与下颌支矢状骨劈开术相关的下颌前突患者下颌支的形态学研究
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摘要
下颌支矢状骨劈开术(SSRO)，根据下颌支解剖特点进行巧妙设计，是下颌骨外科矫治技术发展的一大突破。从最初报道至今50年的时间里，经历了大量的改进和提高，使之成为矫治各种下颌骨畸形应用最为广泛的一种手术方式。但同时也存在着许多并发症，包括过度肿胀和出血、术中颞下颌关节的损伤、下牙槽神经损伤以及下颌骨近远中段意外骨折。
有关的许多改进方法都是围绕着降低手术过程中相关并发症进行的，而且大多是依据临床的观察和经验，可用于SSRO借鉴的解剖数据非常有限。本文用螺旋CT对下颌前突患者下颌支的解剖结构进行测量，从不同角度提示术者减少术后意外骨折和神经损伤并发症应注意的问题。论文第一部分测量下颌前突患者下颌小舌平面下颌支的厚度，并与对照组进行比较。论文第二部分针对意外骨折这一并发症，描述下颌前突患者的下颌支骨松质的分布以及骨皮质厚度变化情况，指导舌侧骨切开的位置、深度和方向。论文第三部分针对下牙槽神经损伤这一并发症，描述下颌前突患者下颌管的定位和走行，并评价下颌管与颊侧骨皮质之间骨髓腔宽度和术后感觉神经障碍之间的关系，以便给临床医师提供有意义的信息，减少对下牙槽神经的损伤。
材料与方法
(一)临床资料
1、下颌前突组与对照组下颌支厚度的对比研究
实验组为2005年1月-2007年3月期问在中国医科大学附属口腔医院颌面外科实施双侧下颌支矢状骨劈开术的下颌前突患者35例(男19例，女16例)，年龄18-35岁，平均21.7岁。对照组是无颌面畸形因其它的颌骨疾病而拍摄CT的患者20例(男9例，女11例)，年龄18-37岁，平均22.2岁。
2、下颌前突患者下颌支的测量
2005年1月-2007年3月期间在中国医科大学附属口腔医院颌面外科施行SSRO的下颌前突患者45例(男24例，女21例)，年龄18-37岁，平均22.1岁
(二)器械设备
所有患者术前采用GE lightspeed plus 16层螺旋CT扫描仪(GE MedicalSystem,American)，患者仰卧，进行上下颌骨轴位螺旋扫描，层厚1．25mm，螺距1．375:1，矩阵512×512，电压120kV，电流320mA。
(三)测量方法
1、下颌前突组与对照组下颌支厚度的对比研究
下颌管最先形成的平面作为测量平面，测量通过下颌管中心处下颌支的厚度D；下颌管的内径I；下颌管外壁到颊侧骨皮质之间骨髓腔的宽度P；颊舌侧骨皮质的厚度B和L。
2、下颌前突患者下颌支的测量
紧邻下颌小舌上方的平面作为基础平面0平面，向上每2．5mm为一层面，共测量9个平面。在每一平面测量以下项目：升支前后向宽度(AP)，前部骨皮质宽度(AC)，后部骨皮质宽度(PC)，升支前1／4处厚度(AT)，升支前1／4处舌侧骨皮质厚度(atc)，升支前1／4处骨髓腔厚度(a)，升支中部厚度(MT)，升支中部舌侧骨皮质厚度(mtc)，升支中部骨髓腔厚度(m)，升支后1／4处厚度(PT)，升支后1／4处舌侧骨皮质厚度(ptc)，升支后1／4处骨髓腔厚度(p)，下颌神经沟最凹处距离后缘的距离(d)，若出现骨松质分开，记录前、后两段骨髓腔的长度aa和pp，在下颌小舌平面还需测量下颌小舌距离升支后部骨皮质融合处的距离LP。
3、下颌前突患者下颌管的定位和走行
通过下颌管最先形成的平面作为基础平面0平面，向下每5mm作为一个测量平面。在每一平面测量以下项目：下颌管内径(ID)、通过下颌管中心的下颌骨的厚度(LB)、颊舌侧骨皮质的厚度(BC和LC)和下颌管外侧壁到颊舌侧骨皮质之间的距离(BP和LP)。
(四)感觉异常的评价
以问卷的形式，让每一位患者描述术后下牙槽神经分布区域的感觉改变、感觉异常的持续时间，以及感觉不适的程度和对手术结果的满意程度。根据下颌管与外侧骨皮质之间骨髓腔的存在或缺失，90个半侧分成2组，比较两组间感觉神经障碍(Neurosensory Disturbance NSD)发生率之间的差异。用下颌管与外侧骨壁之间最近距离作为评定指标，评价骨髓腔宽度与术后NSD之间的关系。
(五)统计学分析
测量结果采用SPSS13.0软件包进行统计学分析。采用独立样本t检验比较各测量值之间的差异，用单因素方差分析比较各测量项目在不同层面之间的差异，并用Dunnett t法进行两两比较，用卡方检验评价骨髓腔宽度和术后NSD之间的关系。以P<0.05作为显著性差异的标准。
实验结果
1、在下颌小舌平面，下颌支的厚度分别为：实验组8．42mm，对照组9．65mm，下颌管外壁到颊侧骨皮质之间骨髓腔的宽度，实验组为1．58mm，对照组为2．39mm。2组下颌支厚度D之间存在统计学差异(t=-4.612，P=0.000)，颊侧下颌管外壁到颊侧骨皮质之间骨髓腔的宽度P在2组之间也存在统计学差异(t=-5.434，P=0.000)。P与D之间的相关系数为r=0.744。
2、下颌管的内径I、颊舌侧骨皮质的厚度B和L在两组之间的差异没有统计学意义。下颌管的内径I和颊侧骨皮质的厚度B存在性别差异(P=0．042，P=0．023)，男性略大于女性。各项测量值左右两侧间无统计学差异。
3、升支前后向的宽度AP从下颌小舌平面向上逐渐增加；前部骨皮质宽度AC也逐渐增加(近乙状切迹平面有骨松质分开的情况除外)；后部骨皮质宽度PC逐渐减小。
4、AP的性别差异有统计学显著性(t=8．502，P=-0．000)，下颌小舌距离升支后部骨皮质融合处的距离LP平均为9．45mm，性别间存在统计学差异(t=3．563，P=0．001)，下颌神经沟最凹处距离后缘的距离d的性别差异也有统计学显著性(t=2．488，P=-0．013)。
5、舌侧骨皮质厚度变化，在升支前1／4处，从下颌小舌平面向上有逐渐减小的趋势，升支中部变化不大，升支后1／4处，从下颌小舌平面向上有逐渐增加的趋势。在下颌小舌上5mm平面，舌侧骨皮质的平均厚度分别为：升支前1／4处1．68ram；中部1．68ram；后1／4处1．28mm。
6、下颌升支骨松质分布分成两类，Ⅰ类骨松质分开的占37．5％，Ⅱ类骨松质在任何一层均未分开的占62．5％。
7、下颌管内径(ID)、下颌骨的厚度(LB)、颊舌侧骨皮质的厚度(BC和LC)和下颌管外侧壁到颊舌侧骨皮质之间距离(BP和LP)，左右两侧无显著性差异，ID和BP性别差异有显著性(BP：F=5．923，P=0．003，ID：F=32．058，P=0．000)，其它4项的性别差异没有统计学显著性。
8、从下颌小舌到下颌骨下缘，下颌骨厚度增加，颊舌侧骨皮质也逐渐增厚，下颌管内径变化不大。舌侧骨髓腔的宽度是从无到有的逐渐递增趋势，而在每一层测量值中，颊侧骨髓腔的宽度均大于舌侧骨髓腔的宽度。
9、根据下颌管在下颌骨内的位置分为3种类型，分开类型占绝大多数，接触和融合型分别占10．37％和2．04％。
10、45例患者，90个半侧，其中27侧至少有一个层面颊侧骨髓腔缺失的患者，术后发生NSD的几率为100％；在4侧骨髓腔宽度小于0．3mm中，术后NSD的发生率为25％；在6侧骨髓腔宽度小于0．6mm中，术后NSD的发生率为66．7％；在9侧骨髓腔宽度小于0．9mm中，术后NSD的发生率为44．4％；在骨髓腔宽度为1．2mm或更宽时，均未发生术后NSD。
结论
1、下颌前突患者与对照组下颌支厚度上的差异主要是因为其颊侧骨髓腔的宽度之间的差异造成的。与对照组相比，下颌前突患者下颌支的厚度更薄，下颌管外壁到颊侧骨皮质之间骨髓腔的宽度更小，术中更易损伤下牙槽神经和产生意外骨折。
2、舌侧骨切开应位于下颌小舌上5mm以内的区域，在下颌小舌后方9．45mm以前切开，骨切开线由后向前可轻度向下，切开深度2mm左右，向前逐渐加深。
3、下颌管最初形成后，渐渐远离舌侧向颊侧靠近，在下颌孔下15～20mm之间，下颌管到颊侧距离相对较近，然后又有渐远趋势，但其总体走行还是靠近舌侧。
4、当颊侧骨髓腔的宽度是0．9mm或更小时，NSD容易发生。当骨髓腔缺如时，从外侧骨皮质中分离下牙槽神经十分困难，若在术前发现那些颊侧骨髓腔缺失的病例，尤其是融合型的患者，建议选用其它更安全的术式，以免造成下牙槽神经不必要的损伤。
The sagittal split ramus osteotomy (SSRO) has been used for 50 years after Trauner and Obwegeser first popularized this technique in 1957 for correction of prognathism and retrognathism. During the past half century, undergoing numerous modifications and improments,it has been one of the most popular surgical procedure for correcting various mandibular deforminties.SSRO involved soft tissue dissection and a horizontal corticotomy on the medial and lateral aspects in the vertical ramus to the posterior border. They found that this technique provided good contact of wide cancellous bone surfaces that resulted in quick bony union. However, there are a number of complications inherent in this technique, including excessive swelling and bleeding, intraoperative trauma to the temporomandibular joint, damage to the inferior alveolar nerve(IAN), and unfavorable fracture of the proximal and/or distal segments of the mandible.
