Chinese Journal of Tissue Engineering Research ›› 2016, Vol. 20 ›› Issue (20): 2992-2999.doi: 10.3969/j.issn.2095-4344.2016.20.015
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Ding Yu-de, Yang Bin
Received:
2016-03-11
Online:
2016-05-13
Published:
2016-05-13
Contact:
Yang Bin, M.D., Professor, Maxillofacial Plastic Surgery Center, Digital Simulation Center, Plastic Surgery Hospital (Institute), China Academy of Medical Sciences & Peking Union Medical College, Beijing 100144, China
About author:
Ding Yu-de, Studying for master’s degree, Maxillofacial Plastic Surgery Center, Digital Simulation Center, Plastic Surgery Hospital (Institute), China Academy of Medical Sciences & Peking Union Medical College, Beijing 100144, China
Supported by:
the Science and Technology Plan for Capital Clinical Featured Application in Beijing, No. Z15110004015056
CLC Number:
Ding Yu-de, Yang Bin. Application of three-dimensional scanning and measuring techniques in the diagnosis and treatment of mandibular prognathism[J]. Chinese Journal of Tissue Engineering Research, 2016, 20(20): 2992-2999.
三维扫描技术,是一种显示体表三维形态的立体测量技术,作为能够提取物体的三维几何形状,进行体表器官解剖形态建模,采集、测量体表生物信息数据的新兴辅助技术,而被逐渐运用到下颌前突畸形的诊断、手术设计以及术后的随访评估中来[7]。 现阶段,国内外主流的数字化扫描测量技术主要包括如下:①接触式扫描测量。②非接触式扫描测量。现就其分类、原理、在下颌前突畸形中的运用简要阐述如下。 2.1 接触式扫描测量 接触式机械化测量:即通过测量头,直接与物体表面相接触,从而记录测量头所在测量点的坐标位置,再根据各测量点的三维坐标,利用计算机的重建功能,将所测物体的三维形态重建起来[8]。 Nakashima等[9]研究了接触式测量装置在口腔牙科领域的测量,将测量头与石膏表面直接接触,记录测量点位置的三维坐标,通过计算机自动测量,记录,从而重建出记录口腔牙齿形态的石膏模型,将牙颌模型转存为数字信息,测量其各解剖标志点的数据,并与口腔内的真实数据相比较,评估其数值的准确性,认为接触式的机械化测量在牙科领域运用有一定的临床价值。但是,接触式的测量难以对模型上的皱襞曲面以及较细小的窝沟点隙等盲区进行扫描,而逐点的测量也大大增加了扫描时间,难以在口腔内进行实测。同时,测量力度以及测量头的直径都会对测量的精确性有所影响,且易导致物体表面变形或划伤,影响测量精度。测量软组织时,接触变形的问题更是接触式测量的一大限制,被认为不适于软组织的扫描重建。 2.2 非接触式扫描测量 2.2.1 CT扫描重建 CT重建即通过X射线对人体的各部位进行扫描,经探测接收器接收后,通过光点转换器转换及计算机处理后获得图像,再经过计算机模拟软件,通过设定不同阈值,对骨组织或软组织不同层面的图像叠加,进行结构提取,从而获得颅颌面的骨组织、牙齿结构或颜面部的软组织的三维重建模型[10]。 虽然,CT扫描能同时获得硬组织与软组织的全部信息,但由于放射剂量对人体的伤害,扫描层之间的层距以及层厚对数据精确度的影响,以及颌面部或者口腔内的金属可能产生的伪影等问题,限制了其在口腔颌面实测的运用以及对患者术后长期多次的随访观察。 2.2.2 莫尔云纹测量 莫尔云纹测量是光学测试技术中的一种,由光栅、光源、摄影机等组成,其原理是将平行光透过两有差异的基准光栅后投照于物体表面,光栅在物体表面产生形变,而表面的各点高度与位置信息就由基准栅与变形栅叠合产生的云纹所包含,经过计算分析云纹,得到各点的三维坐标,从而重建物体表面的三维形态。 高崎和Meadous等[11]在1970年开始提出,之后迅速运用于口腔、解剖等领域。Chen等[12]在1995年就运用莫尔云纹测量对25例下颌前突畸形患者的面部软组织进行了评估。但是,莫尔云纹测量只能获得物体表面一部分的三维坐标,不能重建出整个表面的三维信息,主要是用于相对较平缓的软组织的重建测量,以及无牙牙合的扫描,对于具有尖锐外形的物体则成像不佳,对形态复杂的表面更是难以达到精确[13]。 2.2.3 三维激光扫描技术 三维激光扫描技术是目前在口腔领域运用较多的一种三维扫描技术。其很早便被运用于术前术后的软组织变化评估中,从而分析正颌手术的术后组织复发率问题[14]。