使用肋軟骨移植重建半邊小臉症骨缺損之長期評估及治療

Long-term Evaluation and Treatment for A Patient with Costochondral Graft Reconstruction in Hemifacial Microsomia – A Case Report

本病例報告一名Pruzansky第三類半邊小臉症（hemifacial microsomia）的女性病患以早期肋軟骨重建下顎之長期追蹤與顏面咬合改正之過程。患者求診主訴為顏面歪斜及咬合面傾斜。患者的右邊患側下顎枝和髁突在六歲左右時接受肋軟骨重建。口外檢查顯示嚴重顏面歪斜，右臉較長，左臉較凸出，下顎因為移植的肋軟骨過度生長而嚴重往左側歪斜。此外，右側重建的顳顎關節呈現黏連。口內檢查顯示上顎牙齒嚴重擁擠，因橫向補償偏斜的下顎導致上顎牙弓塌陷，顯著的咬合平面傾斜，中線偏差與全口牙齒嚴重錯咬。術前矯正包含初期排齊與上顎牙弓使用四環擴張器擴張，並在正顎手術前先進行右側黏連髁突的釋放手術。正顎手術包含上顎兩塊的勒福第一型（2-piece LeFort I）手術排齊上顎牙弓，雙側矢向面骨切開術（bilateral sagittal split osteotomies）改正歪斜的下顎。術後達到穩定的牙齒咬合與排列，並且上下顎都給予固定與活動維持器。這篇病例報告將呈現此複雜病例治療形態的選擇，正顎手術與矯正的治療過程，手術設計的特殊考量以及術後併發症。

A 17-year-old girl who was diagnosed as Pruzansky Grade III hemifacial microsomia (HFM) at right side, came with chief complaint of face asymmetry and occlusal deviation. The patient was regularly followed up in the Chang Gung Craniofacial Center. She had her affected right side ramus and condyle reconstructed with costochondral graft (CCG) around 6 years of age. The extraoral examinations indicated severe facial asymmetry with longer right face and prominent left face; the lower jaw was severely deviated to the left side due to overgrowth of the CCG at right mandible; besides, the right reconstructed condyle was ankylosed. The presurgical orthodontics involved initial leveling and alignment and expansion of upper dental arch. The right ankylosed condyle was released before orthognathic surgery (OGS). The OGS included 2-pieces LeFort I osteotomy to align the maxillary arch form, and bilateral sagittal split osteotomies to correct the severely displaced mandible. The treatment outcome showed improvement of face symmetry and profile. Stable dental occlusion and alignment was achieved then further retained with both fixed and removable retainers. We illustrated the decision of treatment modalities, process of orthognathic and orthodontic treatment, special consideration of surgical design and complications for this case.