����-����������ƹ��԰��Ϣ�������϶�����ؽ�Ӱ���ٴ��о�

目的 研究成人骨性安氏Ⅲ类错(殆)正畸-正颌联合治疗前后颞下颌关节(TMJ)变化.方法 选择2002-2010年在中国医科大学口腔医院正畸科就诊的成人骨性安氏Ⅲ类错(殆)患者30例,采用正畸治疗加双侧下颌升支矢状劈开后退术(BSSRO)的正畸-正颌联合治疗方案,分别在BSSRO术前、术后1个月、矫治结束时拍摄标准薛氏位片,采用Cohlmia测量法对关节片进行关节间隙及关节窝形态测量,观察髁突位置及关节形态的变化.结果 (1)关节间隙变化:与术前比较,术后1个月双侧关节各间隙均明显变大(P＜0.05);矫治结束后关节间隙测量值与术前比较,差异无统计学意义(P＞0.05).(2)髁突位置和关节窝形态变化:术后1个月髁突位置与术前比较,矢状向髁突位置后移,垂直向髁突位置下移.矫治结束后与术前比较,髁突位置各项指标差异无统计学意义(P＞005).反映关节窝形态的指标在术前、术后1个月和矫治结束后三者间比较差异均无统计学意义(P＞0.05).(3)30例患者中治疗前9例有关节弹响,治疗后5例弹响消失,术前无关节弹响者术后均未出现弹响,所有患者治疗前后均未出现关节疼痛及开口受限.结论 (1)BSSRO术后1个月关节间隙增大,髁突位置稍偏后,矫治结束后恢复正常.正畸-正颌联合治疗未引起关节窝形态的改变.(2)所有患者均未引起颞下颌关节紊乱病(TMD),且部分患者治疗后关节弹响消失,提示正畸-正颌联合治疗可能对TMD有一定的治疗作用.     

Effect of bilateral sagittal split ramus osteotomy on temporomandibular joint symptom and condylar position in patients with skeletal class Ⅲ malocclusion by cone beam computed tomography

目的 探讨双侧下颌骨升支矢状劈开截骨后退术（BSSRO）对行正畸—正颌联合治疗的骨性Ⅲ类错牙合患者颞下颌关节（TMJ）症状及髁突位置的影响。方法 选取24例行正畸-正颌联合治疗的骨性Ⅲ类错牙合患者,分别在BSSRO术前、术后1个月、术后12个月按Helkimo指数整理记录关节症状,并行锥形束CT（CBCT）扫描,在三维方向上测量髁突水平位及冠状截面最大径、髁突短轴径、髁突颈部宽度、髁突高度、不同角度（45°、90°、135°）下关节间隙宽度、双侧髁突间距及髁突角度（水平角、垂直角、受力角）,分析不同时期TMJ症状及骨性结构的变化情况。结果 BSSRO术前与术后的Helkimo指数均为Ai、Di 0级或1级,二者之间无差异。与术前相比,术后1个月时髁突水平角、45°及90°下关节间隙宽度增大,135°下关节间隙宽度减小（P<0.05）;术后12个月时,除髁突水平角增大（P<0.05）外,其余测量项目间差异均无统计学意义（P>0.05）。结论 在正畸—正颌联合治疗中,BSSRO不会对Helkimo指数为Ai、Di 0级或1级的骨性Ⅲ类错牙合患者的TMJ症状及髁突位置产生明显的影响。     

下颌偏斜畸形术后髁突位置改变的研究

目的:观察下颌双侧升枝矢状劈开术Bilateral Sagittal Split Ramous Osteotomy(以下简称BSSRO)矫治下颌偏斜畸形术后髁突位置的变化.方法:通过定位薛氏位片研究BSSRO矫治20例下颌偏斜畸形病例术前、术后1周及术后1年关节间隙的改变.结果:BSSRO术后1周髁突位置发生变化,1年后髁突位置恢复到术前状态,关节弹响症状多数缓解.结论:BSSRO矫治下颌偏斜畸形术后髁状突位置远期无明显改变.     

