王志鵬 曹勇
[摘要]目的:探討不同術(shù)式矯正下頜角肥大伴長頦畸形的應(yīng)用效果。方法:選取筆者科室2017年1月-2019年1月收治的26例下頜骨肥大伴長頦畸形患者,分別采用U形截骨術(shù)和下頜骨超長弧形截骨術(shù)兩種術(shù)式進(jìn)行矯正,比較兩組患者的療效、術(shù)后并發(fā)癥及滿意度情況。 結(jié)果:U形截骨術(shù)組總有效率為90.00%,下頜骨超長弧形截骨術(shù)組總有效率為100.00%,下頜骨超長弧形截骨術(shù)組總有效率高于U形截骨術(shù)組,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05)。采用U形截骨術(shù)后,其中5例患者出現(xiàn)下唇麻木或腫脹,1例有輕微皮膚軟組織下垂;采用下頜骨超長弧形截骨術(shù)后,其中8例患者口唇有不同程度的麻木或腫脹,1例出現(xiàn)下頜部局部輕度血腫。所有患者均未出現(xiàn)嚴(yán)重并發(fā)癥,兩組患者術(shù)后并發(fā)癥發(fā)生情況比較,無統(tǒng)計學(xué)差異(P>0.05)。術(shù)后6個月對所有患者進(jìn)行隨訪,U形截骨術(shù)組患者滿意度為80.00%,下頜骨超長弧形截骨術(shù)組患者滿意度為100.00%,下頜骨超長弧形截骨術(shù)組滿意度高于U形截骨術(shù)組,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05)。結(jié)論:相較于傳統(tǒng)下頜角截骨術(shù),U形截骨術(shù)以及下頜骨超長弧形截骨術(shù)均可進(jìn)一步改善矯正效果,滿足患者術(shù)前要求。其中,下頜骨超長弧形截骨術(shù)具有更佳的矯正效果,并能提高患者對矯正術(shù)后的滿意度及預(yù)后質(zhì)量。
[關(guān)鍵詞]下頜角肥大;長頦畸形;U形截骨術(shù);下頜骨超長弧形截骨術(shù);并發(fā)癥
[中圖分類號]R782.2 ? ?[文獻(xiàn)標(biāo)志碼]A ? [文章編號]1008-6455(2020)05-0055-04
Abstract: ?Objective ?To explore the application effect of different surgical methods to correct mandibular angle hypertrophic with long chin deformity. Methods ?26 patients with mandibular angle hypertrophic with long chin deformity were treated in plastic surgery department of our hospital from January 2017 to January 2019 were selected. U-shaped osteotomy and super-length arc osteotomy were used for correction. The efficacy, occurrence of postoperative complications and satisfaction of the two groups were compared. Results ?The total effective rate of the U-shaped osteotomy group was 90.00%, and the total effective rate of the super-length arc osteotomy group was 100.00%. The total effective rate of super-length arc osteotomy group was higher than that of U-shaped osteotomy group, and the difference was statistically significant (P<0.05). After U-shaped osteotomy, 5 cases of patient with lower lip numbness or swelling after operation, 1 cases of patient with slight sagging of soft tissue after operation. After super-length arc osteotomy, 8 cases of patient with lower lip numbness or swelling after operation, 1 cases of patient with slight local hematoma of mandible after operation. No serious complications occurred in all patients. There was no significant difference in the incidence of complications between the two groups (P>0.05). All patients were followed up 6 months after operation. The satisfaction rate of U-shaped osteotomy group was 80.00%, and the satisfaction rate of super-length arc osteotomy group was 100.00%. The satisfaction of super-length arc osteotomy group was higher than that of U-shaped osteotomy group, and the difference was statistically significant (P<0.05). Conclusion ?Compared with traditional mandibular angle osteotomy, U-shaped osteotomy and super-length arc osteotomy can further improve the correction effect and meet the preoperative requirements of patients. Among them, the super-length arc osteotomy has better correction effect, and can improve the patient's satisfaction and quality of prognosis after correction.
