徐雪楊超劉坤黃寧鄭謙石冰

1.口腔疾病研究國(guó)家重點(diǎn)實(shí)驗(yàn)室 華西口腔醫(yī)院唇腭裂外科（四川大學(xué)）；2.正畸科 成都 610041

牙槽突裂治療方法的研究進(jìn)展

徐雪1楊超1劉坤1黃寧2鄭謙1石冰1

1.口腔疾病研究國(guó)家重點(diǎn)實(shí)驗(yàn)室 華西口腔醫(yī)院唇腭裂外科（四川大學(xué)）；2.正畸科 成都 610041

牙槽突裂整復(fù)術(shù)現(xiàn)已成為唇腭裂序列治療的重要環(huán)節(jié)，上頜骨裂隙骨移植在20世紀(jì)初就已提出，但至今，對(duì)牙槽突裂的治療方法仍存在許多爭(zhēng)議，本文就牙槽突裂整復(fù)術(shù)的手術(shù)時(shí)機(jī)、植入物選擇、手術(shù)方法、術(shù)前術(shù)后正畸干預(yù)等方面的研究進(jìn)展作一綜述。

牙槽突裂； 植骨術(shù)； 手術(shù)

自1901年，Eiselsberg首次報(bào)道應(yīng)用自體小指指骨修復(fù)牙槽突裂以來(lái)，各國(guó)學(xué)者[1-6]均開(kāi)始對(duì)牙槽突裂整復(fù)術(shù)進(jìn)行研究，先后提出了初期牙槽突裂植骨及牙齦骨膜成形術(shù)，由于這2種整復(fù)方法均影響上頜骨生長(zhǎng)發(fā)育，故許多學(xué)者不再使用這2種方法。直到20世紀(jì)70年代，Boyne和Sands[7-8]提出了移植髂骨松質(zhì)骨來(lái)修復(fù)牙槽突裂，并提出植骨手術(shù)一定要在尖牙萌出前，且用自體髂骨松質(zhì)骨。Boyne和Sands[8]用該方法治療了10例患者，發(fā)現(xiàn)植骨術(shù)后有正常的牙槽間隔形成，尖牙萌出，并可通過(guò)正畸將尖牙調(diào)整到正常位置。另有其他治療中心[9-14]使用該方法，也取得了較好的效果。自此，在混合牙列期移植髂骨的骨松質(zhì)來(lái)修補(bǔ)牙槽突裂，被廣泛使用[15]。

牙槽突裂整復(fù)術(shù)現(xiàn)已成為唇腭裂序列治療的重要環(huán)節(jié)。上頜骨裂隙骨移植在 20 世紀(jì)初就已提出，但半個(gè)世紀(jì)后才被廣泛認(rèn)識(shí)[16]。至今，對(duì)牙

槽突裂的治療方法仍存在許多爭(zhēng)議，本文就牙槽突裂整復(fù)術(shù)的手術(shù)時(shí)機(jī)、植入物選擇、手術(shù)方法、術(shù)前術(shù)后正畸干預(yù)等方面的研究進(jìn)展作一綜述。

1 手術(shù)時(shí)機(jī)

由于行一期植骨的單側(cè)唇腭裂患者的大部分植入骨被吸收，牙槽突仍存在裂隙，上頜骨的生長(zhǎng)受到抑制，患者前牙反和面中份凹陷畸形的比例較高[17]，故多數(shù)學(xué)者不提倡一期植骨。

現(xiàn)學(xué)者[18]普遍認(rèn)同在恒牙列建立過(guò)程中，面中1/3發(fā)育完成后，年齡在9~11歲，恒尖牙萌出前，尖牙牙根已形成1/2~3/4時(shí)，行牙槽突裂植骨術(shù)。此時(shí)植骨后裂隙兩側(cè)的尖牙或側(cè)切牙萌出，牙齒萌出和咬合刺激植入骨質(zhì)，減少移植骨的吸收；上頜骨橫向及縱向生長(zhǎng)迅速階段發(fā)生在6~7歲，8歲時(shí)頜骨前部橫向和矢狀向的生長(zhǎng)已基本結(jié)束，8歲以后進(jìn)行植骨手術(shù)，不會(huì)對(duì)上頜骨的生長(zhǎng)發(fā)育產(chǎn)生不良影響[19]。

