curs 10,11 - malformatii despicaturi.pdf
TRANSCRIPT
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= defecte ale structurilor cranio-cervico-faciale produse de factori genetici sau de
mediu care actioneaza in perioada embrionara sau postnatal, sau reflexia modificarilor
prezente la nastere sau in adolescenta simple
complexe
- dupa Scoala Americana
- dupa Kernahan si Starch
- dupa Valerian Popescu, acesta tine cont de criteriul morfologic+
evolutia ulterioara+principii de tratament
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- despicaturi de buza: intereseza structurile palatului primar (buza, prag
narinar, palat dur)
- despicaturile de buza si palat : malformatii ale buzei+despicaturi ale valului
palatin si a palatului dur
- despicaturi de buza-palat: despicaturi de buza+despicaturi de val palatin
- despicaturi ale palatului: lueta, val palatin, palat dur
- despicaturi ale palatului primar unilaterale
bilaterale
mediane
- despicaturi ale palatului secundar (palat dur gaura incisiva+lueta+val palatin)
totale
partiale
submucoase
- despicaturi ale palatului primar si secundar
unilaterale:partiale totale
bilaterale partial totale
mediane
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- despicaturi partiale
- anterioare unilaterale complete
incomplete
bilaterale complete
incomplete
- posterioare incomplete care intereseza lueta / val palatin
complete care intereseza lueta / val palatin / palat dur
- despicaturi asociate combinatii despicaturi anterioare incomplete
despicaturi posterioare incomplete
- despicaturi totale unilaterale: intereseaza structurile palatului primar pe o
parte si structurile palatului secundar pe linia mediana
bilaterale: intereseaza structurile palatului primar bilateral
simetric, structurile palatului secundar pe linia mediana
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Formele clinice ale despicaturilor labio- maxilopalatine:
1. D. anterioara unilaterala incompleta 2. D. anterioara unilaterala completa 3. D. anterioara bilaterala completa 4. D. posterioara incompleta 5. D. posterioara completa 6. D. totala unilaterala 7. D. totala bilaterala 8. D. asociata (anterioara incompleta si posterioara incompleta)
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Embriogeneza
- fata se formeaza din proliferarea mezenchimului format din celulele crestei neurale
- formare prin proliferarea succesiva a lobului frontal a creerului si a primordiilor optice
- sapt. a 3-a se evidentiaza mugurii: primul mugure cel frontal format din mezenchim si
ectoderm
- mezenchimul va forma baza craniului in regiunea anterioara
tesutul conjunctiv/scheletul al etajului mijlociu al fete
pulpa dentara
ligamentul dintilor superiori
- etajul inferior se formeaza din arcurile branhiale
- formarea palatului primar: teoria clasica Hiss ; palatul primar se formeaza prin penetrarea
mezenchimului, marginea libera ale proceselor palatine dezvoltate din mugurii maxilari cresc
spre linia mediana si spre posterior, realizand o fuziune epiteliala in sapt.a 6-a urmata de
penetrarea mezenchimului
- se realizeaza prin fuziunea procesului mx. si nazal median sau prin fuziunea proc. nazale
mediane si laterale
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Formarea mugurilor faciali
mugure frontal
placa olfactiva
mugure maxilar superior
vezicula optica
mugure maxilar inferior
mugure nazal intern
mugure nazal extern
mugure maxilar superior
mugure maxilar inferior
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Formarea palatului primar
BMS mugure maxilar superior
BMI mugure maxilar inferior
TM tuberculul median
BNI mugure nazal intern
BNE mugure nazal extern
A. Acolarea mugurilor. Aparitia proceselor
globulare din care se vor forma buzele si
orificiile narinare
B. Defectul de acolare provoaca aparitia
despicaturii (dupa Mugnier)
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Teoria moderna
- epiteliul din santul nazal traverseaza catre post. mezenchimul, fuzionand cu epiteliul oral
formand membrana epiteliala buco-nazala.
- formarea palatului secundar
- procesele palatine de pe fetele mediale ale mugurilor maxilari se dezvolta ajungand in
contact cu limba, care are o pozitie inalta fiind in contact cu septul nazal.
Dupa coborarea limbii procesele se orizontalizeza si se unesc median.