双侧升支矢状劈开截骨后退下颌术后骨的稳定性的研究

目的：探讨双侧升支矢状劈开截骨术（BSSRO）后退下颌骨以钢丝结扎固定两骨段加颌间固定术后骨的稳定性，了解导致复发的有关因素。方法：双侧下颌升支矢状劈开截骨手术后退下颌的患者14例，于手术前1周，手术后1周，术后6个月分别拍摄定位头颅侧位片及许勒位X线片，用于测量下颌移动的距离及确定下颌骨髁状突的位置。结果：双侧下颌升支矢状劈开截骨后退术后，6个月的复发率为27.2%，多元逐步回归分析示下颌后退的距离与复发相关。结论：BSSRO后退下颌骨的距离越大，术后下颌骨向前移位的可能越大。     

BSSRO后退矫正下颌发育过度对颞下颌关节的影响

目的：采用MRI影像学方法,研究成人骨性Ⅲ类错畸形（简称Ⅲ类畸形）正畸正颌联合治疗后颞下颌关节（TMJ）的盘突关系的空间位置变化。方法：24例下颌发育过度的Ⅲ类畸形患者,采用正畸治疗及双侧下颌支矢状劈开后退术（BSSRO）,分别在术前和术后6个月进行MRI检测、头颅定位侧位片以及关节症状记录,比较矫正前后关节症状、关节盘长度以及移位量的变化。采用SPSS11.0软件包进行配对t检验。结果：矫正前有关节弹响的患者3例6侧髁突中,矫正后弹响消失1侧;矫正前关节区有疼痛1例,手术后3个月疼痛消失,术后半年疼痛症状重新出现;治疗前未发现有关节症状者20例,矫正后也未发生。48个关节盘长度测量,矫正前关节盘长度最大12.928mm,最小3.040mm,均数为8.288mm;矫正后关节盘长度最大11.589mm,最小3.699mm,均数为8.097mm。2组均数自身比较,无显著性差异（P〉0.05）。关节盘移位测量结果：矫正前关节盘位置最大前移6.090mm,均数为1.383mm;矫正后关节盘位置最大前移11.931mm,均数为2.193mm。2组均数自身比较,无显著性差异（P〉0.05）。结论：骨性Ⅲ错畸形可以被正畸正颌联合治疗良好地矫正,达到面形美观和最大牙尖咬合位的效果。正畸正颌联合治疗、下颌骨BSSRO未引起关节盘明显移位和关节盘长度明显改变,但是也未发现正颌正畸联合治疗对TMJ症状有明显的改善作用。     

双颌手术升支截骨后退术后下颌稳定性及与关节关系的研究

目的　探讨升支矢状劈开截骨术(BSSRO)小钛板坚固内固定与口内入路升支垂直截骨术(BIVRO)下颌后退术后颌稳定性的不同规律,了解导致复发的有关因素特别是髁状突移位在不同手术后复发过程中的意义。方法　升支截骨手术后退下颌的患者共38例,皆为双颌手术,其中下颌BSSRO19例,BIVRO后退术19例。于手术前1周(T1),手术后1周(T2),3个月(T3)及1年(T4)分别拍摄定位头颅侧位片及定位颞下颌关节薛氏位片用于测量下颌移动幅度及关节髁状突的手术后移位。结果　双颌手术下颌升支截骨后退术后,BSSRO坚固内固定组1年时的复发率为25%,而BIVRO组大部分患者1年时下颌发生了与手术目的相同的移动,两组的不稳定主要发生在术后3个月内。结论　手术使髁状突移位术后位置的调整可导致BIVRO术后的下颌继续后移而不稳定,而髁状突近心骨段术中向后旋转术后位置的调整可导致BSSRO术后的下颌骨继续向前而不稳定     

双侧下颌骨矢状劈开截骨术矫正骨性Ш类畸形对下颌支及颞下颌关节的影响

目的观察双侧下颌骨矢状劈开截骨术(BSSRO)后移下颌骨对下颌升支及颞下颌关节的影响。方法采用定位头颅后前位片及薛氏关节片,研究16例成人骨性Ш类患者术前及术后下颌升支整体及关节间隙的变化。结果BSSRO术前与术后的下颌升支宽度减小,但无显著性差异。关节间隙在术后1月时有明显改变,6~12月后恢复为原位,且临床表现关节症状多有所缓解。结论BSSRO矫治成人骨性Ш类错畸形对下颌升支及颞下颌关节无显著影响。     

双侧下颌骨升支矢状劈开截骨术治疗下颌前突畸形

目的探讨口内进路双侧下颌骨升支矢状劈开截骨后退小钛板内固定治疗重度下颌前突畸形的临床疗效。方法9例上颌骨发育正常、下颌骨真性前突、严重反He关系的患者，行术前牙齿正畸治疗后，采用口内进路双侧下颌骨升支矢状劈开截骨后退小钛板内固定，术后正畸治疗，恢复尖窝咬He关系。结果所有病例均取得满意的疗效，获得协调的上下颌骨关系，术后随访1年，未见下颌前突复发。结论重度下颌前突畸形采用口内进路双侧下颌骨升支矢状劈开截骨术及正畸治疗是有效的，值得临床推广应用。     