近些年學(xué)者提出，可將牙槽突裂植骨年齡提前到5~7歲[20]，在中切牙和側(cè)切牙萌出前進(jìn)行，從而為中切牙和側(cè)切牙的萌出提供骨支持[21-23]，但提前行植骨手術(shù)是否會(huì)影響上頜骨發(fā)育，目前還沒(méi)有足夠的研究。

2 植入材料的選擇

牙槽突裂植入骨質(zhì)通常采用自體骨，如髂骨、顱骨、下頜骨、脛骨、肋骨，也有使用異體胚胎骨和生物材料的報(bào)道。適宜供區(qū)的選擇取決于供骨成活和尖牙在植骨區(qū)萌出的難易程度。目前仍首選髂骨作為供骨區(qū)，因?yàn)轺墓怯胸S富的純粹骨松質(zhì)的骨源，顆粒狀骨松質(zhì)比塊狀骨松質(zhì)移植表面積大，接觸面大，有利于術(shù)后血管化，其取骨方法也較簡(jiǎn)便。

使用自體骨移植，組織相容性好，但對(duì)于移植骨供區(qū)有一定的損害。近年來(lái)，學(xué)者們對(duì)牙槽突裂植入骨的替代品及生物材料做了很多研究。這些替代品及生物材料的應(yīng)用可縮短手術(shù)時(shí)間，減少對(duì)患者的損害及其并發(fā)癥的發(fā)生。

Nique等[24]應(yīng)用異體骨治療牙槽突裂，術(shù)后牙槽突裂隙處出現(xiàn)骨性連接，術(shù)前未萌出的牙齒長(zhǎng)入移植骨內(nèi)。有學(xué)者嘗試采用凍干異體骨、脫鈣異體骨以及羥磷灰石、磷酸三鈣等生物材料取代自體骨，并取得較為滿意的效果。但另有學(xué)者認(rèn)為，凍干骨存在延遲創(chuàng)口愈合、使骨移植材料部分丟失以及使前頜骨不穩(wěn)定性延長(zhǎng)等并發(fā)癥。

在自體移植骨中加入各種生長(zhǎng)因子，能有效減少骨吸收、促進(jìn)骨生長(zhǎng)。Segura-Castillo等[25]在植入的自體骨中加入纖維蛋白黏合劑，3個(gè)月后骨吸收率較對(duì)照組低，且骨密度較高。Carstens等[26]和Chin等[27]在髂骨的骨松質(zhì)中加入重組人骨形態(tài)發(fā)生蛋白-2（recombinated human bone morphogenetic protein-2，rhBMP-2）后發(fā)現(xiàn)，絕大多數(shù)患者裂隙區(qū)形成了骨聯(lián)合，新骨可行使與自身正常骨相同的功能，可促使天然牙萌出和正畸牙移動(dòng)，且新骨具有與天然骨相同的結(jié)構(gòu)。骨形態(tài)發(fā)生蛋白（bone morphogenetic protein，BMP）在體內(nèi)促進(jìn)人骨髓間充質(zhì)細(xì)胞分化的能力遠(yuǎn)大于在體外，且將高質(zhì)量濃度的BMP置于羥磷灰石支架材料上，促進(jìn)骨形成的作用更強(qiáng)[28]。由于rhBMP-2誘導(dǎo)的骨再生過(guò)程將由周圍組織的血管提供營(yíng)養(yǎng)，所以血供及缺損范圍對(duì)這一技術(shù)的應(yīng)用效果有很大的影響[26]。BMP具有異位成骨性，加大劑量后會(huì)促進(jìn)局部的血液循環(huán)，從而在術(shù)后早期加劇腫脹的不良反應(yīng)，所以BMP在生長(zhǎng)發(fā)育期的患者中應(yīng)慎用。BMP臨床應(yīng)用的時(shí)間相對(duì)較短，其長(zhǎng)期的致瘤性等不良反應(yīng)尚不清楚[29]。

