骨性III類錯(cuò)采用正畸聯(lián)合雙頜手術(shù)治療前后上氣道變化的Meta分析

陳德余 郭婉露 王豫蓉

陳德余 郭婉露 王豫蓉

骨性III類錯(cuò)牙合； 正畸治療； 正頜手術(shù)； 氣道； Meta分析

1 材料與方法

1.1 納入排除標(biāo)準(zhǔn)

1.1.3 干預(yù)措施 采用雙頜手術(shù)(上頜行Lefort I型前徙，下頜行SSRO或IVRO后退)并配合術(shù)前、術(shù)后正畸治療。排除單獨(dú)上頜前徙或單獨(dú)下頜后退者；排除正畸正頜外還聯(lián)合其他治療方式者。

1.1.4 結(jié)局指標(biāo) 鼻咽部體積(nasopharyngeal volume，NPV)、口咽部體積(oropharyngeal volume，OPV)及鼻咽口咽總體積(total volume，TV)的變化值。納入測(cè)量方法采用CT、CBCT或是其它三維測(cè)量方式者。排除采用頭顱側(cè)位片等二維手段作為測(cè)量方式者。

1.2 文獻(xiàn)檢索

1.2.1 檢索來源 電子檢索中英文數(shù)據(jù)庫(kù)：Cochrane library，Embase，PubMed，Web of Science、中國(guó)生物醫(yī)學(xué)文獻(xiàn)數(shù)據(jù)庫(kù)(CBM)、萬方數(shù)據(jù)庫(kù)(Wanfang)、中文科技期刊數(shù)據(jù)庫(kù)(VIP)、中國(guó)期刊全文數(shù)據(jù)庫(kù)(CNKI)。手動(dòng)檢索中華正畸學(xué)雜志、中華口腔醫(yī)學(xué)雜志以及中國(guó)循證醫(yī)學(xué)等。并追蹤已檢索文獻(xiàn)的參考文獻(xiàn)以查缺補(bǔ)漏。語言包括英語和漢語。檢索截止時(shí)間2015-12。

1.2.2 檢索策略 英文檢索式：#1.skeletal class III malocclusion；#2.mandibular prognathism；#3.#1 OR #2；#4.orthodontic*；#5.orthognathic surgery；#6.#3 AND #4 AND #5；#7.airway；#8.phayrngeal space；#9.pharynx；#10.OR(7-9)；#11.#6 AND #10。中文檢索式：#1.骨性III類；#2.下頜前突；#3.#1 OR #2；#4.正畸治療；#5.正頜治療；#6. #3 AND #4 AND #5；#7.氣道；#8.咽部；#9. #7 OR #8；#10. #6 AND #9。

1.3 文獻(xiàn)篩選及資料提取

2 位評(píng)價(jià)者獨(dú)立地進(jìn)行文獻(xiàn)篩選及數(shù)據(jù)提取。然后資料匯總，遇分歧則通過討論解決或請(qǐng)第三方介入。本研究主要提取信息包括：第一研究作者、樣本量、發(fā)表時(shí)間、研究對(duì)象的性別及年齡、干預(yù)措施、結(jié)局指標(biāo)。

1.4 質(zhì)量評(píng)價(jià)

采用Cochrane協(xié)作網(wǎng)推薦的NOS(newcastle-ottawa scale)量表[5]對(duì)納入文獻(xiàn)進(jìn)行質(zhì)量評(píng)價(jià)：總分9 分，高質(zhì)量>7 分，中等質(zhì)量6～7 分，低質(zhì)量≤5 分。

1.5 統(tǒng)計(jì)分析

數(shù)據(jù)分析采用Revman 5.3軟件完成。本研究納入文獻(xiàn)的結(jié)果為連續(xù)型變量資料，效應(yīng)量選擇加權(quán)均數(shù)差(WMD)和95%CI。異質(zhì)性檢驗(yàn)采用I2檢驗(yàn)[6],只要I2小于50%，異質(zhì)性可被接受[7]；I2大于50%時(shí)需要首先解釋異質(zhì)性來源，可通過亞組分析、隨機(jī)效應(yīng)模型等處理。發(fā)表偏倚的檢測(cè)采用漏斗圖分析。

