三焦点牵引成骨下颌骨缺损重建的实验研究

目的探讨采用内置式三焦点牵引器在犬下颌骨骨段缺损功能重建中牵引成骨的特点、规律。方法使用内置式三焦点牵引器对4只成年犬下颌骨骨段缺损进行牵引成骨重建。制作3cm下颌骨缺损区,同期植入内置式三焦点牵引器。牵引间歇期8天,牵引速度0.5mm×2次/天,稳定期3个月。结果下颌骨牵引成骨约30mm,牵引成骨过程中无感染、成骨不良等并发症。牵引完成后第3个月X线片、组织学观察及扫描电镜观察均可见新生骨的形成,新生骨的形态、组织结构接近正常下颌骨。结论三焦点牵引成骨技术重建的颌骨形态、组织结构和功能接近正常颌骨,牵引成骨区和压力成骨区局部应用rh-BMP2可以促进新骨的形成及钙化。     

口内入路个体化三焦点圆弧牵引器修复下颌骨大型缺损

目的:根据下颌骨缺损类型,设计个体化内置式圆弧牵引器,通过三焦点牵引成骨技术修复下颌骨缺损畸形。方法:对患成釉细胞瘤行下颌骨部分切除的患者,确定手术切除范围及修复后下颌骨形态,在快速原型模型上设计个体化内置式圆弧形牵引器,应用三焦点转移盘牵引方式,在肿瘤切除同期行牵引成骨手术,牵引前间歇期7d,牵引参数为0.4 mm/次,2次/d,固定期6个月。拆除牵引器后,二期行牙列修复。结果:牵引器植入后牵引过程顺利,固定6个月后X线片显示新骨形成均良好,但2个转移盘间见纤维愈合,拆除牵引器时需行钛板内固定。牙列修复前,发现下颌骨形态略小、矢状向后缩,再次行双侧下颌支矢状劈开前移下颌骨,到达设计位置并稳定后,行覆盖义齿修复。结论:个体化内置式圆弧牵引器可以有效修复下颌骨大型缺损,避免传统骨移植手术造成的供区创伤,但在前期设计时,需要适当矫枉过正。     

下颌骨缺损自体骨移植术后种植修复

目的：下颌骨缺损自体骨移植术后采用种植义齿修复。方法：6例髂骨移植患者，3例直接植入种植体；2例经颌骨骨块上置法植骨后植入种植体；1例经牵引成骨术增高牙槽突后植入种植体。2例腓骨移植患者，分别经腓骨上置法移植和牵引成骨术增高牙槽突后植入种植体。结果：8例患者最终都植入种植体，其中3例已完成上部义齿修复。结论：下颌骨缺损自体骨移植术后，常有牙槽突骨量不足，需行牙槽突Ⅱ期重建。上置法植骨和牵引成骨术能成功地重建牙槽突缺损骨量。     

个体化内置式牵引器在修复下颌骨部分缺损中的应用

目的：应用个体化设计的内置式下颌骨牵引器,通过牵引成骨技术修复下颌骨部分缺损。方法：对因肿瘤行下颌骨部分切除的2例患者,术前根据头颅三维模型,设计个体化内置式牵引器,同期（1例）行肿瘤切除与牵引成骨手术,或二期1例行牵引成骨手术,运用转移盘牵引方式修复下颌骨部分缺损,固定期8～9个月,行X线及CT检查。结果：2例患者均成功进行了牵引器植入手术,术后牵引顺利,其中（1例）出现伤口感染,给予抗生素后得到控制,未影响牵引成骨治疗的进行。2例患者新骨形成均良好,转移盘远端骨质连接间隙处在拆除牵引器时需以植骨或钛板固定。结论：个体化设计的内置式下颌骨牵引器,可以根据不同患者颌骨缺损情况,进行一次性复杂牵引成骨,修复下颌骨部分缺损。     