1998年，Marx等[30]首次將富含血小板的血漿（platelet-rich plasma，PRP）技術(shù)用于腫瘤術(shù)后患者的下頜重建。2011年，Marukawa等[31]將PRP混合骨松質(zhì)以及骨髓，移植修復(fù)了14例牙槽突裂患者，結(jié)果表明，PRP能促進(jìn)骨再生，PRP混合植骨患者的骨質(zhì)吸收明顯低于單純骨松質(zhì)移植患者。PRP能促進(jìn)骨修復(fù)主要是由其釋放的多種高濃度生長(zhǎng)因子的聯(lián)合作用所致。PRP來(lái)源于自體，制取容易，富含大量生長(zhǎng)因子，在凝血酶作用下易生成凝膠，形成的三維凝膠纖維成為骨誘導(dǎo)的支架結(jié)構(gòu)，提供細(xì)胞生長(zhǎng)以及成骨分化的細(xì)胞外基質(zhì)，為骨成熟提供良好的環(huán)境。

使用患者自身骨髓基質(zhì)干細(xì)胞（bone marrow derived stroma cell，BMSC）修復(fù)牙槽突裂，可以在體內(nèi)形成穩(wěn)定的組織工程化骨組織，無(wú)明顯的骨吸收現(xiàn)象，臨床治療效果穩(wěn)定[32]，且減少了患者的創(chuàng)傷及術(shù)后疼痛。BMSC亦已應(yīng)用于臨床修復(fù)牙槽裂骨缺損[33-34]。

組織工程支架材料為細(xì)胞在裂隙區(qū)的生長(zhǎng)、分化、黏附、移行提供了支架。理想的支架材料應(yīng)具有良好的生物相容性和降解性，能引導(dǎo)成骨細(xì)胞和血管長(zhǎng)入，具有良好的骨傳導(dǎo)作用和一定的骨誘導(dǎo)作用，多孔結(jié)構(gòu)能適應(yīng)一定范圍的應(yīng)力變化。羥磷灰石有較好的生物相容性，能促進(jìn)骨祖細(xì)胞分化為成骨細(xì)胞[35]，但由于其不可吸收并缺乏形變，會(huì)妨礙牙的萌出及正畸治療所需要的骨移動(dòng)[27，36]，愈合期受力時(shí)容易移位[37]。用生物活性玻璃類材料修復(fù)牙槽突裂，術(shù)后尖牙可向移植區(qū)移動(dòng)萌出[38]，但有些病例的移植人工骨材料與自體骨界限明顯，未能很好地融合。此外，也有用其他支架材料，如PRP中的纖維蛋白原、可吸收牛膠原基質(zhì)[39]、β-磷酸三鈣陶瓷（tricalcium phosphate ceramic，TCPC）[40]等修復(fù)牙槽突裂的病例報(bào)道。人工合成的多聚物的代謝產(chǎn)物影響細(xì)胞代謝，易導(dǎo)致植骨區(qū)炎癥及支架過(guò)早降解。

3 牙槽突裂手術(shù)方法進(jìn)展

各手術(shù)方法的不同主要集中在瓣的設(shè)計(jì)上，相同的是要將帶有附著齦的黏骨膜瓣覆蓋在植骨區(qū)邊緣，因?yàn)檫@樣可為裂隙區(qū)附近牙齒提供正常的牙周環(huán)境。常用的牙槽突裂植骨術(shù)有Turvey等[10]的唇側(cè)和腭側(cè)雙切口術(shù)式和Abyholm等[9]的唇側(cè)單切口術(shù)式。目前，國(guó)內(nèi)外常用的牙槽突裂植骨術(shù)切口設(shè)計(jì)存在以下不足：1）牙槽骨斷端腭側(cè)骨邊緣暴露不充分；2）唇側(cè)黏膜剩余組織量少，需要大范圍松弛切口，減張縫合或利用轉(zhuǎn)移瓣關(guān)閉創(chuàng)面；3）牙槽突植骨床鼻底平面和腭側(cè)平面交界處暴露不充分；4）植骨術(shù)后裂隙處前庭溝變淺，紅唇變短。故楊超和石冰[41]于2012年提出了腭側(cè)入路修復(fù)牙槽突裂的術(shù)式：沿牙槽突腭側(cè)裂隙兩側(cè)做切口，再?gòu)碾駛?cè)裂隙牙槽嵴頂沿兩側(cè)齦乳頭做水平切口，在裂隙兩側(cè)形成2個(gè)蒂在后的腭瓣；沿裂隙牙槽突裂兩端唇側(cè)附著齦向兩側(cè)做水平切開(kāi)約2個(gè)牙位，并將唇側(cè)切口與腭側(cè)切口在牙槽突頂聯(lián)通；在牙槽突裂隙斷端側(cè)壁，自前下至后上切開(kāi)，形成2個(gè)蒂在后的裂隙鼻腔瓣。腭瓣關(guān)閉腭側(cè)裂隙，唇瓣關(guān)閉唇側(cè)裂隙，兩側(cè)鼻腔瓣向上翻轉(zhuǎn)關(guān)閉鼻底，縫合裂隙兩側(cè)腭瓣和唇瓣尖端以關(guān)閉牙槽突裂面，形成理想的梯形袋。楊超等[42]認(rèn)為該術(shù)式有如下優(yōu)點(diǎn)：1）無(wú)張力狀態(tài)下關(guān)閉裂隙；2）唇側(cè)輔助切口范圍局限，避免損傷牙胚；3）植骨范圍暴露充分，植入骨量充分，避免唇腭側(cè)黏膜組織對(duì)植入骨的擠壓；4）解剖范圍局限，不會(huì)改變唇系帶附著的位置，不會(huì)出現(xiàn)前庭溝變淺，紅唇變短的現(xiàn)象。