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Conceptul clasic al formarii palatului primar
A, B. Mugurii faciali inainte de fuzionare
(aspect frontal si palatinal)
C, D. Mugurii frontali dupa fuzionare
Formarea palatului secundar
(sectiune frontala) A. Aspectul regiunii superioare a
cavitatii orale primitive
B. Postura linguala inalta ce
permite coborirea lamelor palatinale
C, D. Coborirea limbii si orizontalizarea
proceselor palatine
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factori de mediu
Ag. Chimici rol important medicamentele Thalidomida, aminopterina si alti
antagonisti ai ac. folic (Dilantinul)
ATB
antimicotice (citostatice)
Ag. Fizici radiatiile ionizante
- efectul lor depinde de absorbita de tesutul iradiat
densitatea relativa de ionizare
radiosensibilitatea celulelor
- sursele de contaminare - radiatii naturale: contaminarea
radioactiva din atmosfera cu
elemente radioactive din sol si apa
- radiatii artificiale: iradiere profesionala biologica, iradiere
accidentala si iradiere medicala, terapeutica sau diagnostica
- radioelemente prin inglobarea izotopilor radioactivi in
substante biologice
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Fact. nutritionali
deficientele in principii aliment. de baza si deficientele minerale nu par sa joace
un rol in geneza malformatiilor la om, vitaminele sunt implicate
Vitamina A
- deficit malformatii oculo-auriculo-faciale
malformatii urogenitale
- creste riscul aparitiei despicaturilor palatine
- hipervitaminoza A intarzierea orizontalizarii proceselor palatine
tulburari conc. sangvine a hormonului tiroidian
interfereaza cu metab. hidratiilor de C
Exces vitamina A are efect direct asupra fetusului.
Vitamina B1 deficit malformatii scheletice specifice
B2 deficit scurtarea membrelor
sindactilii
despicaturi palatine
brahigenii
Vitamina E deficit hidrocefalie/anencefalie
despicaturi palatine
sindactilie
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Fact. Infectiosi
- infectiile virale ale mamei gravide
mama rubeola (sapt12)-malformatii-bolta ogivala +despicatura de palat
secundar
- virusul incluziilor citomegalice
- v. herpetic
- v. urlian
- v. gripal
- femelele soarece cu toxoplasmoza-pui cu anomalii somatice
chiar si dupa vaccinare pot aparea anomalii cromozomiale
Caracteristicile materne
- variatii anatomice/fiziologice la nivelul uterului - determina malf. ale palatului sec
- alterarea aportului sangvin
- modificarea presiunii uterine
- cantitatea de fluid uterin
- alterari metabolice
- hormoni+ produsii de degradare metabolici traverseaza placenta si infl. dezv. palatului
primar si sec., a valului si a luetei
- DZ-malformatii
- scaderea tiroxinei –despicaturi faciale
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Fact. Genetici
- gena are expresivitate variabila, modul de transmitere este recesiv
- sunt responsabile mai multe gene si factori de mediu= determinare multifactoriala
- exista predispozitie genetica: parintii copiilor cu buza superiora retrudata, etaj mijlociu
micsorat, hipertelorism
- exista malformatii distribuite la 2-3 generatii
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- lipsa contactului dintre mugurii faciali:
in urma modificarilor de volum
prin distorsiuni asociate ale mugurilor faciali cu celalalte
structuri cranio-faciale
- lipsa fuziunii epiteliale
- perforari ale pct. de fuziune epiteliala
- prin aparitia chistelor si perlelor epitel.
- esecul migrarii mezenchimale
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Regiunea nazala
- domul nazal prabusit , cu columela scurta si deviat de partea sanatoasa
- aripa nazala situata pe partea afectata este etalata, orizontalizata, pin alungirea anormala a
cartilajului alar
- pragul narinar este intrerupt prin despicatura. Defectul se intinde pana la podeaua nazala
- septul nazal este atasat de partea sanatoasa si sufera o deformatie anterioara, deviind fata de
linia mediana catre partea sanatoasa cu ingustarea ant. a fosei nazale neafectate
- oasele nazale si procesul frontal al maxilarului sufera o distorsiune
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Reg. buzei superioare
- exista doua bonturi unul lateral mai bine dezvoltat fertil
unul median mai slab dezvoltat
- buza superioara este intrerupta la nivelul tuturor structurilor (rosul buzei, mm.
