计算机辅助设计和制作技术在髁突骨软骨瘤合并颌骨畸形治疗中的应用:附1例报告

目的:探讨计算机辅助设计与制作(computer-aided design/manufacture,CAD/CAM)技术在髁突骨软骨瘤合并颌骨畸形治疗中的应用。方法:髁突骨软骨瘤合并上、下颌骨畸形1例,采用计算机辅助设计技术(SurgiCase CMF 5.0软件进行CT数据处理)模拟切除肿瘤,上、下颌骨截骨,设计虚拟中间和终末板及截骨导板,并进行术后效果预测;应用快速原型(rapid prototyping,RP)技术制作中间板和截骨导板,术中应用。术后进行CT检查,并与术前设计进行比较,评价应用效果。结果:术后CT显示,截骨效果与术前设计吻合度高,术后随访6个月肿瘤无复发,患者面形对称。结论:应用CAD/CAM技术进行髁突肿瘤切除及合并颌骨不对称畸形的辅助治疗,可以提高手术的准确性,节约手术时间,具有一定的应用前景。     

基于增强现实的下颌角截骨配准技术的研究

目的:通过增强现实技术,将下颌骨的虚拟三维数字模型及术前设计的预截骨平面同时显示在快速成型实体模型上,实现虚拟图像与实体的重叠配准.方法:选取20例下颌骨肥大患者,行三维CT扫描,重建下颌骨三维数字模型.利用上海九院整形设计系统完成术前设计,生成截骨平面,并与下颌骨合并为STL文件.取患者下牙石膏牙模,制作包含下牙咬合板在内的标志物支架,固定于石膏牙模,两者一并扫描.然后将扫描数据和下颌骨三维数字模型数据导入同一三维处理平台,选择右第一磨牙的远中舌尖、第二磨牙的近中舌尖、左第一磨牙的近中舌尖,进行标志物支架和下颌骨的拟合,生成虚拟影像.此时的三维虚拟数字化影像包括标志物、下颌骨及预截骨平面.然后将标志物支架的下牙咬合板固定于下颌骨快速成型模型上,采用增强现实视频检测方法.用视频捕捉器识别到标志物后,将虚拟影像与下颌骨快速成型实体模型进行配准.结果:该技术实现了三维虚拟数字化影像与下颌骨快速成型模型的虚实融合叠加,使下颌骨和术前设计的预截骨平面实时显示在下颌骨实体上.结论:本研究建立的配准方法具有良好的重复性,有望成为下颌角截骨术可视化手术有效的配准途径,为未来增强现实手术应用研究奠定了基础.     

数字化技术辅助颌骨截骨及颌面修复的临床应用

目的:将系列数字化导板用于上下颌骨截骨及修复,实现上、下颌骨缺损的个体化精确修复。方法:15例上颌骨次全切除及下颌骨节段性截骨的患者,男性9例,女性6例,均行术前规划,并3D打印数字化导板,术中分别应用即刻赝复体修复上颌骨缺损,同期血管化腓骨瓣移植修复下颌骨缺损。术中使用导航验证截骨范围,术后利用图像融合技术评价术后效果。结果:导板术中就位顺利,截骨范围与术前设计基本一致。即刻赝复体能顺利戴入,重建钛板及髁突位置准确,面型及咬合关系恢复良好。术后图像融合显示,15例上/下颌骨截骨实际手术与虚拟手术平均偏差,平均为(0.43±0.10) mm。结论:数字化系列导板能够在术中准确还原术前设计,减少手术时间;其与手术导航相辅相成,能实现颌骨个体化、精确化的截骨及颌面缺损修复。     

3D打印截骨导板辅助赝复体术中修复BrownⅡ类缺损的精准度评价

目的 设计制作3D打印截骨导板用于赝复体术中修复BrownⅡ类缺损,评价其临床应用的精准度.方法 8例因肿瘤致BrownⅡ类缺损患者纳入研究,术前设计制作3D打印截骨导板及赝复体,术中在截骨导板引导下完成手术,即刻戴入赝复体修复缺损,将术前虚拟计划与术后CBCT融合,对整体及局部区域行偏差分析评价手术精准度.应用SPS...     

