计算机辅助下颌骨重建的术后评估指南

由于成像方式、下颌骨缺损分类以及研究间评估方法的异质性,很难在计算机辅助下颌骨重建中对术后准确性结果进行有效比较。本指南使用分步方法指导成像、下颌骨缺损分类以及三维(3D)模型体积评估,之后使用定量的准确性评估方法分析术后临床情况和术前虚拟规划之间的差异。以下颌骨髁突以及下颌骨的垂直和水平角作为骨性标记,在计算机辅助手术(CAS)软件中定义虚拟线。     

颌骨缺损分类的探讨

目前国内外对颌骨缺损的分类方法较多,但都存在着一定的缺点,尚没有一个简单明了,易于记忆,对临床工作具有指导意义的分类方法。本文作者提出了一种新的分类方法,首先根据缺损情况的不同,将上下颌骨缺损各分为四种类型。然后再按照缺损区和缺牙区的不同部位,尽量按统一的顺序进行编排,每一类缺损又细分成四个亚类,第四类缺损是指两侧颌骨缺损,故无亚类。     

功能优先的新型下颌骨缺损分类（COM）法及临床应用

下颌骨缺损多由良恶性肿瘤切除、创伤和感染所致,会导致患者不同程度的颜面畸形和生理功能障碍。下颌骨缺损具有复杂性,不同部位、范围的缺损,将产生不同程度的形态和功能损害,相应的修复重建难度也不相同。因此,下颌骨缺损的精准分类对功能性重建及术后康复意义重大。本文在前期大量临床实践基础上提出了新的基于髁区（condyle region）、区（occlusion region）和肌区（muscle region）3大不同功能区域的新型下颌骨缺损分类方法,即COM法,希望有助于下颌骨的功能性修复重建指导及康复效果预测。     

下颌骨节段性缺损及其功能康复研究现状

下颌骨位于面部中下1/3,解剖位置和形态特殊,是面部诸多骨骼中唯一可动骨,正常行使功能要求双侧关节联动,功能结构复杂。下颌骨节段性缺损通常是指下颌骨连续性中断的部分下颌骨缺损,多由良恶性肿瘤切除所致,其他疾病如创伤和感染等也可以导致下颌骨节段性缺损。本文就下颌骨节段性缺损分类、功能影响和功能评价方法作一综述。     

下颌骨缺损的修复重建

下颌骨缺损在临床上较常见 ,80 %为肿瘤切除术后所致。下颌骨缺损的修复旨在重建下颌骨的完整性 ,恢复下颌骨的功能 ,矫正颌面畸形。修复的方法较多 ,自体髂骨或助骨游离移植 ,依然是目前修复下颌骨缺损较理想的方法。我们自 1993年以来 ,采用此二种方法修复下颌骨缺损均取得满意效果。本文将其治疗体会总结如下 :1　临床资料1.1　本组共选择病例 18例 ,男性 10例 ,女性 8例 ,年龄 12～6 5岁之间。1.2　下颌骨缺损的原因均为肿瘤切除后所致。1.3　一侧下颌骨缺损 1例 ,一侧下颌体缺损 4例 ,部分下颌体缺损 9例 ,一侧下颌升支缺损 2例 ,部分…     

血管化腓骨移植与下颌骨功能重建

因下颌骨肿瘤切除术可造成下颌骨的缺损 ,并导致患者严重的颜面畸形及语言、咀嚼功能障碍。因此寻求一种理想的修复下颌骨缺损的方法是临床医师共同思考的问题。下颌骨缺损修复方法很多 ,血管化腓骨移植修复下颌骨缺损是目前较好的方法之一 ,依据血管化腓骨移植具有可靠血供的特点 ,我科自 1 996年以来 ,对下颌骨缺损行血管化腓骨移植取得了理想的临床效果。1　材料与方法1 .1　临床资料本组共 6例 ,男性 4例 ,女性 2例 ,年龄 1 8～ 4 6岁 ,病理诊断 :成釉细胞瘤 3例 ,化牙骨质纤维瘤 1例 ,囊肿 1例 ,牙龈癌 1例。 6例患者均采用带腓动、静…     

自体骨游离移植修复下颌骨缺损效果观察

自体骨游离移植仍然是目前临床上最常用的下颌骨缺损修复方法之一,现就我科自1995年以来自体骨游离移植修复下颌骨缺损方法做临床总结。     

非血管化髂骨移植修复下颌骨部份缺损

目的 总结应用非血管化髂骨移植同期修复不同类型下颌骨缺损的临床经验.方法 对1996年1月～2006年1月136例应用非血管化髂骨移植同期修复下颌骨部份缺损的病例进行回顾性研究,按HCL分类法对下颌骨缺损分类,分析不同类型的下颌骨缺损应用非血管化髂骨移植同期修复术后的效果,植骨区并发症及移植骨吸收情况.结果 总体移植骨成活率89.7%,其中L类缺损成功率最高.术后总体感染发生率16.9%,其中H类缺损感染率最高.术后6个月植入骨均有不同程度的吸收,以H类缺损骨吸收最明显.结论 非血管化髂骨移植是修复下颌骨节段性缺损的简单有效的方法,以L类缺损最适宜.     

