朱麗莎 孫世怡 包佳佳 李彪 任利玲
[摘要]兒童阻塞性睡眠呼吸暫停低通氣綜合征(OSAHS)是指在睡眠過(guò)程中反復(fù)出現(xiàn)打鼾、憋氣、呼吸暫停從而引起低氧血癥和高碳酸血癥的綜合征,臨床表現(xiàn)為呼吸困難、張口呼吸、白天多動(dòng)或嗜睡、下頜后縮和唇肌無(wú)力等,對(duì)患兒的生長(zhǎng)發(fā)育、認(rèn)知、聽(tīng)力以及心肺功能等都造成了一定危害。近年來(lái),隨著該類患兒數(shù)量的增加,兒童OSAHS引起了耳鼻喉、口腔科、呼吸科等多學(xué)科的重視。而正畸治療不僅可以改善呼吸,還可以改善患者面型,達(dá)到一定的美學(xué)效果。因此,通過(guò)對(duì)兒童OSAHS的發(fā)病機(jī)制及正畸治療進(jìn)行綜述,以提高公眾對(duì)兒童OSAHS的認(rèn)識(shí),并為正畸治療兒童OSAHS提供一定的指導(dǎo)。
[關(guān)鍵詞]兒童OSAHS;正畸治療;氣道阻塞;錯(cuò)牙合畸形;美學(xué)效果
[中圖分類號(hào)]R783.5 [文獻(xiàn)標(biāo)志碼]A [文章編號(hào)]1008-6455(2018)09-0155-03
Orthodontic Therapy for Chirdren with OSAHS and the Aesthetic Effect
ZHU Li-sha1, SUN Shi-yi2, BAO Jia-jia3,LI Biao1, REN Li-ling4
(1. Stomatology College of Lanzhou University, Lanzhou 730000,Gansu,China; 2. The First Clinical Medical College of Lanzhou University,Lanzhou 730000,Gansu, China;3.Department of Neurology, West China Hospital of Sichuan University,Chengdu 610041,Sichuan ,China;4. Department of Orthodontic, Hospital of Stomatology Lanzhou University, Lanzhou 730000,Gansu,China)
Abstract: Children with obstructive sleep apnea hypopnea syndrom (OSAHS) refers to the repeated snoring ,Suffocating, and apnea during sleep, which leads to hypoxemia and hypercapnia syndrome. Clinical manifestations of children with OSAHS include difficulty breathing, mouth breathing, hyperactivity or sleepiness during the day , mandibular retractionandand lip muscle weakness. These phenomenons are harmful to the growth, cognition, hearing and cardiopulmonary function of the children. In recent years, with the increase of the number of children with OSAHS, OSAHS has attracted the attention of many subjects such as otolaryngology, oral cavity and respiratory department.Whats more ,the orthodontic treatment can not only improve the breathing, but also the appearance ,in order to achieve the beauty. Therefore, this article reviewed the pathogenesis of childrens OSAHS and orthodontictreatment ,which raise the public awareness for the childrens OSAHS and provide some guidance for orthodontic treatment.