骨支持式3D打印导板在上颌骨LeFortⅠ型截骨术中的应用

目的 探讨3D打印技术制作的截骨导板和再定位导板在上颌骨LeFortⅠ型截骨术中的应用效果。方法 选择8例因上颌发育不良行LeFortⅠ型截骨术的的患者为研究对象,所有患者均进行锥形束CT（CBCT）扫描并建立上颌骨三维模型,使用3D打印技术制作上颌骨截骨导板和再定位导板。所有手术均由同一名医生操作,术中使用截骨导板截骨和再定位导板固定上颌骨块。术后复查CBCT,测量6个标志点到3个基准平面的距离,比较术前虚拟手术与实际手术中上颌骨的位移误差,评估其用于正颌术中上颌骨截骨和再固定的准确性。结果 术后所有患者口内切口均Ⅰ期愈合,无明显并发症。位移误差均值最大为1.35 mm,是左上磨牙点到冠状平面的位移误差;标准差最大为0.85,标准误最大为0.30。位移误差均为临床所接受范围。结论 3D打印技术制作的截骨导板和再定位导板有助于安全、准确地完成上颌骨LeFortⅠ截骨术。     

快速原型个体化牵引成骨在颌骨畸形治疗中的应用

目的:探讨颅颌快速原型制作在颅颌面畸形牵引成骨治疗中应用的方法及其临床意义。方法:对16例平均年龄16.8岁的下颌骨畸形病例,应用计算机辅助设计制作颅颌三维原型,分析颌骨畸形的类型并在模型上进行个性化牵引成骨设计,选择牵引器及模拟牵引过程以指导实际手术操作。结果:16例均进行了术前模拟,术中按术前设计顺利进行了骨切开及牵引器的固定安置,所有16例病例术后牵引均达到了预期的目标,牵引长度15～23mm(平均18.5mm)。结论:通过计算机辅助的头颅三维原型制作及分析,可以大大增加牵引成骨的合理性及可靠性,有助于降低手术难度并获得良好的预期效果。     

牙支持式数字化导板在水平截骨颏成形术中的应用及精确性分析

目的: 探讨牙支持式数字化导板在水平截骨颏成形术中的应用价值。方法: 选择2017年3月~2018年3月就诊于昆明医科大学附属口腔医院口腔颌面外科的颏部畸形患者7例,通过建立数字化模型,进行三维影像学测量,精确判断颏部在三维空间上的畸形程度,进行手术前模拟设计,虚拟截骨,设计并3D打印成型牙支持式截骨导板应用于手术。术后3个月拍摄CBCT与手术设计进行拟合,评价导板的精确性。结果: 患者均为一期愈合,术后患者对效果均比较满意,拟合数据显示术后CBCT与术前虚拟手术的平均误差为0.7335 mm。结论: 利用数字化技术进行三维重建、手术模拟,3D打印牙支持式导板引导截骨,提高手术精度,可有效改善各种颏部畸形,具有实际应用价值。     

3D打印导板辅助髁突骨软骨瘤及继发复杂牙颌面畸形的手术治疗

目的:研究3D打印手术导板辅助髁突骨软骨瘤及继发牙颌面畸形同期矫治的临床可行性。方法:根据影像学资料,运用Dolphin Imaging 11.7 Premium 和Mimics软件进行虚拟外科手术设计并制作3D打印手术导板,指导髁突骨软骨瘤及继发牙颌面畸形的手术矫治。通过对比模拟头颅模型与实际术后CT重建模型评估此方法的临床价值。结果:所有患者患侧关节功能、咬合关系以及颜面对称性都得到了良好的恢复。模拟术后模型与术后扫描重建模型对比中,中切牙与第一磨牙的误差均保持在1.4 mm以下,最大误差出现在颏部,约2.4 mm,显示了新方法的准确性。结论:结果显示虚拟外科手术设计和手术导板有助于髁突骨软骨瘤继发牙颌面畸形的准确诊断、治疗方案设计、准确截骨以及重置骨块。     