orbicular, mucoase, tegument)
- frenul buzei este atasat de partea mediana
- musculatura orbicularului prezinta o directie anormala,de-a lungul marginilor despicaturii
- frenul buzei sup. este deplasat de partea sanatoasa
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Reg. alveolara
tractiunea laterala a segmentului alveolar, cu rotatia zonei premaxilare catre
ant. si alteral aceasta deplasare este favorizata si de intreruperea limbii in
despicatura si de prez. septului nazal atasat de segm. premaxilar
in potiunea post. alveolara expansiunea laterala este foarte redusa
despicatura trece prin vecinatatea IL care prezinta frecvent anomalii/ IC
rotat spre despicatura
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Reg. palatului secundar
- defectul intereseaza palatul dur si moale pe linia mediana. Vomerul este atasat pe parteaa
neafectata
- anterior valul palatin si lueta sunt divizate pe linia mediana
- cavitatea nazala si bucala nu sunt separate, fiind posibila comunicarea buco-nazala cu fosa
nazala de partea afectata
Reg. faringiana
- mucoasa congestionata, vegetatiile
adenoide marite
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Reprezentarea schematica a fortelor ce actioneaza la nivelul
segmentelor maxilare in despicatura unilaterala totala Zigomaticul nu este afectat de actiunea fortelor, un punct de sprijin si reper
Orientarea anormala a fibrelor muschiului
orbicular in despicatura unilaterala completa
Aspect intraoral
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Desp. unilaterala totala operata
Arcada super.
Arcada inf.
Detaliu plastie
buza
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Aspect clinic intraoperator
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Reg. nazala
- domul nazal prabusit
- columela scurta, pe linia mediana, uneori dispare
- aripile nazale-etalate, orizontalizate datorita modificarilor cartilajului alar
- orificile nazale largi
- exista 3 bonturi unul median-premaxila
2 laterale-buzele simetrice, bine dezvoltate
- Premaxila este formata port. anterioara prolabium=restul de buza
port. din palatul primar (osul incisiv restant)= o
portiune de os alveolar
- rosul buzelor slab reprezentat
- sant vestibutal de adancime redusa
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Reg. alveolara laterala
- datorita fortelor exercitate de musculatura procesul alveolar este presat spre interior,
realizand o ingustare a maxilarului
- capetele proximale sunt rotate spre interior realizand o ingustare a maxilarului
- palatul secundar - despicatura pe linie mediana, intereseaza palatul dur+valul
palatin+lueta
- vomer liber la mijlocul despicaturii
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Aspect clinic al unei despicaturi bilaterale
totale
Orientarea anormala a fibrelor musculaturii velare
Despicatura si directia de orientare prin plastie
(linia punctata)
Despicatura bilaterala totala cu reorientarea fibrelor
muschiului orbicular prin plastie (linia punctata)
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Pozitia anterioara a premaxilei in despicaturile
bilaterale totale
Echivalenta minora la niv. buzei sup.
Bonturile labiale prezinta orientari anormale ale
fibrelor musculare
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Incomplete gradul1 dehiscenta rosului buzelor+buzei+pragului narinar
gradul2 dehiscenta rosului buzelor+buzei +procesului alveolar
Complete buza+prag narinar+proces alveolar+ portiunea anterioara +palat
Gradul1 sub forma unor echivalente minore, nu exista dehiscenta la nivelul rosului buzelor
exista sant=defect la nivel muscular
- in despicaturile incomplete/complete avem 2 bonturi lateral fertil
median deviat
- exista o scurtare a columelei, devierea spre partea sanatoasa
+/- deficienta la nivelul orificiului narinar care este mai mare si orizontalizat
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Desp. partiala ant.
