上颌骨大型缺损的个体化三维闭合式功能性重建

目的：介绍一种以CAD／CAM快速原型模型预成钛网支架，结合前臂皮瓣或串联腓骨肌瓣行闭合式上颌骨缺损三维重建的新方法。方法：自2000年3月起，对10例上颌骨因肿瘤及外伤后缺损的病例，分别行上颌骨次全切除4例(Ⅱ类缺损)，全上颌骨切除6例(Ⅲ类缺损)。术前均以三维CT及快速原型技术预成实体模型，并通过CAD／CAM将健侧上颌骨复制到患侧缺损处，在模型上精确塑形钛网。8例前臂皮瓣与2例前臂串联腓骨肌瓣覆盖钛网以重建上颌骨，关闭口鼻腔。结果：10例上颌骨缺损病例经6—24个月随访观察，皮瓣除2例因术后放疗部分坏死外全部成活，面部外形满意。除1例于术后9个月眶外侧壁复发外，其余经CT或MRI检查证实，肿瘤未见复发。张口度2、5—4cm，进食时无食物从鼻腔返流。语言较为清晰，其清晰度经语音工作人员评定，术前术后趋于一致。其中6例钛网支架构筑外形的患者已行可摘局部义齿修复，能进普食。经TekscanⅡHe力测定仪术前术后对比研究，发现能在一定程度上恢复患者原有的咬合力。3例上颌骨全切的病例修复术后6—12个月经鼻咽内窥镜检查，发现钛网内衬有正常软组织覆盖。结论：我们设计的这种以CAD／CAM快速原型模型预成钛网支架、结合前臂皮瓣或串联腓骨肌瓣闭合式三维重建上颌骨缺损的新方法，使术后患者上颌骨外形和口腔功能令人满意，值得推广应用。

Closed Three-Dimensional Reconstruction of Large Maxillary Defects with Titanium Mesh and Myocutanous Fibular Flap and Chinese Flap

Objective To introduce a new method of closed maxillary reconstruction,in which CAD/CAM was used to copy model of lost maxilla.Titanium mesh was covered by Chinese flap(CF)or by fibular myocutanous flap combined CF to restore maxillary defects.Methods Since March of2000,10cases underwent maxillectomy.Among them,6cases had maxillectomy(type III defect)and4cases had subtotal maxillectomy(type II defect).Each case underwent3D-CT and rapid prototype technique to get three-dimensional model.The lost maxilla model was copied from the opposite side by CAD/CAM technique.After the working model was completed by CAM,the titanium mesh was then re-built to have an accurate stereo shape.8Chinese flaps and2CF combined with fibular flap were covered the mesh to restore the maxilla.Oral and nasal wounds were closed by these flaps.Results10cases were followed up for6-24months,all flaps were alive with satisfactory form of nasal and oral cavity.They were also confirmed tumor free by CT or by MRI except one case.Their mouth opening was from2.5to4.0cm and without nasal foods return.6cases got a partial denture and could eat normal food.All these cases had a good speech quality confirmed by phonetic exam and mastication evaluated by occlusive analysis.In three patients,normal tissue growth was found in the titanium mesh by ENT endoscopy.Conclusions Our new design of closed three-dimensional maxillary reconstruction method had a satisfactory recovery both in facial contour and function.It is recommended for popularization.