导航手术在颅颌面外科的应用及误差控制

导航手术越来越多地应用于颅颌面种植修复、损伤、面部整复、正颌外科、放疗及射频热凝治疗。精确性是导航手术的关键,误差的控制贯穿于影像获取、配准、实时跟踪及导航手术操作的各个步骤中。本文就颅颌面外科的导航手术应用及误差控制作一综述。     

手术机器人系统在颅颌面外科中的应用及发展

近年来机器人辅助外科手术以其微创、精准、安全的特点受到了越来越多的关注。颅颌面外科传统手术严重影响美观。机器人辅助手术延伸了医生的视觉范围和可操作空间,提高了手术效果及患者术后生活质量。本文对手术机器人系统的发展以及近年来在颅颌面外科的应用进行综述。     

9例经口入路机器人手术在口腔颌面外科应用报道

目的: 总结口腔颌面外科机器人手术的应用经验。方法: 解放军总医院口腔科应用达芬奇机器人手术系统对9例位于口腔深部肿瘤患者行经口入路机器人手术（transoral robotic surgery, TORS）,总结手术经验与体会。结果: 患者均顺利完成手术,摆位及术区暴露用时20~90 min,平均42.2 min;手术时间5~90 min,平均40.9 min。除1例双侧颈淋巴清扫术患者外,其余纯口腔入路患者8例,术后平均住院日3.25 d,术后均顺利出院,平均住院天数7.75 d。结论: 达芬奇机器人手术系统可以独立完成口腔深部肿瘤手术,但在特殊患者如舌根肿瘤手术上仍有一定困难,主要是术区暴露时间较长。     

正颌外科术后患者的满意度调查

本文通过问卷回顾性地调查了126位正颌外科术后1年以上患者的满意度。93．6%的患者对手术后容貌的改变满意;849%的患者愿意向有类似畸形的亲朋好友推荐正颌外科手术;74.8％的患者愿意再选择手术;64.3％以上的患者术后感觉自信心提高,与他人交往更自如,幸福感增强。     

Role of robotic surgery in oral and maxillofacial, and head and neck surgery

We review the current status of robotic surgery in the head and neck region and its role in oral and maxillofacial surgery.     

Skeletal stability in orthognathic surgery with the surgery first approach: a systematic review

The surgery first approach (SFA) is a therapeutic strategy used in orthognathic surgery that is constantly evolving. With this approach, the pre-surgical orthodontic treatment can be eliminated, the maxilla and the mandible are surgically repositioned into the desired position, and the therapy is ended with a short orthodontic phase. Several studies have reported that the SFA is an acceptable approach, but postoperative stability is unclear. In this study, a systematic review on the SFA was performed. The PubMed, Google Scholar, Scopus, LexisNexis, Web of Science, and Cochrane Library databases were accessed. Studies from which data could be extracted on skeletal stability based on specific cephalometric points were included. The search yielded 2766 publications. Application of the selection criteria resulted in a final group of 14 articles. Five hundred and sixty patients with class III malocclusion underwent orthognathic surgery, 339 with the SFA. Study parameters such as evaluation time points and reference planes varied, making it impossible to perform a meta-analysis. The studies suggest that surgery with the SFA is as stable as surgery with the conventional approach. However, all articles described stability using a penultimate time point of ‘after surgery’ and not ‘after debonding’; hence orthodontic movements and consequent mandibular movements could have influenced cephalometric measurements. Thus, to verify the real stability of the SFA, further research with longer follow-up periods is required, with evaluation at the same time points.     

牙冠延长术的临床应用

牙冠延长术是近年来临床研究和推广的热门课题。临床上经常遇到因龋病、冠折等原因造成龈上牙体组织过短,给冠修复带来困难;如果冠边缘延伸至龈下过深,侵犯了生物学宽度,则易引起牙周问题。牙冠延长术利用生物学宽度的原理,应用翻瓣术联合牙槽骨修整的方法,延长牙冠或暴露龈下的牙体断端,其重点在于切除牙龈的同时,去除部分牙槽骨,以便在更根方的位置重建健康的牙周组织。     

Psychological issues in oral and maxillofacial reconstructive surgery

Many psychological problems affect patients who have oral and maxillofacial operations. This article reviews these problems among patients with craniofacial conditions, facial injuries, facial cancer, and those having orthognathic surgery. Facial cosmetic surgery is not addressed. Problems such as depression, anxiety, low self-esteem, poor social relationships, and changes in body image are considered. The roles of mental health professionals is emphasised to enhance postoperative satisfaction and to provide a better quality of life for these patients.     

