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目的 分析正颌手术不同术式治疗重度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apneahypopnea syndrome,OSAHS)的疗效.方法 对2011年1月至2014年1月就诊于第四军医大学口腔医学院口腔颌面外科重度OSAHS患者24例,采用3种手术术式:①双颌水平前徙术+颏成形术(5例);②双颌逆时针前旋转+颏成形术(13例);③双颌水平前徙术+根尖下截骨后退术(6例).手术前、后对患者进行多导睡眠监测(polysomnography,PSG)和头影测量分析,比较术前、术后患者的呼吸紊乱指数(apnea and hypopea index,AHI)、体质量指数(body mass index,BMI)、平均血氧饱和度(average blood oxyen saturation,AOS)、后气道间隙(posterior airway space,PAS)、反映上颌突度的SNA角及反映下颌突度的SNB角等参数指标,采用SAS 8.02软件进行术前、术后配对t检验,评估手术效果.结果 依据斯坦福标准,手术治疗成功率达100％.双颌水平前徙术+颏成形术术前、术后AHI、SNA、SNB、SNPg(反映颏突度)、PAS比较,差异均有统计学意义(P＜0.000 1);双颌逆时针前旋转+颏成形术术前、术后患者AHI、SNB、SNPg、PAS比较,差异均有统计学意义(P＜0.01),SNA术前(82.25±2.71)°、术后(86.54±3.65)°(P=0.000 2),SNB术前(73.65±3.80)°,术后(81.37±2.96)°(P＜0.000 1);双颌水平前徙术+根尖截骨后退术术前、术后患者AHI、SNPg、PAS比较,差异均有统计学意义(P＜0.0001),SNA术前(82.18±4.27)°、术后(84.19±2.70)°(P=0.201 5),SNB术前(73.28±3.04)°、术后(75.35±2.56)°(P=0.2640),SNPg术前(75.91±4.06)°、术后(85.42±3.05)°(P＜0.000 1).术后患者平均正畸时间8.3个月.结论 ①双颌前徙术是治疗重度OSAHS的有效术式,术前需行头影测量、计算机辅助设计,选择个性化手术术式;②双颌水平前徙术+颏前徙术术后面型前突畸形明显;③逆时针旋转双颌前徙术+颏前徙术达到治疗目的同时尽量减小对面型的影响;④双颌水平前徙术+根尖下截骨后退术对面型影响小,但手术时间长、创伤大,术后需较长时间正畸治疗.

Objective To review the outcomes of three different methods of maxillomandibular advancement for the treatment of severe obstructive sleep apnea-hypopnea syndrome(OSAHS).Methods Twenty-four patients with severe OSAHS from January 2011 to January 2014 treated by three different methods of maxillomandibular advancement(MMA) and genioplasty,maxillomandibular advancement without rotation plus genioplasty,maxillomandibular advancement with counterclockwise rotation plus advancement genioplasty,maxillomandibular advancement with first premolars extraction and subapical osteotomy setback under general anesthesia were included in the study.Comparison of per-operative and post-operative cephalometric analysis,polysomnography(PSG),apnea and hypopea index(AHI),body mass index(BMI),average blood oxygen saturation(AOS),lowest oxygen saturation(LSaO2) and posterior airway space(PAS) data were performed.The operative time and post-surgical orthodontic treatment data were collected and analyzed.Results According to Stanford criteria,the success rate of 100％ was achieved with all the three methods.The difference between per-operative and post-operative AHI,AOS,SNPg and PAS were statistically significant(P＜0.000 1) for all the three methods.Significant difference was found between per-operative and post-operative SNA(81.51 °±3.36° vs 88.17°±4.51 °,P＜0.000 1),(82.25°±2.71 ° vs 86.54°±3.65°,P=0.000 2) and SNB(72.37°±3.99° vs 80.59°±3.40°,P＜0.000 1),(73.65°±3.80° vs 81.37°±2.96°,P＜0.000 1) among MMA without rotation plus genioplasty and MMA with counterclockwise rotation and advancement genioplasty respectively.However,no significant difference was found between the pre-operative and post-operative SNA(82.18°±4.27° vs 84.19°±2.70°,P=0.201 5) and SNB(73.28°±3.04° vs 75.35°±2.56°,P=0.264 0) among MMA with first premolars extraction and subapical osteotomy setback.The average duration of postoperative orthodontics treatment was 8.3 months.Conclusions MMA and advancement genioplasty is an effective surgical management for severe OSAHS.Cephalometric analysis and computer aided design are needed for personalized surgical methods.MMA without rotation and advancement genioplasty method leads to the protrusive skeletal deformity.MMA with counterclockwise rotation and advancement genioplasty method is effective in curing severe OSAHS with little effect on facial profile.MMA with first premolars extraction and subapical osteotomy requires longer operative time and longer postoperative orthodontic treatment.