双侧下颌骨矢状劈开截骨术矫正骨性Ⅲ类畸形对下颌支及颞下颌关节的影响

目的观察双侧下颌骨矢状劈开截骨术(BSSRO)后移下颌骨对下颌升支及颞下颌关节的影响.方法采用定位头颅后前位片及薛氏关节片,研究16例成人骨性Ⅲ类患者术前及术后下颌升支整体及关节间隙的变化.结果BSSRO术前与术后的下颌升支宽度减小,但无显著性差异.关节间隙在术后1月时有明显改变,6～12月后恢复为原位,且临床表现关节症状多有所缓解.结论 BSSRO矫治成人骨性Ⅲ类错(牙合)畸形对下颌升支及颞下颌关节无显著影响.     

下颌前突患者升支矢状劈开截骨术后骨性复发因素的探讨

目的：探讨下颌前突患者升支矢状劈开截骨术（bilateral sagittal split ramus osteotomy,BSSRO)术后骨性复发的相关因素。方法：以术后长期面角（∠NP－FHT4－3）的变化作为因变量,选择术前术后12项自变量,对两者之间的关系进行多元线性相关及偏相关分析。结果：术后长期下颌平面角（∠MP－FHT4－3）、术前正畸疗程、术后观察期与因变量呈显著负相关关系（r分别为－0．568、－0．406、－0．400,P＜0．01－0．05）。结论：下颌前突患者BSSRO术后的骨性复发非常有限,术前正畸疗程、术后下颌旋转与术后矢状颌位的稳定相关。     

Biomechanical effect of asymmetric mandibular prognathism treated with BSSRO and USSRO on temporomandibular joints: a three-dimensional finite element analysis

Asymmetric mandibular prognathism is a clinically common skeletal dentomaxillofacial deformity. Unilateral sagittal split ramus osteotomy (USSRO) is an effective alternative procedure to bilateral sagittal split ramus osteotomy (BSSRO) for some patients. However, the biomechanical effect of temporomandibular joint (TMJ) of USSRO has not been fully studied. This study aims to evaluate the stress distribution changes in the TMJ of asymmetric mandibular prognathism treated with BSSRO/USSRO, to validate the clinical feasibility of USSRO. Nineteen patients with mandibular prognathism patients who were treated with BSSRO (n = 12) and USSRO (n = 7) had preoperative and postoperative computed tomographic scanning. Preoperative and postoperative 3-dimensional finite element analysis (FEA) of functional TMJ movements were made on one BSSRO patient and one USSRO patient. In all patients, the ANB angle and mandibular deviation were significantly improved postoperatively. There was no significant difference in the postoperative ANB angle and mandibular deviation between the BSSRO group and the USSRO group. In two preoperative FEA models, the maximum stresses of non-deviation side TMJ structures were greater than the deviation side during functional movements. The unbalanced stress distribution was corrected postoperatively in both BSSRO/USSRO FE models. Both BSSRO/USSRO can improve the ANB angle and mandibular deviation. The bilateral TMJ structure in patients with asymmetric mandibular prognathism had unbalanced stress, which could be significantly improved with the USSRO as effectively as BSSRO.     

不同正颌外科方案对骨性Ⅲ类伴前牙开(恰) 垂直向稳定性的影响

目的 比较不同正颌外科手术方案对骨性Ⅲ类错伴前牙开术后垂直向稳定性的影响.方法 收集入院接受手术的骨性Ⅲ类错伴前牙开畸形患者122例,分别采用双侧下颌升支矢状劈开(BSSRO)(50例)、下颌升支垂直骨劈开(IVRO)(30例)、BSSRO+Le FortⅠ(22例)、IVRO+Le FortⅠ(20例)作为手术方案,并且除IVRO方案外其他所有方案病例均接受钛板颌骨内坚固内固定术.术后正畸完成时及完成后6、24个月时随访接受临床检查与头影测量分析评估垂直向复发情况,观察指标包括覆、下颌平面角、颌间夹角.结果 01)BSSRO+Le FortⅠ与IVRO+Le FortⅠ组覆显著减小的比率在6、24个月都少于BSSRO与IVRO组.2)BSSRO+Le FortⅠ组与IVRO+Le FortⅠ组下颌平面角显著增加的比率在6、24个月都少于BSSRO与IVRO组.3)6个月时BSSRO+Le FortⅠ组与IVRO+Le FortⅠ组颌间夹角显著增加的比率少于BSSRO组与IVRO组,而24个月时无统计学差异.结论 双颌外科(BSSRO+Le FortⅠ与IVRO+Le FortⅠ)均比单颌外科(BSSRO与IVRO)能更加有效地减少垂直向复发的数量和幅度.     