隨著學(xué)者們對(duì)牙槽突裂植入骨的替代品及生物材料研究的不斷深入，許多骨替代品及生物材料相繼應(yīng)用于臨床治療。用骨替代品及生物材料修復(fù)牙槽突裂與用自體骨修復(fù)牙槽突裂的區(qū)別在于，自體骨取出后直接移植入牙槽突裂隙區(qū)，而骨替代品及生物材料需行植入前的預(yù)處理。目前常用的是rhBMP-2和組織工程成骨材料（tissueengineered osteogenic material，TEOM）。

以rhBMP-2修復(fù)牙槽突裂需用載體，現(xiàn)載體常為膠原海綿。將rhBMP-2與蒸餾水混合成1.5 g·L-1的濃度，將膠原海綿浸入該溶液20 min[29，43]，膠原海綿中含3.2~4.2 mg rhBMP-2[44]，然后將浸有rhBMP-2的膠原海綿置于牙槽突裂隙內(nèi)，關(guān)閉軟組織，封閉裂隙。也有報(bào)道[45]在術(shù)前3 h將rhBMP-2制成50 μg·mL-1或250 μg·mL-1的凝膠，于4 ℃保存?zhèn)溆茫g(shù)中植入牙槽突裂隙。美國(guó)食品藥品監(jiān)督管理局已批準(zhǔn)將其應(yīng)用于臨床[46]。

TEOM由PRP和自體間質(zhì)干細(xì)胞組成[34]，PRP中含血小板衍生生長(zhǎng)因子（platelet-derived growth factor，PDGF）、胰島素樣生長(zhǎng)因子（insulin-like growth factor，IGF）、成纖維細(xì)胞生長(zhǎng)因子（fibroblast growth factor，F(xiàn)GF）、內(nèi)皮細(xì)胞生長(zhǎng)因子、表皮生長(zhǎng)因子等眾多生長(zhǎng)因子[47]，可以誘導(dǎo)骨形成，從全血中提取PRP，術(shù)前將PRP與骨髓基質(zhì)細(xì)胞（marrow stroma cell，MSC）和氯化鈣混合成凝膠，術(shù)中將該凝膠與髂骨骨松質(zhì)混合，植入牙槽突裂隙區(qū)，上覆PRP膜，關(guān)閉軟組織，手術(shù)完成。

4 術(shù)前術(shù)后正畸干預(yù)