基于快速原型技术的导航辅助下颌骨内置式牵张成骨术的实验研究

目的：应用自主研发的导航手术系统,在快速原型技术制作的三维头颅模型上进行内置式下颌骨牵张成骨术的实验研究,通过三维定点测量,分析该导航手术的精度。方法：对1例单侧下颌骨发育不足的患者行螺旋CT扫描后,采用快速原型技术制作5个相同的头模,按导航配准原则植入定位钉后再行CT扫描。应用AccuNavi 1.0软件对三维图像进行测量,并与游标卡尺实体测量的相应指标进行头模制作精度检测。然后进行下颌骨三维测量分析与虚拟单侧内置式下颌支牵张成骨术,将制定的手术规划通过实时TBNavis-CMFS导航系统在三维头模上实施,牵引到位后,行CT扫描图像重建,应用AccuNavi1.0软件与Surgicase5.0软件进行三维测量与牵引长轴间成角测量,采用SPSS13.0软件包对结果进行配对t检验。结果：快速原型制作的三维头模与AccuNavi1.0软件重建的三维图像间各测量指标无统计学差异（P〉0.05）。模型手术平均牵引长度12.40mm（11.79～12.68mm）,模拟手术与导航模型术后牵引长轴间成角均值为4.67°（2.01°～6.49°）。导航术后各项指标中,除CoL-CoR（P=0.037）、CoL-GoL（P=0.017）与模拟手术值间有显著性差异外,其余指标间均无显著性差异（P〉0.05）。结论：应用快速原型技术制作的三维头颅模型与AccuNavi1.0软件的三维重建图像精度相仿。通过TBNavis-CMFS导航系统平台,建立了导航辅助下颌骨牵引成骨术的实验方法,准确地将手术规划转移到模型手术中。     

3D打印技术在上颌Le Fort Ⅰ型截骨术中的应用

目的:探讨3D打印技术制作的定位导板在上颌Le Fort Ⅰ型截骨术中的应用效果。方法:选择牙颌面畸形患者8例,男4例,女4例;年龄18~32岁,平均24.6岁。所有患者术前均行头颅CT扫描,将CT数据导入Mimics16.0,重建出上颌骨和下颌骨的三维模型,用3-matic 9.0设计定位导板,在上颌Le Fort I型截骨线的上方骨壁厚的位置选4个点作为标志点,利用这4个标志点来定位上颌骨术后的位置,设计好后采用光敏树脂用三维打印机打印制作,在术中应用。结果:所有患者均采用新的方法行正颌手术,上颌骨模拟位置和术后实际位置绝对差异的平均值小于1 mm,患者对术后美学效果均满意。结论:初步的结果显示此技术定位上颌骨精确,可在临床应用。     

Error analysis of a CAD/CAM method for unidirectional mandibular distraction osteogenesis in the treatment of hemifacial microsomia

Our aim was to investigate the errors in a computer-aided design and manufacture (CAD/CAM) method of unidirectional mandibular distraction osteogenesis. Six patients with hemifacial microsomia were selected, and studied on computed tomographic (CT) scans taken at 3 time intervals: preoperatively, at the end of the latent period, and at the end of consolidation. The plan for mandibular distraction osteogeneisis was designed using CT-based 3-dimensional visible software. The osteotomy line and site of the drill were transferred to a rapid prototyping surgical guide. The osteotomy of the mandible and implantation of the distraction device were completed under guidance. The accuracy of the transferred surgical plan was confirmed by fusion of images after the latency period. The 3-dimensional superimposition of the preoperative simulation, and the postoperative actual models at the end of consolidation, showed that the mean (SD) error between the actual and the predicted height of the ramus was 0.6 (0.6) mm. The error between the actual and predicted intercondylar distance was 8.1 (2.1) mm. There was a significant difference in intercondylar distance between the simulated and actual groups (p = 0.00024). The 3-dimensional CT-based planning system described in this paper was transferred precisely from the virtual plan to the real-time operation. The planning system also gave a precise prediction of the height of the ramus after mandibular distraction osteogenesis. However, because of the pull of the lateral pterygoid muscle and pseudarthrosis, the intercondylar distance decreased compared with the predicted value. These influencing factors should be considered when the planning system is refined.     

计算机辅助牵引成骨术的模拟和初步评价

目的 介绍并应用计算机辅助正颌外科模拟系统（CASSOS 2001）模拟，预测上颌骨牵引成骨术，评价治疗前后的软，硬组织变化。方法 1例男性，14岁唇腭裂术后上颌严重发育不足患者，应用CASSOS 2001系统作术前头影测量分析，手术和牵引方向模拟，牵引后面型预测,实际牵引成骨治疗后的头影测量分析等，手术模拟中分别进行了Le Fort I型截骨术和Le Fort Ⅱ型截骨术的模拟。对多项头影测量作了比较。结果 牵引前后数据比较显示，面中部凹隐畸形获得了显著改善；手术模拟与实际术后结果比较显示，上颌骨Le Fort I型截骨后牵引成骨术所获得的面型改善可以达到正颌外科Le Frot Ⅱ型截骨前移后的效果。结论 上颌牵引成骨对于严重的上颌骨局部畸形，尤其是唇腭裂术后上颌骨严重发育不足，是一种极其有效的治疗方法：CASSOS 2001系统不仅为正颌外科手术，也为牵引成骨治疗提供了一种对医生和患者都有极大帮助的模拟和预测方法。     

Original sagittal split osteotomy revisited for mandibular distraction.