There have been numerous modifications to this technique, all attempting to optimize a variety of factors to aid in proper healing of osteotomy and decrease the associated complications with this procedure. Although anatomic sthdies of the mandibular have been performed, they generally involved human cadaver or dry mandibulles. Patients undergoing SSRO are generally young individuals with a mandibular deformity and it is likely that the mandibular ramus anatomy of these patients is quite different from those of typical cadaveric specimens or dry mandibles.
The mediolateral width of the ramus is one of the important aspects during the surgery.Thus,one of the purposes of this study was to assess thickness of the mandibular ramus at lingular plane using spiral computed tomography,and to compare with the control patients, the finding of this investigation should provide the surgeon with meaningful informations for the SSRO.The purpose of the second parts of this study was to determine the location of cancellous bone and the changes of cortical plates width in the mandibular ramus of patients with mandibular prognathism using computed tomography(CT) scanning. The finding of this studies should provide the surgeons with meaningful informations about the best medial osteotomy site,depth and direction for the SSRO, and avoid unfavourable fracture.The aim of the third parts of this study was to investigate the position and course of the mandibular canal through the mandibular ramus using computed tomographic imaging and examined its relationship with postoperative nerosensory disturbance, and also to describe the anatomical variability of the mandibular canal within the rami in order to assist in finding the safest site for a verital corticotomy through the buccal plate when splitting the mandible,and to reduce injuries to the inferior alveolar nerve.
Materials and methods
1.Patients
(1)Patients in the first part of this artical
The prognathism group was composed of 25 skeketal ClassⅢpatients(19 males and 16 females;age range,18-35 years;mean age 21.7 years;50 mandibular sides) who were scheduled to undergo SSRO from the Department of Oral and Maxillofacial Surgery,school of stomatology,China Medical University,from January 2005 to March 2007. The control group was composed of 20 individuals without dentofacial deforminties(9 males and 11 females;age range, 18-37 years;mean age 22.2 years;40 mandibular sides)who underwent a CT examination for other maxillomandibular diseases.
(2) Patients in the second and third part of this artical45 patients(24 males and 21 females)who underwent SSRO between January 2005 and March 2007 at the Department of Oral and Maxillofacial Surgery, school of stomatology,China Medical University. The age of the patients ranged from 18 to 37 years with an everage of 22.1 years.
2.Computed Tomography Examination
The CT scan machine was GE Lightspeed 16 (GE Medical System,American) with the following scan parameters for all patients: slice thickness of 1.25mm; slice interval of 1mm, tube voltage of 120 kVp, tube current of 320 mA, the image matrix size of 512×512. Patients were positioned in a supine position with cervical hyperextension and head support for stabilization.
3.Methods and Area of Measurement
(1) Method and Area of Measurement in the first part of this artical
The location of ramus thickness measurement was taken from the scans at the lowest point of the mandibular forman. A total of 110 CT scans from 55 patients were examined, The following parameters were measured: total thickness of the mandible through the center of the mandibular canal(D); diameter of the inner mandibular canal(I); the bone marrow space between the outer mandibular canal and the inner surface of the buccal cortical bone(P);The width of the buccal cortex(B) and lingual cortex(L).For each measurement, the same examiner performed two times.
(2)Method and Area of Measurement in the second part of this artical
45 patients, 90 mandibular sides. In each side,the plane which just superior to the lingular was used as the base plane.The region from the base plane to 20mm above it with a slice interval of 2.5mm was observed on spiral computed tomography, and a total of 9 planes were obtained. The fllowing parameters were measured at each plane: anteroposterior length of the ramus(AP), thickness of the anterior cortical plate(AC), thickness of the posterior cortical plate(PC), thickness of the anterior third of the ramus(AT), thickness of the lingular cortex and marrow space of the anterior third of the ramus(atc,a),thickness of the center of the ramus(MT), thickness of the lingular cortex and marrow space of the center of the ramus(mtc,m) and thickness of the posterior third of the ramus(PT), thickness of the lingular cortex and marrow space of the posterior third of the ramus(ptc,p) At each plane, it was decided whether the region of cancellous bone was separated, if it was separated, then measured the length of the anterior and posterior bone marrow space(aa,pp). At the base plane,we still measured the distances from lingula to the fusion of the posterior cortical plates(LP).
(3) Method and Area of Measurement in the third part of this artical
The region from a plane containing the lowest point of the mandibular foramen(base plane o) to 25 mm below it was mensured with 5mm distance every plane. The following parameters were measured: total thickness of the mandible through the center of the mandibular canal(LB), the thicknessof the buccal and lingular cortical plate(BC and LC), and the narrowest portion of the bone marrow space between the outer mandibular canal and both the buccal and lingular cortical(BP and LP).
4.Evalution of Sensory Disturbance
All patients were examined 1,6 and 12 months postoperation using questionnaire. We evaluated the prevalence of neurosensory disturbance according to the presence or absence of marrow space between the mandibular canal and the external cortical bone. The 90 sides were classified into 2 groups: a contact group, in which the mandibular canal came into contact with the external cortical bone(ie. no marrow space); and a noncontact group, in which no contact was observed. The incidence of neurosensory disturbance between the 2 groups was then compared. The vertical extent of contact between the mandibular canal and external cortical bone in the contact group was cauculated by multiplying the number of consecutive sliced planes. The relationship between the width of the bone marrow space and the presence or absence of postoperative neurosensory disturbance was then evaluated.
5.Statistical Analysis
All measurements were analyzed with SPSS 13.0. Differences between groups were examined for statistical significance based on the Student t test,differences between the measurements from different slices were examined for statistical significance based on the ANOVA, the relationship between the width of the bone marrow space and the presence or absence of the postoperative neurosensory disturbance was evaluated using the chi-square test, multiple comparisons using Dunnett.t,and a p value less than 0.05 was considered a statistically significant difference.
Results
1.The thickness of the mandible was 8.42mm in prognathic patients,and was 9. 65mm in control patients.The width of the bone marrow space at the buccal in prognathic patients was 1.58mm,and in control patients was 2.39mm.There was a significant statistic difference between two groups in the total thickness of the mandible(D)(t=-4.612,P=0.000).This trend was also found in the bone marrow space between the outer mandibular canal and the inner surface of the bucal cortical bone(P) (t=-5.434,P=0.000),and the correlation coefficient between D and P was 0.744 (P<0.01).
2.There were no statistical difference between prognathic and control groups with regards to the other 3 distances I, L and B. There were no statistical difference between two sides and for all measurements, and there were significant statistic difference between two genders in I and B (P=0.042,P=0.023).
3.The anteroposterior length of the ramus (AP) increased in length from the lingular to the mandibular north, the anterior cortical plate(AC)increased too,the posterior cortical plate(PC)decreased.
4.The anteroposterior length of the ramus (AP) was longer in the male than in the female (36.11mm vs 33.50mm),and there was a statistically significant difference (t=-8.502,P=0.000).We also found the statistically significant difference in LP(t=3.563,P=0.001) and d(t=2.488,P=0.013).
5.The thickness of the lingular cortical plate decreased from the lingular to the mandibular north at the anterior of the ramus, remained relatively even at the center, and increased at the posterior of the ramus.At the plane 5mm above the lingular plane, the mean thickness of the lingular cortical plate was 1.68mm,1.68mmand 1.28mm separately at the anterior, center and the posterior.
6.The distribution of the cancellous bone was classified into 2 categories: no separation of cancellous bone was 62.5%, separation of cancellous bone at any plane was 37.5%.
7.There were no statistical difference between two sides with regards to the distances ID, LB, BC, LC, BP and LP, and there were significant statistic difference between two genders in ID and BP (BP:F=5.923,P=0.003, ID:F=32.058,P=0.000).