下颌骨缺损30例即刻修复重建的临床分析

目的 对30例下颌骨缺损即刻修复重建作回顾性分析。方法 对不同修复方法进行比较分析。结果 不同修复下颌骨缺损的方法均有其优点,但在面部外形及功能恢复上存在差异。结论 根据下颌骨缺损情况,术者技术水平及患者本身条件选择适应证,游离腓骨瓣移植值得临床推广。     

12例两侧下颌骨缺损的修复

因肿瘤和创伤致两侧下颌骨体部和颏部同时缺损时 ,称之为两侧下颌骨缺损 ,亦有称巨大下颌骨缺损[1] ,此种缺损严重影响患者的面容并造成咀嚼、咬合、吞咽和语言功能的破坏 ,修复较为困难 ,是口腔颌面部疑难的问题之一[2 ,3] 。我科 1990～ 2 0 0 0年间共修复下颌骨缺损 2 16例 ,其中两侧下颌骨缺损 12例 ,现总结如下。1　材料与方法1.1　临床资料男 7例、女 5例 ,年龄 2 5～ 5 8岁 ,平均 39岁。缺损原因及范围 :下颌骨巨大造釉细胞瘤 3例 ;下颌骨多发性角化囊肿 2例 ;恶性肿瘤致下颌骨缺损 5例 ;电击伤和爆炸伤致下颌骨缺损 2例。缺损范围 :…     

75例下颌骨粉碎性骨折的治疗效果评价

目的 提出一种针对下颌骨粉碎性骨折的分类方法,并尝试将其用于临床评价。方法 回顾75例下颌骨粉碎性骨折患者,按照下颌骨是否伴有节段性骨缺损、下颌骨形态、下颌骨的粉碎程度、可否恢复稳定的咬合关系对其进行分类。按照严重程度,进行保守治疗或使用小型钛板、钛网或重建板进行手术。其中,44例按照分类及治疗策略进行治疗（实验组）,另外31例未按照分类进行治疗（对照组）。结果 高空坠落和车祸是下颌骨粉碎性骨折最主要的原因。实验组中3例患者术后出现感染,1例出现咬合紊乱;对照组中4例患者出现感染,2例出现骨不连,2例出现咬合紊乱,1例出现颌骨不对称畸形。结论 本研究尝试创建一种全新的以治疗为导向的下颌骨粉碎性骨折分类方法及治疗策略,对在该类骨折治疗过程中治疗手段的选择具有一定的指导作用,其价值仍需进一步研究。     

Free fibular flap vascular pedicle calcification

Osseous free flaps are major reconstruction choices of the segmental mandibular defects. However, etiology of defects in mandible is variable; tumor-related surgery, trauma, radiation, or congenital anomalies are the most common causes. The advent of microvascular surgery has achieved the reconstruction of complex mandibular defects. The options for bony free-tissue transfer for mandibular reconstruction primarily depend on the fibula, iliac, scapula, and radius bone. The free fibular flap continues to be first choice in the reconstruction of mandibular defects because of its advantages. In this report, rare complication of vascular pedicle calcification after mandibular reconstruction with free fibular flap is presented.     

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.     

Three-dimensional virtual technology in reconstruction of mandibular defect including condyle using double-barrel vascularized fibula flap

ObjectiveThe aim of this study is to demonstrate the reconstruction of mandibular defects including the condyle using a double-barrel vascularized fibula flap aided by three-dimensional virtual technology.MethodsTen patients with the type H mandibular defects, who had undergone mandibular reconstruction using a double-barrel vascularized fibula flap, were reviewed for this study. Prior to the surgery, the patients CT scan data were analyzed virtually using SimPlant Pro? software (version 11.04). The simulation allowed construction of an individual mandibular model serving to guide the clinical operation.ResultsThe preoperative virtual surgery greatly benefitted the actual surgery. The vertical height of the neomandible and facial contour were precisely predicted. Some minor complications were encountered. Postoperative three-dimensional reconstruction revealed a close match with the simulated condyle.ConclusionA double-barrel vascularized fibula flap can provide sufficient bone, both in length and vertical height, for the reconstruction of a type H mandibular condylar defect. Combined virtual three-dimensional reconstruction and rapid prototyping can improve postoperative outcomes in mandibular reconstruction.     