INTRODUCTION: A malformed mandible and an abnormally positioned mandibular foramen make it difficult to plan an ideal osteotomy line for mandibular distraction. In addition, there have been reports of such complications as nonunion, damage and stretch injury of the inferior alveolar nerve and tooth germ damage when conventional osteotomy or corticotomy are used for mandibular distraction. The authors utilized the original sagittal split ramus osteotomy for mandibular distraction. PATIENTS AND METHODS: Five patients (three unilateral hemifacial microsomia, one bilateral hemifacial microsomia, and one mandibular retrusion) were included in this study of distraction osteogenesis using the sagittal split ramus osteotomy. Extraoral distraction devices were applied to the first four patients. An intraoral device with mono-cortical screw fixation was used for the fifth patient. RESULT: In all five cases, the results of the distraction were satisfactory. Complications (as listed) of conventional osteotomy when used for distraction were avoided. Satisfactory results were achieved and these were also well maintained postoperatively (mean follow up: 36 months). CONCLUSION: The authors believe that sagittal osteotomy for mandibular distraction osteogenesis makes it possible, to avoid injury to the inferior alveolar nerve during operation and stretching injury during distraction and to prevent tooth germ injury. It is also possible to diversify the osteotomy line for various force vectors to enlarge the bony contact surface area. Therefore, we suggest that sagittal split ramus osteotomy should be used as a preferred modification of osteotomy for mandibular distraction.     

Original sagittal split osteotomy revisited for mandibular distraction

Introduction: A malformed mandible and an abnormally positioned mandibular foramen make it difficult to plan an ideal osteotomy line for mandibular distraction. In addition, there have been reports of such complications as nonunion, damage and stretch injury of the inferior alveolar nerve and tooth germ damage when conventional osteotomy or corticotomy are used for mandibular distraction. The authors utilized the original sagittal split ramus osteotomy for mandibular distraction. Patients and Methods: Five patients (three unilateral hemifacial microsomia, one bilateral hemifacial microsomia, and one mandibular retrusion) were included in this study of distraction osteogenesis using the sagittal split ramus osteotomy. Extraoral distraction devices were applied to the first four patients. An intraoral device with mono-cortical screw fixation was used for the fifth patient. Result: In all five cases, the results of the distraction were satisfactory. Complications (as listed) of conventional osteotomy when used for distraction were avoided. Satisfactory results were achieved and these were also well maintained postoperatively (mean follow up: 36 months). Conclusion: The authors believe that sagittal osteotomy for mandibular distraction osteogenesis makes it possible, to avoid injury to the inferior alveolar nerve during operation and stretching injury during distraction and to prevent tooth germ injury. It is also possible to diversify the osteotomy line for various force vectors to enlarge the bony contact surface area. Therefore, we suggest that sagittal split ramus osteotomy should be used as a preferred modification of osteotomy for mandibular distraction. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.     

Cost, operation and hospitalization times in distraction osteogenesis versus sagittal split osteotomy.

INTRODUCTION: Distraction osteogenesis in 'common' surgical orthodontics is mentioned as an alternative for conventional sagittal split osteotomy. After a 'learning curve' in the surgical skills of distraction, the two techniques can be compared concerning time and cost aspects. PATIENTS: Forty-seven patients (male n=28, female n=19, age 11.7-17.9 yr (mean 14.2) with an Angle's class II division 1malocclusion of skeletal mandibular origin were operated on using distraction osteogenesis and were compared with a second group of 21 patients (male n=4, female n=17, age 16-36yr (mean 22.8) who underwent bilateral sagittal split osteotomies in the same period in order to correct the same type of dysgnathia. METHOD: The first group of 47 patients was treated with intraorally placed bone-born distraction devices to correct mandibular deficiency following a standard protocol, with removal of the third molar tooth germs if present. The second group of 21 patients underwent standard sagittal split osteotomies to correct the mandibular deficiency. The costs of hospitalization, distraction devices and operation time were compared. RESULTS: In this study, distraction osteogenesis took on average more operative time (mean 37%), but 1 day less hospitalization than the bilateral sagittal split osteotomies. The surgical cost of distraction osteogenesis was 36% higher than the conventional sagittal split osteotomy. CONCLUSION: In this study, correcting Angle's class II deficiencies by means of distraction osteogenesis was shown not to be a time-saving procedure when compared with sagittal split osteotomy. Surgical costs were significantly higher using distraction, mainly due to the price of the distractors. Changes in hospital policies concerning hospital admission of adults and children and European legislation concerning re-usability of surgical instruments may balance the cost of both procedures.     

