不同正頜外科方案對骨性Ⅲ類伴前牙開垂直向穩定性的影響

劉顯文 艾偉健 周會喜 李運峰 劉曙光

·臨床研究·

不同正頜外科方案對骨性Ⅲ類伴前牙開垂直向穩定性的影響

劉顯文1艾偉健1周會喜1李運峰2劉曙光1

1.南方醫科大學口腔醫院·廣東省口腔醫院頜面外科，廣州 510280；2.口腔疾病研究國家重點實驗室，國家口腔疾病臨床醫學研究中心，四川大學華西口腔醫院正頜外科及顳下頜關節外科，成都 610041

目的 比較不同正頜外科手術方案對骨性Ⅲ類錯伴前牙開術后垂直向穩定性的影響。方法 收集入院接受手術的骨性Ⅲ類錯伴前牙開畸形患者122例，分別采用雙側下頜升支矢狀劈開（BSSRO）（50例）、下頜升支垂直骨劈開（IVRO）（30例）、BSSRO+Le FortⅠ（22例）、IVRO+Le FortⅠ（20例）作為手術方案，并且除IVRO方案外其他所有方案病例均接受鈦板頜骨內堅固內固定術。術后正畸完成時及完成后6、24個月時隨訪接受臨床檢查與頭影測量分析評估垂直向復發情況，觀察指標包括覆、下頜平面角、頜間夾角。結果 1）BSSRO+Le FortⅠ與IVRO+ Le FortⅠ組覆顯著減小的比率在6、24個月都少于BSSRO與IVRO組。2）BSSRO+Le FortⅠ組與IVRO+ Le FortⅠ組下頜平面角顯著增加的比率在6、24個月都少于BSSRO與IVRO組。3）6個月時BSSRO+Le FortⅠ組與IVRO+Le FortⅠ組頜間夾角顯著增加的比率少于BSSRO組與IVRO組，而24個月時無統計學差異。結論 雙頜外科（BSSRO+Le FortⅠ與IVRO+Le FortⅠ）均比單頜外科（BSSRO與IVRO）能更加有效地減少垂直向復發的數量和幅度。

骨性Ⅲ類錯； 正頜外科； 開； 覆； 下頜平面角； 頜間夾角

盡管目前正頜外科手術技術和頜骨堅固內固定技術均取得了長足進步，然而對骨性Ⅲ類錯伴前牙開患者的矯治仍較其他單純的牙頜面畸形治療更加困難且術后效果難以預測[13]。事實上，不少患者在接受完正畸正頜聯合治療后早期均表現出外形與功能俱佳的治療效果，但是隨著時間推移，部分患者出現前牙覆減小，甚至開的情況，進一步的頭影測量分析發現下頜平面角與頜間夾角也顯著增加，從而導致面下1/3高度增加。這種現象被稱為“垂直向復發”[14-15]。本研究旨在應用多中心、回顧性隊列研究方法評價不同正頜外科手術方案對骨性Ⅲ類錯伴前牙開術后垂直向穩定性的影響，評價指標主要包括覆、下頜平面角與頜間夾角，從而為臨床手術方案的擬定提供有價值的參考信息。

1 材料和方法

1.1 納入對象的基本資料

收集廣東省口腔醫院與四川大學華西口腔醫院2010—2016年入院接受手術的骨性Ⅲ類錯伴前牙開畸形患者共122例（廣東省口腔醫院48例，四川大學華西口腔醫院74例），其中男性50例，女性72例。患者手術時的平均年齡為23歲。

排除標準：患者同時具有其他顱頜面部畸形；上頜骨存在顯著的橫向發育不足者；顏面部存在不對稱畸形，中線偏斜超過10 mm；有頜面部創傷、頜骨骨折病史。

1.2 研究方法

所有患者均接受標準化的臨床檢查以及X線頭影測量分析。石膏模型分析與正畸正頜工作小組討論后擬定手術方案。手術方式包括上頜Le FortⅠ型截骨術、BSSRO和IVRO，根據患者面型和咬合關系及主觀訴求選擇搭配術式，共有4種手術方案，即BSSRO、IVRO、BSSRO+Le FortⅠ、IVRO+Le FortⅠ作為干預措施。采用各種手術方案的人數分別為：BSSRO，50例；IVRO，30例；BSSRO+Le FortⅠ，22例；IVRO+Le FortⅠ，20例。除IVRO方案外其他所有方案病例均接受鈦板頜骨內堅固內固定術。