在20世紀(jì)，學(xué)者們普遍認(rèn)為牙槽突裂植骨術(shù)前應(yīng)行術(shù)前擴(kuò)弓，然后行牙槽突裂植骨手術(shù)，術(shù)后植入骨可穩(wěn)定擴(kuò)弓后不穩(wěn)定的上頜骨弓，并防止骨段塌陷[48-51]，且術(shù)前擴(kuò)弓可減少尖牙阻生概率。對(duì)牙槽突裂兩斷端錯(cuò)位的患者，應(yīng)術(shù)前糾正錯(cuò)位的骨段[52]，因?yàn)樾g(shù)后很難將錯(cuò)位的骨段調(diào)整到正常位置。有研究[53]表明，行牙槽突裂植骨術(shù)前擴(kuò)弓的患者，植骨成功率高達(dá)91％。近來(lái)，有學(xué)者[22]提倡術(shù)后行擴(kuò)弓，而術(shù)前不擴(kuò)弓，因?yàn)樾g(shù)后擴(kuò)弓產(chǎn)生的力可以對(duì)植骨塊產(chǎn)生牽拉作用，更有利于植入骨的成活及成骨。且術(shù)前擴(kuò)弓導(dǎo)致的裂隙越寬，就需要越多的骨組織和軟組織封閉裂隙，使植骨的成功率難以保證。而對(duì)于雙側(cè)完全性唇裂伴腭裂及牙槽突裂的患者，術(shù)前應(yīng)用弓絲來(lái)穩(wěn)定前頜骨，術(shù)中將弓絲取下，術(shù)畢再將弓絲重新放入以穩(wěn)定前頜骨[54]。

由于裂隙側(cè)切牙可能向裂隙內(nèi)傾斜而影響植骨術(shù)入路，故應(yīng)在術(shù)前4~5個(gè)月行術(shù)前正畸以糾正傾斜的切牙，為手術(shù)提供良好的入路。但也有學(xué)者認(rèn)為，術(shù)前不需移動(dòng)裂隙附近的牙齒，因?yàn)榱严秴^(qū)附近的牙齒牙根周圍骨質(zhì)菲薄，移動(dòng)牙齒易導(dǎo)致骨開(kāi)裂或骨開(kāi)窗，而術(shù)后移動(dòng)裂隙區(qū)附近牙齒對(duì)植入骨的刺激，利于植入骨成活及成骨，且不會(huì)導(dǎo)致牙根移出牙槽骨外。

對(duì)于術(shù)后開(kāi)始正畸治療的時(shí)間，各學(xué)者看法并未統(tǒng)一。一般認(rèn)為牙槽突裂術(shù)后應(yīng)用正畸方法繼續(xù)穩(wěn)定牙弓3~6個(gè)月，再行正畸牽引或擴(kuò)弓治療。但Craven等[55]認(rèn)為，植骨術(shù)后穩(wěn)定牙弓6周即可行正畸牽引，此時(shí)若尖牙未正位萌出，則正畸牽引尖牙至裂隙區(qū)植骨處。Precious[22]認(rèn)為，應(yīng)在術(shù)后2~3月再行正畸擴(kuò)弓。da Silva Filho等[52]和Habel等[56]認(rèn)為，術(shù)后用弓絲穩(wěn)定牙弓3個(gè)月，然后才可行正畸治療。

5 牙槽突裂植骨術(shù)后的效果評(píng)價(jià)及評(píng)價(jià)指標(biāo)

植骨術(shù)療效評(píng)價(jià)主要是從植骨區(qū)骨量恢復(fù)的情況、鼻唇外形的矯正程度、尖牙向植骨區(qū)移動(dòng)萌出情況、口鼻瘺關(guān)閉情況和植骨部位唇頰溝深度等方面進(jìn)行。在這些評(píng)價(jià)指標(biāo)中，裂隙處的骨量恢復(fù)情況是最重要的指標(biāo)，現(xiàn)一般采用二維影像學(xué)方法進(jìn)行評(píng)價(jià)[57]。

Bergland等[11]于1986年提出通過(guò)比較植入牙槽骨間隙的高度與正常牙槽骨高度的比例來(lái)評(píng)價(jià)植骨效果，分為：Ⅰ型，與正常牙槽嵴高度一致；Ⅱ型，達(dá)到正常牙槽嵴高度的3/4以上；Ⅲ型，少于正常牙槽嵴高度的3/4；Ⅳ型，缺損區(qū)無(wú)骨橋形成。這一方法是現(xiàn)在被廣泛接受的金標(biāo)準(zhǔn)，但該方法對(duì)鼻底部植骨評(píng)價(jià)不足，于是Hynes 和Earley[58]對(duì)Bergland標(biāo)準(zhǔn)進(jìn)行改進(jìn)，提出了改良的Bergland評(píng)價(jià)標(biāo)準(zhǔn)為：Ⅰ型為正常牙槽嵴高度，Ⅱ型為植入骨的牙槽嵴高度達(dá)到總的牙槽高度（即鼻底到釉牙骨質(zhì)界的高度）的3/4以上，Ⅲ型為植入骨的牙槽嵴高度少于總的牙槽高度（即鼻底到釉牙骨質(zhì)界的高度）的3/4，Ⅳ型為牙槽突裂裂隙內(nèi)沒(méi)有植入骨的骨橋存在。