8.From mandibular foramen to the mandibular body,the thickness of the mandibule(LB) increased, the thicknessof the buccal cortical plate(BC) and the bone marrow space between the outer mansubular canal and the lingular cortical(LP) were also increased.At every plane, the BP was thicker than LP.
9.The width of the buccal side bone marrow space at each site could be classified into three types: (l)separated type with the bone marrow space visible, (2)contact type with the outer surface of the canal and inner surface of the buccal cortical bone in contact, and (3)fusion type with the outer cortical plate of the canal not evident. The separate type was most prevalent(n=473 of 540,87.59%), followed by the contact and fusion types(10.37% and 2.04%).
10.Neurosensory disturbance was observed on all 27 sides on which the mandibular canal came into contact with the external cortical bone( width of bone marrow space 0 mm).Neurosensory disturbance was observed on 1 of 4side with a bone marrow space of 0.3mm, on 1 of 4 side with a bone marrow space of 0.3mm, on 4 of 6 side with a bone marrow space of 0.6mm, on 4 of side with a bone marrow space of 0.9mm. Howerver, no neurosensory disturbance was observed on the 17 sides with a bone marrow spaces of 1.2 mm or more.
Conclusion
1.Compared with the control patients ,the mandibular ramus of the prognathism patients was thinner, and the width of the bone marrow space at the buccal was smaller. and the width of the bone marrow space at the buccal and the thickness of the mandible were positively significant correlated.
2.The safest region in which to establish the medial osteotomy line was just 5mm superior to the lingular,and about 9.45mm posterior, with depth about 2mm,directing the line slightly inferior.
3.On average, The mandibular were situated more lingulally at all sites,and the width of the bone marrow space at the buccal side was more narrow at 15-20mm bellow the mandibular foramen.
4.Neurosensory disturbance was significantly more likely to be present When the width of the marrow space at buccal side was 0.9 mm or less. The increased risk of neurosensory disturbance associated when there was absent of the marrow space, especially the fusion type, the surgeon was suggested to select a procedure other than SSRO.
有关的许多改进方法都是围绕着降低手术过程中相关并发症进行的，而且大多是依据临床的观察和经验，可用于SSRO借鉴的解剖数据非常有限。本文用螺旋CT对下颌前突患者下颌支的解剖结构进行测量，从不同角度提示术者减少术后意外骨折和神经损伤并发症应注意的问题。论文第一部分测量下颌前突患者下颌小舌平面下颌支的厚度，并与对照组进行比较。论文第二部分针对意外骨折这一并发症，描述下颌前突患者的下颌支骨松质的分布以及骨皮质厚度变化情况，指导舌侧骨切开的位置、深度和方向。论文第三部分针对下牙槽神经损伤这一并发症，描述下颌前突患者下颌管的定位和走行，并评价下颌管与颊侧骨皮质之间骨髓腔宽度和术后感觉神经障碍之间的关系，以便给临床医师提供有意义的信息，减少对下牙槽神经的损伤。
材料与方法
(一)临床资料
1、下颌前突组与对照组下颌支厚度的对比研究
实验组为2005年1月-2007年3月期问在中国医科大学附属口腔医院颌面外科实施双侧下颌支矢状骨劈开术的下颌前突患者35例(男19例，女16例)，年龄18-35岁，平均21.7岁。对照组是无颌面畸形因其它的颌骨疾病而拍摄CT的患者20例(男9例，女11例)，年龄18-37岁，平均22.2岁。
2、下颌前突患者下颌支的测量
2005年1月-2007年3月期间在中国医科大学附属口腔医院颌面外科施行SSRO的下颌前突患者45例(男24例，女21例)，年龄18-37岁，平均22.1岁
(二)器械设备
所有患者术前采用GE lightspeed plus 16层螺旋CT扫描仪(GE MedicalSystem,American)，患者仰卧，进行上下颌骨轴位螺旋扫描，层厚1．25mm，螺距1．375:1，矩阵512×512，电压120kV，电流320mA。
(三)测量方法
1、下颌前突组与对照组下颌支厚度的对比研究
下颌管最先形成的平面作为测量平面，测量通过下颌管中心处下颌支的厚度D；下颌管的内径I；下颌管外壁到颊侧骨皮质之间骨髓腔的宽度P；颊舌侧骨皮质的厚度B和L。
2、下颌前突患者下颌支的测量
紧邻下颌小舌上方的平面作为基础平面0平面，向上每2．5mm为一层面，共测量9个平面。在每一平面测量以下项目：升支前后向宽度(AP)，前部骨皮质宽度(AC)，后部骨皮质宽度(PC)，升支前1／4处厚度(AT)，升支前1／4处舌侧骨皮质厚度(atc)，升支前1／4处骨髓腔厚度(a)，升支中部厚度(MT)，升支中部舌侧骨皮质厚度(mtc)，升支中部骨髓腔厚度(m)，升支后1／4处厚度(PT)，升支后1／4处舌侧骨皮质厚度(ptc)，升支后1／4处骨髓腔厚度(p)，下颌神经沟最凹处距离后缘的距离(d)，若出现骨松质分开，记录前、后两段骨髓腔的长度aa和pp，在下颌小舌平面还需测量下颌小舌距离升支后部骨皮质融合处的距离LP。
3、下颌前突患者下颌管的定位和走行
通过下颌管最先形成的平面作为基础平面0平面，向下每5mm作为一个测量平面。在每一平面测量以下项目：下颌管内径(ID)、通过下颌管中心的下颌骨的厚度(LB)、颊舌侧骨皮质的厚度(BC和LC)和下颌管外侧壁到颊舌侧骨皮质之间的距离(BP和LP)。
(四)感觉异常的评价
以问卷的形式，让每一位患者描述术后下牙槽神经分布区域的感觉改变、感觉异常的持续时间，以及感觉不适的程度和对手术结果的满意程度。根据下颌管与外侧骨皮质之间骨髓腔的存在或缺失，90个半侧分成2组，比较两组间感觉神经障碍(Neurosensory Disturbance NSD)发生率之间的差异。用下颌管与外侧骨壁之间最近距离作为评定指标，评价骨髓腔宽度与术后NSD之间的关系。
(五)统计学分析
测量结果采用SPSS13.0软件包进行统计学分析。采用独立样本t检验比较各测量值之间的差异，用单因素方差分析比较各测量项目在不同层面之间的差异，并用Dunnett t法进行两两比较，用卡方检验评价骨髓腔宽度和术后NSD之间的关系。以P<0.05作为显著性差异的标准。
实验结果
1、在下颌小舌平面，下颌支的厚度分别为：实验组8．42mm，对照组9．65mm，下颌管外壁到颊侧骨皮质之间骨髓腔的宽度，实验组为1．58mm，对照组为2．39mm。2组下颌支厚度D之间存在统计学差异(t=-4.612，P=0.000)，颊侧下颌管外壁到颊侧骨皮质之间骨髓腔的宽度P在2组之间也存在统计学差异(t=-5.434，P=0.000)。P与D之间的相关系数为r=0.744。
2、下颌管的内径I、颊舌侧骨皮质的厚度B和L在两组之间的差异没有统计学意义。下颌管的内径I和颊侧骨皮质的厚度B存在性别差异(P=0．042，P=0．023)，男性略大于女性。各项测量值左右两侧间无统计学差异。
3、升支前后向的宽度AP从下颌小舌平面向上逐渐增加；前部骨皮质宽度AC也逐渐增加(近乙状切迹平面有骨松质分开的情况除外)；后部骨皮质宽度PC逐渐减小。
4、AP的性别差异有统计学显著性(t=8．502，P=-0．000)，下颌小舌距离升支后部骨皮质融合处的距离LP平均为9．45mm，性别间存在统计学差异(t=3．563，P=0．001)，下颌神经沟最凹处距离后缘的距离d的性别差异也有统计学显著性(t=2．488，P=-0．013)。
5、舌侧骨皮质厚度变化，在升支前1／4处，从下颌小舌平面向上有逐渐减小的趋势，升支中部变化不大，升支后1／4处，从下颌小舌平面向上有逐渐增加的趋势。在下颌小舌上5mm平面，舌侧骨皮质的平均厚度分别为：升支前1／4处1．68ram；中部1．68ram；后1／4处1．28mm。
6、下颌升支骨松质分布分成两类，Ⅰ类骨松质分开的占37．5％，Ⅱ类骨松质在任何一层均未分开的占62．5％。
7、下颌管内径(ID)、下颌骨的厚度(LB)、颊舌侧骨皮质的厚度(BC和LC)和下颌管外侧壁到颊舌侧骨皮质之间距离(BP和LP)，左右两侧无显著性差异，ID和BP性别差异有显著性(BP：F=5．923，P=0．003，ID：F=32．058，P=0．000)，其它4项的性别差异没有统计学显著性。
8、从下颌小舌到下颌骨下缘，下颌骨厚度增加，颊舌侧骨皮质也逐渐增厚，下颌管内径变化不大。舌侧骨髓腔的宽度是从无到有的逐渐递增趋势，而在每一层测量值中，颊侧骨髓腔的宽度均大于舌侧骨髓腔的宽度。
9、根据下颌管在下颌骨内的位置分为3种类型，分开类型占绝大多数，接触和融合型分别占10．37％和2．04％。
10、45例患者，90个半侧，其中27侧至少有一个层面颊侧骨髓腔缺失的患者，术后发生NSD的几率为100％；在4侧骨髓腔宽度小于0．3mm中，术后NSD的发生率为25％；在6侧骨髓腔宽度小于0．6mm中，术后NSD的发生率为66．7％；在9侧骨髓腔宽度小于0．9mm中，术后NSD的发生率为44．4％；在骨髓腔宽度为1．2mm或更宽时，均未发生术后NSD。
结论
1、下颌前突患者与对照组下颌支厚度上的差异主要是因为其颊侧骨髓腔的宽度之间的差异造成的。与对照组相比，下颌前突患者下颌支的厚度更薄，下颌管外壁到颊侧骨皮质之间骨髓腔的宽度更小，术中更易损伤下牙槽神经和产生意外骨折。
2、舌侧骨切开应位于下颌小舌上5mm以内的区域，在下颌小舌后方9．45mm以前切开，骨切开线由后向前可轻度向下，切开深度2mm左右，向前逐渐加深。
3、下颌管最初形成后，渐渐远离舌侧向颊侧靠近，在下颌孔下15～20mm之间，下颌管到颊侧距离相对较近，然后又有渐远趋势，但其总体走行还是靠近舌侧。
4、当颊侧骨髓腔的宽度是0．9mm或更小时，NSD容易发生。当骨髓腔缺如时，从外侧骨皮质中分离下牙槽神经十分困难，若在术前发现那些颊侧骨髓腔缺失的病例，尤其是融合型的患者，建议选用其它更安全的术式，以免造成下牙槽神经不必要的损伤。
The sagittal split ramus osteotomy (SSRO) has been used for 50 years after Trauner and Obwegeser first popularized this technique in 1957 for correction of prognathism and retrognathism. During the past half century, undergoing numerous modifications and improments,it has been one of the most popular surgical procedure for correcting various mandibular deforminties.SSRO involved soft tissue dissection and a horizontal corticotomy on the medial and lateral aspects in the vertical ramus to the posterior border. They found that this technique provided good contact of wide cancellous bone surfaces that resulted in quick bony union. However, there are a number of complications inherent in this technique, including excessive swelling and bleeding, intraoperative trauma to the temporomandibular joint, damage to the inferior alveolar nerve(IAN), and unfavorable fracture of the proximal and/or distal segments of the mandible.
