应用综合技术矫治(牙合)颌面偏斜的临床研究

 目的 介绍采用以双颌正颌外科为主的综合技术矫正(牙合)颌面偏斜的经验和技巧.方法 过去10年间采用以双颌正颌外科为主的综合技术矫治(牙合)颌面偏斜12例.主要术式是Le Fort Ⅰ行截骨+下颌支矢状劈开+颏成形术,选择性结合牵引成骨和快速成形技术.根据下颌支手术是在双侧进行或在单侧进行将患者分为2组,每组6例.结果 两组病例术中术后经过顺利,在出血量和并发症方面没有差别.经8个月～2年随访,9例临床效果稳定,面形基本对称,面高度比例和谐,张口度均大于35 mm.特别介绍了采用计算机虚拟外科和快速成形技术制作硬组织植入体的优点.1组有2例,2组有1例存在明显的复发倾向,可以用术后正畸控制.结论 双颌正颌外科+颏成形技术结合快速成形技术矫正(牙合)颌面偏斜是未来的发展方向,同期手术解决软组织增容问题将进一步提高临床疗效.     

下颌升支矢状截骨后固定技术的研究进展

下颌升支矢状截骨术是目前正颌外科下颌截骨最常用的方法。术后近远心骨段的妥善固定对于实现骨创面的早期愈合,减少术后并发症等具有重要意义。本文对下颌升支矢状截骨术后近远心骨段间固定技术的发展过程及目前的临床研究进展进行了综述。     

自攻型微螺钉支抗与正颌手术矫治成年骨性开患者的比较研究

目的比较自攻型微螺钉支抗与正颌外科手术矫治成年开畸形患者疗效的差异。方法将25例骨性开的成年患者分为微螺钉支抗组(n=14)、正颌手术组(n=11)两组。微螺钉支抗组将自攻型微螺钉分别植入在上下颌第一、第二磨牙之间颊侧齿槽骨,上下颌使用横腭杆和固定舌弓,每侧加力1.5 N以压低后部牙齿槽;正颌手术组对患者进行LeFortⅠ型截骨术+下颌升支矢状劈开截骨术(sagittal spilt ramus osteotomy,SSRO),或者单颌手术SSRO,两组患者在治疗前后分别拍摄头颅侧位定位片,并进行头影测量的分析比较。结果 25例骨性开畸形均得到有效治疗,微螺钉支抗组的前牙覆由治疗前的平均-4.6 mm增加至治疗后平均2.0 mm(P<0.05),正颌手术组的前牙覆由治疗前的平均-5.5 mm增加至治疗后平均1.7 mm(P<0.05)。微螺钉支抗组压低后牙的效果更为明显,U6-PP(1.8 mm,0.2 mm,P<0.01)、L6-MP(1.2 mm,0.3mm,P<0.05),差异有统计学意义,而正颌手术组对垂直向的控制更为有效,MP/SN(6.3°,3.3°,P<0.01)、N-Me(3.8 mm,1.8 mm,P<0.05)、ANS-Me(3.9 mm,1.6 mm,P<0.05)、Gn-TH(2.8 mm,0.9 mm,P<0.05)。结论自攻型微螺钉支抗能够实现后部牙齿槽高度的压低,是矫治骨性开畸形的一种损伤小、患者依从性好的治疗手段。     

成人后牙锁23例烤瓷冠修复体会

后牙锁是临床上一种常见的成人个别后牙错颌畸形。锁分为正锁和反锁,正锁是上颌后牙舌尖的舌斜面咬在下颌后牙颊尖的颊斜面,反锁是上颌后牙颊尖的颊斜面咬在下颌后牙舌尖的舌斜面。锁畸形不但咀嚼效率低,在咬合时还会引起颊黏膜损伤。锁的治疗通常采用矫正治疗,     

正颌外科技术在多发性陈旧性下颌骨骨折治疗中的应用

目的探讨正颌外科技术在多发性陈旧性下颌骨骨折治疗中应用的先进性、可行性及实用性。方法本组颌骨陈旧性骨折病例52例,男性38例,女性14例。均采用口内切口或联合入路（如合并下颌角或髁状突骨折）,修整骨折断端,去除骨痂,上预制定位颌板,进行坚强内固定,术后均行简单的颌间弹性牵引固定1～2W。结果术后感染1例,抗感染后骨折延迟愈合,1例重新手术后1期愈合,5例术后咬合关系欠妥,颌间牵引固定,调合后改善。其他病例创口一期愈合,术后经简单调颌,颌关系恢复正常。结论正颌外科技术治疗多发性陈旧性下颌骨骨折术后效果稳定,颌关系恢复良好。     