1.3 手術步驟

1.3.1 上頜Le FortⅠ型截骨術 手術入路經由傳統的上頜前庭溝切口，之后在骨膜下剝離暴露上頜骨的前外側壁，由梨狀孔邊緣向內剝離鼻腔外側壁及鼻底黏骨膜并剪斷鼻中隔連接。以往復鋸切開上頜竇的前外側壁延伸至上頜結節。保護鼻底黏膜，以專用骨刀由梨狀孔邊緣的骨切口插入敲擊，逐步鑿開上頜竇內側骨壁。當骨刀到達腭骨垂直板時停止并保護好腭降動脈。將彎骨刀緊貼上頜結節的后部，略斜向下插入翼上頜縫處。將手指置于腭側黏膜處，敲擊刀柄，當有落空感時停止敲入。在鑿開翼上頜連接后，以手指按壓上頜骨前部向下用力使上頜骨沿鋸骨線分離。戴入板引導上頜骨按術前設計的方向與距離移動，上頜骨就位后以鈦板行骨內固定。V-Y成形縫合黏膜切口。

1.3.2 BSSRO 從上頜平面稍下方的升支前緣斜向下做切口，至下頜第一磨牙近中齦頰溝偏頰側8 mm處。切開黏膜、黏膜下組織和骨膜，用“燕尾”形牽開器沿升支前緣向上剝離顳肌附著。用Kocher鉗夾持住喙突根部，大約在上頜平面稍上方的位置，在骨膜下剝離升支內側軟組織，直至看見下頜小舌或下牙槽神經血管束，然后向前下剝離顯露下頜支前緣、外斜線及第一磨牙近中處下頜下緣。將下牙槽神經血管束及周圍軟組織與骨面分離，以往復鋸在下頜小舌上方約3 mm處作水平骨切開越過下頜孔上方至其后方的下頜神經溝，切透骨皮質。由水平切口前端升支前緣處開始沿升支前緣稍內側和外斜線向前下作矢狀鋸骨線至第一磨牙頰側骨板，后轉向下作垂直鋸骨線切透頰側骨皮質至下頜骨下緣處。以2把骨刀交替插入水平與矢狀骨切口將下頜骨內外側骨板逐漸分開。以板引導遠心骨段至新的矯正位，并用橡皮圈或鋼絲行頜間固定。于近心骨段垂直切口處截除一段與遠心骨段后退距離相當的皮質骨，將近、遠心骨段行鈦板堅固內固定。拆除頜間固定并移除板，沖洗傷口，止血后縫合傷口。

1.3.3 IVRO 口內切口與BSSRO類似，用Kocher鉗夾持住喙突，在骨膜下剝離下頜升支外側面，上達乙狀切跡，后至升支后緣，向下達角前切跡下頜下緣處。用升支后緣牽開器鉤住下頜支后緣，用擺動鋸從下頜支后緣向前移約7 mm，對應下頜孔的稍后方，先鋸一條平行于升支后緣的骨溝，然后深入鋸透舌側骨板。以彎骨刀分離近、遠心骨段，撬離近、遠心骨段使近心骨段重疊于外側。戴入板，橡皮圈行頜間固定。沖洗傷口、縫合，放置負壓引流管。術后4周解除橡皮圈頜間固定。

1.4 臨床檢查與X線頭影測量分析

術后正畸完成時及完成后6、24個月時隨訪接受臨床檢查與頭影測量分析評估垂直向復發情況。觀察指標包括覆、下頜平面角、頜間夾角。

參照以往相關研究[7,16]將覆變化（減小或增加的幅度）大于2 mm視為變化顯著，計算變化顯著人數占總人數的百分比。同理，下頜平面角、頜間夾角的計算也是以變化（減小或增加的幅度）大于2°視為變化顯著，并計算變化顯著人數占總人數的百分比。

圖1 X線頭影測量分析顱頜面骨骼與牙標志點Fig 1 Skeletal and dental landmarks used in the cephalometric analysis

1.5 統計分析

采用SPSS 19.0軟件進行統計分析。對數據資料進行描述統計分析，包括均值、標準差；對基本平面測量進行2次測量，并取均值。組間比較采用Student’s t檢驗，檢驗水準為雙側α=0.05。

