An Update on the Timing of Hard Palate Closure: A Critical Long-Term Analysis
An Update on the Timing of Hard Palate Closure: A Critical Long-Term Analysis
复制标题
硬腭闭合时间的更新：关键的长期分析
DOI：
10.1097/01.prs.0000097286.00667.4f
复制
发表时间：
2004
影响因子：
3.6
通讯作者：
A. Gosman
中科院分区：
文献类型：
--
作者：
Rod J. Rohrich;A. Gosman
1996年，我们在《硬腭闭合的时机：一项重要的长期分析》中发表了牛津腭裂研究的结果。1我们在这项研究中的目的是批判性地评估关于硬腭闭合时机的争议，特别是早期腭成形术改善语音与延迟腭成形术不受干扰的面部生长。采用多学科方法评价硬腭早期闭合（10.8个月）与晚期闭合（48.6个月）的长期结果，并确定语言缺陷、腭瘘、听力异常和颌面部生长障碍的发生率。我们最初的分析结果显示，延迟硬腭闭合的语音缺陷具有统计学意义，特别是在发音，鼻共鸣，可懂度和替代模式评估方面。延迟闭合组总体腭瘘和持续性腭瘘的发生率也显著更高。听力和颌面部发育无显著差异。根据我们的数据结果，我们认为延迟硬腭闭合会导致严重的语言障碍，而不会有利于保持颌面部的生长。我们的长期分析的影响反映在我们目前的目标导向的方法来治疗腭裂患者。腭裂患者的治疗目标是正常的语言，听力，颌面部发育和避免瘘管。我们目前的治疗方案和牛津腭裂研究中使用的早期治疗方法之间有几个重要的差异。这些变化是基于我们的数据结果以及我们在过去15年的临床经验。我们提倡早期两阶段腭修复。我们目前的治疗方案从1至2周龄的术前婴儿骨科开始。唇裂和软腭在3 ~ 6个月时修复，残留的硬腭裂在15 ~ 18个月时修复。在过渡牙列期进行正畸治疗后，对牙槽嵴裂进行二期植骨。唇修复采用改良Millard旋转前移法，软腭修复采用行内腭成形术，硬腭修复采用双层一期闭合术或von Langenbeck手术。牛津腭裂研究中的早期腭闭合技术是一种一期、三瓣或四瓣、改良的Wardill-Kilner手术，平均年龄为10.8个月（范围，6至18个月）。我们的数据显示，在10.8个月大时，硬腭修复对语言有显著的益处，而对颌面部的生长没有影响，但我们承认，在较早的年龄，腭和犁骨组织的骨膜破坏可能会导致显著的生长障碍。单独修复软腭而不破坏骨膜，可以在不影响硬腭生长的情况下释放提肌机制。此外，通过唇裂修复重建前腭弓和通过修复腭帆重建后上颌弓，可通过牙槽弓扩张产生塑形效应。2，3塑形效应导致牙槽弓变窄。
In 1996, we published the results of the Oxford Cleft Palate Study in “The Timing of Hard Palate Closure: A Critical Long-term Analysis.”1 Our objective in this study was to critically assess the controversy about the timing of hard palate closure, specifically early palatoplasty for improved speech versus delayed palatoplasty for undisturbed facial growth. A multidisciplinary approach was used to evaluate the longterm results of early (10.8 months) versus late closure (48.6 months) of the hard palate and to determine the incidence of speech deficiencies, palatal fistulas, hearing abnormalities, and maxillofacial growth disturbances. The results of our original analysis revealed statistically significant speech deficiencies with delayed hard palate closure, specifically in articulation, nasal resonance, intelligibility, and substitution pattern assessment. The delayed closure group also had a significantly greater incidence of overall palatal fistulas and persistent palatal fistulas. No significant differences were noted in hearing or maxillofacial growth. Given the results of our data, we believe that delayed hard palate closure results in significant speech impairment without the benefit of preserving maxillofacial growth. The impact of our long-term analysis is reflected in our current goal-oriented approach to the treatment of cleft palate patients. The goals for treatment of the cleft palate patient are normal speech, hearing, maxillofacial growth, and avoidance of fistulas. There are several important differences between our current treatment protocol and the early treatment method used in the Oxford Cleft Palate Study. These changes are based on the results of our data as well as our clinical experience during the past 15 years. We advocate an early, two-stage palate repair. Our current treatment protocol starts with presurgical infant orthopedics at 1 to 2 weeks of age. The cleft lip and velum are repaired at age 3 to 6 months, and the residual hard palate cleft is repaired at age 15 to 18 months. Secondary bone grafting of alveolar clefts after orthodontic manipulation is performed during transitional dentition. The lip is repaired using a modified Millard rotationadvancement, the velum is repaired by intravelar veloplasty, and the hard palate is repaired using a two-layered primary closure or the von Langenbeck procedure. The technique for early palate closure in the Oxford Cleft Palate Study was a one-stage, three-flap or four-flap, modified Wardill-Kilner procedure at an average age of 10.8 months (range, 6 to 18 months). Our data showed significant speech benefits without maxillofacial growth consequences of hard palate repair at age 10.8 months, but we acknowledge that periosteal undermining of palatal and vomerine tissues at an earlier age could potentially result in a significant growth disturbance. Isolated repair of the velum without periosteal undermining allows release of the levator mechanism without disturbing hard palate growth. Furthermore, reconstruction of the anterior palatal arch with the cleft lip repair and posterior maxillary arch with repair of the velum creates a molding effect with alveolar arch alignment.2,3 The molding effect results in a narrowing of the