incompleta
Desen Final plastie buza
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Despicatura unilaterala anterioara incompleta – este efectata numai buza fara
interesarea procesului alveolar
Despicatura bilaterala anterioara incompleta – buza este
interesata partial fara afectarea pragului
narinar si a procesului alveolar
Despicatura anterioara completa – toate structurile
palatului primar sunt interesate de despicatura
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Despicaturile unilaterale complete
- apar modificari la nivelul IC/IL(asemanatoare cu modificarile din despicaturile
unilaterale totale)
Despicaturile bilaterale incomplete
prezente bont median putin dezvoltat
doua bonturi laterale simetrice
fara modificari la nivelul portiunii nazale
Despicaturile unilaterale totale
dehiscenta buzei + prag narinar + proces alveolar + palat dur + palat posterior + val
palatin+lueta
IC este rotat spre despicatura
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- intereseaza structurile palatului secundar (palat dur si palatul moale de la gaura incisiva catre
post.)
- segm. alveolare sunt relativ normale
- prez. tulb. functionale: fonetice, deglutitie-refluarea lichidelor pe nas
- fibrele musc. oriz. ale valului palatin sunt fixate de marginea posterioara a palatului dur astfel
incat terapia presupune reorientarea fibrelor musculare din directie oblica in directie orizontala
- despicaturile complete intereseaza lueta+val palatin+palatul secundar ( pana la gaura
incisiva)cu aparitia comunicarii cavitatii nazale cu cavitatea orala, vomer pe linie mediana
- in cele unilaterale vomerul este de partea neafectata
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Despicatura posterioara completa – palatul
secundar este interesat in totalitate, de la
gaura incisiva catre posterior
Despicatura posterioara incompleta –
intereseaza valul palatin si lueta fara
afectarea lamelor osoase palatine
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- scaderea in greutate determinata de: absenta continuitatii m. orbiculari
prezenta comunicarii cav. bucale cu cav. nazala
absenta continuitatii M. orbicular-impiedica suptul la san/utilizarea biberonului
prezenta comunicari/dehiscentei-refluarea alimentelor in fosele nazale- alimentatia
dificila
diferenta de greutate: 1-1,5 kg dintre un copil cu /fara despicatura
adeziunea labiala +confectionarea placii palatine-poate impiedica refluarea alimentelor
- tulburarile de fonatie determinate de:
intreruperea anvelopei functionale anterioare –m. orbiculari
anvelopei posterioare – m.valului palatin
incompetenta velo-faringiana lipsa inchiderii luetei de peretele posterior al faringelui
lipsa mobilitatii valului palatin in articularea cuvintelor
modificarea procesului alveolar-pozitia dintiilor frontali-disfunctionalitate in pronuntia
dentalelor, labialelor
deperditia aerului prin fosele nazala =rinolalia aperta
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- tulb. respiratorii
modificari calitative date de aerul inspirat nu este purificat complet si nu
e incalzit-hipertrofia amigdalelor palatine si aparitia vegetatiilor adenoide (fav.
pt. vorbire)
- tulb. de auz: date de existenta orientarii patologice a musc. din jurul orificiului
trompei lui Eustachio, acre nu se deschide in mod fiziologic –apar tulburari de auz de la
nastere
- tulburari de auz –m. tensor a valului palatin dezinserat de pe carligul apofizei
pterigoide sau carlig apofizar fracturat
- modif. fizionomice
probleme de integrare sociala
sent. de frustrare
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chirurgical, ortodont, logoped, pediatru,ORL,genetician, psihoterapeut, stomatolog
Etape de tratament
- precoce
- tardiv
Etape precoce de tratament
tratament ortodontic prechirurgical
- intre 1-4 sapt.
- cand deplasarile segm. alv. sunt foarte mari
- cu placile palatine active ( cu arc de expansiune)sau placi pasive (Hotz)-
favorizeaza alimentatia si contribuie la alinierea celor doua segment
- unii autori realizeaza adeziunea labiala si apou refacerea finala
(in ideea realinierii procesului alveolar)
- favorizeaza suptul
- realizeza presiune pe bontul medial deplasat spre anterior
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- tratamentul chirurgical propriu-zis
- plastia buzei: - cheilorafia sau cheiloplastia, la 8-10-12 sapt.