There have been numerous modifications to this technique, all attempting to optimize a variety of factors to aid in proper healing of osteotomy and decrease the associated complications with this procedure. Although anatomic sthdies of the mandibular have been performed, they generally involved human cadaver or dry mandibulles. Patients undergoing SSRO are generally young individuals with a mandibular deformity and it is likely that the mandibular ramus anatomy of these patients is quite different from those of typical cadaveric specimens or dry mandibles.
The mediolateral width of the ramus is one of the important aspects during the surgery.Thus,one of the purposes of this study was to assess thickness of the mandibular ramus at lingular plane using spiral computed tomography,and to compare with the control patients, the finding of this investigation should provide the surgeon with meaningful informations for the SSRO.The purpose of the second parts of this study was to determine the location of cancellous bone and the changes of cortical plates width in the mandibular ramus of patients with mandibular prognathism using computed tomography(CT) scanning. The finding of this studies should provide the surgeons with meaningful informations about the best medial osteotomy site,depth and direction for the SSRO, and avoid unfavourable fracture.The aim of the third parts of this study was to investigate the position and course of the mandibular canal through the mandibular ramus using computed tomographic imaging and examined its relationship with postoperative nerosensory disturbance, and also to describe the anatomical variability of the mandibular canal within the rami in order to assist in finding the safest site for a verital corticotomy through the buccal plate when splitting the mandible,and to reduce injuries to the inferior alveolar nerve.
Materials and methods
1.Patients
(1)Patients in the first part of this artical
The prognathism group was composed of 25 skeketal ClassⅢpatients(19 males and 16 females;age range,18-35 years;mean age 21.7 years;50 mandibular sides) who were scheduled to undergo SSRO from the Department of Oral and Maxillofacial Surgery,school of stomatology,China Medical University,from January 2005 to March 2007. The control group was composed of 20 individuals without dentofacial deforminties(9 males and 11 females;age range, 18-37 years;mean age 22.2 years;40 mandibular sides)who underwent a CT examination for other maxillomandibular diseases.
(2) Patients in the second and third part of this artical45 patients(24 males and 21 females)who underwent SSRO between January 2005 and March 2007 at the Department of Oral and Maxillofacial Surgery, school of stomatology,China Medical University. The age of the patients ranged from 18 to 37 years with an everage of 22.1 years.
2.Computed Tomography Examination
The CT scan machine was GE Lightspeed 16 (GE Medical System,American) with the following scan parameters for all patients: slice thickness of 1.25mm; slice interval of 1mm, tube voltage of 120 kVp, tube current of 320 mA, the image matrix size of 512×512. Patients were positioned in a supine position with cervical hyperextension and head support for stabilization.
3.Methods and Area of Measurement
(1) Method and Area of Measurement in the first part of this artical
The location of ramus thickness measurement was taken from the scans at the lowest point of the mandibular forman. A total of 110 CT scans from 55 patients were examined, The following parameters were measured: total thickness of the mandible through the center of the mandibular canal(D); diameter of the inner mandibular canal(I); the bone marrow space between the outer mandibular canal and the inner surface of the buccal cortical bone(P);The width of the buccal cortex(B) and lingual cortex(L).For each measurement, the same examiner performed two times.
(2)Method and Area of Measurement in the second part of this artical
45 patients, 90 mandibular sides. In each side,the plane which just superior to the lingular was used as the base plane.The region from the base plane to 20mm above it with a slice interval of 2.5mm was observed on spiral computed tomography, and a total of 9 planes were obtained. The fllowing parameters were measured at each plane: anteroposterior length of the ramus(AP), thickness of the anterior cortical plate(AC), thickness of the posterior cortical plate(PC), thickness of the anterior third of the ramus(AT), thickness of the lingular cortex and marrow space of the anterior third of the ramus(atc,a),thickness of the center of the ramus(MT), thickness of the lingular cortex and marrow space of the center of the ramus(mtc,m) and thickness of the posterior third of the ramus(PT), thickness of the lingular cortex and marrow space of the posterior third of the ramus(ptc,p) At each plane, it was decided whether the region of cancellous bone was separated, if it was separated, then measured the length of the anterior and posterior bone marrow space(aa,pp). At the base plane,we still measured the distances from lingula to the fusion of the posterior cortical plates(LP).
(3) Method and Area of Measurement in the third part of this artical
The region from a plane containing the lowest point of the mandibular foramen(base plane o) to 25 mm below it was mensured with 5mm distance every plane. The following parameters were measured: total thickness of the mandible through the center of the mandibular canal(LB), the thicknessof the buccal and lingular cortical plate(BC and LC), and the narrowest portion of the bone marrow space between the outer mandibular canal and both the buccal and lingular cortical(BP and LP).
4.Evalution of Sensory Disturbance
All patients were examined 1,6 and 12 months postoperation using questionnaire. We evaluated the prevalence of neurosensory disturbance according to the presence or absence of marrow space between the mandibular canal and the external cortical bone. The 90 sides were classified into 2 groups: a contact group, in which the mandibular canal came into contact with the external cortical bone(ie. no marrow space); and a noncontact group, in which no contact was observed. The incidence of neurosensory disturbance between the 2 groups was then compared. The vertical extent of contact between the mandibular canal and external cortical bone in the contact group was cauculated by multiplying the number of consecutive sliced planes. The relationship between the width of the bone marrow space and the presence or absence of postoperative neurosensory disturbance was then evaluated.
5.Statistical Analysis
All measurements were analyzed with SPSS 13.0. Differences between groups were examined for statistical significance based on the Student t test,differences between the measurements from different slices were examined for statistical significance based on the ANOVA, the relationship between the width of the bone marrow space and the presence or absence of the postoperative neurosensory disturbance was evaluated using the chi-square test, multiple comparisons using Dunnett.t,and a p value less than 0.05 was considered a statistically significant difference.
Results
1.The thickness of the mandible was 8.42mm in prognathic patients,and was 9. 65mm in control patients.The width of the bone marrow space at the buccal in prognathic patients was 1.58mm,and in control patients was 2.39mm.There was a significant statistic difference between two groups in the total thickness of the mandible(D)(t=-4.612,P=0.000).This trend was also found in the bone marrow space between the outer mandibular canal and the inner surface of the bucal cortical bone(P) (t=-5.434,P=0.000),and the correlation coefficient between D and P was 0.744 (P<0.01).
2.There were no statistical difference between prognathic and control groups with regards to the other 3 distances I, L and B. There were no statistical difference between two sides and for all measurements, and there were significant statistic difference between two genders in I and B (P=0.042,P=0.023).