下颌骨缺损牵张成骨动物模型的建立

目的建立兔下颌骨缺损牵张成骨动物模型,为进一步研究牵张成骨奠定实验基础。方法25只健康成年兔随机分成6组,实验组5组,每组4只,对照组1组共5只。25只兔均行一侧下颌骨切开截骨术,实验组安置自行设计的下颌骨牵张器,经6 d间歇期后,以每天2次,每次0.4 mm的速度牵张8 d进入固定期,于牵张中期(牵张第4天)、牵张末期(牵张第8天),固定期第2、4、6周分别处死4只动物;对照组术后仅保持缺隙而不牵张,与实验组对应的每个时间点处死1只动物,取下颌骨观察骨愈合情况。结果牵张器牵张效率好,固位稳定,实验组动物的下颌骨被成功牵张,牵张区可见新骨形成。实验对照组表现为不同程度的骨不连及骨缺损。结论本研究建立的兔下颌骨缺损牵张成骨模型是较理想的动物模型。     

Accuracy of a CAD/CAM surgical template for mandibular distraction: a preliminary study

We have assessed the accuracy and clinical validation of virtual planning using a surgical template in 16 patients with hemifacial microsomia being treated by mandibular distraction osteogenesis. Virtual planning and simulation were first done on three-dimensional models. Distraction was simulated on the virtual model and the new morphology of the mandible was previewed. Both the position and direction of the distractor were calculated to achieve the optimal morphology. The templates were designed based on the virtual planning, and manufactured using a 3-dimensional printing technique. The template was designed to assist the surgeon to make the osteotomy and predrill the screw-holes to guide the distractor into position. The outcome was evaluated by comparing planned with postoperative outcomes. The osteotomy was made and the distractor implanted successfully under the guidance of the template in all patients. The linear and angular differences for the distractor were measured and reported using the root mean square deviation. There was no difficulty in using the templates. The largest linear root mean square deviation between the planned and the postoperative distractors was 0.93 mm in the anteroposterior direction, and the largest in the horizontal plane was 4.64°. We suggest that the preoperative plan can be transferred accurately to a patient using the template.     

rhBMP-2对兔下颌骨牵引成骨区骨保护素表达的影响

目的：通过动物实验,研究应用外源性rhBMP-2对兔下颌骨牵引成骨区骨保护素（osteoprotegerin,OPG）的影响。方法：在48只成年大耳白兔的一侧下颌骨前部行骨切开术,分别将空白胶原、rhBMP-2 1.5mg胶原复合物植入下颌骨切开处,用牵引器延长一侧下颌骨4mm,稳定期第1、3、7、14天,分别处死各组动物,取牵引区新生骨痂行组织学及OPG免疫组化染色。结果：下颌牵引延长后牵引间隙均有新骨形成,应用rhBMP-2 1.5mg效果好。免疫组化染色OPG主要定位于成骨细胞的胞浆中。在同一时间内,应用rhBMP-2组较对照组有显著性差异（P〈0.05）。结论：动物实验表明,rhBMP-2能促进兔下颌骨牵引成骨区新骨的生成。     

Virtual planning in Le Fort III distraction osteogenesis: A case series

The objective of this study is to determine the value of using 3D planning tools and 3D printed cutting guides in Le Fort III osteotomies with external frame distraction osteogenesis.The process of planning and transfer of the virtual planning to the operating room is illustrated with 5 case. The virtual planning is transferred to the operating room using a 3D-printed supra-orbital reference bar with puzzle connections for the planned osteotomy guides. Different systems are presented to transfer the vector of distraction and the position of the external midface distractor.Three-dimensional planning tools and cutting guides help to design the Le Fort III osteotomy and the distraction vector, to anticipate possible difficulties, and to avoid adverse events.     

小型猪胫骨垂直牵张成骨模型的建立

目的：以小型猪建立管状骨垂直牵张成骨的实验动物模型。方法选用6只巴马小型猪,随机选择一侧胫骨,进行胫骨切开术及安置牵引器,术后每日牵引2次,每次牵开0.4mm,连续牵引20日,术后6个月处死动物,获取双侧胫骨标本,测量胫骨宽度并作组织病理学检测。结果经牵引,实验组胫骨直径明显大于正常胫骨。组织学观察发现,非暴露侧成骨较好,暴露侧成骨不连续。结论本实验提供了一种操作容易、效果稳定可靠的建立管状骨垂直牵张成骨模型的方法。