2 結(jié) 果

2.1 文獻(xiàn)檢索流程及結(jié)果

按照檢索策略初步得到文獻(xiàn)488 篇(中文281 篇，英文207 篇)，排除重復(fù)文獻(xiàn)220 篇，閱讀題目和摘要排除215 篇，仔細(xì)閱讀全文排除44 篇，最終納入文獻(xiàn)9 篇[8-16](英文7 篇，中文2 篇)。

2.2 納入研究特征及質(zhì)量評(píng)價(jià)

2.3 Meta分析結(jié)果

表 1 納入研究基本特征

注： ——： 文獻(xiàn)未提及； SSRO： 下頜矢狀劈開術(shù)； IVRO： 下頜垂直切開術(shù)； ①NPV： 鼻咽體積； ②OPV： 口咽體積； ③TV： 總體積

圖 1 鼻咽體積變化的Meta分析結(jié)果

圖 2 口咽體積變化的Meta分析結(jié)果

圖 3 總體積變化的Meta分析結(jié)果

2.4 敏感性分析

Lee[10]報(bào)道中，患者采取的術(shù)式為L(zhǎng)eFort I型截骨術(shù)+IVRO，其余各報(bào)道中均采用LeFort I型截骨術(shù)和SSRO；在Park[9]、Yuh[14]研究中，患者的性別比例文獻(xiàn)中未提及，而Li[11]研究中研究對(duì)象均為女性，其余各研究均由男女組成。

2.4.1 鼻咽體積變化 排除Lee[10]行敏感性分析，結(jié)果顯示：鼻咽部體積變化無統(tǒng)計(jì)學(xué)意義(WMD=0.01 cm3，95%CI[-0.38,0.40])；各研究間同質(zhì)性好(I2=0，P=0.85)。排除Park[9]、Li[11]行敏感性分析，結(jié)果示：鼻咽部體積變化無統(tǒng)計(jì)學(xué)意義(WMD=0.08 cm3，95%CI[-0.47,0.63])；各研究間同質(zhì)性好(I2=0，P=0.66)。各項(xiàng)分析結(jié)果未見明顯改變(表 2)。

2.4.2 口咽體積變化 排除Lee[10]行敏感性分析，結(jié)果顯示：口咽部體積變化有統(tǒng)計(jì)學(xué)意義(WMD=-2.32 cm3，95%CI[-3.41,-1.23])；各研究間有輕度異質(zhì)性(I2=32%，P=0.18)。排除Park[9]、Li[11]、Yuh[14]行敏感性分析，結(jié)果示：口咽部體積變化有統(tǒng)計(jì)學(xué)意義(WMD=-2.17 cm3，95%CI[-3.64,-0.70])；各研究間有輕度異質(zhì)性(I2=39%，P=0.16)。各項(xiàng)分析結(jié)果未見明顯改變(表 2)。

2.4.3 總體積變化 排除Lee[10]行敏感性分析，結(jié)果顯示：總體積的變化無統(tǒng)計(jì)學(xué)意義(WMD=-1.10 cm3，95%CI[-2.42,0.23])；各研究間同質(zhì)性好(I2=0，P=0.99)。排除Park[9]、Li[11]行敏感性分析，結(jié)果示：總體積的變化無統(tǒng)計(jì)學(xué)意義(WMD=-0.92 cm3，95%CI[-2.24,0.40])；各研究間同質(zhì)性好(I2=0，P=0.89)。各項(xiàng)分析結(jié)果未見明顯改變(表 2)。