2 結果

各手術方案術后指標顯著變化的情況見表1。

術后及正畸治療結束后6、24個月，BSSRO組與IVRO組的覆變化顯著的比率均無統計學差異，BSSRO+Le FortⅠ組與IVRO+Le FortⅠ組的覆變化顯著的比率也無統計學差異。BSSRO+Le FortⅠ與IVRO+Le FortⅠ組覆顯著減小的比率在6、24個月都明顯少于BSSRO與IVRO組，覆顯著增加的比率卻只有在24個月時BSSRO+Le FortⅠ與IVRO+Le FortⅠ組多于BSSRO與IVRO組。

2.2 下頜平面角

表1 各手術方案術后指標顯著變化的情況Tab 1 The significant changes of postoperative index of every surgical options %

2.3 頜間夾角

3 討論

[1] Iannetti G, Fadda MT, Marianetti TM, et al. Long-term skeletal stability after surgical correction in Class Ⅲ open-bite patients: a retrospective study on 40 patients treated with mono- or bimaxillary surgery[J]. J Craniofac Surg, 2007,18(2):350-354.

[2] Sarver DM, Weissman SM. Nonsurgical treatment of open bite in nongrowing patients[J]. Am J Orthod Dentofacial Orthop, 1995, 108(6):651-659.

[3] Nguyen PD, Caro MC, Smith DM, et al. Long-term orthognathic surgical outcomes in Treacher Collins patients[J].J Plast Reconstr Aesthet Surg, 2016, 69(3):402-408.

[4] Marzouk ES, Kassem HE. Evaluation of long-term stability of skeletal anterior open bite correction in adults treated with maxillary posterior segment intrusion using zygomatic miniplates[J]. Am J Orthod Dentofacial Orthop, 2016, 150(1):78-88.

[5] Gracco A, Siviero L, de Stefani A, et al. Anterior open-bite orthodontic treatment in an adult patient: a clinical case report[J]. Int Orthod, 2016, 14(2):171-183.

[6] Cozza P, Mucedero M, Baccetti T, et al. Early orthodontic treatment of skeletal open-bite malocclusion: a systematic review[J]. Angle Orthod, 2005, 75(5):707-713.

[7] Proffit WR, Bailey LJ, Phillips C, et al. Long-term stability of surgical open-bite correction by Le Fort I osteotomy[J].Angle Orthod, 2000, 70(2):112-117.

[8] 徐冰, 秦科. 骨性Ⅲ類錯上頜拔牙與不拔牙去代償對雙頜手術矯治效果的影響[J]. 華西口腔醫學雜志, 2012,30(2):143-147.

Xu B, Qin K. The effect of extraction and non-extraction decompensation to bimaxillary orthognathic surgery in skeletal class Ⅲ malocclusion[J]. West Chin J Stomatol, 2012,30(2):143-147.

[9] Stansbury CD, Evans CA, Miloro M, et al. Stability of open bite correction with sagittal split osteotomy and closing rotation of the mandible[J]. J Oral Maxillofac Surg, 2010, 68(1):149-159.

[10] Proffit WR, Turvey TA, Phillips C. The hierarchy of stability and predictability in orthognathic surgery with rigid fixation: an update and extension[J]. Head Face Med, 2007,3:21.

[11] Espeland L, Dowling PA, Mobarak KA, et al. Three-year stability of open-bite correction by 1-piece maxillary osteotomy[J]. Am J Orthod Dentofacial Orthop, 2008, 134(1):60-66.

[12] Choi SH, Kang DY, Cha JY, et al. Is there a difference in stability after intraoral vertical ramus osteotomy between vertically high-angle and normal-angle patients[J]. J Oral Maxillofac Surg, 2016, 74(11):2252-2260.

[13] Hoppenreijs TJ, Freihofer HP, Stoelinga PJ, et al. Skeletal and dento-alveolar stability of Le FortⅠintrusion osteotomies and bimaxillary osteotomies in anterior open bite deformities.A retrospective three-centre study[J]. Int J Oral Maxillofac Surg, 1997, 26(3):161-175.

[14] Wriedt S, Buhl V, Al-Nawas B, et al. Combined treatment of open bite-long-term evaluation and relapse factors[J]. J Orofac Orthop, 2009, 70(4):318-326.

[15] Ding Y, Xu TM, Lohrmann B, et al. Stability following combined orthodontic-surgical treatment for skeletal anterior open bite-a cephalometric 15-year follow-up study[J]. J Orofac Orthop, 2007, 68(3):245-256.

