摘要：
目的 探索手术优先模式正颌正畸联合序列治疗AngleⅢ类牙颌畸形的临床效果.方法 收集2010年1月至2017年6月期间就诊的185例AngleⅢ类牙颌畸形病例,根据X线头影测量结果及面型特征分为3种类型.①Ⅰ型:下颌前突或偏突畸形;②Ⅱ型:上颌后缩并下颌前突畸形;③Ⅲ型:磨牙轻度近中错 、前牙対刃或轻度反 、或前牙覆 覆盖正常但面中部轻度凹陷.全部采用先正颌、后正畸的治疗模式,术前应用数字化技术进行模拟设计,针对不同类型选择手术方式.Ⅰ型采用下颌升支矢状劈开截骨术式;Ⅱ型采用Le Fort Ⅰ上颌截骨同期下颌升支矢状劈开截骨术式;Ⅲ型采用下颌根尖下截骨术式配合上颌前牙正畸或同期行梨状孔四周生物材料植入充填术.术后2周所有患者均行术后快速正畸治疗6～12个月.分析患者术前、术后7 d、正畸完成后的X线片标记点测量数据.结果 所有患者整体疗程时间缩短,容貌面型显著改善,咬合关系恢复正常,咀嚼功能及颞颌关节功能良好.未出现重度感染、骨质不愈合等严重并发症.术中骨折6例(3.24%),即刻钛板固定;下牙槽血管神经束损伤2例(1.1%);术后暂时性开颌19例(10%),经术后颌间牵引1个月消除.其X线头影测量结果显示:经正颌正畸联合治疗,硬、软组织测量指标恢复到正常范围内.手术优先模式治疗后的颌骨、牙齿咬合关系的稳定性与传统常规正颌外科模式相近,在术后6个月以上的随访中,SNB角、ANB角平均复发率约为22%、19.8%,复发角度小于2°.结论 先手术后正畸的手术优先治疗模式可以作为多数Angle Ⅲ 类牙颌畸形的治疗方法,但要注意适应证和手术术式的选择.%Objective The purpose of this study was to explore the surgery-first approach in sequential combined orthodontic-orthognathic treatment to shorten total treatment duration and improve the clinical outcome.Methods This study included 185 patients with Angle classⅢ malocclusion.The patients were divided into 3 different types according to cephalometry analyses and facial features .①TypeⅠ: mandibular prognathism or asymmetry mandibular prognathism ;②Type Ⅱ: mandibular prognathism and maxillary retrusion;③Type Ⅲ: mild Angle's Class Ⅲmalocclusion, cross bite in anterior teeth, or normal overlap and overbite relation with midfacial hypoplasia .All of patients received surgery first approach therapy.The surgical procedures were chosen according to different malformation types .TypeⅠ was treated with the sagittal split ramus osteotomy (SSRO).Type Ⅱ was treated by Le Fort Ⅰmaxillary osteotomy combined with SSRO.Type Ⅲ underwent anterior subapical osteotomy combined pyriform aperture augmentation with biomaterials as well as maxillary anterior orthodontics .All patients received postoperative rapid orthodontic treatment for 6 -12 month after 2 weeks of operation.Using the straight arch wire techniques and the class Ⅲintermaxillary traction, we removed the overcrowding upper and lower teeth, the compensatory axial tilt of teeth , and the deviation of the dental arch and maintained the neutral relationship of the molar.The mandible Hawley retaining devices were used during the maintaining stage . Results The cases in study acquired satisfactory clinical outcome , which included the shortened overall treatment duration, the significantly improved facial features , the corrected occlusion relationship , and the restored function of mastication and temporomandibular joint .There were some complications as follows :intraoperative fracture (6 cases,3.24%), the inferior alveolar nerve bundle injury (2 cases,1.1%), and temporary open-bite that diminished by inter-maxillary elastic distraction one month after operation (19 cases, 10%).All cases in this study accepted postoperative orthodontic treatment .Follow-up time ranged from 6 months to 5 years.The cephalometric analysis results of 126 cases who had complete image data and over 6 months of follow-up showed that hard and soft tissue indexes were restored to normal range after combined orthognathic-orthodontic treatment.The stability of the maxillary and occlusive relationship of SFA( surgery-first approach ) was similar to that of the COS ( conventional orthodontics-first system) [relapse ratio=(T2-T1)/(T1-T0) ×100%].Over six months of follow-up , SNB and ANB showed that the average relapse ratio were 22% and 19.8%, whereas the relapse angle are less than 2°. Conclusions The Surgery-first approach could be used to treat most patients with Angle skeletal Class Ⅲmalocclusion, but the indications and the surgical procedures should be noticed and chosen .