涉及下颌骨体部和升支部缺损的定向二次牵引成骨治疗

目的探讨分期牵引成骨技术在下颌骨体部和升支部同期缺损修复中的应用方法及临床意义。方法对2001～2006年就诊的因各种原因导致下颌骨体部和升支部同期缺损患者12例,应用计算机辅助设计制作三维头颅模型,在模型上进行牵引成骨设计,预制个性化内置式颌骨牵引器,先期完成下颌体部及角部牵引,Ⅱ期完成下颌升支牵引。结果①下颌体及角部牵引长度4.5 cm～6.0 cm,平均5.2 cm;下颌升支牵引长度4.0 cm～6.0 cm,平均5.4 cm。②创口I期愈合,下颌外形良好,无感染等情况发生,下颌体及升支部成骨良好,健侧咬颌关系无偏斜。③平均追踪37.8个月,面下1/3外形恢复良好,张口度正常,咬合关系正常,牵引器放置软组织区无红肿等炎症表现。结论三维头颅模型为下颌骨体部和升支部同期缺损分期牵引成骨修复提供了精细的设计和操作平台,分期牵引成骨修复下颌骨体部和升支部同期缺损疗效确切。     

微型种植体支抗辅助牵引成骨重建上颌骨部分缺损的效果评估

目的：评价正畸技术自制牵引成骨装置及微型种植体支抗辅助弹力牵引重建上颌骨部分缺损的疗效。方法：选择5例上颌骨部分缺损病例,均为男性,年龄19～43岁,平均33.2岁。制作特殊的牵引装置,采用微型种植体支抗辅助支持的弹力牵引方式,进行三焦点式牵引成骨。3个月后,在两侧牵引区植入种植体,进行牙列修复。结果：骨缺损区牵引成骨后成骨良好,形成完整的牙槽嵴,可应用种植和托牙技术进行牙列修复,恢复良好的咬合关系。结论：对上颌骨部分骨缺损病例,可应用正畸技术和牵引成骨技术联合治疗,以恢复颌骨复杂的解剖结构,尤其是牙槽嵴,为牙列修复提供必备的条件。     

膜引导辅助弹力牵引成骨重建节段缺失下颌骨的实验研究

目的利用膜引导骨再生技术促进记忆合金牵引器弹力自动牵引成骨进程。方法手术截除杂种犬一侧下颌骨2．5-4．0cm骨段，按bi-focal牵引成骨原理安置记忆合金牵引固定装置，并将聚四氟乙烯膜覆盖于骨膜剥离的下颌骨颊侧面；术后3个月取下颌骨观察并测量骨密度和强度。结果节段缺失下颌骨得到重建，传送盘前后各形成1．5-2．5cm再生骨段；新骨高度及厚度接近正常下颌骨，骨密度和强度接近或超过正常骨半量值。结论膜引导技术可以避免骨不连，加快弹力牵引再生骨的骨化成熟过程。     

功能性颌骨重建61例临床分析

目的:评价采用多种骨瓣进行功能性颌骨重建的临床效果。方法:61例颌骨缺损患者,首先应用多种骨瓣重建颌骨的连续性,然后植入骨结合种植体,利用种植义齿重建患者的咀嚼和发音功能。61例患者中,男39例,女22例,平均年龄48岁(20～61岁)。游离髂骨瓣32例,血管化腓骨瓣21例,单纯牵引成骨重建颌骨7例,其他骨瓣1例。共植入种植体247颗。种植固定义齿修复29例,种植体支持的活动义齿修复32例。结果:种植义齿修复完成后平均追踪49个月(6～114个月),种植体脱落6颗。1例患者在修复完成2年后因肿瘤复发死亡(含4颗种植体,不计入存活种植体)。至最后复查,共237颗种植体仍在行使功能,累计5年存活率为95.95%。结论:应用游离髂骨瓣、血管化腓骨瓣重建颌骨的连续性后,植入骨结合种植体,能够有效地重建患者的咀嚼、发音功能,近期效果满意。     

下颌骨单侧骨皮质牵引的实验研究

目的 探讨下颌骨囊肿手术后遗留的单侧骨皮质缺损能否通过骨牵引延长技术而得到修复。方法 成年杂种犬6只，在下颌骨双尖牙区制备一个单皮质缺损区，安装牵引器，将其远中的骨皮质向骨缺损区牵引。结果 被移动颊侧骨板正常成活，牵引区成骨良好。结论 本实验的结果揭示了保持下颌骨连续性的单侧骨皮质牵引是可行的，牵引成骨表现与传统的全层离断的下颌骨延长的表现是相似的。     