正颌外科技术在颌骨陈旧性骨折临床治疗中的应用

目的　探讨正颌外科技术在陈旧性颌骨骨折治疗的临床应用价值。方法　对 8例陈旧性颌骨骨折伴有咬合关系紊乱的患者 ,术前经头影测量分析、模型外科等确定截骨部位及手术方案 ,并制作定位咬合导板 ,然后采用正颌外科术式在预定部位截骨或截开部分错位愈合的骨段 ,恢复咬合关系及面型后予以坚强内固定。结果　 8例患者术后均恢复了正常面型 ,咬合关系满意。结论　利用正颌外科手段结合坚强内固定技术治疗颌骨陈旧性骨折 ,既可恢复良好的面部外形 ,又能最大限度地改善其咬合关系     

牵张成骨修复火器伤性下颌骨缺损的临床应用

目的 探讨应用牵张成骨技术修复火器伤性下颌骨缺损的临床应用.方法 采用牵张成骨方法为3例火器伤致下颌骨缺损患者实施治疗,2例为牙槽突缺损修复,1例为升支缺损修复.结果 3例患者均顺利完成治疗,2例牙槽突缺损得到恢复,1例恢复了下颌升支高度和下颌骨完整性,并在后期接受了正颌治疗,患者对治疗效果满意.结论 牵张成骨技术可以...     

耳后小切口矫正下颌角重度肥大的临床价值

目的探讨耳后微创纵形切口下颌角截骨术对矫正重度下颌角肥大的疗效。方法应用耳后微创纵形切口下颌角截骨术对26例重度下颌角肥大患者进行矫正,通过X线测量,比较术前术后数据变化及容貌改变来评价疗效。结果手术前后测量比较有明显差异,术后数据接近正常人群。本组26例中,非常满意者23例(88%),满意3例(12%)。未出现下颌骨骨折,下齿槽神经损伤,出血感染等并发症。结论针对重度下颌角肥大患者采用耳后微创纵形切口下颌角截骨术,结合术前三维CT设计截骨线,可以有效矫正下颌角肥大,且效果良好。     

口腔入路髁突颈及下颌支骨折复位内固定术

目的为避免面颈部留下手术瘢痕，探讨从口腔入路复位固定髁突颈及下颌骨支骨折的方法。方法采用口腔内下颌骨矢状截骨手术切口入路，用摆动锯将下颌支后缘垂直截骨，取出升支后缘骨块，髁突游离取出，体外直视下与升支后缘骨块固定后再从口腔原切口回植入，钛板固定。15例17侧采用本方法治疗，其中2例为外地医院行下颌角截骨整形术中意外将下颌骨髁突颈部劈裂骨折，其余13例为闭合性骨折。结果术后1年复查全部患者的开口范围25～40mm，平均为35．8mm，1例有患侧后牙早接触，下切牙中线偏斜1mm。另1例张口约25mm，轻度受限，其余患者咬合关系良好，无主诉关节疼痛与弹响症状。全部患者无面神经、耳大神经损伤，无涎瘘，面颈皮肤无手术瘢痕结论在目前美容要求越来越高的趋势下，口腔入路具有无外部瘢痕优势，且不会损伤面神经缺点是操作范围较小，增加了下颌支后缘垂直截骨。     

鼻眶筛区复杂骨折的处理

目的 总结鼻眶筛区（NOE）复杂骨折处理的经验。介绍两种单侧内眦韧带复位固定的新方法。方法 1983-2001年共收治NOE复杂骨折患者289例，分别按伤情行初期，延期和晚期手术，手术方法主要通过原伤口或冠状切口，口内切口和下睑缘下切口联合入路；根据不同类型分为解剖复位（初期），正颌外科矫正和植骨或植骨代用品修复（延期或晚期）；单侧内眦韧带撕脱移位采用“拴马桩式”或“抽屉式”复位固定术。结果 本组病例全部救治成功，功能和面容明显改善。“拴马桩式”和“抽屉式”复位固定术。结果 本组病例全部救治成功。功能和面容明显改善，“拴马桩式”和“抽屉式”单侧内眦韧带复位固定新方法效果较好。结论 将NOE骨折分为爆裂型，震碎型，塌平型，塌陷型和颅面分离型有助于选择治疗方法，应在掌握手术适应证的情况下，进行比较专业的初期手术或延期手术；晚期处理需综合应用颅面外科，正颌外科，整形外科，坚强内固定，柱骨或植骨代用品等技术。     

