血管化腓骨瓣修复涉及髁突下颌骨缺损的临床应用

目的:对累及髁突的不同类型下颌骨缺损采用游离腓骨瓣修复的方法、经验进行总结。方法:2001年10月-2004年10月,53例累及下颌升支上部的颌骨良性病损,行下颌骨切除后采用游离腓骨瓣进行下颌骨重建,分别采用了腓骨代替髁突法(30例)、游离髁突法(7例)及保留髁突法(16例)3种方法进行下颌骨缺损修复重建。分析总结临床方法经验,并对患者术后外形和功能进行临床评价。结果:本组血管化游离腓骨瓣移植成活率98.1%(52/53);41例患者术后随访,进行了临床检查及外形、功能评价,经Fisher检验,腓骨替代髁突组、游离髁突组及保留髁突组患者在术后外形和进食、语音功能上无显著差别。结论:3种不同髁突处理方法进行游离腓骨瓣下颌骨缺损重建,在临床上实用可行,可依据患者病损的具体情况选用。     

血管化腓骨肌瓣下颌骨重建中髁突不同处理方法对颞下颌关节功能的影响评价

目的 对髁突采用不同处理方法的血管化腓骨肌瓣下颌骨缺损重建后评价患者的临床及颞下颌关节(TMJ)功能状态.方法 患者41例,其中男性21例,女性20例.41例均为累及下颌升支上部且未超过下颌中线的颌骨良性病损,其中应用腓骨替代髁突法重建24例、游离髁突法重建5例、保留髁突法重建12例.采用Fricton TMJ功能量表评价患者术后的TMJ功能,并进行统计学分析.结果 所有患者均未发生关节强直,术后最大开口度31～53 mm,平均值(42.8±5.7)mm.不同术式患者术后面部外形、进食及语音功能比较,差异无统计学意义(P＞0.05);但患者的TMJ功能指数,即功能障碍指数(dysfunction index,DI)及功能紊乱指数(cramiomandibular index,CMI)间比较,差异有统计学意义(P＜0.01).保留髁突组患者的TMJ功能优于腓骨替代髁突组.结论 保留髁突的血管化腓骨瓣下颌骨重建有助于恢复TMJ功能;以腓骨瓣末端替代髁突进行下颌骨重建时,重建髁突的位置和形态对于TMJ的功能有明显影响.     

Fibula flap reconstruction of the condyle in disarticulation resections of the mandible: a case report and review of the technique

Segmental resection of the mandible with disarticulation of the temporomandibular joint is occasionally required in the management of extensive tumors. The reconstruction of these deformities is complex, frequently involves staged procedures, and may result in significant deformity and loss of function for patients. The fibula free flap has become a standard treatment option for primary restoration of segmental mandibular deformities. However, little is published about its role in reconstructing the mandibular condyle. This paper describes a simplified technique for primary reconstruction of mandibular defects, including the mandibular condyle, in disarticulation resections of the mandible utilizing the fibula free flap.     

One-stage microvascular mandible reconstruction and alloplastic TMJ prosthesis

Severely deformed or absent temporomandibular joints (TMJ) benefit from total alloplastic joint replacement and large mandibular defects from revascularized free tissue transfer for reconstruction. However no cases of their combined one-stage placement with outcomes can be found in the literature. We present two cases with different indications and reconstruction.The first patient required mandibular body and ascending ramus reconstruction after previous sarcoma resection. This was with a condyle-bearing reconstruction plate which resulted in significant dysfunction, leaving the patient unable to open her mouth. A one-stage vascularized iliac crest free flap and alloplastic TMJ prosthesis was used to reconstruct the mandible. Subsequently, metal removal, soft tissue augmentation by lipotransfer and dental implant placement were performed. At 63 months follow-up patient was pain-free, with mouth opening, protrusion and lateral excursion back to normal.The second patient required mandibular body, ascending ramus and joint reconstruction, performed by transoral vascularized fibula free flap with temporal vessel anastomosis. The traumatic deep bite and posterior facial height were corrected, additional submandibular scars avoided by transoral placement of the fibula transplant and a miniaturized TMJ prosthesis along with the vascularised free flap with 28 months follow-up.A miniaturized TMJ prosthesis may become placed transorally for reconstruction of the TMJ, together with a vascularized free flap for mandibular reconstruction and promises good long-term stability with normal function above all for protrusion and lateral excursion.     

Osteofascial compartment syndrome

The free fibula osteocutaneous flap has been widely used in the reconstruction of facial bone, especially the mandible. Donor-site morbidity for free fibula osteocutaneous flap is generally considered to be low and minor. However, a severe and rare complication, osteofascial compartment syndrome (OCS), should be paid more attention to after the harvesting of the fibula osteocutaneous flap. In this report, we described a case where the OCS occurred in 56-year-old man after fibula osteocutaneous flap was transplanted for mandible reconstruction, and its treatment is reported. We suggest that if free fibula osteocutaneous flap is used, the OCS of the leg should be considered seriously, and the drainage must be effective and adequate.     