下颌骨牵引成骨过程及机理的实验研究

目的　观察猴下颌骨牵引成骨的动态过程 ,探讨其成骨方式及机理。方法　恒河猴 10只行单侧下颌骨牵引 ,间歇期 5天 ,牵引速度 0 .5mm× 2次 /日 ,共 15天。于牵引后不同时期拍摄X线片 ,行四环素荧光双标记 ,将牵引区骨块标本平分 ,上部骨块制作不脱钙树脂切片 ,5u切片行甲苯胺蓝染色 ,2 0u切片荧光显微镜下测骨组织沉积率 ;下部骨块制作脱钙石蜡切片 ,HE染色。结果　牵引后早期 ,牵引区以平行于牵引方向排列的胶原纤维为主 ,可见纤细骨小梁及大量骨吸收陷窝 ,X线片上表现为低密度透光区。稳定期新骨逐渐由两端向中间形成 ,牵引后 4周 ,牵引中心充满平行排列的骨小梁 ,新骨密度仍低于正常 ;牵引后 6～ 12周 ,牵引区粗大的骨小梁呈网状排列 ,可见成熟哈佛氏系统 ,新骨表面形成骨皮质 ,X线片表现接近正常。牵引完成时骨组织沉积率为对照组的4.2倍 ,在稳定期逐渐减慢 ,但牵引后 12周时仍较对照高 40 .91%。结论　缓慢有规律地牵引下颌骨可明显促进新骨形成速度 ,延长骨段。牵引后足够时间的稳定期是新骨生成的必要条件。牵引区主要以膜内成骨方式形成新骨 ,成骨过程为新生与改建并存。     

Trifocal distraction osteogenesis for segmental mandibular defect: a technical innovation

Distraction osteogenesis in the mandible is a promising method, not only for correction of mandibular hypoplasia such as hemifacial microsomia, but also for reconstruction of segmental bone defects in the mandible. The authors report a case in which a mandibular segmental defect, about 60 mm in length, was reconstructed by distraction osteogenesis. The patient was a 45-year-old man who had been treated for an oral floor cancer. After preoperative chemotherapy and irradiation therapy, the mandible had been resected from the second incisor on the right side to the first molar on the left side, and had been reconstructed with a titanium plate and a vascularized rectus-abdominis compound flap. However, an infection developed around the titanium plate and this plate had to be removed. Therefore, trifocal distraction using an original three-dimensional distractor was performed, at the rate of 1 mm per day (0.5 mm in the morning and 0.5 mm in the evening). During the distraction period, the skin flap was pushed out from the bone defect. Although small free bone transplants were needed for complete continuity, the segmental bone defect was almost filled by the regenerated bone with the lengthened gingiva. Radiographic observation showed successful new bone formation in the lengthened area.     

Mandibular reconstruction using intraoral trifocal bone transport: report of a case

On the mandibular reconstruction after tumor resection, it is easy to achieve esthetic and functional results when mandibular defect is relative small, however, it is difficult to reconstruct adequately larger defected mandible. Recently, with progress of devices, distraction osteogenesis that is the method of tissue regeneration is used as mandibular reconstruction. A 19-year-old male patient presented complaining of right lower jaw swelling. Biopsy suspected a multiple-cystic ameloblastoma in mandible. Under the general anesthesia, a mandibulectomy was performed from the right side ramus to the left side incisor. A mandibular reconstruction plate was attached to the proximal and distal bone segments. 2 types of intraoral distraction devices were placed inside the plate. These devices had 25 mm and 60 mm distraction length. After 9 days of latency, trifocal bone transport was started by 0.5 mm 2 times activation per day. After consolidation for 23 weeks, reconstruction plate and distraction devices were removed. 2.5 m x 2.0 cm iliac bone and cancellous bone were placed in the docking site with platelet rich plasma. The mandibular defect (85 mm) was reconstructed adequately using intraoral distraction osteogenesis trifocal bone transport technique. Symmetric facial balance was achieved. Now there is no recurrence and dental implants were placed on new bone.     