Superimposition of 3D cone-beam CT models of orthognathic surgery patients

OBJECTIVES: To evaluate the registration of 3D models from cone-beam CT (CBCT) images taken before and after orthognathic surgery for the assessment of mandibular anatomy and position. METHODS: CBCT scans were taken before and after orthognathic surgery for ten patients with various malocclusions undergoing maxillary surgery only. 3D models were constructed from the CBCT images utilizing semi-automatic segmentation and manual editing. The cranial base was used to register 3D models of pre- and post-surgery scans (1 week). After registration, a novel tool allowed the visual and quantitative assessment of post-operative changes via 2D overlays of superimposed models and 3D coloured displacement maps. RESULTS: 3D changes in mandibular rami position after surgical procedures were clearly illustrated by the 3D colour-coded maps. The average displacement of all surfaces was 0.77 mm (SD=0.17 mm), at the posterior border 0.78 mm (SD=0.25 mm), and at the condyle 0.70 mm (SD=0.07 mm). These displacements were close to the image spatial resolution of 0.60 mm. The average interobserver differences were negligible. The range of the interobserver errors for the average of all mandibular rami surface distances was 0.02 mm (SD=0.01 mm). CONCLUSION: Our results suggest this method provides a valid and reproducible assessment of craniofacial structures for patients undergoing orthognathic surgery. This technique may be used to identify different patterns of ramus and condylar remodelling following orthognathic surgery.     

An anatomical and radiographic study of medial depression of the human mandibular ramus.

OBJECTIVES: To determine the prevalence of the medial depression of mandibular ramus (MDMR) in dry human mandibles and in clinical panoramic radiographs and to compare the prevalence in dentoskeletal deformities with Angle Class I occlusion. METHODS: Two hundred and fifty-one dry skulls and three groups of patients were used for this study: Group 1 consisted of 1358 panoramic radiographs from a general population, Group 2, 426 radiographs from individuals with Angle class I occlusion and Group 3283 individuals with dentoskeletal deformities. The prevalence of MDMR was determined in the skulls and each group and the shape from the radiographs alone. RESULTS: The prevalence of MDMR in dry mandibles was 33.9% (bilateral in 13.1% and unilateral in 20.8%). MDMR was found in 276 radiographs (20.3% - Group 1 - bilateral in 40% and unilateral in 59.5%). MDMR was more common in Group 3 compared with Group 2 (chi(2)=35.98 P<0.01). A triangular MDMR was the most frequent (39.7%). CONCLUSION: MDMR is a relatively common finding in panoramic radiographs. Patients with dentoskeletal deformities have a higher prevalence of MDMR and this should be taken into consideration if orthognathic surgery is proposed.     

A novel measurement method for the morphology of the mandibular ramus using homologous modelling

Objectives:

It is important to assess the mandibular morphology when orthognathic surgery, especially mandibular ramus osteotomy, is performed. Several studies on three-dimensional (3D) facial asymmetry have reported differences in linear and angle measurements between the deviated and contralateral sides in asymmetric mandibles. However, methods used in these studies cannot analyse the 3D morphology of the ramus. In this study, we aimed to evaluate the differences in mandibular ramus between the deviated and contralateral sides in asymmetric mandibles using traditional measurements as well as 3D shape analysis.

Methods:

15 Japanese females with jaw deformities treated by orthodontic surgery were enrolled. 3D CT images were reconstructed, and 14 landmarks were identified on the model surface. Ten linear and four angle measurements were calculated using these landmarks. Homologous ramus models were constructed for each sample, and after converting all homologous models to the right side, 30 homologous models of the ramus were analysed using principal component analysis.

Results:

Firstly, eight principal components explained >80% of the total variance. Differences between the deviated and contralateral sides in measurements and scores of the eight principal components were tested. Significant difference at the 5% level between the deviated and contralateral sides was observed in five linear measurements, three angle measurements and the third principal component. The variance of the deviated side was significantly larger in the diameter between the mandibular notch and coronoid process, horizontal dilated angle of the mandibular ramus and vertical dilated angle of the mandibular ramus. The variance of the contralateral side was significantly larger in the height of mandibular ramus, height of posterior of mandibular ramus, condylar width, height of condylar head and mandibular angle. The squared multiple correlation coefficient adjusted for the degrees of freedom was 0.815. The third principal component showed the difference between the deviated and contralateral sides. Shape variation represented by the third principal component visually indicated that the contralateral side was larger and had inwardly directed coronoid process and the deviated side had a mandibular angle that was turned inwards to a greater extent.

Conclusions:

In conclusion, we successfully created a homologous model of the mandibular ramus and demonstrated the effectiveness of this model in the 3D comparison of the ramus morphology between the contralateral and deviated sides in asymmetric mandibles.     

Biomechanical analysis of flat and oblique tibial tubercle osteotomy for recurrent patellar instability.

