下頜部畸形26例治療體會

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

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)科大學附屬第一醫(yī)院 整形外科

目的 總結近5年我科收治下頜部畸形的治療經驗，以指導臨床工作。方法 收集26例下頜部畸形的病歷資料，對其進行回顧性分析總結。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，1例行經口內入路下頜支垂直骨切開術，3例同期行頦成形術；下頜角肥大9例，其中，7例行下頜角外板劈開截除術，2例行下頜角磨骨術；小頦畸形5例，其中，3例行膨體隆頦術，2例行硅膠假體隆頦術。結果 所有患者術后效果滿意，并發(fā)癥發(fā)生率為7.69%。結論 下頜支矢狀骨劈開術可以通過向前、向后移動或旋轉遠心骨段來完成下頜后縮、前突及偏突畸形的矯正，效果確切；下頜角磨骨術對于外翻型下頜角肥大治療效果較好，對于下頜角肥大向外側與后方較明顯突出的患者應選用下頜角外板劈開截除術；填充頦成形術僅適用于輕、中度的小頦畸形，其他類型的畸形應考慮頦成形術。

下頜支矢狀骨劈開術； 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(sagittal split ramus osteotomy, SSRO)，1例行經口內入路下頜支垂直骨切開術(intraoral vertical ramus osteotomy, IVRO)，12例中3例同期行頦成形術；下頜角肥大9例，其中7例行下頜角外板劈開截除術，2例行下頜角磨骨術；小頦畸形5例，3例行膨體隆頦術；2例行硅膠假體隆頦術。

2 手術方法

2.1 安氏骨性Ⅲ類畸形、下頜前突、偏突頜畸形 治療程序均按照術前正畸、模型外科、正頜手術、術后正畸與康復治療[5]進行。術前頜面部三維CT重建按正頜手術要求精確測量。經鼻氣管插管全身麻醉。11例患者行SSRO，遠心骨段移動距離為3.00～13.00 mm，平均6.72 mm，以鈦板與單皮質骨螺釘固定，其中2例患者同時行上頜Lefort Ⅰ型骨切開術，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行植骨，鉆孔后絲線縫合固定，其中3例患者同時行頦成形術。1例患者行IVRO，術后4周解除頜間橡皮圈固定。術后1個月左右開始術后正畸治療，同時進行恢復頜周肌肉及顳頜關節(jié)功能的康復訓練。

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

2.3 小頦畸形 經口內橫切口行硅膠假體或膨體置入術，3例行膨體隆頦術，2例行硅膠假體隆頦術。

3 結果

4 典型病例

圖1 下頜過度前突治療前后對比 a.術前正位 b.術后1個月正位 c.術前斜位 d.術后1個月斜位 e. 術前側位f. 術后1個月側位

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，國際上公認的矯治術式有SSRO和IVRO[6-7]。使用最普遍的矯正下頜前突畸形的手術方法是SSRO[8]，適用于矯正下頜發(fā)育不足和下頜發(fā)育過度，當伴有上頜發(fā)育不足、小頦畸形時可同期行上頜Lefort Ⅰ型骨切開術、頦成形術，手術順序為上頜手術、下頜手術、頦部手術。術中應用鈦板堅固內固定。改良的SSRO有如下優(yōu)點:⑴口內切口，面部不留瘢痕；⑵矢狀截骨使牙槽神經血管束得以完整保留，減少并發(fā)癥的發(fā)生；⑶近遠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, 有利于嚴重下頜前突的矯治[9]；⑸對面部側方形態(tài)影響不大，咀嚼肌適應迅速。兩種截骨術改變了原來的頜骨形態(tài)和位置，也改變了顳下頜關節(jié)前、上、后間隙，從而導致髁突位置在術后也發(fā)生了改變。但因影響這種改變的因素復雜，移位方向也多種多樣，有向前移位[10]、向內向后旋轉[11]，顳頜關節(jié)的各個間隙在術前術后也有明顯改變[12]。IVRO由于術后不需要進行堅固內固定，術后近心端骨段可以發(fā)生旋轉移位。Bell等[13-14]報道IVRO后髁狀突向前向下移位，但是當全身神經肌肉恢復后，髁狀突有回到原來位置的傾向[15]。有報道稱，IVRO術后顳頜關節(jié)紊亂癥狀消失[16-18]。Lai等[19]建議應用單側IVRO聯合對側SSRO的方法來改善下頜不對稱畸形，同時改善顳頜關節(jié)紊亂的癥狀。

5.2 下頜角肥大 下頜角縮小成形術主要包括磨骨術和MASO。MASO適用于向外側與后方較明顯突出者，對于正面觀下頜角骨質外翻的患者尤其適合磨骨術，術中需注意預防出血[20]。該術式不會導致骨折和顳下頜關節(jié)損傷，創(chuàng)傷小。本研究中應用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 隆頦術作為常見的美容整形手術，手術難度不大，但易出現下唇外翻、假體移位等并發(fā)癥。這些并發(fā)癥的產生與切口的選擇有關[21]。下唇及頦部有3對肌肉與口內切口相關，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]。切口應順應頦肌、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構，可最大限度地減少術后并發(fā)癥的發(fā)生，可以選用雙側縱切口及口內環(huán)系帶U形切口。

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

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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)