Witherow等[59]認(rèn)為，Bergland的評(píng)價(jià)方法過(guò)于依賴尖牙的萌出，于是針對(duì)尖牙未完全萌出的混合牙列期患者提出了Chelsea標(biāo)準(zhǔn)，根據(jù)植骨的位置以及骨量，分為6級(jí)：A，裂隙區(qū)近遠(yuǎn)中牙體釉牙骨質(zhì)界間有骨橋形成，且75％以上根面被骨質(zhì)覆蓋；B，裂隙區(qū)近遠(yuǎn)中牙體釉牙骨質(zhì)界間有骨橋形成，且從釉牙骨質(zhì)界起25％以上根面被骨質(zhì)覆蓋；C，裂隙區(qū)從根方起至少75％根面有骨橋形成；D，裂隙區(qū)從根方起至少50％根面有骨橋形成；E，裂隙區(qū)根方或冠方無(wú)骨橋形成，僅中份有骨橋存在；F，裂隙區(qū)從根方起僅25％或少于25％根面有骨橋形成。該方法可在混合牙列期對(duì)裂隙部位牙槽突高度及形態(tài)進(jìn)行評(píng)估，同時(shí)對(duì)于骨橋的具體位置及量進(jìn)行記錄。但也有學(xué)者認(rèn)為，裂隙部位鄰近牙根面所覆蓋骨質(zhì)，尤其是近中中切牙根面覆蓋骨質(zhì)，多為天然骨，而非移植骨，這些骨給植骨術(shù)的評(píng)估帶來(lái)一定的誤差。

牙片、咬合片及全景片等二維檢查方法均無(wú)統(tǒng)一標(biāo)準(zhǔn)，投照角度無(wú)法固定，易使圖像放大畸變，許多解剖結(jié)構(gòu)重疊，難以判斷結(jié)構(gòu)間的三維關(guān)系，無(wú)法反映術(shù)后骨質(zhì)空間及體積的變化，而且二維影像學(xué)檢查往往夸大了植骨的效果[60-62]。于是，近年出現(xiàn)了以三維CT為媒介來(lái)判定牙槽突裂植骨術(shù)后效果。

如何進(jìn)行CT測(cè)量，目前尚無(wú)公認(rèn)的方法。van der Meij等[63-64]對(duì)患者裂隙部位進(jìn)行CT掃描，并根據(jù)骨性解剖標(biāo)志從裂隙中心區(qū)域選定3個(gè)層面，將該3個(gè)層面術(shù)后即刻圖像與術(shù)后1年影像相比較，通過(guò)影像面積變化計(jì)算術(shù)后1年移植骨的存留比例，以評(píng)價(jià)植骨術(shù)的療效。Feichtinger等[65]和Kawakami等[66]亦采用與此相似的方法，將裂隙區(qū)分層測(cè)量來(lái)評(píng)估植骨術(shù)后效果。

盡管三維CT比二維X線片能提供立體、清晰的圖像，但是由于其輻射量大、照射時(shí)間長(zhǎng)、清晰度不能滿足口腔檢查的要求，近年來(lái)，錐形束CT越來(lái)越多的被應(yīng)用于口腔臨床檢查以及研究中。錐形束CT檢查的體素可達(dá)0.125 mm[11，67]，分辨率可以達(dá)到2.0 lp·mm-3，一次錐形束CT檢查的放射劑量相當(dāng)于拍攝一張全景片，照射時(shí)間短，故可廣泛推廣。

Oberoi等[68]定義了一個(gè)矢狀位的矩形植骨范圍，并且在每張矢狀圖像上測(cè)量骨組織圖像的面積以及缺隙的面積，將所有有關(guān)植骨區(qū)的截面再次進(jìn)行重建，即可算出骨組織的體積及未充填的體積，從而得出骨質(zhì)的充填率，通過(guò)對(duì)比手術(shù)后不同時(shí)間點(diǎn)的充填率來(lái)評(píng)價(jià)手術(shù)的效果。