regula lui 10 (10 sapt., 10 Hb, 10 pounds, 10.000 leucocite)
- restaurarea m. orbic. permite incadrarea proc. alv. intr-o matrice functionala
si se elimina tractiunea orbicularului pe frag. premaxilar
- ehnica Millard modificata rezolva si aripioara nazala
- plastia palatului: la 12-18-24 luni (mai multe ipoteze)
- unii autori practica plastia intr-o singura etapa si realizeaza separarea
cavitatii bucale de cea nazala cu refacerea morfo-functionala a palatului moale cu asigurarea
fonatiei si a deglutitiei
- alti autori reliazeaza in 2 etape: prima etapa –refacerea palatului
moale+buza, iar a doua etapa –refacerea palatului dur (la 3-5 ani dupa prima interventie)
- buza: 8 sapt.-3 luni iar palatul 18 luni se rezolva
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- tratamentul precoce ortodontic : asigura alinierea dintilor, corectarea ocluziei incrucisate si a
ocluziei inverse frontale
- se intervine in caz de tulb. de ocluzie grave, IC rotati spre despicatura sau
retrudati+roatati( despicaturile unilaterale), IL absenti (rotati in despicatura)
- se utilizeza aparate mobile placi palatinale cu surub ortodontic
fixe: - cu arc lingual fixat la nivelul molarilor
- cu atasamente la nivelul I + arc vestibular pt.
alinierea dintilor frontali
- se utilizeza in dentatia temporara sau mixta
- tratamentul foniatric
- incepe la 5 ani, frecvent la 6-11ani
- scop: rezolvarea rinolaliei aperta, emisie de aer pe nas det. de val palatin
scurt care nu intra in contact cu peretele post. al faringelui
- tulb. de mobilitate la nivelul valului palatin
- fistule oro-nazale
- rezolvarea tulb. de pronuntie a alabialelor, denatalelor
det. de lipsa de aliniere a d. frontali +cicatrici labio - alveolare stranse
- rezolvarea erorilor de articulare,S in fistule oro-nazale
incompetenta velo-faringiana
malocluzie frontala
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- plastia defectului alveolar: osteoplastia defectului la nivelul procesului alveolar - realizarea
continuitatii acestuia si simetrizarea lui cu os autogen, homogen (creasta
iliaca, tibie,tuberozitate, mastoida)
- materiale aloplastice (ceramohidroxiapatita)
- substante osteoinductoare (BMP)
- culturi de celule osoase cuprinse intre doua lambouri nazal si bucal
varsat inainte de eruptia C, pt.a crea suport osos C+ aparat de sustinere
Etapele tardive de tratament
- tratament ortodontic tardiv: la 11-14ani, are ca scop alinierea dento-alveolara si evitarea
angrenajului invers anterior/ocluziei incrucisate posterior
- in malocluziile clasa III Angle - tratamentul vizeaza inhibareadezvoltarii excesive a
mand., trat.chirurgical ulterior fiind dificil
- este limitat datorita intervent. chirurgicale anterioare cu producerea de cicatrici
retractile/cicatrici fibroase in zona palatului - nu exista sutura medio-palatina, ci numai cicatrici
fibroase
- expansiunea laterala dento-alveolara e limitata dat. cicatricilor periodontale
posteoperatorii
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Plastia sec. a nasului si a buzei
- in timp dupa refacerea buzei apare disorsiunea narinei. Astfel se produce un colaps partial al
anrinei afectate, cu devierea varfului nasului.
- rinoplastia se poate practica si in copilarie, este bine sa se astepte pana dupa terminarea
perioadei de crestere (15-18 ani)
- la 5-6 ani , se poate interveni la nivelul cicatricilor vicioase ale buzei:
- se poate corecta o buza care initial a fost refacuta in tensiune
- fundul de sac vestibular e bine conformat=vestibuloplastie
- alungirea columelei-tehnica Millard, cu lambouri in furculita
Trat. chirurgical al incompetentei velo-faringiene
- incompetenta velo-faringiana se refera la imposibilitatea valului palatin de a lua contact in fonatie cu
peretele sup. al faringelui
- se pot produce compensari prin modificarea peretelui lateral faringian, tonsilele palatine largite si t.