3.The anteroposterior length of the ramus (AP) increased in length from the lingular to the mandibular north, the anterior cortical plate(AC)increased too,the posterior cortical plate(PC)decreased.
4.The anteroposterior length of the ramus (AP) was longer in the male than in the female (36.11mm vs 33.50mm),and there was a statistically significant difference (t=-8.502,P=0.000).We also found the statistically significant difference in LP(t=3.563,P=0.001) and d(t=2.488,P=0.013).
5.The thickness of the lingular cortical plate decreased from the lingular to the mandibular north at the anterior of the ramus, remained relatively even at the center, and increased at the posterior of the ramus.At the plane 5mm above the lingular plane, the mean thickness of the lingular cortical plate was 1.68mm,1.68mmand 1.28mm separately at the anterior, center and the posterior.
6.The distribution of the cancellous bone was classified into 2 categories: no separation of cancellous bone was 62.5%, separation of cancellous bone at any plane was 37.5%.
7.There were no statistical difference between two sides with regards to the distances ID, LB, BC, LC, BP and LP, and there were significant statistic difference between two genders in ID and BP (BP:F=5.923,P=0.003, ID:F=32.058,P=0.000).
8.From mandibular foramen to the mandibular body,the thickness of the mandibule(LB) increased, the thicknessof the buccal cortical plate(BC) and the bone marrow space between the outer mansubular canal and the lingular cortical(LP) were also increased.At every plane, the BP was thicker than LP.
9.The width of the buccal side bone marrow space at each site could be classified into three types: (l)separated type with the bone marrow space visible, (2)contact type with the outer surface of the canal and inner surface of the buccal cortical bone in contact, and (3)fusion type with the outer cortical plate of the canal not evident. The separate type was most prevalent(n=473 of 540,87.59%), followed by the contact and fusion types(10.37% and 2.04%).
10.Neurosensory disturbance was observed on all 27 sides on which the mandibular canal came into contact with the external cortical bone( width of bone marrow space 0 mm).Neurosensory disturbance was observed on 1 of 4side with a bone marrow space of 0.3mm, on 1 of 4 side with a bone marrow space of 0.3mm, on 4 of 6 side with a bone marrow space of 0.6mm, on 4 of side with a bone marrow space of 0.9mm. Howerver, no neurosensory disturbance was observed on the 17 sides with a bone marrow spaces of 1.2 mm or more.
Conclusion
1.Compared with the control patients ,the mandibular ramus of the prognathism patients was thinner, and the width of the bone marrow space at the buccal was smaller. and the width of the bone marrow space at the buccal and the thickness of the mandible were positively significant correlated.
2.The safest region in which to establish the medial osteotomy line was just 5mm superior to the lingular,and about 9.45mm posterior, with depth about 2mm,directing the line slightly inferior.
3.On average, The mandibular were situated more lingulally at all sites,and the width of the bone marrow space at the buccal side was more narrow at 15-20mm bellow the mandibular foramen.
4.Neurosensory disturbance was significantly more likely to be present When the width of the marrow space at buccal side was 0.9 mm or less. The increased risk of neurosensory disturbance associated when there was absent of the marrow space, especially the fusion type, the surgeon was suggested to select a procedure other than SSRO.
引文
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31 华泽权，邹明宇，李树华．下颌升支截骨手术相关下颌管解剖标志的多层CT测量研究．临床口腔医学杂志．2006：22(1)：3-4
32 Mebra P,Castro V,Freitas RZ,et al.Complication of the mandibular sagittal split ramus osteotomy associater with the presence or absance of third molar.J Oral Maxillafac Surg.2001;59:854-858.
33 Precious DS,Lung KE,Pynn BR,et al.Presence of impacted teeth as a determining factor of unfavorable splits in 1256 sagittal split osteotomies.Oral Surg Oral Med Oral Pathol Oral Radiol Endod .1998;85:362-368.
34 Castro V,Freitas RZ,Wolford LM,et al.Complications of mandibular ramus sagittal split osteotomies associated with third molars.Presented as Scientific abstract for American Association.Oral Maxillofacial Surgeons-Annual Meeting.Boston.MA,September 29 to October 2,1999.J Oral Maxillofac Surgery.1999(suppl 1);57: 94-99.
35 Smith BR,Rajchel JL.Waite DE,et al: Mandibular ramus anatomy as it relates to the medial osteotomy of the sagittal split ramus osteotomy.J Oral Maxillofac Surg．1991；49：112-116
36 赵保东，李宁毅，周仰光，等．下颌骨的三维重建及实体解剖研究．华西口腔医学杂志．2002：20(1)：21-23．
37 Honrado CP. Larrabee WF．Update in three-dimensional imaging in facial plastic surgery.Lippincott Williams & Wilkins Inc.2004;12(4):327-331
38 胡静，王大章．正颌外科．北京：人民卫生出版社，2006;114
39 Fridrich KL，Holton TJ，Pansegrau KJ，et al.Neurosensory recovery following the mandibular bilateral sagittal split osteotomy．J Oral Maxillofac Surg．1995；53:1300-1306
40 Bell WH，Schendel SA．Biologic basis for mosification of the sagittal ramus split osteotomy.J Oral Surg．1977；35：362-367
41 Gowgiel JM.The position and course of the mandibular canal.J Oral Implantol.1992;18:383-385
42 August M，Marchena J，Donady J，et al.Nerosensory，deficit and functional impariment after sagittal ramus osteotomy：a long-term follow-up study．J Oral Maxillofac Surg．1998；56：1231-1235．
43 Becelli R，Renzi G,Carboni A，et al.Inferior alveolar nerve impairment after mandibular sagittal split osteotomy:an analysis of spontaneous recovery，patterns observed in 60 patients.J Craniofac Surg．2002;13:315-320
44 Yoshida T,Nagamine T,Kobayashi T,et al.Impairment of the inferior alveolar nerve after sagittal split osteotomy．J Craniomaxillofac Surg．1989；17：271-277．
45 Hwang K,Lee WJ,Song YB,et al.Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty:an anatomy study.J Craniofac Surg .2005;16:10-14.
46 Teerijoki-Oksa T,Jaaskelainen SK,Forssell K,et al.Risk factors of nerve injury during mandibular sagittal split osteotomy.Int J Oral Maxillofac Surg .2002;31:33-39.
47 Gianni AB,D'Orto O,Biglioli F,et al.Neurosensory alterations of the inferior alverolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus.J Craniomaxillofac Surg .2002;30:295-303.
48 Blomqvist JE,Alberius P,Isaksson S.Sensibility following sagittal split osteotomy in the mandible:a prospective clinical study.Plast Reconst Surg.1998;102:325-333.
49 廖进民，陈海芳，张美超，等．下颌骨截骨术相关的骨学测量及临床意义．解剖学研究．2004;26(2)：139-141．
50 冉炜，郭冰，陈松龄，等．下颌神经管全长三维走向的测量及其临床意义．解剖学研究．2002：24(2)：116-117．
51 姚小武，殷学民，朱明仁．下颌管的应用解剖学研究．中国口腔种植学杂志.2001:6(4)：151-153．
52 Pratt CA,Tippett H,Barnard JD.Labial sensory function following sagittal split osteotomy.Br J Oral Maxillofac Surg.1996;34:75-81.
53 Cunningham LL,Tiner BD,Clark GM,et al.A comparison of questionnaire versus monofilament assessment of neurosensory deficit.J Oral Maxillofac Surg .1996;54: 454-459.
54 Chen N,Neal CE,Lingenbrink P,et al.Neurosensory changes following orthognathic surgery.Int J Adult Orthod Orthognath Surg.1999;14:259-267.
55 Nesari S,Kahnberg K-E,Rasmusson L.Neurosensory function of the inferior alveolar nerve after bilateral sagittal ramus osteotomy: a retrospective study of 68 patients.Int J Oral Maxillofac Surg.2005;34:495-498.
56 Westermark A,Bystedt H,Vonkonow L.Inferior alveolar nerve function after sagittal split osteotomy of the mandible: correlation with the degree of intraoperative nerve encounter and other variables in 496 operations.Br J Oral Maxillofac Surg .1998;36:429-433.
57 Bouwman JPB,Husal A,Putnam GD,et al.Screw fixation following bilateral sagittal ramus osteotomy for mandibular advancement-complications in 700 consecutive cases.Br J Oral Maxillofac Surg .1995;33:231-234.
58 Lindorf HH.Sagittal ramus osteotomy with tanderm screw fixation: Technique and results.J Maxillofac Surg.1986;14:311-316.
59 Ochs MW.Bicortical screw stabilization of sagittal split osteotomies.J Oral Maxillofac Surg .2003;61:1477-1484.
60 Stoelinga PJ,Borstlap WA.The fixation of sagittal split osteotomy with miniplates: the versatility of atechnique.J Oral Maxillofac Surg.2003;61:1471 -1476.
61 Joos U. An adjustable bone fixation system for sagittal split ramus osteotomy:preliminary report. Br J Oral maxillofac Surg .1999;37:99-103.
