计算机辅助下单侧腓骨修复双侧下颌骨放射性骨坏死1例

2019-10-22 金婷婷 李世豪 张汉卿 中国口腔颌面外科杂志

男,63岁,2010年被诊断为鼻咽癌,随后经过37次放疗,总剂量达74Gy。2016年3月患者由于下颌疼痛难忍就诊。口腔全景片显示:双侧下颌骨角广泛破坏(图1);三维CT结果显示:双侧下颌骨颊舌侧广泛破坏,下颌骨正中联合和颞下颌关节关节盘完整,患者颊部和颈部僵直,无瘘管。临床诊断为MarxⅢ级,拟行计算机辅助下坏死骨切除+骨缺损修复重建术。

鼻咽癌是我国南部地区一种常见的恶性肿瘤,目前放疗是治疗鼻咽癌的首选方式。随着放疗技术的发展,以及与化疗方法的联合使用,大多数无远处转移的患者都能有较好的远期生存率。鼻咽癌放疗后的主要并发症包括口腔干燥、听力损伤、吞咽困难、牙关紧闭、放射性骨坏死等,其中放射性骨坏死已成为影响患者生存的最主要问题。1983年,Marx提出放射性骨坏死的发生、发展过程:①放疗;②低氧、低细胞、低血管组织形成;③组织崩解,形成一个慢性非愈合性伤口。
 
放射性骨坏死的治疗主要取决于组织的坏死程度,表浅和局限性病变主要选择保守治疗,包括使用抗生素、口腔冲洗、高压氧、外科刮治术。但对于严重病例,手术切除和清除坏死组织仍然是唯一有效的治疗方式。放疗后患者由于颈部软组织纤维化和血管质量受损,给手术切除病灶后的修复重建带来了巨大挑战。腓骨肌游离皮瓣是最常见的下颌骨修复重建方法,近年来也有不少学者将其用于修复下颌骨放射性骨坏死术后缺损,但是关于双侧下颌骨缺损的文献报道却很罕见。本文报告1例采用计算机辅助,术前进行计算机虚拟手术计划,定制切除导板和复位导板,利用单侧腓骨制备2个独立腓骨肌皮瓣修复双侧下颌支放射性骨坏死的病例。
 
1.病例报告
 
男,63岁,2010年被诊断为鼻咽癌,随后经过37次放疗,总剂量达74Gy。2016年3月患者由于下颌疼痛难忍就诊。口腔全景片显示:双侧下颌骨角广泛破坏(图1);三维CT结果显示:双侧下颌骨颊舌侧广泛破坏,下颌骨正中联合和颞下颌关节关节盘完整,患者颊部和颈部僵直,无瘘管。临床诊断为MarxⅢ级,拟行计算机辅助下坏死骨切除+骨缺损修复重建术。



图1 术前全景片显示双侧下颌支广泛破坏
 
1.1虚拟手术计划(virtual surgical planning,VSP)
 
首先用CMF程序(Materialize,Leuven,比利时)将下颌骨和下肢的CT扫描资料转化成3D虚拟的下颌骨和腓骨模型。术前CT结果显示下颌骨正中联合和双侧髁突结构完整。利用计算机3D虚拟技术为腓骨模型塑形,叠加于下颌骨缺损部位,以维持下颌骨外形的完整性。最后将数据导入虚拟手术软件,用于制作下颌骨切除导板和复位导板。下颌骨切除导板用于精准切除下颌骨,复位导板用于引导腓骨瓣置于预定的位置(图2)。运用计算机3D打印重建下颌骨立体模型,术前使用模型预弯2块钛板。



图2 虚拟手术。A.在下颌骨切除导板的引导下行下颌骨切除术;B.通过腓骨复位导板将腓骨瓣置于缺损处
 
1.2手术过程
 
在腓骨肌皮瓣制取过程中,尽可能保留足够长度的腓骨和血管蒂,在下颌骨切除导板的引导下有序切除下颌骨,用4个钛钉将其固位(图2)。在VSP引导下,先切除右侧下颌骨,切除后在右侧下颌升支和下颌骨正中联合末端可见丰富血流,肯定了手术边界选择的正确性。同法确定左侧下颌骨的切除边界,然后沿腓骨中心的骨膜向下剥离腓骨,切除约3.91cm长的腓骨。在位置导板的引导下塑形成2个独立的腓骨肌皮瓣(图3),其过程中注意保护骨膜、腓动脉和成对的伴行静脉。2个腓骨瓣在复位导板的引导下置于下颌骨缺损处,通过预弯的钛板将其固定。将面动脉作为受区吻合动脉,面静脉和颈外静脉作为受区吻合静脉,与供区血管吻合。