Key words: paediatric obstructive sleep apnoea syndrome; orthodontic therapy; airway obstruction; malocclusion; aesthetic effect
兒童阻塞性睡眠呼吸暫停低通氣綜合征(obstructive sleep apneahypopnea syndrome , OSAHS)是在睡眠過(guò)程中頻繁出現(xiàn)上氣道阻塞,擾亂睡眠過(guò)程中的正常通氣和睡眠結(jié)構(gòu)而引起病理生理變化的一類疾病。主要表現(xiàn)為夜間打鼾、憋氣、呼吸暫停、張口呼吸以及性格行為異常。嚴(yán)重時(shí)會(huì)導(dǎo)致患兒顱面畸形、生長(zhǎng)發(fā)育遲緩,甚至對(duì)心肺系統(tǒng)等造成不可逆的損害[1]。兒童OSAHS的治療方法主要包括外科手術(shù),持續(xù)正壓通氣(continuous posi-tive airway pressure,CPAP)和正畸治療,其中正畸治療比其它兩種方法更具優(yōu)勢(shì),美國(guó)睡眠醫(yī)學(xué)研究會(huì)曾提出口腔矯治器能治療輕中度OSAHS和不能耐受CPAP的重度OSAHS[1]。本文就兒童OSAHS的發(fā)病機(jī)制及正畸治療進(jìn)行綜述,以期為臨床進(jìn)行兒童OSAHS的治療提供一定的指導(dǎo)。
1 兒童OSAHS的發(fā)病機(jī)制
兒童OSAHS的發(fā)病機(jī)制與成人有所不同,Tapia[2]等指出,成人OSAHS多是由軟腭以及懸雍垂松弛、肥大引起,阻塞平面主要在舌咽部。而兒童OSAHS產(chǎn)生的主要原因是扁桃體/腺樣體肥大導(dǎo)致患兒氣道狹窄。國(guó)外學(xué)者[3]通過(guò)對(duì)上氣道進(jìn)行計(jì)算機(jī)斷層掃描分析得出兒童氣道的阻塞平面是在腺樣體所在的鼻咽至腭咽區(qū)域。對(duì)于OSAHS患兒,除了扁桃體和腺樣體肥大外,上氣道狹窄、舌根后置及松弛也會(huì)造成上氣道阻塞,引起打鼾、呼吸暫停等癥狀。有研究表明[4],OSAHS與舌骨位置以及氣道形狀與大小有關(guān)。低角型患兒更不易出現(xiàn)OSAHS的癥狀,因?yàn)榈徒切突純呵懊娓咻^小,下頜向前發(fā)育。在下頜舌骨肌作用下,下頜骨牽拉上氣道,從而使得上氣道的舌咽、口咽段矢狀徑增大。另外,顱面發(fā)育異常,神經(jīng)肌肉功能異?;蜻\(yùn)動(dòng)失調(diào)以及一些影響頜骨發(fā)育的先天畸形或遺傳綜合征也有可能導(dǎo)致兒童OSAHS的發(fā)生。
2 兒童OSAHS的正畸學(xué)治療
在臨床中,OSAHS與錯(cuò)牙合畸形的發(fā)生密切相關(guān),可以導(dǎo)致Ⅱ類、Ⅲ類錯(cuò)牙合及開(kāi)牙合的形成,并對(duì)患兒的面型造成一定影響。OSAHS患兒的顱頜面結(jié)構(gòu)可以出現(xiàn)矢狀向和垂直向的異常。矢狀方向的異常,主要表現(xiàn)為上頜骨發(fā)育過(guò)度,或/和下頜骨發(fā)育不足[5],形成Ⅱ類錯(cuò)牙合;也有部分患兒因下頜前伸代償氣道狹窄,出現(xiàn)下頜骨發(fā)育過(guò)度,表現(xiàn)為Ⅲ類錯(cuò)牙合;垂直方向的異常主要表現(xiàn)為上頜后部齒槽骨發(fā)育過(guò)度,或/和下頜后部齒槽骨發(fā)育過(guò)度,形成開(kāi)牙合畸形。此外,長(zhǎng)期張口呼吸會(huì)影響面部骨骼生長(zhǎng)發(fā)育,引起上頜變長(zhǎng)、下頜后縮、腭蓋高拱、牙列不齊、頦部后縮、舌骨位置低、唇厚等骨骼和面型特征,即“腺樣體面容”[6]。因此,正畸治療不僅可以解決患兒上氣道阻塞問(wèn)題,還可以改善患兒的錯(cuò)牙合畸形及面型。目前,臨床上對(duì)于兒童OSAHS的治療主要有外科治療、CPAP及正畸治療。