缝牵引成骨矫正面中部骨骼发育不全的基础和临床研究
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摘要
第一部分面缝增龄性变化的实验研究
目的研究兔的前颉缝、鼻额缝、颧颞缝、腭横缝的交错性及纳米弹性性能及其缝的生物力学特性的增龄性变化,为缝牵引成骨技术的临床应用提供实验依据。
方法选取3月龄及6月龄同种日本大耳白兔各8只,切取颧颞缝、鼻额缝、前颌缝及腭横缝组织,观察缝大体交错性并应用原子力显微镜检测缝的微观形貌和生物力学特性,并比较不同年龄组动物之间的差异。
结果缝交错度研究,幼年组ZTS与NFS、ZTS与PMS、NFS与PMS、ZTS与TPS、PMS与TPS之间差异有显著性(p＜0.01)。NFS与TPS之间差异不显著性(p＞0.05)。NFS与TPS＜PMS,NFS与TPS＞ZTS。成年组ZTS与NFS、ZTS与PMS、NFS与PMS、ZTS与TPS、PMS与TPS、NFS与TPS之间差异有显著性(p＜0.01)。PMS＞NFS＞TPS＞ZTS。幼年组和成年组之间比较,NFS、PMS差异有显著性(p＜0.01),而ZTS、TPS在两组之间差异无显著性。随年龄增大NFS和PMS的交错性是增加的。
缝微观形貌研究:幼年组兔的各个面颅骨缝之间的微观形貌不同,ZTS及其对应矿化前缘的表面形貌与PMS、NFS、TPS相比,表面较为平坦。成年组兔的各个面缝之间的微观形貌不同,ZTS、NFS、TPS及其对应矿化前缘的表面形貌与PMS相比,表面较为平坦。成年组兔NFS、TPS及其对应矿化前缘的表面形貌与幼年组对应缝相比较为平坦。
缝及其矿化前缘弹性模量:幼年组缝ZTS与PMS、ZTS与TPS、NFS与PMS、NFS与TPS之间比较差异显著(P＜0.01),ZTS与NFS、PMS与TPS之间比较差异不显著(P＞0.05)。且ZTS和NFS都小于PMS和TPS。幼年组缝矿化前缘弹性模量ZTS-smf与PMS-smf、ZTS-smf与TPS-smf、NFS-smf与PMS-smf、NFS-smf与TPS-smf之间比较差异显著(P＜0.01),ZTS-smf与NFS-smf、PMS-smf与TPS-smf之间比较差异不显著(P＞0.05),且ZTS-smf和NFS-smf都小于PMS-smf和TPS-smf。成年组缝弹性模量ZTS与PMS、ZTS与TPS、NFS与PMS、NFS与TPS之间比较差异显著(P＜0.01),ZTS与NFS、PMS与TPS之间比较差异不显著(P＞0.05),且ZTS和NFS都小于PMS和TPS。成年组缝矿化前缘弹性模量ZTS-smf与PMS-smf、ZTS-smf与TPS-smf、NFS-smf与PMS-smf、NFS-smf与TPS-smf之间比较差异显著(P＜0.01),ZTS-smf与NFS-smf、PMS-smf与TPS-smf之间比较差异不显著(P＞0.05),且ZTS-smf和NFS-smf都小于PMS-smf和TPS-smf。幼年组和成年组相同变量(ZTS、ZTS-SMF、NFS、NFS-SMF、PMS、PMS-SMF、TPS及TPS-SMF)之间比较差异显著(p＜0.01),随着年龄的增加,缝及其矿化前缘的弹性模量是增加的。幼年组和成年组缝及其矿化前缘弹性模量的分布方式基本相同,都是ZTS与NFS小于PMS与TPS。
结论通过应用原子力显微镜可以观察骨缝及其矿化前缘的微观形貌和测定其弹性模量,可以观察到面缝的微观生物力学的增龄性改变,认识缝的生物力学性质和生物学行为对面颅缝生长发育的研究和缝牵引成骨的临床应用具有重要的意义,也可作为必备数据用于数学模型的生物力学模拟。
缝及其矿化前缘的弹性模量与上颌骨抗力中心相关性的研究,进一步支持文献报道的人上颌骨抗力中心的定位。缝形貌粗糙程度与缝弹性模量的大小及其增龄性变化为临床上逢牵引成骨技术的应用提供了实验依据。
第二部分缝牵引矫正唇腭裂病人面中部发育不全的临床应用
目的初步探索钛镍记忆合金牵引系统在缝牵引成骨技术的效能、缝牵引技术在不同年龄段患者的应用、效果评价及其对缝生长发育和腭咽闭合功能的影响。
方法16例患者均为唇腭裂术后面中部发育不全,单侧唇腭裂12例,双侧唇腭裂患者4例,患者年龄最小的10岁,最大者19.5岁,平均12.6岁。采用自行设计制作的钛镍记忆合金牵引系统进行缝牵引成骨治疗。牵引前后进行照相、拍X片、牙模、CT及鼻咽纤维镜检查及测量分析,并进行统计学分析,以进行术前诊断、术后效果评价。