吳軍和王國(guó)民[69]利用錐形束CT，將牙槽突裂隙假定為長(zhǎng)方體，將該長(zhǎng)方體在三維方向進(jìn)行分割（在X軸方向及Z軸方向均分為3等分，將Y軸方向均分為4等分），分割后形成不同平面，再根據(jù)平面上是否有骨橋，來(lái)判斷植入骨的量并進(jìn)行定位分析。此外，吳軍等[70]還利用錐形束CT，將不同垂直高度上的裂隙的橫斷面進(jìn)行截圖，然后進(jìn)行人工圈定，記算不同層面上裂隙的橫斷面的面積，然后將不同高度的值和面積的值來(lái)計(jì)算牙槽突裂的缺損體積。

6 影響術(shù)后效果的因素

牙槽突裂隙寬度、裂隙類型、術(shù)者、植骨時(shí)機(jī)、植入骨密度、植入骨與宿主骨關(guān)系、植骨區(qū)黏膜封閉情況、口腔衛(wèi)生等均對(duì)牙槽突裂植骨效果有一定影響。

多數(shù)學(xué)者觀察單、雙側(cè)牙槽突裂隙植骨的術(shù)后效果發(fā)現(xiàn)，單側(cè)裂術(shù)后植骨效果較雙側(cè)裂好[63，71]。但也有學(xué)者[54]研究表明雙側(cè)裂術(shù)后植骨效果較單側(cè)裂好。

一般認(rèn)為，在混合牙列期行牙槽突裂植骨手術(shù)，術(shù)后效果較好，成功率較高[23，72-73]。有研究發(fā)現(xiàn)，若以植骨后形成骨橋的高度高于牙槽嵴的3/4為成功標(biāo)準(zhǔn)，那么在裂隙側(cè)尖牙萌出前植骨的成功率為96％，尖牙萌出后植骨的成功率約85％。故在裂隙側(cè)尖牙萌出前植骨效果較好[11，74-75]。

植入骨是否負(fù)重是影響骨重建最重要的因素，在植骨區(qū)域行正畸干預(yù)或種植牙修復(fù)可減少植入骨的吸收。正畸移動(dòng)裂隙區(qū)附近牙根入裂隙區(qū)或未萌牙在植骨區(qū)萌出，不僅對(duì)植入骨有功能性刺激，并且利于植入骨成骨，防止植入骨吸收[76]。Feichtinger等[65]的研究表明，植骨區(qū)缺乏應(yīng)力刺激將導(dǎo)致1年內(nèi)骨質(zhì)吸收可高達(dá)95％，而骨植入有負(fù)重的區(qū)域可減少吸收，且可以增加骨密度。Takahashi等[77]的長(zhǎng)期隨訪研究發(fā)現(xiàn)，在植骨區(qū)種植牙能夠保持植入骨質(zhì)不被吸收。將骨植入無(wú)負(fù)重的區(qū)域，會(huì)導(dǎo)致骨吸收增加[78]。Feichtinger等[79]通過(guò)三維CT行術(shù)前、術(shù)后的比較后發(fā)現(xiàn)，1年后有尖牙萌出的患者的移植骨吸收在67％左右；尖牙與側(cè)切牙同時(shí)萌出的患者，移植骨吸收只有13％，而沒(méi)有牙萌出的患者，移植骨吸收達(dá)90％。

植入骨與裂隙區(qū)的骨及骨膜緊密接觸可使宿主骨及骨膜中的血液和成骨細(xì)胞滲透到植入骨中，假如植入骨與植骨床接觸不緊密，即會(huì)影響成骨的效果[54]。

植入骨的改建發(fā)生在植入骨與宿主骨的交界面，植入骨與宿主骨間不穩(wěn)定會(huì)影響成骨，并會(huì)引起骨吸收和感染。雙側(cè)裂植骨區(qū)的血供差、氧分壓低會(huì)使成骨延遲甚至阻止骨形成[80]。此外，雙側(cè)裂植骨區(qū)局部條件差，軟組織缺乏，導(dǎo)致張力增加，易引起植入骨暴露，繼而影響植骨效果。但也有報(bào)道稱，即使創(chuàng)口部分裂開(kāi)，也僅有表層暴露的骨顆粒脫落，在有輕度感染時(shí)，植入骨能較好地存活[19]。

