手术先行模式在牙颌面畸形治疗中的应用进展

Application and research progress of the surgery-first approach in the treatment of dento-maxillofacial deformities

对于接受正畸-正颌联合治疗的牙颌面畸形患者,传统的治疗模式是术前正畸-正颌外科手术-术后正畸。随着牙颌面畸形治疗的不断发展,目前手术先行模式即正颌手术-术后正畸模式得到较为广泛的应用,并显现出可提高治疗效率和患者满意度等优势。本文从手术先行模式的适应证、治疗效果和稳定性等方面,对手术先行模式在牙颌面畸形患者正畸正颌联合治疗中的应用和研究进展进行综述。文献复习结果表明,相较于传统治疗模式,手术先行模式的适应证相对严格,通常仅限于骨性Ⅱ类/Ⅲ类错[牙合]畸形、骨性开[牙合]、双颌前突、面部不对称且不太需要术前正畸排齐牙齿或去除牙齿代偿的患者,具体为:①前牙无拥挤或轻度拥挤;②Spee曲线平坦或浅;③切牙倾斜度正常或轻度唇倾/舌倾;④上下牙弓关系较为协调,横向差异较小;⑤骨块移动后上下牙列咬合接触较为广泛,至少需要3个稳定的咬合触点。任何可能影响手术或最终治疗效果的咬合情况或可能影响术后愈合过程的疾病都被视为其禁忌证,手术先行模式同时存在潜在局限性如咬合不稳定、骨愈合不良等并发症发生率可能较高,但仍有待进一步循证研究证实。多数文献认为两种治疗模式的效果和稳定性无明显差异,但现阶段仍缺乏足够样本量的前瞻性研究提供确切的证据。

For patients with dento-maxillofacial deformities who receive orthodontic-orthognathic combined treatment,the conventional treatment approach is preoperative orthodontic-orthognathic surgery-postoperative orthodontics.However,with the development of techniques used in orthodontic and orthognathic treatment,the surgery-first approach(SFA),namely,orthodontic surgery-postoperative orthodontics,has been widely used currently and displays several advantages,such as improving the treatment efficiency and providing patients with more satisfaction.This review provides a brief discussion and review of SFA concerning its development,indications,advantages and disadvantages,outcomes and stability,and the application and research progress of SFA in orthodontic-orthognathic combined treatment for patients with maxillofacial deformity.The literature review results showed that compared with the conventional treatment approach,SFA has relatively strict indications,which usually include patients with skeletal class Ⅱ/Ⅲ malocclusion,skeletal open bite,and bimaxillary protrusion or patients with facial asymmetry but who require little preoperative orthodontic treatment or removal of the compensation of the dental arch,specifically as follows:①well-aligned to mildly crowded anterior teeth,②flat to mild curve of Spee,③normal to mildly proclined/retroclined incisor inclination,④acceptable arch coordination,⑤extensive occlusal contact between the upper and lower dentition requiring at least 3 occlusal contacts.Any occlusion that may affect the outcome of surgery or final result of the overall treatment,as well as any disease that may jeopardize the healing process after surgery,is regarded as a contraindication.Furthermore,SFA has potential disadvantages,such as a possible higher incidence of complications,including unstable occlusion and malunion of bones,which still require further research to be confirmed.Most researchers believe that no significant difference occurs between the outcome and stability of the two approaches.However,currently,we still need a sufficient sample size of prospective studies to provide accurate evidence.