结果共治疗16例患者,其中14例患者完成治疗、且牵引治疗成功,有2例患者已经结束牵引期、正在保持期中。对完成治疗的14例患者进行术后随访,随访时间最短4月多,最长3年多,11例患者效果非常满意,2例患者由于没有过枉矫正、术后保持时间短、保持装置不可靠,术后有轻微复发、前牙恢复到对刃合,不过面型改善效果基本满意。这13例患者术后疗效稳定,通过对术后1年以上的患者跟踪观察揭示出随年龄的增长面中部骨缝具有生长发育潜能,在停止牵引后面中骨骼保持向前协调生长。有1例患者因为固定时间不到1个月,在拆除固定装置同时行唇裂继发畸形矫正术,致术后完全复发。通过腭咽闭合功能检查分析,在牵引中后期患者都有不同程度的腭咽闭合不全存在(除2例外),在保持期结束后,除了术前腭咽闭合不全较严重的患者,都有了不同程度的恢复。对资料完整的10例患者进行牵引前后头影测量分析经自身前后配对t检验,有显著统计学意义。
结论缝牵引成骨术是一种微创、辅助骨骼生长的再生医学技术。通过缝牵引可使缝恢复或具有了生长发育的潜能,在停止牵引后,上颌骨复合体能够随年龄的增长与面部协调生长前移。采用钛镍记忆合金牵引系统进行持续牵引成骨治疗面中部骨骼发育不全具有简单、方便、安全、可靠、效率高、经济的特点,有着良好的应用前景。
PartⅠEffect of Aging on Mechanical Properties of Facial Surures
Objective The aim of the study is to determine the effect of aging on sutural interdigitation and nanomechanical properties of facial suture in order to provide a experimental basis for feasibility of applying sutural distraction osteogenesis in different ages.
Method Using the digital photograghs of the suture specimens to measure the degree of sutural interdigitation and using the atomic force microcopy(AFM) with the nanoindentation method,the nanomechanical properties of four facial sutures-pre -maxillomaxillary(PMS),the nasofrontal(NFS).the zygomatico-temporal(ZTS),the transverse palatine(TPS) -and their corresponding sutural mineralization fronts in two groups of rabbits-3 month-aged and 6 month-aged,were measured and analyzed.
Results The marked differences were found in the degree of sutural interdigitation between ZTS and NES.ZTS and PMS,NFS and PMS.ZTS and TPS.PMS ard TPS(p＜0.01),though no significant differences were found between NFS and TPS in 3 month-aged rabbits(p＞0.05).The degree of sutural interdigitation in NFS and TPS are lower than in PMS.though they are higher than in ZTS,while in 6 month rabbits,there are significant difference between all the four sutures and the relatice relation between them is PMS＞NFS＞TPS＞ZTS.There are marked difference between two groups of rabbit.The sutural interdigitation of NFS and PMS is increased with age,though ZTS and TPS were found no significant change with age.