外科治療中應(yīng)用最廣泛的是扁桃體/腺樣體摘除術(shù),該術(shù)式能解除上氣道的狹窄和(或)降低上氣道軟組織的塌陷性。然而該術(shù)式有一定局限性,有研究表明[7]單純的扁桃體/腺樣體摘除術(shù)有時(shí)并不能完全解除兒童呼吸困難,有一些患兒術(shù)后并未有癥狀的改善,還有部分兒童會(huì)在青春期復(fù)發(fā)。同時(shí),有些咽淋巴環(huán)增生不明顯的患兒,并不適合手術(shù)治療。CPAP也是治療兒童OSAHS的有效方法,能顯著緩解患兒呼吸困難。但笨重的體積、較高的花費(fèi)及兒童依從性較差限制了它的使用。另外,有報(bào)道[8]稱長(zhǎng)期進(jìn)行CPAP治療可能會(huì)導(dǎo)致患兒面部骨結(jié)構(gòu)畸形。因此,對(duì)于無(wú)手術(shù)適應(yīng)證、難治性O(shè)SAHS以及無(wú)法接受CPAP的患兒,正畸治療有可能是唯一可嘗試的手段。
對(duì)OSAHS兒童來(lái)說(shuō),除了解決其睡眠和呼吸問(wèn)題,面型改善也是關(guān)鍵。一般來(lái)說(shuō),用于兒童OSAHS的正畸治療大致可分為兩大類:各類口腔矯治器及正牙合手術(shù)。正畸治療不僅牽拉上氣道,使上氣道的舌咽、口咽段矢狀徑增大,解決患兒上氣道阻塞問(wèn)題。并且對(duì)于佩戴矯治器的患兒,該治療無(wú)創(chuàng)傷,家長(zhǎng)及孩子的接受度較高。最重要的是,佩戴矯治器可以有效矯正各類錯(cuò)牙合畸形,刺激骨骼發(fā)育,使得骨性和牙性關(guān)系協(xié)調(diào),從而改善面型。而正牙合手術(shù)則可以在解除OSAHS患兒氣道解剖異常的同時(shí),較快速地改變面部側(cè)貌,達(dá)到一定的美學(xué)效果,有利于患兒的身心健康。
2.1 口腔矯治器(oralappliances,OA):OA是氣道狹窄以及舌根后置、松弛導(dǎo)致上氣道阻塞的輕、中度OSAHS患兒的有效治療方法。它通過(guò)改變下頜的位置,牽舌前移,使軟腭抬高,擴(kuò)大或穩(wěn)定上氣道,使腭咽到喉咽全程發(fā)生三維方向的變化。此外,OA可以改善上氣道附近軟組織形態(tài)、位置及肌肉功能,減少會(huì)厭及腭咽水平的氣道梗阻等,有利于改善睡眠時(shí)的呼吸紊亂[9]。治療兒童OSAHS的OA大致分為四大類:下頜前移器、上頜快速擴(kuò)弓、軟腭上抬器和舌前伸器。
2.1.1 下頜前移器(Mandibualar advance mentdevice, MAD):目前,MAD已成為一種較為有效的治療方法,因其無(wú)明顯的不良反應(yīng),受到臨床醫(yī)師和患者的歡迎。MAD的作用機(jī)制是前伸下頜骨,從而改善上下頜間關(guān)系,同時(shí)使舌骨向前上移位,使上氣道舌后和腭后間隙增加,導(dǎo)致上氣道橫向擴(kuò)張,腭咽和舌咽氣道明顯擴(kuò)張。MAD可分為固定式和可調(diào)式,其中固定式包括ActivatorⅠ型矯治器、改良Twin-block矯治器、Bionator矯治器、磁力矯治器等??烧{(diào)式有Herbst矯治器、Jasper Jumper矯治器、KlearwayTM矯治器、Thornton可調(diào)式定位器等類型。固定式下頜前移器將上下頜作為一整體前導(dǎo)下頜,而可調(diào)式下頜前伸類口腔矯治器是將上下頜分體設(shè)計(jì),通過(guò)牽引桿或螺旋開(kāi)大器等連接,并可提供一定范圍的下頜前伸量,下頜前伸量每次為4~6mm,最多不超過(guò)8mm,可根據(jù)患兒自身癥狀及主觀舒適度調(diào)整下頜前伸量。兩者相比,可調(diào)式下頜前移器下頜定位微調(diào)精確,并且有一定程度的開(kāi)閉及左右側(cè)運(yùn)動(dòng),可避免盲目地前伸下頜甚至治療失敗。Banhiran等[10]通過(guò)可調(diào)式熱塑性下頜前移器對(duì)64名OSAHS患者進(jìn)行治療,結(jié)果顯示患者治療后的AHI降低,睡眠呼吸暫停的情況得到明顯改善。此外,一項(xiàng)Mintz SS等[1]進(jìn)行的為期14年的回顧性研究中,學(xué)者們對(duì)510名OSAHS患者進(jìn)行治療前、后的睡眠研究,結(jié)果表明使用個(gè)性化的可調(diào)式MAD治療中度和重度OSAHS患者的成功率達(dá)80%。因此,可調(diào)式前移器在治療兒童OSAHS方面的應(yīng)用更加廣泛。
