改良上颌骨牵引成骨治疗中重度唇腭裂上颌后缩效果评价

Evaluation of the modified maxillary distraction osteogenesis for cleft lip and palate with moderate to severe maxillary hypoplasia

目的探讨改良上颌骨牵引成骨治疗中、重度唇腭裂上颌后缩的手术效果及可能出现的相关并发症。方法回顾性分析2017年7月至2019年12月中国医学科学院整形外科医院收治的采用改良上颌骨牵引成骨治疗的唇腭裂修复术后上颌后缩患者的临床资料。术中行上颌Le FortⅠ型截骨后,采用经鼻引出上颌骨坚固外固定牵引支架,牵引3~4周;牵引完成后立即行上颌骨坚固内固定。对患者术前、牵引完成即刻头颅CT颌面部骨性结构进行三维重建及测量分析。术前、后各指标测量数据的比较采用配对样本t检验,P<0.05为差异有统计学意义。结果共纳入15例患者,男12例,女3例,年龄14~25岁。牵引完成即刻上、下颌形态与术前相比,所有测量指标差异均具有统计学意义(P<0.05)。上颌骨上牙槽座点前移(10.69±9.01)mm,上牙槽座点-鼻根点-下牙槽座点形成的角增加(13.53±7.14)°,上牙槽平面角增加(3.97±5.87)°,下颌平面角增加(4.65±3.67)°,前面高增长(5.63±4.41)mm。上颌骨向前下方移位,中面部突度增加,轮廓获得改善。牵引过程会对下颌骨位置产生一定影响,15例患者中有5例出现中、重度张口度下降,在牵引结束进行固定后再配合张口训练,张口受限自行缓解;1例同时出现颞下颌关节脱位,通过关节手法复位、上颌骨固定及下颌矢状劈开后退术,张口受限和脱位问题均得到解决。结论改良上颌骨牵引成骨治疗中、重度唇腭裂上颌后缩,能够有效前移上颌骨,使下颌骨出现顺时针旋转,改善面部轮廓,并且明显缩短牵引治疗时间,但牵引过程中可能出现张口受限和颞下颌关节脱位等并发症。

Objective To present the clinical results and potential complications of modified maxillary distraction osteogenesis in the treatment of moderate to severe maxillary hypoplasia for patients with cleft lip and palate.Methods All the cases were treated with a modified distraction osteogenesis in the Plastic Surgery Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College from July 2017 to December 2019.A rigid external distraction(RED)with intranasal bone-borne traction hooks was performed after the Le FortⅠosteotomy and a maxillary internal rigid fixation was done immediately after 3-4 weeks of RED device distraction.Paired-samples t-test was used to analyze the three-dimensional reconstruction and measurements of the patient’s preoperative(T0)and immediate completion of traction(T1)cranial CT maxillofacial bony structures.Results Fifteen patients(12 males and 3 females,ranging from 14 to 25 years in age)with moderate to severe maxillary hypoplasia were analyzed retrospectively.There were significant differences(P<0.05)in all measures of maxillary and mandibular morphology at the completion of distraction compared to preoperatively.The mean advancement of A point(subspinale)was(10.69±9.01)mm,and the mean increase in ANB(subspinale-nasion-supramental)was(13.53±7.14)°.The average increase of alveolar plane and mandibular plane was(3.97±5.87)°and(4.65±3.67)°separately.The average growth of anterior facial height was(5.63±4.41)mm.The maxilla moved forward and downward,increasing the midface prominence and improving the facial contour.The traction process had an effect on the position of the mandible,with 5 in 15 patients experiencing moderate to severe decreased mouth opening,and the mouth opening limitation was relieved by mouth opening training after fixation at the end of distraction.One patient experienced temporomandibular joint(TMJ)dislocation,which was relieved by manual repositioning and mouth opening training after maxillary fixation and sagittal split ramus osteotomy.Conclusions Modified maxillary distraction osteogenesis can effectively advance the maxilla,allowing clockwise rotation of mandible,improving facial contour,and significantly shortening the traction time.Limited mouth opening and TMJ dislocation may occur during traction.