62 Lemke PR, Rugh JD, Van Sickels J, et al. Neurosensory differences after wire and rigid fixation in patients with mandibular advancement. J Oral Maxillofac Surg .2000;58:1354-1359.
63 Kaji M, Ohashi Y, Mutoh Y. Study of late sensory paralysis in the lower lip after sagittal split osteotomy, Part 2: Investigation of location of mandibular canal by computed tomography.Niigata,Dent J .1998;28:7-12.
64 Ghali GE, Sikes JW. Intraoral wertical ramus osteotomy as the preferred treatment for mandibular prognathism. J Oral Maxillofac Surg .2000;58:313-315.
65 Weber W. A modified mandibular ramus osteotomy for orthognathic surgery. J Oral Maxillofac Surg .2001;59:237-240.
66 Westermark A. Bystedt H, Konow L. Inferior alveolar nerve function after mandibular osteotomies. Br J Oral Maxillofac Surg .1998;36:425-428.
67 Adams GL, Gansky, SA, Miller, Ai,et al. Comparison between traditional 2-dimensional cephlometry and a 3-dimensional approach on human dry skulls.Am J Orthod Dentofacial Orthop. 2004;126:397-409.
68 Alder ME, Deahl ST, Matteson SR. Clinical usefulness of two-dimensional reformatted and three- dimensionally rendered computerized tomographic images:Literature review and a survey of surgeons' opinions. J Oral Maxillofac Surg .1995;53:375-379.
69 Katsumata A, Fujishita M, Maeda M, et al. 3D-CT evaluation of facial asymmetry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod .2005;99:212-220.
70 Park SH. A proposal for a new analysis of craniofacial morphology by 3D-CT. Am J Orthod Dentofaxial Orthop .2005;129(5):600e23-24.
1 邱蔚六．口腔颌面外科学．第五版．北京：人民卫生出版社，2004．422-445．
2 傅民魁 口腔正畸学．第三版．北京：人民卫生出版社，2004．249-253．
3 张震康，张熙恩，傅民魁．正颌外科学．北京：人民卫生出版社，1995
4 张震康．我国正颌外科近年来的进展．中华口腔医学杂志．1996：31(3)：131-134
5 王兴，张震康．我国正颌外科的新进展．中华口腔医学杂志．2000：35(3)：165-167．
6 王大章．正颌外科学．中华医学杂志．2002：82(24)：1702-1704．
7 Trauner R,Obwegeser H:The surgical correction of mandibular prognathism and retrognathia with consideration for genioplasty.Oral Surg Oral Pathol.1957;10:677682.
8 Hunsuck EE.A modified intraoral sagittal splitting technique for correction of mandibular prognathism.J Oral Surg.1968;26:250-256.
9 Epker BN.Modifications in the sagittal osteotomy of the mandible.[J].J Oral Surg.l977;35:157-161.
10 Wolford LM,Davis WM.The mandibular inferior border split: A modification in the sagittal split osteotomy.J Oral Maxillofac Surg.1990;48,92-97.
11 Fun-Chee L.Technical modification of the sagittal split mandibular ramus osteotomy.Oral Surg Oral Med Oral Pathol.1992;99:212-220.
12 Wolford LM.The sagittal split ramus ostrotomy as the preferred treatment for mandibular prognathism.J Oral Maxillafac Surg .2000; 58:310-312.
13 Peterson GP,Haug RH,Sickels JV.A biomechanical evaluation of bilateral sagittal ramus osteotomy fixation techniques.J Oral Maxillafac Surg.2005;63:1317-1324.
14 Hallikainen D,Iizuka T,Lindqvist C.Cross-sectional tomography in evaluation of patients undergoing sagittal split osteotomy.J Oral Maxillafac Surg .1992; 50:1269-1273.
15 Fujimura K,Segami N,Kobayashi S.Anatomical study of the complications of interoral vertico-sagittal ramus osteotomy.J Oral Maxillofac Surg.2006;64:384-389.
16 Acebal-Bianco F,Vuylsteke P,Mommaerts MY,et al.Perioperative complication in maxillofacial orthopaedic surgery:A 5-year retrospective study.J Oral Maxillofac Surg.2000;58:754-759.
17 Akal UK,Sayan NB,Aydogan S,Yaman Z.Evaluation of the neurosensory deficiencies of oral and maxillofacial region following surgery.Int J Oral Maxillofac Surg .2000;29:331-336.
18 Vande Perre JPA, Stoelinga PJW, Blijdorp PA, et al. Perioperative morbidity in maxillofacial orthopaedic surgery: A retrospective study. J Craniomaxillofac Surg . 1996;24:263-268.
19 Ghali GE, Sikes JW. Intraoral vertical ramus osteotomy as the preferred treatment for mandibular prognathism. J Oral Maxillofac Surg .2000;58:313-315.
20 Weber W. A modified mandibular ramus osteotomy for orthognathic surgery. J Oral Maxillofac Surg .2001;59:237-240.
21 Westermark A. Bystedt H, Konow L. Inferior alveolar nerve function after mandibular osteotomies. Br J Oral Maxillofac Surg .1998;36:425-428.
22 Daw JLJr, Paz MG, Han H, et al. The mandibular foramen: An anatomical study and its relevance to the sagittal split ramus osteotomy.J Craniofac Surg .1999; 10:475-479.
23 Nicholson ML. A study of the position of the mandibular foramen in the adult human mandibular.Anat Rec. 1985;212:110-114.
24 Kaffe I, Ardekian L, Gelerenter I, et al: Location of the mandibular foramen in panoramic radiographs.Oral Surg Oral Med Oral Pathol .1994;78:662-667.
25 Kim HJ,Lee HY,Chung IH,et al. Mandibular anatomy related to sagittal split ramus osteotomy in Koreans.Yonsei Med J .1997;38(1):19-25.
26 Fontoura RA, Vasconcellos HA, Campos AES. Morphologic basis for the intraoral vertical ramus osteotomy: anatomic and radiographic localization of the mandibular foramen. J Oral Maxillafac Surg .2002;60:660-665.
27 Danilo PB, Italo HA, Paulo J. Comparison of mandibular rami width in patients with prognathism and retrognathia .J Oral Maxillofac Surg .2006;64:1506-1509.
28 Muto T, Shigeo K, Yamamoto K,et al.Computed tomography morphology of the mandibular ramus in prognathism:effect on the medial osteotomy of the sagittal split ramus osteotomy.J Oral Maxillofac Surg .2003;61:89-93.
29 Carter TB, Frost DE, Tucker MR, et al. Cortical thickness in human mandibles: Clinical relevance to the sagittal split ramus osteotomy. Int J Adult Orthod Orthognath Surg.1991;6:257-262.
30 Smith BR,Rajchel JL.Waite DE,et al: Mandibular ramus anatomy as it relates to the medial osteotomy of the sagittal split ramus osteotomy.J Oral Maxillofac Surg . 1991 ;49:112-116.
31 August M, Marchena J, Donady J, et al. Nerosensory deficit and functional impariment after sagittal ramus osteotomy: a long-term follow-up study. J Oral Maxillofac Surg.1998;56:1231-1235.
32 Becelli R, Renzi G, Carboni A, et al. Inferior alveolar nerve impairment after mandibular sagittal split osteotomy:an analysis of spontaneous recovery patterns observed in 60 patients. J Craniofac Surg .2002; 13:315-320.
33 Yoshida T, Nagamine T, Kobayashi T, et al. Impairment of the inferior alveolar nerve after sagittal split osteotomy. J Craniomaxillofac Surg . 1989; 17:271 -277.
34 Mebra P, Castro V, Freitas RZ, et al. Complication of the mandibular sagittal split ramus osteotomy associater with the presence or absance of third molar. J Oral Maxillafac Surg .2001;59:854-858.
35 Castro V, Freitas RZ, Wolford LM, et al. Complications of mandibular ramus sagittal split osteotomies associated with third molars. Presented as Scientific abstract for American Association. Oral Maxillofacial Surgeons-Annual Meeting. Boston. MA, September 29 to October 2,1999. J Oral Maxillofac Surgery.1999(suppl 1);57:94-99.
36 Tsuji Y, Muto T, Kawalami J,et al.Computted tomographic analysis of the position and course of the mandibular canal:relevance to the sagittal split ramus osteotomy. Int J Oral Maxillofac Surg .2005;34(3):243-246.
37 Yamamoto R, Nakamura A, Ohno K,et al. Relationship of the mandibular canal to the lateral cortex of the mandibular ramus as a factor in the development of neurosensory disturbance after bilateral sagittal split osteotomy.J Oral Maxllifac Surg .2002;60(5):490-495.
38 Al-Bisshri A, Barghash Z, Rosenquist i,et al.Neurosensory disturbance after sagittal split and intraoral vertical ramus osteotomy: as reported in questionnaires and patients' records.Int J Oral Maxillofac Surg .2005;34(3):247-251.
39 胡静,王大章.正颌外科.北京:人民卫生出版社, 2006.114.