国际牙及牙槽外科发展史

牙及牙槽外科以前亦称口腔外科或牙外科,是口腔颌面外科的基础分支,也是口腔颌面外科最常见、最基本、应用最广的临床专业学科。本文从牙拔除术、根尖外科手术、牙移植和牙再植术、修复前外科等方面概述了国际牙及牙槽外科发展的历史,为广大读者提供参考。     

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牙颌面畸形正颌外科治疗需要根据畸形的情况、治疗的要求以及术前患者的生理、心理状态评估综合制定治疗方案.在术前必须对治疗方案、(牙合)关系的调整、骨切开的部位、骨段移动的方向和距离经过精确的设计.正颌外科的术前设计包括头影描迹设计、预测,计算机辅助设计以及模型外科等.本文结合笔者的临床经验和国内外文献对牙颌面畸形正颌外科治疗的术前设计进行述评,强调了牙颌面畸形正颌外科手术方案的设计原则,提出了计算机辅助外科在正颌外科领域具有显著的优势和广阔的应用前景.     

现代牙槽外科新技术

现代医疗技术的进步,为牙槽外科的发展带来了勃勃生机。人性化、无痛化、微创化、安全化、舒适化的服务理念和医疗技术正逐渐被广大医患双方接受和应用。越来越多的新技术、新设备应用到牙槽外科手术中,推动牙槽外科不断地向无痛、微创方向前行。本文对全身麻醉技术、笑气镇静技术、无痛麻醉技术、安全监护拔牙、埋伏阻生牙定位技术、微创拔牙、纤维内窥镜及数字显微镜技术、正畸牵引拔牙技术、即刻种植拔牙、超声拔牙刀拔牙、牙槽骨外形及功能保留技术等现代牙槽外科新技术的适用对象、技术优势、临床应用、操作要点等进行阐述。     

手术导航系统在颅颌面外科的应用

总结术中导航技术的发展历史、基本组成、工作原理和精度影响因素，重点讨论了近年来术中导航技术在颅颌面外科的应用现状，包括神经外科、口腔颌面外科、耳鼻咽喉科、放疗科等。结果显示术中导航将使手术更加个性化，精度更高，更加微创，因而有着良好的应用前景。     

牙种植外科技术探讨

牙种植外科技术是牙种植学的重要组成部分之一，它直接关系到牙种植的成功与失败。本文结合几年来的临床实践，介绍了牙种植患者的术前评估、治疗设计，重点对于该手术的外科手术问题进行探讨。文章还对该手术的注意事项，如何保证正确的种植部位与方向，防止副损伤等问题介绍了作者的体会。     

牙周手术后龈缘位置变化的影响因素

牙周手术的目的之一是恢复患牙的美观和功能。而术后牙龈退缩不但影响美观,而且造成牙根敏感,加重食物嵌塞。如何减少牙龈退缩,是临床关注的问题。本文就牙周手术后龈缘位置变化的影响因素加以阐述。     

Benefits of the enhanced recovery after surgery pathway for orthognathic surgery

The enhanced recovery after surgery (ERAS) protocol was designed to improve patient outcomes and decrease complications, opioid use, and postoperative nausea and vomiting (PONV). The aim of this retrospective cohort study was to examine the effectiveness of ERAS protocols implemented in orthognathic surgeries from 2017 to 2018 at the University of Alabama at Birmingham Hospital by measuring opioid use and PONV. Two groups were identified through chart review, a non-ERAS group (traditional) of patients who had surgery without a protocol and an ERAS group of patients who had surgery with the ERAS protocol. The anesthesia and surgical teams followed a standardized protocol for perioperative management. All procedures were performed by a single surgeon and included single- and double-jaw surgeries and adjunctive procedures. The patient charts were analyzed for postoperative opioid consumption (measured in morphine milligram equivalents, MME) and PONV. IBM SPSS Statistics version 26 was used to conduct the statistical analyses. The ERAS group received less opioids during the postoperative period than the control group (31.2 MME vs 54.6 MME, P =  0.002). The ERAS group also had a lower incidence of PONV, with 1.2 episodes of PONV compared to 2.4 episodes in the non-ERAS group (P =  0.008). This study demonstrates that the ERAS protocol is effective in decreasing postoperative opioid consumption and PONV.     