图3 用1个腓骨制备2个腓骨肌皮瓣示意图。A.1个腓骨瓣被分为2个单独的腓骨肌皮瓣,2个皮瓣都有携带穿支血管的皮岛;B.2个单独的腓骨肌皮瓣用于重建双侧下颌骨缺损
 
2.结果
 
患者术后12d即可正常饮食,言语清晰。术后3个月随访,患者双侧腓骨肌皮瓣成功存活,供瓣区未出现畸形,疼痛和牙关紧闭症状较术前明显减轻,美观效果满意。8个月后随访,左侧髁突无钛钉松动、无继发性骨折。双侧髁突和下颌骨正中联合处无ORN进展表现(图4)。
 


图4 术后8个月全景片
 
3.讨论
 
鼻咽癌放疗后的放射性骨坏死较为常见,手术治疗已成为常规治疗方式,但用1侧腓骨制作成2个腓骨肌皮瓣修复双侧下颌骨缺损的报道并不多见,与计算机虚拟手术计划相结合的修复双侧下颌骨缺损就更为罕见。本文报告1例计算机辅助下用一侧腓骨制备2个腓骨肌皮瓣修复双侧下颌骨缺损的病例,此类患者在缺损修复重建上面临巨大挑战,主要表现为:①术区缺损范围大;②术区边界难以准确定位;③双侧血管损伤,正中联合部极易出现无供血可能;④双侧下颌骨缺损切除后修复难以精准复位。
 
计算机虚拟手术计划的运用,较普通手术方式明显缩短了手术时间,提高了手术效果。既往有研究表明,腓骨体积足以修复下颌骨缺损。计算机虚拟手术计划使腓骨得到了最优化应用。通过定制的切除导板和复位导板将虚拟手术计划转变成真实的手术计划,更加精准地恢复了颌面部美观和下颌骨功能。VSP技术广泛用于双侧下颌骨缺损修复,即使更大范围的下颌骨坏死,只要在两边最末端钛钉固位不受影响的情况下,移植的腓骨和余留骨可通过复位导板或预弯的钛板固位,能继续在VSP的引导下行双侧下颌骨修复重建;反之则弃用VSP。
 
手术中无法确定在去除双侧下牙槽动脉后,下颌骨正中联合部是否还有丰富血供,一旦发现正中联合无血供,则将其去除,用另一侧腓骨瓣修复。幸运的是,本例患者在VSP引导切除后,下颌正中联合两侧仍然血供丰富。Jacobson等曾报道,腓动脉发出数条血管,穿过骨膜,营养腓骨;当腓骨中央部分与骨膜分离后,这些穿支对腓骨远端的供血起着至关重要的作用。
 
Fan等曾经报道31例类似的病例,发现这种手术方案存在一定局限,骨膜的连续性限制了两段骨的位移。对于放射性骨坏死累及下颌支中部尤其是双侧“H”型缺损患者,腓骨长度明显不够。本研究创新性地将一个腓骨瓣分成2个独立的腓骨肌皮瓣,不受骨膜牵连,拥有更好的灵活性;即使累及双侧下颌支的缺损,也能够通过单个腓骨成功修复。然而也存在一些局限性:①需准备双侧受体血管;②2个独立皮岛的设计必须有穿支血管;③血管蒂需有足够的解剖长度,这对放疗后患者十分困难。皮瓣设计过程中,皮岛应基于腓动脉干近心端垂直发出的穿支而设计。
 
研究表明,腓动脉干邻近穿支一般位于腓骨头和外踝连线的1/3处,此处一般有1~3条穿支,这有利于两端或2个独立皮岛的设计。此外,还应对患者颈部血管进行术前评估,术中应精细操作。如果血管蒂长度不够,必要时需进行血管移植。当缺损难以用此方法修复时,考虑同期或后期用另一侧腓骨修复。
 
综上所述,计算机辅助下用单侧腓骨修复双侧下颌骨放射性骨坏死术较传统技术明显缩短了手术时间,实现了咬合关系的精准复位,提高了晚期放射性骨坏死患者的生存质量,后期美观和功能效果良好。
 
原始出处:

金婷婷,李世豪,张汉卿,黄子贤,汪延,黄志权.计算机辅助下单侧腓骨修复双侧下颌骨放射性骨坏死1例报告及文献复习[J].中国口腔颌面外科杂志,2018,16(06):568-571.

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    2019-12-19 bioon14
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    2020-06-14 zll0634
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    2020-04-21 xlysu
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    2020-06-21 axin020
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    2019-10-24 millore
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    2019-10-24 珙桐
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