40 Lindorf HH. Sagittal ramus osteotomy with tanderm screw fixation: Technique and results. J Maxillofac Surg. 1986; 14:311 -316.
41 Blomqvist JE, Alberius P, Isaksson S. Sensibility following sagittal split osteotomy in the mandible: a prospective clinical study. Plast Reconst Surg .1998;102:325-333.
42 Nesari S, Kahnberg K-E, Rasmusson L. Neurosensory function of the inferior alveolar nerve after bilateral sagittal ramus osteotomy: a retrospective study of 68 patients.lnt J Oral Maxillofac Surg .2005;34:495-498.
43 Gianni AB,D'Orto O, Biglioli F, et al. Neurosensory alterations of the inferior alverolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus. J Craniomaxillofac Surg. 2002; 30:295-303.
44 Pratt CA, Tippett H, Barnard JD. Labial sensory function following sagittal split osteotomy.Br J Oral Maxillofac Surg .1996;34:75-81.
45 Westermark A, Bystedt H, Vonkonow L. Inferior alveolar nerve function after sagittal split osteotomy of the mandible: correlation with the degree of intraoperative nerve encounter and other variables in 496 operations. Br J Oral Maxillofac Surg .1998;36:429-433.
46 Bouwman JPB, Husal A, Putnam GD, et al. Screw fixation following bilateral sagittal ramus osteotomy for mandibular advancement-complications in 700 consecutive cases. Br J Oral Maxillofac Surg .1995;33:231-234.
47 Ochs MW. Bicortical screw stabilization of sagittal split osteotomies. J Oral Maxillofac Surg .2003; 61:1477-1484.
48 Stoelinga PJ, Borstlap WA. The fixation of sagittal split osteotomy with miniplates: the versatility of a technique. J Oral Maxillofac Surg .2003;61:1471 -1476.
49 Joos U. An adjustable bone fixation system for sagittal split ramus osteotomy:preliminary report. Br J Oral maxillofac Surg .1999;37:99-103.
50 Lemke PR, Rugh JD, Van Sickels J, et al. Neurosensory differences after wire and rigid fixation in patients with mandibular advancement. J Oral Maxillofac Surg .2000;58:1354-1359.
51 Kane AA, Lo LJ, Chen YR, et al. The course of the inferior alveolar nerve in the normal human mandibular ramus and in patients presenting for cosmetic reduction of the mandibular angles.Plast Reconstr Surg.2000;106(5):1162-1175.
52 Leira JI,Gilhuus-Moe OT.Sensory impairment following sagittal split osteotomy for correction of mandibular retrognathism.Int J Adult Orthod Orthognath Surg.1991;6:161-165.
53 Hwang K, Lee WJ, Song YB, et al. Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty:an anatomy study.J Craniofac Surg .2005;16:10-14.
54 Teerijoki-Oksa T,Jaaskelainen SK, Forssell K,et al.Risk factors of nerve injury during mandibular sagittal split osteotomy. Int J Oral Maxillofac Surg .2002;31:33-39.
55 Nakafawa K,Ueki K, Takatsuka S, et al. Trigeminal nerve hypesthesia after sagittal split osteotomy in setback cases:correlation of postoperative computed tomography and long-term trigeminal somatosensory evoked potentials.J Oral Maxillofac Surg.2003;61:898-903.
56 Tamas F.Position of the mandibular canal. Int J Oral Maxillofac Surg.1987;16:65-69.
57 Rajchel J,Ellis Ⅲ E, Fonseca RJ.The anatomical location of the mandibular canal: its relationship to the sagittal ramus osteotomy.Int J Adult Orthod Orthognath Surg.1986;1:37-47.
58 Bell WH, Schendel SA. Biologic basis for mosification of the sagittal ramus split osteotomy. J Oral Surg.1977;35:362-367.
59 Gowgiel JM.The position and course of the mandibular canal. J Oral Implantol .1992;18:383-385.
60 柯国平，戴冀斌，周新华，等．下颌支矢状劈开术与下颌管位置关系的应用．解剖学研究．2000：16(3)：175-176
61 廖进民，陈海芳，张美超，等．下颌骨截骨术相关的骨学测量及临床意义．解剖学研究．2004：26(2):139-141．
62 华泽权，刘妍琼，宋九余，等．与下颌升支久状劈开截骨相关的卜颌管解剖研究．现代口腔医学杂志．2003：17(5)：444-445
63 Ylikontiola L，Moberg K，Huumonen S，et al.Comparison of three tadiographic methods used to locate the mandibular canal in the buccolingual direction before bilateral sagittal split osteotomy.Oral Surg Oral Med Oral Pathol .2002;93:736-742.
64 Yang J,Cavalcanti M,Ruprecht A,et al.2-D and 3-D reconstructions of spiral computed tomography in localization of the inferior alveolar canal for dental implants.Oral Surg Oral Med Oral Pathol .1999 ;87:369-374.
65 Ozawa Y,Shibahara T,Takagi,T,et al.Surgical simulation of Class edentulous patient using a 3D craniofacial model: Report of a case.Bull Dent Coll .2000;41:73-78.
66 Tsunori M,Mashita M,Kasai K.Relationship between facial types and tooth and bone characteristics of the mandible obtained by CT scanning.Angle Orthod .1997;68: 557-561.
67 Alder ME,Deahl ST,Matteson SR.Clinical usefulness of two-dimensional reformatted and three-dimensionally rendered computerized tomographic images:Literature review and a survey of surgeons' opinions.J Oral Maxillofac Surg .1995;53:375.
68 赵保东，李宁毅，周仰光，等．下颌骨的三维重建及实体解剖研究．华西口腔医学杂志．2002：20(1)：21-23．
69 华泽权，邹明宁，李树华．下颌升支截骨手术相关下颌管解剖标志的多层CT测量研究．临床口腔医学杂志．2006：22(1)：3-4.
70 Honrado CP,Larrabee WF.Update in three-dimensional imaging in facial plastic surgery.Lippincott Williams & Wilkins.Inc.2004;12(4):327-331.
71 Adams GL,Gansky,SA,Miller,Ai,et al.Comparison between traditional 2-dimensional cephlometry and a 3-dimensional approach on human dry skulls.Am J Orthod Dentofacial Orthop.2004;126:397-409.
72 Katsumata A,Fujishita M,Maeda M,et al.3D-CT evaluation of facial asymmetry.Oral Surg Oral Med Oral Pathol Oral Radiol Endod .2005;99:212-220.
73 Park SH.A proposal for a new analysis of craniofacial morphology by 3D-CT.Am J Orthod Dentofacial Orthop .2005;129(5):600e23-24.
2 Hunsuck EE. A modified intraoral sagittal splitting technique for correction of mandibular prognathism.J Oral Surg .1968;26:250-256.
3 Epker BN. Modifications in the sagittal osteotomy of the mandible.J Oral Surg.1977;35:157-161.
4 Wolford LM, Davis WM. The mandibular inferior border split: A modification in the sagittal split osteotomy. J Oral Maxillofac Surg .1990;48,92-96.
5 Fun-Chee L. Technical modification of the sagittal split mandibular ramus osteotomy. Oral Surg Oral Med Oral Pathol .1992;99:212-220.
6 Wolford LM. The sagittal split ramus osteotomy as the preferred treatment for mandibular prognathism. J Oral Maxillofac Surg .2000;58:310-312.
7 Peterson GP, Haug RH, Sickels JV. A biomechanical evaluation of bilateral sagittal ramus osteotomy fixation techniques. J Oral Maxillafac Surg .2005;63:1317-1324.
8 Hallikainen D, Iizuka T, Lindqvist C. Cross-sectional tomography in evaluation of patients undergoing sagittal split osteotomy. J Oral Maxillafac Surg . 1992;50:1269-1273.
9 Kim HJ,Lee HY,Chung IH,et al. Mandibular anatomy related to sagittal split ramus osteotomy in Koreans.Yonsei Med J .1997;38(1):19-25.
10 Danilo PB, Italo HA, Paulo J. Comparison of mandibular rami width in patients with prognathism and retrognathia. J Oral Maxillofac Surg .2006;64:1506-1509.
11 Muto T, Shigeo K, Yamamoto K,et al.Computed tomography morphology of the mandibular ramus in prognathism:effect on the medial osteotomy of the sagittal split ramus osteotomy.J Oral Maxillofac Surg .2003;61:89-93.
12 Tsuji Y, Muto T, Kawalami J,et al.Computted tomographic analysis of the position and course of the mandibular canal:relevance to the sagittal split ramus osteotomy. Int J Oral Maxillofac Surg .2005;34(3):243-246.
13 Ylikontiola L, Moberg K, Huumonen S, et al.Comparison of three radiographic methods used to locate the mandibular canal in the buccolingual direction before bilateral sagittal split osteotomy.Oral Surg Oral Med Oral Pathol .2002;93:736-742.
