半側(cè)顏面短小畸形下頜骨牽張成骨方向的探討

唐曉軍, 石 蕾, 尹 琳, 張智勇, 劉 偉, 尹宏宇, 楊亦楠, 王 璇

作者單位：100144 北京，中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院整形外科醫(yī)院 頜面整形外科中心

半側(cè)顏面短小畸形下頜骨牽張成骨方向的探討

唐曉軍, 石 蕾, 尹 琳, 張智勇, 劉 偉, 尹宏宇, 楊亦楠, 王 璇

半側(cè)顏面短小； 下頜骨； 牽張成骨； 數(shù)字化

半側(cè)顏面短小畸形(hemifacial microsomia, HFM)是由RJ Gorlin和J Pindborg于1964年提出的，發(fā)生率為1/5600～1/3500。半側(cè)顏面短小畸形主要的畸形位于下頜骨，而形成“多米諾骨牌效應(yīng)”，從而進(jìn)一步影響相鄰組織結(jié)構(gòu)的發(fā)育，引起多種多樣復(fù)雜的臨床畸形。因此,我們希望通過在兒童期對(duì)患者進(jìn)行下頜骨治療，以阻斷畸形的進(jìn)一步發(fā)展，促進(jìn)相鄰結(jié)構(gòu)的正常發(fā)育。牽張成骨技術(shù)是目前治療下頜骨發(fā)育不足最有效的方法之一[1]，然而對(duì)于半側(cè)顏面短小畸形患者的下頜骨，最有效的牽引矢量是治療中的重點(diǎn)和最難決定的部分之一[2]。自2010-2014年, 我們對(duì)60例半側(cè)顏面短的患者應(yīng)用牽張成骨技術(shù)進(jìn)行了治療，通過分析對(duì)有效的牽引矢量進(jìn)行初步地探討。

1 臨床資料

2 手術(shù)方法

2.1 術(shù)前設(shè)計(jì)、模擬和導(dǎo)板制作

患者行頭顱螺旋CT掃描，DICOM格式文件刻錄進(jìn)光盤，Pro Plan CMF 1.4軟件(MATERIALISE公司，比利時(shí))讀取DICOM數(shù)據(jù)，通過Segmentation模塊對(duì)上下頜骨、下牙槽神經(jīng)管、未萌出磨牙進(jìn)行三維重建，可重建出手術(shù)區(qū)域骨骼和軟組織三維模型。在計(jì)算機(jī)中進(jìn)行模擬截骨、延長器放置、牽引延長，根據(jù)數(shù)字化手術(shù)模擬結(jié)果，選擇最佳截骨線位置和延長器放置位置，將以上數(shù)據(jù)通過端口輸出為STL格式，通過CAD軟件進(jìn)行下頜骨表面提取，進(jìn)行截骨手術(shù)導(dǎo)板設(shè)計(jì)。將數(shù)字化導(dǎo)板數(shù)據(jù)保存為STL文件，用三維打印機(jī)進(jìn)行打印，打印材料為光敏樹脂。

2.2 手術(shù)過程

手術(shù)采用口外入路，于患側(cè)下頜緣下1.500 cm設(shè)計(jì)3.000～5.00 cm切口，方向與下頜骨下緣平行。切開皮膚、皮下組織和頸闊肌，翻瓣向上，避免損傷面神經(jīng)下頜緣支，顯露下頜升支外側(cè)骨板。置入手術(shù)導(dǎo)板，沿設(shè)計(jì)的不規(guī)則截骨線凹槽截骨，并避開下齒槽血管神經(jīng)束投影線。將牽引器的固位板在導(dǎo)板表面塑形，調(diào)整好后，置入術(shù)區(qū)，達(dá)到與下頜升支外側(cè)骨皮質(zhì)的最大貼合，預(yù)固定牽引器。按設(shè)計(jì)截骨線行下頜升支全層截骨術(shù)。在骨折線兩端安置下頜骨牽引器,鈦釘固定。逐層關(guān)閉切口。術(shù)后5～7 d開始牽引，速度為1 mm/d。牽引結(jié)束后，牽引器保留6個(gè)月。

3 結(jié)果

Fig 1 Design of vector for AngleⅠtype. Fig 2 Lateral view of simulated distraction process. Fig 3 Frontal view of simulated distraction process. Fig 4 Design of vector for AngleⅡtype malocclusio. Fig 5 Lateral view of simulated distraction process. Fig 6 Frontal view of simulated distraction process.

4 討論

Fig 7 Comparison between preview and postview of child with left hemifacial mircrosomia. a.preview (Case 1). b.postview at 12 months (Case 1). c. preview with occlusion of angle Ⅱ malocclusion (Case 1). d. postview with occlusion at 12 months (Case 1). e. preview (Case 2). f. postview at 6 months (Case 2). g. preview with occlusion of angle Ⅰ occlusion (Case 2). h. postview with occlusion at 6 months (Case 2).

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Discussion on the vector of mandibular distraction osteogenesis for hemifacial mircrosomia

TANGXiao-jun,SHILei,YINLin,etal.

(DepartmentofMaxillofacialSurgery,PlasticSurgeryHospital,ChineseAcademyofMedicalSciencesandPekingUnionMedicalCollege,Beijing100144,China)

Objective To explore the most effective vector of mandibular distraction osteogenesis for hemifacial microsomia using the digital techniques. Methods From 2010 to 2014, 60 patients of hemifacial microsomia were performed the procedures of mandibular distraction osteogenesis using digital techniques. The vector perpendicular to the occlusal plane was applied for the patients with classⅠmalocclusion. The vector should be situated between the occlusal plane and its vertical line for the patients with classⅡ, the angle should be determined using the digital techniques. Results The treatment on 60 cases were successful except for 3 cases with distractor displacement and 5 case with infection. The height of the mandibular ramus and the deviation of the chin were improvement and the cant of occlusal plane was almost corrected. Conclusion The most effective distractive direction is perpendicular to the occlusal plane for patients with angle classⅠ, while, to the patients with angle class Ⅱ, the vector should go between the occlusal plane and its perpendicular line, the precise angle should be made and simulated using the digital techniques.

Hemifcial microsomia； Mandible； Distraction osteogenesis； Digital technique

北京市科委首都臨床特色應(yīng)用研究專項(xiàng)-基于數(shù)字化技術(shù)的兒童半側(cè)小面畸形早期綜合治療效果評(píng)估基金資助項(xiàng)目(Z121107001012112)

作者單位：100144 北京，中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院整形外科醫(yī)院 頜面整形外科中心

唐曉軍(1973-)，男，黑龍江人，副主任醫(yī)師，博士.

張智勇，100144，中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院整形外科醫(yī)院 頜面整形外科中心，電子信箱：zhangzh1536@sina.com

10.3969/j.issn.1673-7040.2015.07.004

R782.2

A

1673-7040(2015)07-0394-04

2015-06-10)