纳米羟基磷灰石-聚酰胺人工骨修复犬下颌骨体缺损的实验研究

目的　研究新型纳米羟基磷灰石 聚酰胺 (n HA PA6 6 )复合人工骨修复犬下颌骨缺损的效果。方法　在犬下颌骨体上设计两个 15mm× 10mm× 5mm的箱状缺损 ,在其中一个植入相应大小的n HA PA6 6预制块 ,另一缺损作空白对照。于术后 2、4、8、12、16周切取组织标本 ,进行X线摄片和组织学切片检查 ,观察骨缺损修复情况。结果　术区未见明显的排斥反应。第 2～ 8周人工骨周围被纤维结缔组织包裹 ,12周时人工骨—组织界面上出现膜性成骨迹象 ,第 16周n HA PA6 6人工骨被新生骨组织完全包裹 ,受植床与人工骨形成骨性结合。结论　n HA PA6 6人工骨有良好的生物相容性 ,具有骨引导和潜在的骨诱导作用     

腓骨肌(皮)瓣一期整复下颌骨缺损

目的　应用游离腓骨肌 (皮 )瓣一期整复下颌骨缺损。方法　以腓动静脉为血管蒂切取腓骨肌瓣 ,根据下颌骨缺损的特点 ,对腓骨进行截骨塑形 ,按定位钢板定位后的下颌骨缺损形态和长度准确就位 ,用小钛板或重建板进行移植骨坚固内固定。结果　 18例腓骨肌瓣重建下颌骨缺损全部获得成功。腓骨截成二段者 10例 ,三段者 3例 ,5例未截断。术后伤口均一期愈合 ,术后面部外形恢复满意者 16例 ,咬合关系正常者 14例 ,张口度正常者 14例 ,3例患者术后接受活动义齿修复 ,1例行种植义齿修复并获得良好的咀嚼功能。结论　腓骨肌瓣是重建下颌骨缺损的理想组织瓣 ,其具有骨量充足、外形好、成功率高等优点。     

肿瘤术后下颌骨缺损的成型钛板即刻修复重建

目的研究下颌骨肿瘤切除后成型钛板即刻修复重建的手术方法和临床效果。方法根据患者下颌骨缺损范围及有无软组织缺损采用不同的修复方法,纯钛自动压缩重建固定板4例,纯钛下颌人工关节14例,并对不同缺损骨段修复重建后的面部形态和咬合关系进行比较。结果14例一侧下颌骨缺失成型钛板即刻重建取得良好的效果;而4例超越中线的下颌骨体缺失患者的效果不佳。结论成型钛板是修复一侧下颌骨缺失的良好的替代材料。     

Non-vascularised iliac crest bone graft for immediate reconstruction of lateral mandibular defect

Introduction

Mandibular defect reconstruction is extremely important to achieving an improved quality of life of patients as this bony defect influences facial harmony and aesthetics. Reconstruction of mandibular defects at our centre comprises use of reconstruction plate, non-vascularised anterior iliac crest graft and vascularised fibula flap. Despite the large mandibular defect recorded in our developing environment, non-vascularised iliac crest graft continues to play a role in its exclusive use for lateral mandibular defects. The aim of this study was to analyse the role, complications and outcomes of the use of non-vascularised iliac crest graft for mandibular reconstruction in a free flap-enabled centre.

Patients and method

This was a retrospective case cohort from study institution’s records of mandibular reconstruction following mandibular surgery for benign tumours. Eligibility for study inclusion comprised case cohort with head and neck diseases requiring mandibular surgery and reconstruction with either reconstruction plate, non-vascularised iliac crest graft or vascularised fibula flap.

Results

A total of 18 subjects underwent iliac crest grafting. Of the 18 subjects with iliac crest graft, 7 (39 %) were females while 11 (61 %) were males. Ten of the 18 subjects with iliac crest grafting were diagnosed with ameloblastomas. Six (33.3 %) subjects had class H (Jewer’s classification) mandibular defect. The average graft length was 5.4 cm and height was 2.3 cm. Three cases experienced graft site complications of which two grafts were lost. All 18 cases experienced good to acceptable clinical outcomes. Predictors of graft outcome were not statistically significant.

Conclusion

Despite our small sample size, it is suggestible that non-vascularised iliac crest graft be considered for lateral mandibular defect reconstruction, considering the reduced graft failure rate and satisfactory clinical outcomes from this study.