不同正颌外科方案对骨性Ⅲ类伴前牙开垂直向稳定性的影响

目的 比较不同正颌外科手术方案对骨性Ⅲ类错牙合伴前牙开牙合术后垂直向稳定性的影响。方法 收集入院接受手术的骨性Ⅲ类错牙合伴前牙开牙合畸形患者122例,分别采用双侧下颌升支矢状劈开（BSSRO）（50例）、下颌升支垂直骨劈开（IVRO）（30例）、BSSRO+Le FortⅠ（22例）、IVRO+Le FortⅠ（20例）作为手术方案,并且除IVRO方案外其他所有方案病例均接受钛板颌骨内坚固内固定术。术后正畸完成时及完成后6、24个月时随访接受临床检查与头影测量分析评估垂直向复发情况,观察指标包括覆牙合、下颌平面角、颌间夹角。结果 1）BSSRO+Le FortⅠ与IVRO+ Le FortⅠ组覆牙合显著减小的比率在6、24个月都少于BSSRO与IVRO组。2）BSSRO+Le FortⅠ组与IVRO+ LeFortⅠ组下颌平面角显著增加的比率在6、24个月都少于BSSRO与IVRO组。3）6个月时BSSRO+Le FortⅠ组与IVRO+Le FortⅠ组颌间夹角显著增加的比率少于BSSRO组与IVRO组,而24个月时无统计学差异。结论 双颌外科（BSSRO+ Le FortⅠ与IVRO+Le FortⅠ）均比单颌外科（BSSRO与IVRO）能更加有效地减少垂直向复发的数量和幅度。     

Le FortⅠ型骨切开上颌骨整体后退术矫治骨性Ⅱ类上颌骨前突畸形

目的：探讨Le Fort Ⅰ型骨切开（Le Fort Ⅰ osteotomy）上颌骨整体后退术在矫治骨性Ⅱ类上颌骨前突畸形中的价值。方法：对16例骨性Ⅱ类上颌前突患者（上颌骨前突伴下颌骨后缩14例,其中同时伴颏后缩6例;单纯上颌骨前突2例）进行外科-正畸联合治疗。患者治疗前头影测量∠ANB为7.0°～13.1°,平均9.3°。行Le Fort Ⅰ型骨切开上颌骨整体后退术,其中14例同期行双侧下颌支矢状骨劈开术（bilateral sagittal split ramus osteotomy,BSSRO）前移下颌骨,6例行颏成形术（genioplasty）前移颏部。结果：本组行LeFortⅠ型骨切开上颌骨整体后退4～8mm,14例BSSRO下颌骨前移4～7mm,6例颏成形术颏前移6～8mm。1例一侧腭降动脉术中损伤断裂,经结扎处理,无感染及骨块坏死。16例患者伤口均一期愈合。术后及正畸结束后∠ANB为1.6°～3.5°,平均2.9°。结束治疗后随访6～24个月,牙弓形态及[牙合]曲线正常,牙排列整齐,咬合关系良好,外形明显改善,疗效满意。结论：对于骨性Ⅱ类上颌骨前突畸形患者,Le Fort Ⅰ型骨切开上颌骨整体后退术是一种安全、合理、有效的正颌外科术式。     

骨性安氏Ⅲ类错下颌单颌手术后软硬组织的变化

目的:探讨正畸-正颌联合治疗成人骨性安氏Ⅲ类错,上、下颌软、硬组织的变化及其变化的相关性。方法:选取骨性安氏Ⅲ类错患者20例,手术前、后拍摄X线头颅侧位片,手术方式为双侧下颌骨矢状劈开截骨术(BSSRO)。采用SPSS13.0软件包对数据进行配对t检验。结果:治疗后SNB、B点和Pog点到Y轴的距离变小,ANB变大;软组织颏唇角、TLL点、SB点和TC点到Y轴的距离均变小,且均有显著差异(P<0.01)。SB点到Y轴的距离与B点到Y轴的距离存在线性关系,比值为1∶1,决定系数R2=0.96;TC点到Y轴的距离与Pog点到Y轴的距离比为0.84,决定系数R2=0.97。结论:单纯下颌前突患者经正畸和BSSRO治疗后,上颌软组织无明显变化,上、下唇长度不受影响。颏前点软组织与骨组织变化比值为0.84,颏唇沟点为1:1,相关强度均在0.9以上。     

Stability of skeletal class III malocclusion after combined maxillary and mandibular procedures: rigid internal fixation versus wire osteosynthesis of the mandible.

