sagittal split osteotomy and vertical ramus osteotomy for mandibular excess[J]. Eplasty, 2010,10(1):20-22.

[8] 任 敏, 滕 利, 歸 來, 等. 口內(nèi)入路改良下頜升支矢狀劈開截骨術(shù)矯治下頜前突[J]. 中國美容醫(yī)學(xué), 2006,15(12):1383-1385.

[9] Guven O, S aracoglu U. Changes in pharyngeal airway space and hyoid bone positions af ter body ostectomies and sagittal split ramus osteotomies[J]. J Craniofac Surg, 2005,16(1):23-30.

[10] 楊學(xué)文, 龍 星, 葉翁三杰, 等. 正頜正畸聯(lián)合治療下頜偏突頜畸形[J]. 中華醫(yī)學(xué)美學(xué)美容雜志, 2006,12(1):5-8.

[11] Baek SH, Kim TK, Kim MJ. Is there any difference in the condylar position and angulation after asymmetric mandibular setback[J]. Oral Surg Oral Pathol Oral Radiol Endod, 2006,101(2):155-163.

[12] Ueki K, Moroi A, Sotobori M, et al. Changes in temporomandibular joint and ramus after sagittal split ramus osteotomy in mandibular prognathiam patients with and without asymmetry[J]. J Craniomaxillofac Surg, 2012,40(8):821-827.

[13] Bell WH, Yamaguchi Y, Poor MR. Treatment of temporomandibular joint dysfunction by intraoral vertical ramus osteotomy[J]. Int J Adult Orthodon Orthognath Surg, 1990,5(1):9-27.

[14] Bell WH, Yamaguchi Y. Condyle position and mobility before and after intraoral vertical ramus osteotomies and neuromuscular rehabilitation[J]. Int J Adult Orthodon Orthognath Surg, 1991,6(2):97-104.

[15] Choi YS, Jung HD, Kim SY, et al. Remodelling pattern of the ramus on submentovertex cephalographs after intraoral vertical ramus osteotomy[J]. Br J Oral Maxillofac Surg, 2013,51(8):259-262.

[16] Jung HD, Jung YS, Park HS. The chronologic prevalence of temporomandibular joint disorders associated with bilateral intraoral vertical ramus osteotomy[J]. J Oral Maxillofac Surg, 2009,67(4):797-803.

[17] Hall HD, Navarro EZ, Gibbs SJ. Prospective study of modified condylotomy for treatment of nonreducing disk displacement[J]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2000,89(2):147-158.

[18] Hall HD, Navarro EZ, Gibbs SJ. One-and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement[J]. J Oral Maxillofac Surg, 2000,58(1):7-17.

[19] Lai W, Yamada K, Hanada K, et al. Postoperative mandibular stability after orthognathic surgery in patients with mandibular protrusion and mandibular deviation[J]. Int J Adult Orthodon Orthognath Surg, 2002,17(1):13-22.

[20] 趙弘宇, 羅永萍, 林 華. 局部浸潤麻醉口內(nèi)切口下面部整形術(shù)[J]. 中華醫(yī)學(xué)美學(xué)美容雜志, 2005,11(5):70-71.

[21] 王毅敏, Chua CH, 穆雄錚. 隆頦術(shù)徑路及并發(fā)癥的比較[J]. 組織工程與重建外科雜志, 2007,3(5):273-274.

[22] Bracaglia R, Tambasco D, Gentileschi S, et al. A simple procedure to facilitate chin implants placement via submental approach[J]. J Plast Surg Hand Surg, 2013,47(3):200-203.

[23] Han K, Kim J. Reduction mandibuloplasty: ostectomy of the lateral cortex around the mandibular angle[J]. J Craniofac Surg, 2001,12(4):314-325.

Experience of treatment of mandibular deformity on 26 cases

HANSi-yuan,HEJia-ni,LENGBing,etal.

(DepartmentofPlasticSurgery,TheFirstAffiliatedHospitalofChinaMedicalUniversity,Shenyang110001,China)

Objective To summarize the experience of treatment of mandibular deformity in recent 5 years in our department to guide the clinical work in the future. Methods The data collected from 26 cases of mandibular deformities were performed retrospective analysis and summarized. Of 26 cases, 12 cases were skeletal class Ⅲ malformation, mandibular protrusion, laterognathism of the mandible, in which 11 cases underwent sagittal split ramus osteotomy and 1 case underwent intraoral vertical ramus osteotomy and 3 of 12 cases underwent genioplasty, 9 cases were prominent mandibular angle, in which 7 cases underwent mandibular angle splitting ostectomy and 2 cases underwent mandibular angle ostectomy; 5 cases were microgenia, in which 3 cases underwent augmentation with Teflon and 2 cases with silicone prosthesis. Results All of the patients were satisfied after operation. The complication rate was 7.69%. Conclusion Sagittal split ramus osteotomy could correct mandibular protrusion and laterognathism by forward or backward movement of the mandible and rotation of the distal fragment. Mandibular angle ostectomy was effective for eversion type of prominent mandibular angle. Mandibular angle splitting ostectomy should be considered in the mandibular angle with outward or backward prominent. Chin augmentation was only suitable for light to moderate microgenia. Genioplasty should be considered in other types.

Sagittal split ramus osteotomy; Mandibular protrusion; Laterognathism; Prominent mandibular angle

韓思源(1963-)，男，遼寧沈陽人，副主任醫(yī)師.

10.3969/j.issn.1673-7040.2015.07.002

R782.2

A

1673-7040(2015)07-0389-04

2015-05-15)