用山羊建立下颌骨曲线牵张成骨实验动物模型

目的:探讨用山羊建立下颌骨曲线牵张成骨实验动物模型的可行性和优越性。方法:选用山羊4只,通过自行研制的下颌牵张器经口外途径建立2种下颌骨弧形缺损(下颌角及下颌骨正中联合部)牵张修复的动物模型。术后第6天开始牵引,速率1 mm/d,牵引25~34 d。结果:4只山羊的下颌骨弧形缺损成功地通过牵张成骨被修复,牵张间隙内新骨生成确切。结论:山羊是一种较理想而经济的进行牵张成骨基础研究的实验动物,所建动物模型具有很高的可行性和可重复性。     

下颌前部垂直牵张成骨在种植义齿中的临床应用

目的应用牵张成骨技术治疗下颌前部牙槽骨垂直高度不足,并进行种植义齿治疗下前牙缺失。方法应用国产骨牵张器对3例外伤后多个前牙缺失伴有严重骨缺损、骨高度不足的患者进行下颌前部垂直牵张成骨,牵引增高下颌骨至理想的高度并固定2个月后,去除骨牵张器,同期植入牙种植体,术后3个月完成种植修复。结果3例患者骨牵张手术伤口愈合良好,牵引顺利,平均牵引增高下颌骨8.2 mm。X线检查牵引骨块生长良好,无明显骨吸收。二期手术时未见明显感染,固定骨和牵引骨之间的间隙内充满了新生骨,牵引骨块稳固。共植入骨内种植体14颗,3个月后完成种植二期手术和种植修复。1年后复查,种植体稳固,咬合功能良好,外形满意。结论牵张成骨技术是治疗下颌骨前部严重骨缺损牙槽骨高度明显不足一项非常有效的方法,可以为牙种植术提供足够的骨量。在此基础上及时进行下颌前牙区种植义齿修复临床疗效满意。     

Experimental mandibular regeneration by distraction osteogenesis with submerged devices: preliminary results of a canine model

The authors describe a new technique for reconstruction of mandibular body defects. The feasibility of distraction osteogenesis with submerged (internal) devices for reconstruction of segmental mandibular defects is investigated in an experiment with five adult dogs. A segmental mandibulectomy was performed on the horizontal ramus. The bony defect was regenerated using distraction osteogenesis (bone transport) at a rate of 1 mm daily. The animals were killed after the consolidation period. Complete bone regeneration of the surgically created gap was successful in three of five dogs. Two animals failed to create new bone. In these two cases, the screws did not offer proper stability to the bony fragments, and this caused a lack of ossification. This experimental study demonstrates the possibility to use internal distraction devices to reconstruct segmental mandibular defects in a canine model. Internal devices show enormous advantages in comparison with the external ones. This method with no donor-site morbidity may become a very useful option in human mandibular reconstruction.     

用三焦点牵张成骨技术修复重建颏部骨缺损的实验研究

目的:探讨应用三焦点牵张成骨技术修复重建颏部骨缺损的可行性及其方法。方法:选取4只成年恒河猴,通过下颌前份骨截除术形成颏部正中联合骨缺损。在两侧下颌体部各制备一个输送盘,并用自行研制的可调式多平面牵张装置使双侧输送盘向前内方向缓慢移动,并在颏部正中对接以修复重建颏部骨缺损。通过X线片与螺旋CT三维重建技术检查双侧输送盘移动与新骨形成情况。在牵张结束的第8和16周分别处死2只动物,取下颌骨牵张区标本作组织学检查。结果:牵张结束后,4只恒河猴的颏部形态接近正常猴,X线片与螺旋三维CT片显示两侧输送盘远心端在正中成功对接。牵张结束的第8周,螺旋三维CT与实验组织学观察发现牵张间隙内均有新骨形成;两侧输送盘在下颌正中呈纤维连接,并可见活跃的成骨和改建活动。牵张结束的第16周,牵张间隙内新骨成熟,两侧输送盘下颌正中逐渐呈纤维骨性连接。结论:用可调式多平面牵张装置进行三焦点牵张成骨可以作为修复重建颏部骨缺损的一种选择手段。     