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膜龈手术是多种牙周软组织手术的总称,旨在加宽附着龈,覆盖裸露根面,治疗牙龈退缩,加深前庭沟,矫正系带或肌肉附着异常,以利于口腔卫生的保持和修复治疗的进行。     

An integrated orthognathic surgery system for virtual planning and image-guided transfer without intermediate splint

Accurate surgical planning and transfer of the planning in orthognathic surgery are very important in achieving a successful surgical outcome with appropriate improvement. Conventionally, the paper surgery is performed based on a 2D cephalometric radiograph, and the results are expressed using cast models and an articulator. We developed an integrated orthognathic surgery system with 3D virtual planning and image-guided transfer. The maxillary surgery of orthognathic patients was planned virtually, and the planning results were transferred to the cast model by image guidance. During virtual planning, the displacement of the reference points was confirmed by the displacement from conventional paper surgery at each procedure. The results of virtual surgery were transferred to the physical cast models directly through image guidance. The root mean square (RMS) difference between virtual surgery and conventional model surgery was 0.75 ± 0.51 mm for 12 patients. The RMS difference between virtual surgery and image-guidance results was 0.78 ± 0.52 mm, which showed no significant difference from the difference of conventional model surgery. The image-guided orthognathic surgery system integrated with virtual planning will replace physical model surgical planning and enable transfer of the virtual planning directly without the need for an intermediate splint.     

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随着口腔正畸学的发展与成熟,口腔正畸医生和颌面外科医生通过良好的合作,有效地将口腔正畸学与颌面外科学紧密地结合起来,形成口腔正畸-正颌外科联合治疗骨性错耠畸形的治疗手段。正颌外科对于颌面部和牙弓形态学的改善已经得到学术界的普遍认可,并且获得越来越多患者的接受。正颌手术治疗后,患者颌骨和牙齿均有移动,打破了原有的口颌系统,重建咬合平衡。近些年来,关于患者正颌手术治疗后口颌系统功能改变的研究一直受到广泛关注并存在很多争议。本文就近年来正颌手术治疗后口腔生理功能变化的相关研究进展做一综述。     

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计算机辅助外科是一种基于计算机对大量数据信息的高速处理及控制能力，通过虚拟手术环境为外科医生从技术上提供支援，使手术更安全、更准确的一门新技术。通过运用计算机辅助外科，可以优化手术方案、提供术中实时导航、提高手术的精确性和质量，使外科手术变得更为完美而富于严格的手术程序，从而降低手术危险性。本文主要介绍计算机辅助外科的基本原理、目前在临床上主要涉及的计算机辅助外科相关技术、这些技术的优缺点以及其在1：7腔颌面外科中的应用现状。     

On a definition of the appropriate timing for surgical intervention in orthognathic surgery

Together with the introduction of new orthodontic techniques and minimally invasive surgery protocols, the emergence of modern patient prototypes has given way to novel timing schemes for the handling of dento-maxillofacial deformities. The aim of this study was to define, justify, and systematize the appropriate timing for orthognathic surgery. A retrospective analysis of orthognathic surgery procedures carried out over a 3-year period was performed. Six timing schemes were defined: ‘surgery first’, ‘surgery early’, ‘surgery late’, ‘surgery last’, ‘surgery only’, and ‘surgery never’. Gender, age at surgery, main motivation for treatment, orthodontic treatment length, and number of orthodontic appointments were evaluated. A total of 362 orthognathic procedures were evaluated. The most common approach was ‘surgery late’. While aesthetic improvement was the leading treatment motivation in ‘surgery first’, ‘surgery early’, and ‘surgery last’ cases, occlusal optimization was the chief aim of ‘surgery late’. Sleep-disordered breathing was the main indication for treatment in ‘surgery only’. Compared to ‘surgery late’, orthodontic treatment was substantially shorter in ‘surgery early’ and ‘surgery first’ cases, but the number of orthodontic appointments was similar. In conclusion, the skilful management of dento-maxillofacial deformities requires a comprehensive analysis of patient-, orthodontist-, and surgeon-specific variables. Each timing approach has well-defined indications, treatment planning considerations, and orthodontic and surgical peculiarities.