Key words: mandibular angle hypertrophic; long chin deformity; U-shaped osteotomy; super-length arc osteotomy;complication
亞洲地區(qū)普遍以流暢且柔美的“瓜子臉”或“鵝蛋臉”為美[1]。下頜角肥大伴長頦畸形者的面部輪廓并不符合大眾審美標(biāo)準(zhǔn),通常使女性缺乏溫柔細(xì)膩的特征,表現(xiàn)出男性化的鋒利之感。下頜角肥大主要表現(xiàn)為面部呈方形或梯形,使下頜角寬大、外翻,俗稱為“方型臉”[2]。同時,頦部作為整個面部輪廓的重要組成部分,頦部畸形使整體顏面部呈現(xiàn)出一種不協(xié)調(diào)的觀感,經(jīng)過手術(shù)調(diào)整可擁有輪廓鮮明、弧度優(yōu)美的下頦,使臉型更加小巧精致[3]。隨著社會的快速發(fā)展和精神美學(xué)文化的提高,要求通過手術(shù)矯治不協(xié)調(diào)面部輪廓的患者日益趨多。目前,截骨術(shù)已經(jīng)成為矯正下頜骨肥大及頦部畸形者最安全有效的方法[4]。對于下頜角肥大伴長頦畸形患者,即使在常用的下頜角長弧形截骨術(shù)或下頜角切除術(shù)情況下,術(shù)后也均有第二下頜角發(fā)生的傾向,并且無法解決下頦過長的問題。采用U形截骨術(shù)可避免以上術(shù)式的弊端和局限性,進(jìn)一步優(yōu)化患者的面部輪廓,使患者獲得滿意的矯正效果[5]。同時,下頜骨超長弧形截骨術(shù)通過截除從下頜角到下頦部的骨骼,既增加了正面的視覺美感,也優(yōu)化了側(cè)面的弧度效果,使下頜骨輪廓更加自然流暢[6]。本文通過比較U形截骨術(shù)和下頜骨超長弧形截骨術(shù)對矯正下頜角肥大伴長頦畸形的療效進(jìn)行評估分析,現(xiàn)報道如下。
1 ?資料和方法
1.1 臨床資料:選取筆者科室2017年1月-2019年1月收治的26例下頜骨肥大伴長頦畸形患者,均為女性,年齡19~31歲,平均為25歲。其中3例同期行顴骨降低術(shù),2例行同期顴弓內(nèi)推術(shù),1例同期行頦部打磨術(shù)。將患者隨機(jī)分為兩組,采用U形截骨術(shù)10例,采用下頜骨超長弧形截骨術(shù)16例,均通過口內(nèi)切口入路下頜角。本研究經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會批準(zhǔn),所有患者術(shù)前均已簽署知情同意書。
1.2 手術(shù)方法
1.2.1 術(shù)前設(shè)計:術(shù)前根據(jù)患者頭顱三維CT檢查及頭顱正側(cè)位X線片和下頜骨曲面斷層片確定截骨線,兩側(cè)截骨線貫通。注意下頜孔及下齒槽神經(jīng)血管束的位置,避免造成不必要的損傷。截骨寬度根據(jù)下齒槽神經(jīng)血管束位置及患者的具體要求確定。在模型上模擬術(shù)中截骨線位置及截除骨量,有利于預(yù)測術(shù)后可達(dá)到的效果,與患者達(dá)成共識。
1.2.2 U形截骨術(shù):鼻插管全麻后,截骨術(shù)切口起自雙側(cè)下頜升支前緣偏頰側(cè)8mm至前庭溝中線,在黏膜下給予0.5%利多卡因行局部浸潤麻醉。沿切口線切開黏膜、黏膜下肌肉及骨膜,剝離子沿骨膜下剝離至雙側(cè)下頜骨及頦部,充分暴露術(shù)區(qū)。用大磨球均勻打磨兩側(cè)下頜體部、角區(qū)及頦部外板,小磨球沿設(shè)計截骨線打磨。用擺動鋸沿溝槽行下頜角區(qū)和體部弧形截骨,用來復(fù)鋸行頦體部及頦下緣截骨,雙側(cè)截骨線完全貫通后完成U形截骨。用骨鑿撬動,確保骨塊完全離斷后,用來復(fù)鋸分別在雙側(cè)頦神經(jīng)外側(cè)5mm處將U形骨塊截斷,取出截除骨塊。電鉆打磨截骨緣不平整處,于頦下緣打3個孔,將頦肌連同骨膜以4-0可吸收縫線縫合于下頜骨,恢復(fù)軟組織的穩(wěn)定性。間斷縫合黏膜切口,雙側(cè)各留置引流管一根,術(shù)區(qū)加壓包扎固定。術(shù)后常規(guī)消炎止血補(bǔ)液治療,術(shù)后2d拔除引流,術(shù)后10d拆線。