牵引成骨对牙胚生长发育影响的初步观察

目的:通过对3例下颌骨截骨牵引延长过程的观察,研究牵引成骨对牙胚生长发育及萌出的影响。方法:共有8例小下颌畸形患者接受了下颌骨截开牵引延长治疗以矫治小下颌畸形。其中3例患儿的下颌截骨线上有尚未萌出的牙胚。3例中6侧下颌骨最大牵引延长幅度为22.5mm,最小幅度14mm。在截骨前后、牵引前后及随访过程中X线纵向随访观察,研究牙胚的位置改变及其生长发育的变化过程。结果:经过7～12个月的随访,发现所有在截骨线上或附近的尚未萌出牙胚,在截骨间隙牵开扩大后牙胚将移至牵引间隙中,而且能正常地生长发育、萌出。新骨的沉积钙化速度及新骨成熟所需时间与其他病例无明显差异。结论:手术应避免损伤截骨线上及邻近的尚未萌出的牙胚;在颌骨截开牵引延长的过程中,牵引成骨将不影响牙胚的生长发育,牙胚可以在经牵引形成的新骨中正常地生长发育及萌出;截骨间隙中牙胚的存在不影响新骨的形成。     

Use of a plate-guided distraction device for transport distraction osteogenesis of the mandible.

BACKGROUND: Transport distraction osteogenesis has been used to reconstruct continuity defects by regenerating bone and soft tissues. A challenge has been to maintain the correct vector during the distraction process. A new type of distraction device was recently developed that uses a standard reconstruction plate to "guide" the transported segment of the bone. This plate-guided distractor device (PGD) intimately follows the shape of the plate, thus allowing for 3-dimensional vector control during the distraction process. PATIENTS AND METHODS: Four patients underwent transport distraction osteogenesis for reconstruction of segmental mandibular defects ranging in size from 4 to 7 cm. The age of the patients ranged from 27 to 62 years. Two patients had been treated with radiotherapy as part of treatment for oral malignancy. A standard locking reconstruction plate was placed to bridge the continuity gap. An osteotomy was performed to create a bone transport segment. The PGD was secured to both the reconstruction plate and the transport bone. After a latency period of 7 days, the device was activated at a rate of 1 mm/d. The distraction process continued until the transport segment reached the opposing bone or sufficient bone and soft tissue were reconstructed for oral rehabilitation. RESULTS: All patients achieved hard and soft tissue formation. Two patients had premature consolidation of the distraction regenerate but had sufficient tissue for rehabilitation. CONCLUSION: A PGD can be used to regenerate missing hard and soft tissues. An advantage of this technique is that it uses a reconstruction plate that is routinely placed to bridge mandibular continuity defects. This device allows for ultimate vector control by intimately following a carefully adapted plate.     

腺病毒介导的人骨形成蛋白2基因转染促进下颌牵张成骨的实验研究

目的探讨局部应用腺病毒介导的入骨形成蛋白2（adenovirus vectors containing human bone morphogenetic proteins 2, Ad-hBMP-2）对兔下颌骨牵张成骨的影响。方法24只新西兰大白兔随机分为实验组（12只）和对照组（12只），并建立下颌骨双侧牵张成骨模型。经过5d潜伏期后，以0．5mm／12h的速度牵张7d。固定期第1天，在实验组骨牵张区注射0．2ml滴度为10^12pfu／L的Ad-hBMP2，对照组骨牵张区注射0．2ml滴度为10^12pfu／L的腺病毒介导的增强型绿色荧光蛋白。在固定期第7、14、28天对下颌骨牵张区进行骨密度及新生骨量比较。结果Ad-hBMP-2治疗组牵张区骨密度及新生骨量明显高于对照组。结论腺病毒介导的人骨形成蛋白2具有促进兔下颌牵张成骨的作用。