Placement of implants in the mandible reconstructed with free vascularized fibula flap: comparison of 2 cases

The reconstruction of mandibular continuity defects after tumor resection with free vascularized bone flaps is considered to be a treatment option. Although the fibula flap presents many advantages, it does not offer sufficient bone height to restore the alveolar arch when reconstruction involves a dentate mandible. In this report, 2 patients who were referred to our clinic with reconstructed mandibles with diagnosis of amelablastoma are presented and compared. The mandibles of these patients were reconstructed with free vascularized fibula flaps. Whereas one of the reconstructed mandibles was vertically distracted before implant placement, distraction procedure was not carried out for the other patient. Increasing height of the fibula flap by distraction osteogenesis before implant placement in dentate mandible is desirable from a functional and esthetic point of view.     

血管化腓骨组织瓣游离移植修复下颌骨缺损

目的:探讨血管化腓骨修复各型下颌骨缺损的可行性。方法:对14例因各种原因所致下颌骨缺损患者采用血管化游离腓骨瓣同期移植修复。结果:骨瓣存活成功率100%;下颌骨形状和功能恢复良好。术后3个月摄片示移植骨无吸收,骨段愈合良好。面部外形恢复均达到满意或较为满意。所有患者均能正常行走,无1例出现踝关节不稳定。结论:游离腓骨瓣血供良好,骨量充足,可塑性强,特别是对全下颌骨缺损的修复,具有目前临床常用的其他自体骨组织瓣不可比拟的优点,是下颌骨缺损修复重建的最佳方法之一。     

Microvascular free flaps for mandibular reconstruction in Goldenhar syndrome

Although Goldenhar syndrome is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the osteocutaneous fibula and scapula free flap for mandibular reconstruction in patients with severe mandibular hypoplasia. The cases of 4 patients who underwent free-flap reconstruction of a severely hypoplastic mandible due to Goldenhar syndrome are presented. Microvascular reconstruction of the severely hypoplastic mandible is possible with the osteocutaneous scapula and the fibula flap. Minimal donor-site morbidity is elicited. Furthermore, the vertical relationship can be restored adequately, and breathing is facilitated. The microvascular fibula and scapula flap are a viable option for reconstruction of the severely hypoplastic mandible in patients with Goldenhar syndrome.     

腓骨游离瓣重建下颌骨的骨段塑形与固定方法

目的：探讨腓骨游离瓣同期修复下颌骨缺损过程中骨段的塑形与固定方法。方法：作者自１９９６年４月以来连续应用腓骨游离瓣修复口腔下颌骨缺损２６例。依下颌骨缺损范围,将缺损分为八种类型。根据每类缺损部位及特点,对修复骨瓣进行截开、分段,参照正常下颌骨解剖形态对骨段塑形,分别用微型钛板,修复钛板,记忆合金骑缝钉或２０号不锈钢丝进行固定。结果：所有骨瓣及骨皮瓣均存活,成功率１００％。２６例下颌骨缺损中Ⅰ类缺损４例,Ⅱ类４例,Ⅲ类４例,Ⅳ类５例,Ⅴ类２例,Ⅵ类３例,Ⅶ类３例,Ⅷ类１例。骨瓣截成４段者１例,３段者６例,２段者１４例,剩余５例未分段。术后３个月摄片示仅１例分成３段者最短骨段有轻度吸收,其余骨段愈合良好。术后面形恢复优良率达８５％（２２／２６）。结论：腓骨游离瓣可截成２～４段。截骨部位应选择在正中联合,颏体交界处和下颌角处。修复正中联合缺损时以选用小型钛板固定为宜,二段以上的骨瓣或修复升支缺损时,应选用修复钛板进行固定,钢丝结扎仅用于辅助固定,记忆合金骑缝钉适用于骨瓣与髁突的固定     