The topograghic images of four sutures and their corresponding sutural mineralization fronts are different.The topograghic images of 3 month aged rabbits,ZTS and its corresponding sutural mineralization front are smoother than PMS,NFS and TPS.Though in 6 month-aged rabbits.the topograghic images of PMS are rougher than ZTS.NFS and TPS.The NFS and TPS's topograghic images in 6 month-aged rabbits are smoother than 3 month-aged rabbits.
The significant differences were found in the elastic modulus between ZTS and PMS.ZTS and TPS,NFS and PMS.NFS and TPS.though no significant differences were found between ZTS and NFS.PMS and TPS in 3 month-aged rabbits.Also PMS and TPS have higher elastic modulus than ZTS and NFS.The elastic modulus of sutural mineralization fronts followed the same distribution pattern as the elastic modulus of their corresponding sutures in 3 month-aged rabbits.The elastic modulus of sutures and their corresponding sutural mineralization fronts in 6 month-aged rabbits followed the same distribution pattern as the elastic modulus in 3 month-aged rabbits.The elastic modulus of the four facial and their corresponding sutural mineralization fronts in 6 month-aged group are higher than in 3 month-aged group.The average elastic modulus of the sutural mineralization fronts were significantly higher than their corresponding sutures in two groups.
Conclusion Using the atomic force microscope can measure the topographic and nanoelastic property of the facial suture in a more natural way which helping us to research the biomechanical properties of the sutures.The elastic modulus of sutures and their corresponding sutural mineralization fronts were measured in order to investigate the relationship between them and the resistance center of maxilla.The changes of aging on the characteristics of the topographic and the elastic modulus of the suture may provide a experimental basis for feasibility of applying sutural distraction osteogenesis in different ages.
PartⅡSutural Distraction Osteogenesis(SDO) for Midfacial Advancement in the Cleft lip and palate Patients With Maxillary Hypoplasia:Clinical study
Objective The preliminary research for applying niti-shaped memorial alloy distraction system for sutural distraction osteogenesis of midfacial advancement at different ages and efficacy evaluation.
Methods we design springs and hooks made of niti-shaped memorial alloy and use the rigid external distracting device and continuous sutural distraction technical to treat 16 patients with midface hypoplasia after cleft lip and palate operation.12 patients are UCLP and 4 patients are BCLP.The average age of the patients is 12.6(10～19.5).We taked the photos,x-ray for cephalometry,CT,dental cast and nasopharyngeal fiberscope to evaluate the result after distraction and also evaluate the effects of treatment by statistical analysis.
Results In our clinical study,14 patients were successfully teated with this technique.2 patients are still in the retention period.The follow-up period of these 14 patients is from 4 month to 3 years.13/14 patients achieved satisfactory face contour and normal occlusal relationship,but 2/14 patients have a slightly relapse with the anterior teeth turning into edge-to-edge occlusion within the follow-up period because of not enough over correction and short retention period or unstable retention device.We found the mid-face bone can maintain growing potential and continuously grom forward within the 1-year follow-up period.Only 1/14 patient had a totally relapse because of only 1 month retention for the first reason.The second reason is the patient underwent operation of correction for the secondar deformity of CLP at the same time when the RED is removed.The velopharyngeal function is evaluated after treatment and We found all but 2 patients had different degree of velopharyngeal insufficiency in the midanaphase of treatment which have different degree of recovery after retention period.There are significant statistical differences in any of the outcome measures of cephalometry between pre-treatment and post-treatment in 10/14 patients.
Conclusions The sutural distraction osteogenesis is a kind of less invasive. accessory skeleton growth regenerative technique.Using the niti-shaped memorial alloy distraction system to cure the midface displasia deformity of the CLP patients,it can offer the opportunity for patients to correct the midface hypoplasia with a more simple,safer and effective method.