Both flat (Elmslie-Trillat) and oblique (Fulkerson) osteotomy techniques are successful in treating patellar instability episodes by moving the tibial tubercle medially. The oblique osteotomy also results in anterior displacement that decreases patellofemoral forces. Recent reports have described proximal tibial fractures occurring during early weightbearing after oblique osteotomy. We performed oblique and flat osteotomies on 13 pairs of fresh-frozen cadaveric knees. The knees were then tested to failure on a materials testing system by exerting a load through the quadriceps tendon at a rate of 1000 N/sec to simulate a stumble injury. The failure mechanism for flat osteotomies was more likely to be tubercle "shingle" fracture, while oblique osteotomies more frequently failed through a tibial fracture or fixation failure in the posterior tibial cortex. Mean load to failure was significantly higher in the flat osteotomy specimens (1639 N versus 1166 N), as was total energy to failure (224 N.m versus 127 N.m). There was no significant difference in stiffness (87 N/cm versus 74 N/cm). We recommend the flat osteotomy for patients with isolated recurrent patellar instability and the oblique osteotomy in patients who have concomitant patellofemoral pain or articular degenerative changes. When an oblique osteotomy is used, we recommend postoperative brace protection and restricted weightbearing until the osteotomy heals.     

Intraoperative 3D imaging of the facial skeleton using the SIREMOBIL Iso-C3D

OBJECTIVES: With respect to high-contrast structures, cone beam computed tomography (CBCT) offers an alternative imaging modality to computed tomography (CT), requiring less radiation exposure. The C-arm system SIREMOBIL Iso-C3D for three-dimensional (3D) reconstruction has made this modality available for intraoperative use. This paper presents the first intraoperative images of the facial skeleton using the SIREMOBIL Iso-C3D. METHODS: Cases of a zygomaticomaxillary complex fracture, a mandibular angle fracture and a bimaxillary repositioning osteotomy are described to demonstrate the application possibilities of this system in maxillofacial surgery. RESULTS: In addition to the uncomplicated handling of the SIREMOBIL Iso-C3D, generally important was the low level of metal artefacts in its primary and secondary reconstructions, even in close proximity to the material. However, it has to be kept in mind that while soft tissues are visualized using CBCT, information about soft tissue quality cannot be obtained. CONCLUSION: The SIREMOBIL Iso-C3D generates intraoperative data sets suitable for the visualization of the facial bones after open reduction of fractures.     

Holographic topometry for a dense visualization of soft tissue for facial reconstruction

Facial reconstruction can be used as a forensic technique to identify a person, when no other identification method is applicable. The facial soft tissue thickness applied to the skull is crucial when performing an accurate facial reconstruction. Historically, scientists developed several techniques to measure the soft tissue of the face. It was their aim, to build a database of a unique point-set, differentiated by gender, age, ethnic origin, BMI. All used a limited number of landmarks and an inaccurate measuring technique. We developed a contact-free and precise measuring technique, using low-dose CT and holographic data. Due to the extremely short exposure time, the holographic measurement is very precise. We lay out our first experiences to create a facial soft tissue layer map of the face.     

干细胞原位培植四维抗衰老美容整形的临床应用研究(一)--不同年龄组面部软组织厚度变化

目的：分析研究面部软组织厚度随年龄变化的关系。方法：选择经过体脂含量计算正常140人，按不同年龄段分布测量发际、眉间、鼻背、上唇根部、人中、颏隆凸、颏下、眉中央、眶下缘中点、下颌下缘（咬肌前）、颧弓上缘、下颌升支（咬肌中）、下颌角共15个点，并记录制备图表与曲线。结果：体脂正常不同年龄组面部软组织厚度不同，而且面部软组织不同部位的厚度随年龄变化的程度也不同。结论：衰老在面部的表现不仅仅是组织的松垂及皮肤皱纹的增多，还包括面部各部位组织厚度的改变。     

进一步重视对面中部骨折的处理

面中部骨折常危及生命 ,应以抢救生命体征为主 ;面部创伤处理应待全身情况得以保证后 ,再不失时机地尽快处理面中部骨折。手术宜采用头皮冠状切口 ,骨折开放复位联合正颌外科技术恢复骨折错位畸形和咬合错乱。骨牵张技术的采用有可能为今后提高疗效提供新的思路。     

Imaging of mandibular malformations and deformities

Mandibular deformities and malformations are quite various. They are mostly identified by clinical examination, but imaging is very useful for surgical planning. CT imaging is essential to evaluate patients with dystrophies such as fibrous dysplasia, neurofibromatosis, Gorlin syndrome and cherubism. Some growth abnormalities lead to a pseudomalformative appearance. Sequelae and ankylosis from condylar fracture, and unilateral mandibular hypoplasia due to capillary-venous malformation require CT or/and MR evaluation. CT with 3D reformations is performed as a complement to clinical evaluation in patients with other growth abnormalities such as orthognathic problems, hypercondylia, and some malformations like lateral facial clefts. MR is helpful for soft tissue evaluation in patients with Parry-Romberg syndrome and Pierre Robin dysostosis.