2.1.2 上頜快速擴(kuò)弓(rapid maxillary expansion,RME):一些腭部發(fā)育不足的OSAHS患兒,可采用各種慢速或快速的擴(kuò)弓器進(jìn)行腭部擴(kuò)張,有效改善上氣道通暢從而糾正OSAHS。有學(xué)者提出[12],對(duì)于上頜腭中縫尚未完全融合的患兒,RME能增加上頜骨寬度,促進(jìn)上頜骨向前生長(zhǎng),增加鼻底的寬度。曾晶晶等[13]對(duì)16名兒童采取hyrax擴(kuò)張器治療,CBCT測(cè)量發(fā)現(xiàn)擴(kuò)弓治療能夠有效地使鼻腔和腭部的骨性氣道改善。Ashok等[14]對(duì)8~13歲兒童采取RME,并對(duì)擴(kuò)弓前及擴(kuò)弓3個(gè)月后進(jìn)行對(duì)比,發(fā)現(xiàn)所有患兒睡眠效率增加,覺(jué)醒指數(shù)與氧減指數(shù)減小。同時(shí),多項(xiàng)研究[15-17]顯示,對(duì)于上呼吸道阻塞而導(dǎo)致的睡眠呼吸暫停及張口呼吸的OSAHS患兒,采取RME與扁桃體/腺樣體切除術(shù)協(xié)同治療,有助于糾正因上呼吸道阻塞而導(dǎo)致的睡眠呼吸暫停及張口呼吸習(xí)慣,并且治療效果穩(wěn)定。Saimir等[18]通過(guò)比較RME治療前后生物標(biāo)志物水平、睡眠測(cè)試數(shù)據(jù),咽部面積,上頜牙弓和后前牙寬度,得出RME對(duì)治療OSAHS患兒是可行的。James 等[19]提出早期RME治療能夠減少癥狀并改善多導(dǎo)睡眠變量,避免了功能性反咬牙合導(dǎo)致的面部骨骼不對(duì)稱性發(fā)展和晚期口頜系統(tǒng)的功能和結(jié)構(gòu)障礙。但RME對(duì)患兒氣道改變的長(zhǎng)期穩(wěn)定性是有限且局限的,應(yīng)當(dāng)進(jìn)行進(jìn)一步的研究。
2.1.3 軟腭上抬器和舌前伸器:軟腭上抬器的作用原理是設(shè)計(jì)有伸向軟腭的托墊,抬高并拉緊軟腭, 減小軟腭的震蕩, 加大軟腭與舌背之間的空間, 使其不易產(chǎn)生鼾聲。軟腭上抬器直接作用于軟腭,用于懸雍垂過(guò)長(zhǎng)的患兒,但常引起患兒惡心不適,需要一定的適應(yīng)期。舌牽引器主要是對(duì)舌進(jìn)行直接牽引,間接前移下頜,從而起到擴(kuò)寬上氣道的作用。舌牽引器可應(yīng)用于舌體肥大,下頜前伸受限的OSAHS患兒。Linna等[20]對(duì)9名患兒進(jìn)行3個(gè)月雙側(cè)拉桿式矯治器治療,并分別對(duì)治療后的上呼吸道和舌骨位置進(jìn)行CT掃描和三維重建,結(jié)果顯示雙側(cè)拉桿式矯治器治療OSAHS的有效率為88.9%。但由于患兒對(duì)舌牽引器的耐受性不好,配合度差,故適用的范圍較小。因此,這兩種矯治器在臨床中較少使用。
2.2 正頜手術(shù):對(duì)于一些嚴(yán)重顱面部畸形及下頜發(fā)育不足導(dǎo)致呼吸困難的OSAHS患兒,口腔矯治器不能取得良好的療效,因此引入了正頜手術(shù),如牽張成骨術(shù),它通過(guò)激發(fā)機(jī)體組織再生的潛力延長(zhǎng)下頜骨,從而改善上氣道恢復(fù)其通氣功能,解除呼吸受限并改善面型。Hiroshi Tomonari[21]等對(duì)患有小頜畸形的患兒采取下頜骨牽張成骨術(shù)聯(lián)合滑動(dòng)頦成形術(shù)進(jìn)行正畸治療并推下頜骨向前,有效地改善了牙頜面畸形和呼吸功能受損。
綜上所述,兒童OSAHS是一種涉及多學(xué)科交叉治療的疾病,應(yīng)根據(jù)每位患兒的實(shí)際狀況制訂個(gè)性化的治療方案,以達(dá)到更好的療效。
[參考文獻(xiàn)]
[1]Ramar K,Dort LC,Katz SG,et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015[J]. J Clin Sleep Med,2015,11(7):773-827.