14 Yang J,Cavalcanti M,Ruprecht A,et al.2-D and 3-D reconstructions of spiral computed tomography in localization of the inferior alveolar canal for dental implants. Oral Surg Oral Med Oral Pathol .1999;87:369-374.
15 Yamamoto R, Nakamura A, Ohno K,et al. Relationship of the mandibular canal to the lateral cortex of the mandibular ramus as a factor in the development of neurosensory disturbance after bilateral sagittal split osteotomy.J Oral Maxllifac Surg .2002;60(5):490-495.
16 Al-Bisshri A, Barghash Z, Rosenquist J,et al.Neurosensory disturbance after sagittal split and intraoral vertical ramus osteotomy: as reported in questionnaires and patients' records.Int J Oral Maxillofac Surg .2005;34(3):247-251.
17 Fujimura K, Segami N, Kobayashi S. Anatomical study of the complications of interoral vertico-sagittal ramus osteotomy. J Oral Maxillofac Surg .2006;64:384-389.
18 Acebal-Bianco F, Vuylsteke P, Mommaerts MY, et al. Perioperative complication in maxillofacial orthopaedic surgery: A 5-year retrospective study. J Oral Maxillofac Surg .2000;58:754-759.
19 Akal UK,Sayan NB,Aydogan S,Yaman Z.Evaluation of the neurosensory deficiencies of oral and maxillofacial region following surgery.Int J Oral Maxillofac Surg .2000;29:331-336.
20 Vande Perre JPA, Stoelinga PJW, Blijdorp PA, et al. Perioperative morbidity in maxillofacial orthopaedic surgery: A retrospective study. J Craniomaxillofac Surg .1996;24,263-267.
21 Daw JLJr, Paz MG, Han H, et al. The mandibular foramen: An anatomical study and its relevance to the sagittal split ramus osteotomy.J Craniofac Surg .1999; 10:475-479.
22 Nicholson ML. A study of the position of the mandibular foramen in the adult human mandibular.Anat Rec .1985;212:110-115.
23 Kaffe 1, Ardekian L, Gelerenter I, et al: Location of the mandibular foramen in panoramic radiographs.Oral Surg Oral Med Oral Pathol .1994;78:662-667.
24 Fontoura RA, Vasconcellos HA, Campos AES. Morphologic basis for the intraoral vertical ramus osteotomy: anatomic and radiographic localization of the mandibular foramen. J Oral Maxillafac Surg.2002;60:660-665.
25 Carter TB,Frost DE,Tucker MR,et al.Cortical thickness in human mandibles: Clinical relevance to the sagittal split ramus osteotomy.Int J Adult Orthod Orthognath Surg.l991;6:257-261.
26 Rajchel J,Ellis Ⅲ E,Fonseca RJ.The anatomical location of the mandibular canal: its relationship to the sagittal ramus osteotomy.lnt J Adult Orthod Orthognath Surg.1986;1:37-47.
27 Tamas F.Position of the mandibular canal.Int J Oral Maxillofac Surg .1987; 16:65-71.
28 Kane AA,Lo LJ,Chen YR,et al.The course of the inferior alveolar nerve in the normal human mandibular ramus and in patients presenting for cosmetic reduction of the mandibular angles.Plast Reconstr Surg .2000;106(5):1162-1175.
29 柯国平，戴冀斌，周新华，等．下颌支矢状劈开术与下颌管位置关系的应用．解剖学研究．2000：16(3)：175-176
30 华泽权，刘妍琼，宋九余，等．与下颌升支矢状劈开截骨相关的下颌管解剖研究．现代口腔医学杂志．2003：17(5)：444-445
31 华泽权，邹明宇，李树华．下颌升支截骨手术相关下颌管解剖标志的多层CT测量研究．临床口腔医学杂志．2006：22(1)：3-4
32 Mebra P,Castro V,Freitas RZ,et al.Complication of the mandibular sagittal split ramus osteotomy associater with the presence or absance of third molar.J Oral Maxillafac Surg.2001;59:854-858.
33 Precious DS,Lung KE,Pynn BR,et al.Presence of impacted teeth as a determining factor of unfavorable splits in 1256 sagittal split osteotomies.Oral Surg Oral Med Oral Pathol Oral Radiol Endod .1998;85:362-368.
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35 Smith BR,Rajchel JL.Waite DE,et al: Mandibular ramus anatomy as it relates to the medial osteotomy of the sagittal split ramus osteotomy.J Oral Maxillofac Surg．1991；49：112-116
36 赵保东，李宁毅，周仰光，等．下颌骨的三维重建及实体解剖研究．华西口腔医学杂志．2002：20(1)：21-23．
37 Honrado CP. Larrabee WF．Update in three-dimensional imaging in facial plastic surgery.Lippincott Williams & Wilkins Inc.2004;12(4):327-331
38 胡静，王大章．正颌外科．北京：人民卫生出版社，2006;114
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41 Gowgiel JM.The position and course of the mandibular canal.J Oral Implantol.1992;18:383-385
42 August M，Marchena J，Donady J，et al.Nerosensory，deficit and functional impariment after sagittal ramus osteotomy：a long-term follow-up study．J Oral Maxillofac Surg．1998；56：1231-1235．
43 Becelli R，Renzi G,Carboni A，et al.Inferior alveolar nerve impairment after mandibular sagittal split osteotomy:an analysis of spontaneous recovery，patterns observed in 60 patients.J Craniofac Surg．2002;13:315-320
44 Yoshida T,Nagamine T,Kobayashi T,et al.Impairment of the inferior alveolar nerve after sagittal split osteotomy．J Craniomaxillofac Surg．1989；17：271-277．
45 Hwang K,Lee WJ,Song YB,et al.Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty:an anatomy study.J Craniofac Surg .2005;16:10-14.
46 Teerijoki-Oksa T,Jaaskelainen SK,Forssell K,et al.Risk factors of nerve injury during mandibular sagittal split osteotomy.Int J Oral Maxillofac Surg .2002;31:33-39.
47 Gianni AB,D'Orto O,Biglioli F,et al.Neurosensory alterations of the inferior alverolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus.J Craniomaxillofac Surg .2002;30:295-303.
48 Blomqvist JE,Alberius P,Isaksson S.Sensibility following sagittal split osteotomy in the mandible:a prospective clinical study.Plast Reconst Surg.1998;102:325-333.
49 廖进民，陈海芳，张美超，等．下颌骨截骨术相关的骨学测量及临床意义．解剖学研究．2004;26(2)：139-141．
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56 Westermark A,Bystedt H,Vonkonow L.Inferior alveolar nerve function after sagittal split osteotomy of the mandible: correlation with the degree of intraoperative nerve encounter and other variables in 496 operations.Br J Oral Maxillofac Surg .1998;36:429-433.
57 Bouwman JPB,Husal A,Putnam GD,et al.Screw fixation following bilateral sagittal ramus osteotomy for mandibular advancement-complications in 700 consecutive cases.Br J Oral Maxillofac Surg .1995;33:231-234.
58 Lindorf HH.Sagittal ramus osteotomy with tanderm screw fixation: Technique and results.J Maxillofac Surg.1986;14:311-316.
59 Ochs MW.Bicortical screw stabilization of sagittal split osteotomies.J Oral Maxillofac Surg .2003;61:1477-1484.
60 Stoelinga PJ,Borstlap WA.The fixation of sagittal split osteotomy with miniplates: the versatility of atechnique.J Oral Maxillofac Surg.2003;61:1471 -1476.
61 Joos U. An adjustable bone fixation system for sagittal split ramus osteotomy:preliminary report. Br J Oral maxillofac Surg .1999;37:99-103.
62 Lemke PR, Rugh JD, Van Sickels J, et al. Neurosensory differences after wire and rigid fixation in patients with mandibular advancement. J Oral Maxillofac Surg .2000;58:1354-1359.
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66 Westermark A. Bystedt H, Konow L. Inferior alveolar nerve function after mandibular osteotomies. Br J Oral Maxillofac Surg .1998;36:425-428.
67 Adams GL, Gansky, SA, Miller, Ai,et al. Comparison between traditional 2-dimensional cephlometry and a 3-dimensional approach on human dry skulls.Am J Orthod Dentofacial Orthop. 2004;126:397-409.
68 Alder ME, Deahl ST, Matteson SR. Clinical usefulness of two-dimensional reformatted and three- dimensionally rendered computerized tomographic images:Literature review and a survey of surgeons' opinions. J Oral Maxillofac Surg .1995;53:375-379.
69 Katsumata A, Fujishita M, Maeda M, et al. 3D-CT evaluation of facial asymmetry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod .2005;99:212-220.
70 Park SH. A proposal for a new analysis of craniofacial morphology by 3D-CT. Am J Orthod Dentofaxial Orthop .2005;129(5):600e23-24.
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44 Pratt CA, Tippett H, Barnard JD. Labial sensory function following sagittal split osteotomy.Br J Oral Maxillofac Surg .1996;34:75-81.
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47 Ochs MW. Bicortical screw stabilization of sagittal split osteotomies. J Oral Maxillofac Surg .2003; 61:1477-1484.
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