目的研究兔的前颉缝、鼻额缝、颧颞缝、腭横缝的交错性及纳米弹性性能及其缝的生物力学特性的增龄性变化,为缝牵引成骨技术的临床应用提供实验依据。
方法选取3月龄及6月龄同种日本大耳白兔各8只,切取颧颞缝、鼻额缝、前颌缝及腭横缝组织,观察缝大体交错性并应用原子力显微镜检测缝的微观形貌和生物力学特性,并比较不同年龄组动物之间的差异。
结果缝交错度研究,幼年组ZTS与NFS、ZTS与PMS、NFS与PMS、ZTS与TPS、PMS与TPS之间差异有显著性(p＜0.01)。NFS与TPS之间差异不显著性(p＞0.05)。NFS与TPS＜PMS,NFS与TPS＞ZTS。成年组ZTS与NFS、ZTS与PMS、NFS与PMS、ZTS与TPS、PMS与TPS、NFS与TPS之间差异有显著性(p＜0.01)。PMS＞NFS＞TPS＞ZTS。幼年组和成年组之间比较,NFS、PMS差异有显著性(p＜0.01),而ZTS、TPS在两组之间差异无显著性。随年龄增大NFS和PMS的交错性是增加的。
缝微观形貌研究:幼年组兔的各个面颅骨缝之间的微观形貌不同,ZTS及其对应矿化前缘的表面形貌与PMS、NFS、TPS相比,表面较为平坦。成年组兔的各个面缝之间的微观形貌不同,ZTS、NFS、TPS及其对应矿化前缘的表面形貌与PMS相比,表面较为平坦。成年组兔NFS、TPS及其对应矿化前缘的表面形貌与幼年组对应缝相比较为平坦。
缝及其矿化前缘弹性模量:幼年组缝ZTS与PMS、ZTS与TPS、NFS与PMS、NFS与TPS之间比较差异显著(P＜0.01),ZTS与NFS、PMS与TPS之间比较差异不显著(P＞0.05)。且ZTS和NFS都小于PMS和TPS。幼年组缝矿化前缘弹性模量ZTS-smf与PMS-smf、ZTS-smf与TPS-smf、NFS-smf与PMS-smf、NFS-smf与TPS-smf之间比较差异显著(P＜0.01),ZTS-smf与NFS-smf、PMS-smf与TPS-smf之间比较差异不显著(P＞0.05),且ZTS-smf和NFS-smf都小于PMS-smf和TPS-smf。成年组缝弹性模量ZTS与PMS、ZTS与TPS、NFS与PMS、NFS与TPS之间比较差异显著(P＜0.01),ZTS与NFS、PMS与TPS之间比较差异不显著(P＞0.05),且ZTS和NFS都小于PMS和TPS。成年组缝矿化前缘弹性模量ZTS-smf与PMS-smf、ZTS-smf与TPS-smf、NFS-smf与PMS-smf、NFS-smf与TPS-smf之间比较差异显著(P＜0.01),ZTS-smf与NFS-smf、PMS-smf与TPS-smf之间比较差异不显著(P＞0.05),且ZTS-smf和NFS-smf都小于PMS-smf和TPS-smf。幼年组和成年组相同变量(ZTS、ZTS-SMF、NFS、NFS-SMF、PMS、PMS-SMF、TPS及TPS-SMF)之间比较差异显著(p＜0.01),随着年龄的增加,缝及其矿化前缘的弹性模量是增加的。幼年组和成年组缝及其矿化前缘弹性模量的分布方式基本相同,都是ZTS与NFS小于PMS与TPS。
结论通过应用原子力显微镜可以观察骨缝及其矿化前缘的微观形貌和测定其弹性模量,可以观察到面缝的微观生物力学的增龄性改变,认识缝的生物力学性质和生物学行为对面颅缝生长发育的研究和缝牵引成骨的临床应用具有重要的意义,也可作为必备数据用于数学模型的生物力学模拟。
缝及其矿化前缘的弹性模量与上颌骨抗力中心相关性的研究,进一步支持文献报道的人上颌骨抗力中心的定位。缝形貌粗糙程度与缝弹性模量的大小及其增龄性变化为临床上逢牵引成骨技术的应用提供了实验依据。
第二部分缝牵引矫正唇腭裂病人面中部发育不全的临床应用
目的初步探索钛镍记忆合金牵引系统在缝牵引成骨技术的效能、缝牵引技术在不同年龄段患者的应用、效果评价及其对缝生长发育和腭咽闭合功能的影响。
方法16例患者均为唇腭裂术后面中部发育不全,单侧唇腭裂12例,双侧唇腭裂患者4例,患者年龄最小的10岁,最大者19.5岁,平均12.6岁。采用自行设计制作的钛镍记忆合金牵引系统进行缝牵引成骨治疗。牵引前后进行照相、拍X片、牙模、CT及鼻咽纤维镜检查及测量分析,并进行统计学分析,以进行术前诊断、术后效果评价。