1.2.3 下頜骨超長弧形截骨術(shù):鼻插管全麻后,截骨術(shù)切口起自雙側(cè)下頜升支前緣偏頰側(cè)5mm至前庭溝中線,在黏膜下給予0.5%的利多卡因行局部浸潤麻醉。沿切口線切開黏膜、黏膜下肌肉及骨膜,剝離子沿骨膜下剝離至雙側(cè)下頜骨及頦部,充分暴露術(shù)區(qū)。用大磨球均勻打磨兩側(cè)下頜體部、角區(qū)及頦部外板,小磨球沿設(shè)計截骨線打磨。用擺鋸截骨,截至頦神經(jīng)下方時改用來復(fù)鋸截骨,完全離斷后,彎骨鑿鑿斷殘存骨連接。骨塊徹底游離后,由于骨塊較長,應(yīng)由下向上旋轉(zhuǎn)取出截除骨塊,如不能完整取出骨塊,也可用來復(fù)鋸將其截斷后分別取出。電鉆打磨骨緣不平整處,同時對頦部進(jìn)行截骨或打磨手術(shù)。間斷縫合黏膜切口,雙側(cè)各留置引流管一根,術(shù)區(qū)加壓包扎固定。術(shù)后常規(guī)消炎止血補(bǔ)液治療,術(shù)后2d拔除引流,術(shù)后10d拆線。
1.3 評定指標(biāo):①療效評定標(biāo)準(zhǔn):顯效:面下部形態(tài)改觀明顯,雙側(cè)對稱,無并發(fā)癥發(fā)生;有效:面下部形態(tài)改觀,雙側(cè)基本對稱,有并發(fā)癥發(fā)生;無效:面下部形態(tài)改觀不明顯,面部比例失調(diào),有并發(fā)癥發(fā)生。總有效率以顯效+有效計;②并發(fā)癥:兩組患者術(shù)后并發(fā)癥發(fā)生情況比較;③滿意度評估標(biāo)準(zhǔn):術(shù)后6個月對所有患者進(jìn)行隨訪,通過口頭訪談以及調(diào)查問卷的方法,對外表容貌、咬合功能、咀嚼情況等進(jìn)行詳細(xì)調(diào)查。問卷總分為10分,小于5分為不滿意;6~8分為一般;9~10分為非常滿意。滿意度以非常滿意+一般計。
1.4 統(tǒng)計學(xué)分析:采用統(tǒng)計軟件SPSS 19.0進(jìn)行處理,計數(shù)資料以(%)表示,組間比較采用χ2檢驗。P<0.05為差異有統(tǒng)計學(xué)意義。
2 ?結(jié)果
2.1 兩組療效比較:治療后,U形截骨術(shù)組總有效率為90.00%,下頜骨超長弧形截骨術(shù)組總有效率為100.00%,下頜骨超長弧形截骨術(shù)組總有效率高于U形截骨術(shù)組,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05),見表1。典型病例治療前后圖片見圖1~2。
2.2 術(shù)后并發(fā)癥發(fā)生情況比較:U形截骨術(shù)組中,10例患者術(shù)后均無開口受限、咀嚼不適和關(guān)節(jié)活動異常等并發(fā)癥,所有傷口均一期愈合。其中5例術(shù)后出現(xiàn)下唇麻木或腫脹,兩周后癥狀自行消失;1例術(shù)后有輕微皮膚軟組織下垂,無視覺美觀影響。下頜骨超長弧形截骨術(shù)組中,16例患者中均未出現(xiàn)嚴(yán)重并發(fā)癥。8例患者術(shù)后口唇有不同程度的麻木或腫脹,兩周后癥狀自行消失;1例出現(xiàn)下頜部局部輕度血腫,給予抗生素治療后恢復(fù)良好。兩組患者術(shù)后并發(fā)癥發(fā)生情況比較無統(tǒng)計學(xué)差異(P>0.05),見表2。
2.3 滿意度比較:術(shù)后6個月,U形截骨術(shù)組患者滿意度為80.00%,下頜骨超長弧形截骨術(shù)組患者滿意度為100.00%,下頜骨超長弧形截骨術(shù)組滿意度高于U形截骨術(shù)組,兩組患者比較差異有統(tǒng)計學(xué)意義(P<0.05),見表3。