[2]Tapia IE,Marcus CL,McDonough JM,et al.Airway resistance in children with obstructive sleep apnea syndrome[J].Sleep,2016,39(4):793-799.
[3]Fleck RJ,Ishman SL,Shott SR,et al.Dynamic volume computed tomography imaging of the upper airway in obstructive sleep apnea[J].J Clin Sleep Med,2017,13(2):189-196.
[4]Jiang YY.Correlation between hyoid bone position and airway dimensions in Chinese adolescents by cone beam computed tomography analysis[J]. Int J Oral Maxillofac Surg, 2016,45(7):914-921.
[5]Banabilh SM.Orthodontic view in the diagnoses of obstructive sleep apnea[J].J Orthod Sci,2017,6(3):81-85.
[6]Deng J,Gao X.A case-control study of craniofacial features of children with obstructed sleep apnea [J].Sleep Breath,2012,16(4):1219-1227.
[7]Huynh NT,Desplats E, Almeida FR.Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis[J].Sleep Med Rev,2016,25:84-94.
[8]Roberts SD,Kapadia H,Greenlee G,et al Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions[J].J Clin Sleep Med,2016,12(4):469-475.
[9]Jo SY,Lee SM,Lee KH,et al.Effect of long-term oral appliance therapy on obstruction pattern in patients with obstructive sleep apnea[J]. Eur Arch Otorhinolaryngol,2018, 275(5):1327-1333.
[10]Banhiran W,Kittiphumwong P,Assanasen P,et al.Adjustable thermoplastic mandibular advancement device for obstructive sleep apnea:outcomes and practicability[J].Laryngoscope,2014,124(10):2427-2432.
[11]Mintz SS,Kovacs R.The use of oral appliances in obstructive sleep apnea: a retrospective cohort study spanning 14 years of private practice experience[J].Sleep Breath,2018,22(2):541-546.
[12]Tehranchi A,Ameli N,Najirad Z,et al.Comparison of the skeletal and dental changes of tooth-borne vs. bone-borne expansion devices in surgically assisted rapid palatal expansion:A finite element study[J].Dent Res J,2013,10(6):777-783.
[13]Zeng J,Gao X.A prospective CBCT study of upper airway changes after rapid maxillary expansion[J].Int J Pediatr Otorhinolaryngol,
2013,77(11):1805-1810.
[14]Ashok N,Varma N K S, Ajith V V, et al. Effect of rapid maxillary expansion on sleep characteristics in children[J].Contemp Clin Dent,2014,5(4):489-494.
[15]Guilleminault C,Monteyrol PJ,Huynh NT,et al.Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study[J]. Sleep Breath,2011, 15(2):173-177.
[16]Guilleminault C,Huang YS,Monteyrol PJ,et al.Critical role of myofascial reeducation in pediatric sleep-disordered breathing[J].Sleep Medicine,2013,14(6): 518-525.
[17]Pirelli P,Saponara M,Guilleminault C.Rapid maxillary expansion (RME) for pediatric obstructive sleep apnea: a 12-year follow-up[J].Sleep Med,2015,16(8): 933-935.
[18]Hoxha S,Kaya-Sezginer E,Bakar-Ates F,et al.Effect of semi-rapid maxillary expansion in children with obstructive sleep apnea syndrome:5-month follow-up study[J].Sleep Breath,2018,12:1-9.
[19]McNamara JA,Lione R,F(xiàn)ranchi L,et al.The role of rapid maxillary expansion in the promotion of oral and general health[J].Prog Orthod,2015,16(1):33-39.
[20]Linna D,Jing G.Position change of hyoid bone induced by oral appliance of double-pull rods in patients with obstructive sleep apnea and hypopnea syndrome and analysis of relevant factors[J].West China J Stomatol,2013,31(1):34-37.
[21]Tomonari H,Takada H,Hamada T,et al.Micrognathia with temporomandibular joint ankylosis and obstructive sleep apnea treated with mandibular distraction osteogenesis using skeletal anchorage: a case report[J]. Head Face Med,2017,13(1): 20.
[收稿日期]2018-04-20 [修回日期]2018-06-10
編輯/李陽(yáng)利