结果共治疗16例患者,其中14例患者完成治疗、且牵引治疗成功,有2例患者已经结束牵引期、正在保持期中。对完成治疗的14例患者进行术后随访,随访时间最短4月多,最长3年多,11例患者效果非常满意,2例患者由于没有过枉矫正、术后保持时间短、保持装置不可靠,术后有轻微复发、前牙恢复到对刃合,不过面型改善效果基本满意。这13例患者术后疗效稳定,通过对术后1年以上的患者跟踪观察揭示出随年龄的增长面中部骨缝具有生长发育潜能,在停止牵引后面中骨骼保持向前协调生长。有1例患者因为固定时间不到1个月,在拆除固定装置同时行唇裂继发畸形矫正术,致术后完全复发。通过腭咽闭合功能检查分析,在牵引中后期患者都有不同程度的腭咽闭合不全存在(除2例外),在保持期结束后,除了术前腭咽闭合不全较严重的患者,都有了不同程度的恢复。对资料完整的10例患者进行牵引前后头影测量分析经自身前后配对t检验,有显著统计学意义。
结论缝牵引成骨术是一种微创、辅助骨骼生长的再生医学技术。通过缝牵引可使缝恢复或具有了生长发育的潜能,在停止牵引后,上颌骨复合体能够随年龄的增长与面部协调生长前移。采用钛镍记忆合金牵引系统进行持续牵引成骨治疗面中部骨骼发育不全具有简单、方便、安全、可靠、效率高、经济的特点,有着良好的应用前景。
PartⅠEffect of Aging on Mechanical Properties of Facial Surures
Objective The aim of the study is to determine the effect of aging on sutural interdigitation and nanomechanical properties of facial suture in order to provide a experimental basis for feasibility of applying sutural distraction osteogenesis in different ages.
Method Using the digital photograghs of the suture specimens to measure the degree of sutural interdigitation and using the atomic force microcopy(AFM) with the nanoindentation method,the nanomechanical properties of four facial sutures-pre -maxillomaxillary(PMS),the nasofrontal(NFS).the zygomatico-temporal(ZTS),the transverse palatine(TPS) -and their corresponding sutural mineralization fronts in two groups of rabbits-3 month-aged and 6 month-aged,were measured and analyzed.
Results The marked differences were found in the degree of sutural interdigitation between ZTS and NES.ZTS and PMS,NFS and PMS.ZTS and TPS.PMS ard TPS(p＜0.01),though no significant differences were found between NFS and TPS in 3 month-aged rabbits(p＞0.05).The degree of sutural interdigitation in NFS and TPS are lower than in PMS.though they are higher than in ZTS,while in 6 month rabbits,there are significant difference between all the four sutures and the relatice relation between them is PMS＞NFS＞TPS＞ZTS.There are marked difference between two groups of rabbit.The sutural interdigitation of NFS and PMS is increased with age,though ZTS and TPS were found no significant change with age.