[16] Proffit WR, Turvey TA, Phillips C. Orthognathic surgery:a hierarchy of stability[J]. Int J Adult Orthodon Orthognath Surg, 1996, 11(3):191-204.

[17] Ellis E 3rd, McNamara JA Jr. Components of adult ClassⅢ open-bite malocclusion[J]. Am J Orthod, 1984, 86(4):277-290.

[18] Hoppenreijs TJ, Freihofer HP, Stoelinga PJ, et al. Condylar remodelling and resorption after Le FortⅠand bimaxillary osteotomies in patients with anterior open bite[J]. Int J Oral Maxillofac Surg, 1998, 27(2):81-91.

[19] Mucedero M, Coviello A, Baccetti T, et al. Stability factors after double-jaw surgery in Class Ⅲ malocclusion. A systematic review[J]. Angle Orthod, 2008, 78(6):1141-1152.

[20] Moldez MA, Sugawara J, Umemori M, et al. Long-term dentofacial stability after bimaxillary surgery in skeletal Class Ⅲ open bite patients[J]. Int J Adult Orthodon Orthognath Surg, 2000, 15(4):309-319.

[21] Franco JE, Van Sickels JE, Thrash WJ. Factors contributing to relapse in rigidly fixed mandibular setbacks[J]. J Oral Maxillofac Surg, 1989, 47(5):451-456.

[22] Kor HS, Yang HJ, Hwang SJ. Relapse of skeletal class Ⅲwith anterior open bite after bimaxillary orthognathic surgery depending on maxillary posterior impaction and mandibular counterclockwise rotation[J]. J Craniomaxillofac Surg, 2014, 42(5):e230-e238.

（本文采編 李彩）

Evaluation for vertical stability after various orthognathic surgical treatment plans for skeletal class Ⅲ malocclusion with anterior open-bite

Liu Xianwen1, Ai Weijian1, Zhou Huixi1, Li Yunfeng2, Liu Shuguang1.
(1. Dept. of Oral and Maxillofacial Surgery, Guangdong Provincial Hospital of Stomatology, Southern Medical University, Guangzhou 510280, China; 2.State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Dept. of Orthognathic and Temporomandibular Joint Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China)
Supported by: National Natural Science Foundation of China (81600888); Medical Scientific Research Foundation of Guangdong Province (A2015189). Correspondence: Liu Shuguang, E-mail: 625043130@qq.com.

Objective To evaluate vertical stability after various orthognathic surgical treatment plans for skeletal class Ⅲmalocclusion with anterior openbite. Methods A retrospective multicenter cohort study was conducted to investigate vertical stability after various orthognathic surgical treatment plans for skeletal class Ⅲ malocclusion with anterior openbite. From 2010–2016, 122 patients from two domestic stomatological hospitals were included in our study. Patients were divided into four groups according to their treatment plans, namely, bilateral sagittal split ramus osteotomy (BSSRO), intraoral vertical ramus osteotomy (IVRO), BSSRO+Le FortⅠ, and IVRO+Le FortⅠ. All patients followed a standardized examination procedure at 6 and 24 months post-treatment. The observation indexes include overbite, mandibular plane angle, and intermaxillary angle.Results 1) The significantly reduced ratio of the overbite in the BSSRO+Le FortⅠand IVRO+Le FortⅠgroups were less than the BSSRO and IVRO groups at 6 and 24 months post-treatment. 2) The significantly increased ratio of the mandibular plane in BSSRO+Le FortⅠand IVRO+Le FortⅠgroups were less than BSSRO and IVRO groups at 6 and 24 months post-treatment. 3) The significantly increased ratio of the intermaxillary angles in BSSRO+Le FortⅠand IVRO+Le FortⅠgroups were less than the BSSRO and IVRO groupsat 6 months post-treatment, while there was no stati-stical difference at 24 months post-treatment. Conclusion Bimaxillary surgery (BSSRO+Le FortⅠand IVRO+Le FortⅠ) is more effective than mandibular surgery to control vertical relapse.

skeletal class Ⅲ malocclusion; orthognathic surgery; open bite; overbite; mandibular plane angle; intermaxillary angle

R 782.2

A

10.7518/hxkq.2017.05.007

2017-04-11；

2017-06-09

國家自然科學基金（81600888）；廣東省醫學科學技術研究基金（A2015189）

劉顯文，主治醫師，博士，E-mail：liuxianwen1986@hotmail.com

劉曙光，主任醫師，博士，E-mail：625043130@qq.com