表 2 各項(xiàng)敏感性分析

2.5 發(fā)表偏倚

各項(xiàng)結(jié)局指標(biāo)的漏斗圖如圖 4，均未見明顯不對(duì)稱，說明沒有明顯發(fā)表偏倚。

3 討 論

本研究納入的文獻(xiàn)均采用CBCT作為測(cè)量方式，避免了使用側(cè)位片測(cè)量時(shí)存在的左右影像重疊不清、無法精確定位等缺點(diǎn)，更加準(zhǔn)確的定位、減少偽影，實(shí)現(xiàn)三維體積的測(cè)量[17]，更加真實(shí)準(zhǔn)確的反映氣道變化情況。

3.1 正畸-雙頜手術(shù)對(duì)鼻咽體積的影響

圖 4 各結(jié)局指標(biāo)漏斗圖分析

3.2 正畸-雙頜手術(shù)對(duì)口咽體積的影響

3.3 正畸-雙頜手術(shù)對(duì)總體積的影響

3.4 本研究的臨床意義及局限性

本研究納入文獻(xiàn)數(shù)量有限，質(zhì)量評(píng)價(jià)均為中等質(zhì)量，存在一定的風(fēng)險(xiǎn)偏倚；同時(shí)本次檢索僅限于英文和中文文獻(xiàn)，可能會(huì)影響資料收集的全面性。除此之外，正頜手術(shù)不僅移動(dòng)上下頜骨，而且與頜骨相關(guān)的軟腭、舌骨及神經(jīng)也會(huì)隨之發(fā)生改變，而周圍軟硬組織的改變也會(huì)帶來上氣道體積的變化，所以觀察氣道改變的長(zhǎng)期性研究也十分必要，本研究只納入一篇相關(guān)文獻(xiàn)[9]，無法進(jìn)行Meta分析。今后尚需樣本量更多、設(shè)計(jì)更為完善的高質(zhì)量研究開展。

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Volumetricchangesintheupperairwayafterorthodontic-orthoganthicsurgeryforthetreatmentofskeletalClassIIImalocclusion:Ameta-analysis

CHENDeyu,GUOWanlu,WANGYurong.

401147，DepartmentofOrthodontics,AfiliatedHospitalofStomatology,ChongqingMedicalUniversity;ChongqingKeyLaboratoryforOralDiseasesandBiomedicalScience,China

Objective: To evaluate volumetric changes in the upper airway after orthodontic-bimaxillary surgery for the treatment of skeletal class III malocclusion.MethodsLiteratures about volumetric changes in the upper airway after orthodontic- bimaxillary surgery for the treatment of skeletal class III malocclusion were searched from the database: Cochrane library, Embase, PubMed, Web of Science, Wangfang, China Science and Technology Journal Database(VIP), Chinese Biomedical Medicine Database(CBM) and China National Knowledge Infrastructure(CNKI). All the literatures were evaluated by Newcastle-Ottawa Scale(NOS) and analyzed by RevMan 5.3.Results9 studies with 204 cases about volumetric changes in the upper airway after orthodontic-bimaxillary surgery for the treatment of skeletal III malocclusion were included. Meta-analysis showed that after treatment there was no statistical difference about the nasopharyngeal volume change and the total volume change(P>0.05); there was statistically significant difference about oropharyngeal volume change(P<0.05).ConclusionIt might be better to consider orthodontic-bimaxillary surgery for skeletal class III malocclusion with certain risk factors about OSAHS, but there was still a risk of airway narrow after orthodontic-bimaxillary surgery for skeletal class III malocclusion.

SkeletalclassIIImalocclusion；Orthodontictreatment；Orthoganthicsurgery；Airway；Meta-analysis

重慶市衛(wèi)生局重點(diǎn)項(xiàng)目(編號(hào)： 2009-1-32)

401147， 重慶醫(yī)科大學(xué)口腔醫(yī)院正畸科， 口腔疾病與生物醫(yī)學(xué)重慶市重點(diǎn)實(shí)驗(yàn)室

王豫蓉 E-mail: 1920779581@qq.com

783.5

A

10.3969/j.issn.1001-3733.2017.04.010

(收稿： 2017-01-25 修回： 2017-06-14)