adenoidian marit de volum - evitarea eliminarii de aer pe nas
- tehnicile chirurgicale sunt:
- velofaringoplastiile (lambou faringian median cu pedicul inferior sau superior)
- faringoplastiile
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Teh. de chirurgie ortognata
- la 17-19 ani
- avansarea chirurgicala a maxilarului (se poate practica si inainte de definitivarea cresterii
osoase)
- retropozitionarea mandibulei poate fi uneori utila si se practica in acelasi timp cu avansarea
maxilarului
- osteotomiile mandibulare izolate sunt mai putin indicate
- avansarea maxilarului trebuie cantarita prin prisma tulb. de fonatie ce apar ulterior
- avansarea de 3 mm poate produce incompetenta velo-faringiana
- este bine ca chirurgia ortognata sa fie privita ca o interventie in 2 etape
- dupa chirurgia ortognata trebuie intervenit chirurgical prin una din metodele descrise anterior
de rezolvare a incompetentei velo-faringiene
- cicatricile postoperatorii pot limita posibilitatea de avansare maxilara. La nivelul buzei,
cicatricile pot impiedica o avansare prea mare, iar cicatricile palatinale reduc si vascularizatia si
vindecarea osului postoperator
- tulburarile de adaptare fonetica limiteaza mult gradul de avansare a maxilarelor
- dupa o inocluzie sagitala >8-10mm se prefera retropozitionarea mandibulei in aceeasi sedinta,
si osteogeneza prin bone distraction
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Trat. protetic
- se refera la corectarea anomaliei dentare sau la terapia edentatiilor dupa perioada de crestere
in despicaturile bilat. ramane o premaxila flotanta, aceasta poate fi imobilizata prin lucrari
protetice fixe
- la pacientii cu maxilar hipoplazic si care necesita imbunatatirea ocluzala si a aspectului
fizionomic se pot aplica lucrari protetice adjuncte pt. dintii existenti. Acestea au un rol functional
fizionomic, imbunatatesc masticatia si pot fi folosite ca obturator a unor eventuale fistule,
imbunatatind calitatea fonatiei
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Buza normal conformata prezinta reperele:
1. Columela
2. Filtrum
3. “Arcul lui Cupidon”
3’. Varful “arcului lui Cupidon”
4. Tuberculum
5. Marginea cutaneo-mucoasa
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Operatia (plastia in linie dreapta)
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Operatia cu lambou rectangular in 1/3 inferioara a buzei
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Operatia cu lambouri triunghiulare in 1/3 inferioara
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Tehnica rotatie-avansare - delimitarea punctelor de reper
- trasarea liniilor de incizie
- rotatia din punctul 4 la 3 = cu
distanta 5 - 6 de la nivelul marginii
lamboului de avansare.
- incizia de rotatie care permite
componentelor “arcului lui Cupidon”
(2/3 inferioare ale buzei) sa coboare
intr-o pozitie normala, iar lamboul c
sa ajunga la nielul columelei.
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- croirea lamboului de avansare in
bontul lateral prin extinderea inciziei
la nivelul bazei alare.
- lamboul c este suturat longitudinal
permitand astfel alungirea columelei.
- aspectul postoperator al buzei.
- este necesar ca distanta 1 - 2 sa
fie = cu 7 - 6 pentru obtinerea unei
buze simetrice fara atenuarea rosului
de buza pe partea afectata.
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Lamboul mucozal
croirea lamboului din mucoasa labiala
de pe partea cu despicatura cu pedicul
anterior si aplicarea peste planul nazal
care a fost reconstruit anterior
Lamboul mucozal
recoltat din portiunea extremitatii anterioare
a bontului lat.
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Plastia bresei alveolare in aceeasi sedinta cu refacerea
buzei prin tehnica
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Plastia buzei in despicaturile bilaterale
tehnica ,in linie dreapta
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Plastia buzei in despicaturi bilaterale, cu lambouri
triunghiulare
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Plastia buzei in despicatura bilaterala, cu lambouri
rectangulare
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Palatoplastia tip in despicatura post.
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Palatoplastia tip in despicaturile
unilaterale totale
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Palatorafia prin retropozitionare
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Faringoplastia
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Faringoplastia
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Velo-faringoplastia cu pedicul inferior (aspect de profil)
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Velo-faringoplastia cu pedicul inferior
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Velo-faringoplastia cu pedicul median superior tip
(aspect de profil)
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