此外，植入骨的密度跟術(shù)后骨質(zhì)吸收的關(guān)系密切，>3.0 g·cm-3的植骨密度成功率高[81]，裂隙窄的患者較裂隙寬的患者術(shù)后效果好，激素及營(yíng)養(yǎng)失衡、先天性疾病（如Turner綜合征）會(huì)減慢或阻止骨形成。而無(wú)張力封閉鼻底，封閉口鼻瘺；無(wú)張力、嚴(yán)密封閉受區(qū)創(chuàng)面；保持口腔衛(wèi)生，均可以減少術(shù)后植入骨的吸收。

7 對(duì)生長(zhǎng)發(fā)育的影響

早期的初期骨移植采取廣泛硬腭解剖，圍繞和穿過(guò)犁骨前頜骨縫合以及內(nèi)置骨移植，常繼發(fā)面中部后縮、牙弓形態(tài)差等。初期骨移植不僅影響上頜骨矢狀向生長(zhǎng)[82]，而且影響其垂直向[83-84]及水平向[2，4，85]生長(zhǎng)。不論在行初期唇裂整復(fù)術(shù)的同時(shí)還是初期腭裂整復(fù)術(shù)的同時(shí)行牙齦骨膜成形術(shù)，均會(huì)導(dǎo)致患兒上頜骨發(fā)育嚴(yán)重受限[86-87]，增加后期需行Le Fort Ⅰ截骨的比率[88]，于是許多治療中心停止開(kāi)展牙槽突裂植骨術(shù)。但有學(xué)者[4，89-90]認(rèn)為，在初期植骨術(shù)中若不損傷犁骨-前頜骨縫，則無(wú)明顯上頜骨發(fā)育障礙，不需行正頜手術(shù)。Rosenstein等[91-93]對(duì)初期骨移植進(jìn)行了術(shù)式改良，結(jié)果顯示：骨移植對(duì)面中部生長(zhǎng)無(wú)明顯影響，沒(méi)有降低上頜骨的生長(zhǎng)潛力，患者結(jié)合正畸治療即可形成較好的咬合關(guān)系。Trotman等[82]研究發(fā)現(xiàn)，盡管行一期植骨的患者的上頜骨凸度較未植骨患者的明顯降低，但下頜骨代償性地向后下方旋轉(zhuǎn)，掩飾了面中部的發(fā)育不足[94]，下頜骨良好的代償作用可以降低前牙反率[83]，患者并未出現(xiàn)上下頜骨間骨性Ⅲ類關(guān)系[3]。

牙齦骨膜成形術(shù)后，成骨量在10％~100％之間[7-8]，口鼻瘺發(fā)生率較高，且影響上頜骨生長(zhǎng)發(fā)育[4-6,95-97]，故許多學(xué)者不再使用該術(shù)式。

對(duì)于混合牙列中后期的二期植骨術(shù)，多數(shù)學(xué)者認(rèn)為其對(duì)上頜骨矢狀向及垂直向發(fā)育均無(wú)不利影響[19，97-99]，僅影響牙槽突裂隙周圍局部牙槽骨的形態(tài)[100]。Enemark等[14]的研究結(jié)果示，尖牙萌出前植骨組的前上面高明顯較未植骨組減少。但尖牙的萌出能刺激牙槽嵴骨質(zhì)的沉積，增加上頜骨的垂直高度[99]。

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（本文編輯 張玉楠）

Advances in cleft alveolar repair

Xu Xue1, Yang Chao1, Liu Kun1, Huang Ning2, Zheng Qian1, Shi Bing1. (1. State Key Laboratory of Oral Diseases, Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China; 2. State Key Laboratory of Oral Diseases, Dept. of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China)

Cleft alveolar repair have become to be an important role in cleft treatment procedure. Alveolar bone graft was proposed in the early 20th century, but controversies existed in many issues in alveolar repair. This paper makes a review regarding advances in timing of alveolar repair, implantation materials and surgical methods, and etc.

cleft alveolar； bone graft； surgery

R 782.2

A

10.7518/gjkq.2016.04.014

2015-11-12；

2016-03-11

徐雪，博士，Email：xuxue2008hx@163.com

石冰，教授，博士，Email：shibingcn@sina.com