The topograghic images of four sutures and their corresponding sutural mineralization fronts are different.The topograghic images of 3 month aged rabbits,ZTS and its corresponding sutural mineralization front are smoother than PMS,NFS and TPS.Though in 6 month-aged rabbits.the topograghic images of PMS are rougher than ZTS.NFS and TPS.The NFS and TPS's topograghic images in 6 month-aged rabbits are smoother than 3 month-aged rabbits.
The significant differences were found in the elastic modulus between ZTS and PMS.ZTS and TPS,NFS and PMS.NFS and TPS.though no significant differences were found between ZTS and NFS.PMS and TPS in 3 month-aged rabbits.Also PMS and TPS have higher elastic modulus than ZTS and NFS.The elastic modulus of sutural mineralization fronts followed the same distribution pattern as the elastic modulus of their corresponding sutures in 3 month-aged rabbits.The elastic modulus of sutures and their corresponding sutural mineralization fronts in 6 month-aged rabbits followed the same distribution pattern as the elastic modulus in 3 month-aged rabbits.The elastic modulus of the four facial and their corresponding sutural mineralization fronts in 6 month-aged group are higher than in 3 month-aged group.The average elastic modulus of the sutural mineralization fronts were significantly higher than their corresponding sutures in two groups.
Conclusion Using the atomic force microscope can measure the topographic and nanoelastic property of the facial suture in a more natural way which helping us to research the biomechanical properties of the sutures.The elastic modulus of sutures and their corresponding sutural mineralization fronts were measured in order to investigate the relationship between them and the resistance center of maxilla.The changes of aging on the characteristics of the topographic and the elastic modulus of the suture may provide a experimental basis for feasibility of applying sutural distraction osteogenesis in different ages.
PartⅡSutural Distraction Osteogenesis(SDO) for Midfacial Advancement in the Cleft lip and palate Patients With Maxillary Hypoplasia:Clinical study
Objective The preliminary research for applying niti-shaped memorial alloy distraction system for sutural distraction osteogenesis of midfacial advancement at different ages and efficacy evaluation.
Methods we design springs and hooks made of niti-shaped memorial alloy and use the rigid external distracting device and continuous sutural distraction technical to treat 16 patients with midface hypoplasia after cleft lip and palate operation.12 patients are UCLP and 4 patients are BCLP.The average age of the patients is 12.6(10～19.5).We taked the photos,x-ray for cephalometry,CT,dental cast and nasopharyngeal fiberscope to evaluate the result after distraction and also evaluate the effects of treatment by statistical analysis.
Results In our clinical study,14 patients were successfully teated with this technique.2 patients are still in the retention period.The follow-up period of these 14 patients is from 4 month to 3 years.13/14 patients achieved satisfactory face contour and normal occlusal relationship,but 2/14 patients have a slightly relapse with the anterior teeth turning into edge-to-edge occlusion within the follow-up period because of not enough over correction and short retention period or unstable retention device.We found the mid-face bone can maintain growing potential and continuously grom forward within the 1-year follow-up period.Only 1/14 patient had a totally relapse because of only 1 month retention for the first reason.The second reason is the patient underwent operation of correction for the secondar deformity of CLP at the same time when the RED is removed.The velopharyngeal function is evaluated after treatment and We found all but 2 patients had different degree of velopharyngeal insufficiency in the midanaphase of treatment which have different degree of recovery after retention period.There are significant statistical differences in any of the outcome measures of cephalometry between pre-treatment and post-treatment in 10/14 patients.
Conclusions The sutural distraction osteogenesis is a kind of less invasive. accessory skeleton growth regenerative technique.Using the niti-shaped memorial alloy distraction system to cure the midface displasia deformity of the CLP patients,it can offer the opportunity for patients to correct the midface hypoplasia with a more simple,safer and effective method.
引文
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