腓骨肌皮瓣加种植体植入对颌面部软硬组织缺损的功能重建

目的:总结应用腓骨肌皮瓣游离移植对颌面部软硬组织缺损的功能重建的临床经验。方法:自2007～2011年7月,我科应用腓骨肌皮瓣一期修复下颌骨及周围软组织缺损11例,其中男性8例,女性3例,年龄33～67岁,其中左下颌牙龈鳞癌4例,右下颌牙龈鳞癌2例,右舌下腺腺样囊性癌1例,右口底鳞癌2例,左下颌黏液表皮样癌1例,成釉细胞瘤1例。其中磨牙后区粘液表皮样癌和成釉细胞瘤2例进行即刻种植。受区血管均为同侧,组织瓣均吻合1根动脉、2根静脉。动脉选用颈外动脉分支,静脉选用面总静脉、颈前静脉或颈外静脉,所有动静脉吻合均采用端端吻合法。分析皮岛的设计、大小、修复部位、存活情况等。结果:本组游离腓骨肌皮瓣11例全部成活,均携带1块皮岛,由一个穿支供养,皮岛最大6cm×4cm,最小3cm×2cm,皮岛均用于口内软组织缺损修复,2例即刻种植植入种植体6颗。术后面部外形、功能及咬合关系良好。语音功能基本正常。下肢功能在术后3～6个月恢复正常。结论:腓骨瓣的骨量充足,具有骨膜和骨髓双重血供,血运丰富,抗感染能力强,移植后易于成活。可根据需要做多段截骨塑形从而更加准确的恢复颌骨牙槽突形态。操作过程中远离头颈部,可以双组同时手术。腓骨的高度和宽度以及皮质骨的厚度也十分适合牙种植体的植入。游离腓骨瓣的皮岛不仅可用于口内外的软组织缺损修复,还可作为术后血供的观察窗。腓骨肌皮瓣在修复颌面部软硬组织缺损中具有血供安全可靠,塑形灵活,模拟外形准确,利于监测,并发症少等优点,是能够同时兼顾颌骨缺损及周围软组织缺损修复重建的理想方法。     

外科模板在游离腓骨瓣修复上颌骨缺损术中的应用

目的 探讨外科模板在上颌骨切除同期自体腓骨瓣移植修复术中的作用。方法 7例因上颌骨肿瘤需行上颌骨切除术并同期自体腓骨瓣修复的患者，术前取研究模型，根据拟行的手术范围进行模型外科设计，确定牙槽突缺损范围，并将模型修整成需要重建的理想解剖形态，制作模板。外科医生在术中根据模板对腓骨瓣塑形，并确定腓骨瓣固定的位置。术后取研究模型观测腓骨瓣的就位情况，三维CT评价腓骨与下颌骨的相对位置关系。结果 经过外科模板的术中定位，腓骨瓣与下颌骨达到正常相对位置关系，垂直向间隙适合常规叉齿或种植义齿修复。患者戴用义齿后的咀嚼效率明显提高。结论 外科模板是修复医生和外科医生之间有效的交流载体，为患者术后功能和外形的恢复创造了有利条件。     

游离腓骨复合组织瓣同期修复上下颌骨缺损：1例报告

本文介绍1例游离腓骨瓣同期修复上下颌骨缺损,对其治疗设计及并发症作一临床分析。腓骨瓣同期修复上下颌骨缺损为颌骨重建提供了新思路,可应用于某些特殊病例的治疗,准确的术前设计及细致的腓骨塑形是手术的关键。本病例术后4个月上下颌移植腓骨块之间形成骨桥,导致张口受限,是血管蒂附带的腓骨骨膜成骨所致,再次手术切除骨桥及骨膜,并随诊2.5a,未再出现张口受限。     

Misdiagnosed widespread eosinophilic granuloma of the mandible

Eosinophilic granuloma is the most common expression of Langerhans cell histiocytosis and corresponds with typical bone lesions. Early clinical signs can occur in the mandible and can cause extensive destruction of the periodontal tissues. Pathologic fracture is an unusual finding. A case of misdiagnosed eosinophilic granuloma in a 45-year-old man treated with free fibula flap and implant-supported overdenture prosthesis is reported. Free fibula flap with dental implants is a safe and reliable method for comprehensive functional and aesthetic mandibular defect reconstruction.     

自体髁突再植于血管化髂骨瓣修复下颌骨缺损

目的:评价自体髁突再植于血管化髂骨瓣修复下颌骨缺损的临床应用价值.方法:对17例累及单侧下颌角和下颌升支上部的颌骨良性病变患者行下颌骨部分切除.采用自体髁突再植于血管化髂骨瓣修复下颌骨缺损.结果:自体再植髁突及血管化髂骨瓣移植全部成活,外形满意,咬合关系良好.结论:自体髁突再植于血管化髂骨瓣修复下颌骨缺损效果肯定.     