PURPOSE: The aim of this study was to evaluate skeletal stability after double-jaw surgery for correction of skeletal Class III malocclusion to assess whether there were any differences between wire and rigid fixation of the mandible. PATIENTS AND METHODS: Thirty-seven Class III patients had Le Fort I osteotomy stabilized with plate and screws for maxillary advancement. Bilateral sagittal split osteotomy for mandibular setback was stabilized with wire osteosynthesis and maxillomandibular fixation for 6 weeks in 20 patients (group 1) and with rigid internal fixation in 17 patients (group 2). Lateral cephalograms were taken before surgery, immediately after surgery, 8 weeks after surgery, and 1 year after surgery. RESULTS: Before surgery, both groups were balanced with respect to linear and angular measurements of craniofacial morphology. One year after surgery, maxillary sagittal stability was excellent in both groups, and bilateral sagittal split osteotomy accounted for most of the total horizontal relapse observed. In group 1, significant correlations were found between maxillary advancement and relapse at the posterior maxilla and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. In group 2, significant correlations were found between mandibular setback and intraoperative clockwise rotation of the ramus and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. No significant differences in postoperative skeletal and dental stability between groups were observed except for maxillary posterior vertical position. CONCLUSIONS: Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure independent of the type of fixation used to stabilize the mandible.     

Orthognathic treatment for a patient with facial asymmetry associated with unilateral scissors-bite and a collapsed mandibular arch

Subapical mandibular surgeries have been used to correct vertical malocclusion and interdental problems associated with mandibular deformity. Subapical surgery to the anterior part of the mandible is applicable in many patients with anterior open bite and deepbite. Surgery of the posterior part of the mandible is needed less frequently than surgery of the anterior part. This case report describes the surgical-orthodontic treatment of a 21-year-old woman who underwent posterior subapical mandibular surgery. Her chief complaint was facial asymmetry, and she had a collapsed mandibular arch with a scissors-bite of the right premolars and molars. After subapical osteotomy, surgically assisted correction of the collapsed right mandibular arch was performed with a lingual arch appliance. Comprehensive orthodontic treatment was initiated in both arches after this correction. Le Fort I osteotomy and sagittal split ramus osteotomy were used to correct the facial asymmetry. Her facial appearance and temporomandibular problems were markedly improved, and she achieved a functional and stable occlusion after these treatments. This case report demonstrates the efficiency of posterior subapical mandibular surgery for a patient with a collapsed mandibular arch and a scissors-bite.     

Postoperative mandibular stability after orthognathic surgery in patients with mandibular protrusion and mandibular deviation

Skeletal stability and temporomandibular joint (TMJ) signs and symptoms were analyzed in 23 patients in whom mandibular protrusion and mandibular deviation had been corrected using bilateral sagittal split ramus osteotomy (BSSRO group, n = 10) and unilateral SSRO and intraoral vertical ramus osteotomy (USSRO+IVRO group, n = 13). Miniplate fixation was used in SSRO but no fixation was used in IVRO. The ratio of condylar bony change was 30.4% (7/23) and all condylar bony changes were seen on the deviated side. All preoperative signs and symptoms of TMJ disorders (4/13 patients in the USSRO+IVRO group and 2/10 patients in the BSSRO group) disappeared after surgery. Comparing the USSRO+IVRO group and the BSSRO group, in patients without condylar bony change, the mandible in both groups was stable anteriorly and horizontally after surgery, even though there was a larger horizontal mandibular movement in the USSRO+IVRO group during surgery. Comparing patients with condylar bony change versus no condylar bony change in the USSRO+IVRO group, postoperative horizontal mandibular displacement was significantly larger in the condylar bony change group than in the no condylar bony change group. These results support the idea that USSRO+IVRO can be useful in correcting mandibular deviation as well as improving signs and symptoms of TMJ disorders. However, it also seems important to be aware of the possibility of horizontal mandibular relapse in patients with condylar bony change.     

26例下颌前突畸形外科矫正的临床分析

作者对26例下颌前突畸形患者进行了手术矫正，其中18例行双侧SSRO术，8例采用下颌骨体部截骨术后退下颌骨，正畸保持疗效。除3例复发外，皆达设计要求。作者分析讨论了：1．术中、术后并发症产生及处理。认为只要操作处理得当，大部分并发症皆可避免。2．手术与颞下颌关节病症的联系及手术前后X线片结构改变对比。61％的患者因异常关系有不同程度的关节症状。术后35％症状消失，26％无变化。关节X线片术前后对比无明显结构异常变化。3．引起术后复发的原因：3例患者复发的原因主要为术前设计错误及未能坚持术前、术后正畸治疗所致。