血管化平行折叠腓骨瓣重建下颌骨肿瘤术后骨缺损

目的：探讨应用血管化平行折叠腓骨瓣重建下颌骨肿瘤术后骨缺损的临床效果。方法 ：采用血管化游离平行折叠腓骨肌皮瓣修复重建下颌骨肿瘤术后缺损9例,男6例,女3例,年龄17-61岁,平均37岁;其中,折叠修复5例,部分折叠修复4例,下颌支缺损仅行单层腓骨修复。结果：9例患者术后移植腓骨肌皮瓣均成活,颌面部及腿部术区创口一期愈合,颌面部外形满意,无开口受限,语音清晰,吞咽功能基本正常,下肢腓骨供区无明显并发症。术后3例行二期种植义齿修复,4例因经济原因行可摘义齿修复,2例暂未行义齿修复。已行修复病例义齿与余留牙咬合关系基本正常,咀嚼功能恢复良好。术后6个月复查,全景片提示移植腓骨愈合良好,移植骨高度较正常下颌骨略低。所有病例均随访1-3 a,均无复发。所有患者自我评估对颌面部外形满意。结论：应用血管化平行折叠腓骨瓣技术重建下颌骨缺损,克服了传统腓骨瓣修复后骨质高度不足的缺点,为义齿修复提供足够的骨量,能获得良好的颌面部美学形态和功能效果。     

Dental restoration with endosseous implants after mandibular reconstruction using a fibula free flap and TMJ prosthesis: a patient report

This patient report describes the secondary reconstruction of a hemimandibular and condylar defect and the dental restoration of a 56-year-old woman who had been subjected to radical ablative surgery 30 years earlier to remove a tumor. In the first phase, a fibula free flap was used in combination with a total TMJ prosthesis for the reconstruction of the hemimandible and condyle. Secondly, 3 endosseous implants were placed in the residual mandible. These implants were used to support an overdenture prosthesis that has remained in continuous function for a period of 2 years.     

带血管蒂腓骨组织瓣游离移植修复下颌骨缺损的临床研究

目的:评价带血管蒂腓骨组织瓣游离移植修复下颌骨缺损的临床应用价值。方法:对25例患者用腓骨瓣游离移植修复下颌骨缺损。手术采取血管吻合、坚固内固定方法恢复下颌骨形态及完整性。其中22例患者为单纯腓骨瓣移植,3例患者为携带肌皮瓣或皮瓣的腓骨瓣移植,3例患者还同期植入种植体共5枚。结果:25例患者平均随访917个月,成功率为96%。3个患者的5枚种植体均达到良好的骨整合效果,并已行上部义齿的修复。62% 的患者可正常进食,余38%的患者可进软食。96%的患者面部外形的恢复达满意或较为满意。所有患者均能正常行走,无1例出现踝关节不稳定。结论:带血管蒂的游离腓骨组织瓣具有众多其它自体骨组织瓣不可比拟的优点, 是下颌骨缺损修复重建的最佳方法之一。     

Vertical distraction osteogenesis of fibula transplant for mandibular reconstruction: a case report

Bone continuity defects in the mandible are caused by tumor surgery, trauma, infection, or osteoradionecrosis. Today, reconstruction of long-span mandibular defects with a free fibular flap is a routine procedure. However the bone height of the mandible after reconstruction is about half that of the dentulous mandible. Therefore, the deficiency in bone height makes implant placement impractical. In our case, because it was necessary to restore the mandibular height, a vertical distraction osteogenesis was performed on the grafted mandible of the patient who was referred to our clinic with a reconstructed mandible owing to a gunshot injury. As a result, the vertical discrepancy between the fibula and the native hemimandible of the patient was corrected. And the placement of dental implants was performed without any complications. In conclusion, we believe that the vertical distraction osteogenesis of free vascularized fibula flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation.     

Vertical distraction osteogenesis of fibular free flap in mandibular prosthetic rehabilitation: a case report

A 17-year-old boy underwent three cycles of chemotherapy and a subsequent mandibular resection for a Ewing's sarcoma of the left body and ramus. The mandible was immediately reconstructed with a microvascular osteomuscular fibular flap. One year after the mandibular reconstruction, distraction osteogenesis of the anterior portion of the fibula was performed using a Martin distractor according to the Hoffmeister technique. Bone lengthening was achieved at a rate of 1 mm/day by turning the device twice each day for 12 days. Subsequently, we waited for 70 days for bone consolidation to occur. After 6 additional weeks, five Maestro implants were placed into the distracted fibula. Bone specimens were retrieved with a trephine bur during implant placement. Mature bone was present after 70 days and after 6 months. The bone height increase was 12 mm.     

血管化游离腓骨瓣下颌骨缺损重建的供区并发症及功能评价

目的:评价血管化游离腓骨瓣下颌骨重建患者的供区并发症及功能情况.方法:游离腓骨瓣下颌骨重建41例,通过临床检查及Enneking下肢功能量表评价围手术期及术后6月后的供区并发症及功能情况.结果:2例供区出现围手术期感染;术后6月后,所有患者踝关节稳定性良好,2例出现踝关节的背屈运动受限,19例(46.3%)出现指足脚拇趾运动受限;患者下肢功能总体恢复良好.结论:游离腓骨瓣下颌骨重建术后对患者下肢功能影响较轻.