Moss等[15]在1989年对其装置进行了详细的描述,它其实和三维光学扫描技术一样,同属于结构光三维视觉测量技术。根据激光的三角形测距原理,通过发出的激光束经过反光镜发射到物体表面,形成反光点,在通过CCD(即电荷耦合器件)接受反光点,经过多次的扫描从而计算获得一系列的点云数据,得到被测物体的表面三维坐标[16]。 三维激光扫描操作简单,耗费低,清晰精确,现已被广泛运用于临床中。但是,由于目前的激光扫描多采用线结构模式,在组织存在倒凹时,往往容易产生扫描盲区,而且扫描速度较立体摄影相对较慢,在扫描期间,患者特别是年龄较小的患儿,其微笑、吞咽等细微动作所导致肌肉的收缩变化,眼球运动,鼻呼吸和头部姿势变化都会对数据的精确性产生一定的影响,因而常需在自然状态下获取三维数据[17]。Peluso等[18]报道三维激光扫描技术的测量精度在0.1 mm左右,但较三维光学扫描低。此外,由于激光扫描对于眼睛的伤害,扫描时患者需要保持闭眼动作[19],眼部周围的组织精确度较睁眼状态下相对降低。 2.2.4 立体摄影测量 其原理与三维激光扫描一样,依赖于三角形测距原理成像。通过两个摄像头对被测物体的拍摄,计算出被测物体相对于两个摄像头之间的距离以及两摄像头的焦距间的关系,从而获得物体表面的三维坐标信息[13,20]。1944年,Thalmann- Degan开始运用立体摄影技术比较正畸前后患者面部的差异[21];Hajeer[13]与Balvinder等[20]在2002年开始运用立体摄影技术,对正颌术后的患者组织进行扫描评估。通过立体测图仪与现代化计算机技术的结合,立体摄影测量可以获得相对较高的测量精度,而且操作时间短,即使是年龄较小的患儿也能采集较准确的数据。但由于立体摄影设备的价格昂贵,拍摄时对环境的较高要求,在临床使用时还未得到广泛的应用普及。 2.2.5 三维光学扫描技术 其本质也是结构光三维视觉测量技术的一种,在光学三角测量原理的基础上,运用光学投影系统作为投射器,投影产生的平行条纹在被测物体上发生形变,经过计算机的相位计算分析,计算出物体表面的形状,即光栅投影测量[22]。由于光栅投影可以产生高密度的条纹覆盖物体表面,因而获得的物体表面点的三维坐标信息密度也相对较高,从而可以得到较高的测量精度。 三维光学扫描技术,相较激光扫描技术,其投射能源为可见光,对患者影响小,可形成多个视角的扫描,避免了扫描盲区的产生,扫描时间短(0.2-0.8 s),对被测患者的位置要求相对较低,降低了操作的难度[23],获得的表面纹理信息,更为逼真得显示出物体的表面信息[24]。 2.2.6 3dMD 3dMD是将立体摄影技术与结构光扫描技术相结合的一种三维扫描技术系统,该系统使用多个摄像头(两边各3个,分别包括一个颜色以及两个红外线摄像头)来获取实景照片,即将一组随机光投射于被测物体上,同时多个可捕获精确图像的摄像机自动调整最佳参数从多个角度同步获取信息(见图2)。其图像获取速度最快可达1.5 ms,即使是对年龄较小的患儿,也能较精准的采集信息[25]。3dMD由于其准确度高、误差小、精度大等特点,获得了较高的认可,但也有文献报道其对于面部较突出以及过于平滑的区域,如鼻尖区域以及未行治疗的唇裂边缘,常无法获取较精细的三维数据[26]。 2.3 三维扫描技术在下颌前突畸形的诊治辅助应用中主要包括以下3方面 术前诊断、手术设计与术后评估。 2.3.1 辅助术前诊断 下颌前突畸形的传统诊断治疗,其术前诊断主要包括头影测量、临床检查以及口腔内牙颌石膏模型的制取[1-2]。而随着数字化技术在下颌前突畸形中的逐步运用,传统的测量方法,因其具有图像失真、标志点模糊等缺点,而逐渐被三维CT的数据测量所取代[27],但CT所获得的软组织数据往往因层距的原因,其精准度相对不高,而三维激光扫描、三维光学扫描以及3dMD等在近年的广泛运用,逐渐在软组织扫描重建领域受到越来越多的重视。随着计算机技术的发展,经过国内外的学者大量临床运用三维激光扫描技术以及三维光学扫描技术,对正颌患者扫描后进行统计分析研究,现已成为被人们所认可的可靠测量方法。因而,在对患者的术前面部进行扫描,重建软组织三维模型的领域,三维激光扫描及光学扫描技术发挥出越来越大的作用,在辅助诊断下颌前突畸形中得到广泛运用[5,18]。 2.3.2 辅助手术设计 在下颌前突畸形的手术设计方面,三维激光扫描所获得的牙颌模型数据与CT重建所获得的颌骨数据相拟合,更是极大的简化了传统手术的模型外科设计以及术中咬合导板的制作步骤[6]。 牙颌模型因其真实的记录上下颌牙、牙弓形态等解剖结构以及上下牙的咬合关系,对于下颌前突畸形的诊断及治疗具有重要的意义。而在传统的正颌外科手术前,模型外科的设计操作更是决定手术术后效果的重要因素。 通过三维激光扫描技术对牙颌模型扫描而获取的三维结构,具有精度高的特点[28-29],其准确性可高达1.9-0.8 mm[30-31]。数字化的牙颌模型在与CT数据拟合后,可以获得一个相对精确的牙颌头颅模型,通过计算机软件在模型上模拟正颌手术,确定一个手术最终的颌骨及牙牙合的位置关系数据以及术后的预估效果[32-34],从而获得一个最终的手术方案,可以显著提高手术设计的精准度[35-37]。同时,三维扫描技术对手术设计的辅助,对颅颌面手术的可视化以及提高效率方面,有极大的帮助[10],在与患者交流沟通手术方案方面也有十足的优越性。 近年来,不少学者运用对牙牙合面成像更精细的CBCT(Cone beam computed tomography)数据,来重建患者的模型,模拟正颌手术过程,简化了牙颌模型数据与螺旋CT数据拟合的过程[38]。但该方法对于口腔内存在烤瓷冠、种植体等金属体的患者,CBCT受金属伪影影响,往往牙齿形态成像不佳,对患者对象的限制性较大,而三维扫描技术重建牙牙合面形态就显现出其优势性来。 2.3.3 辅助术后疗效评估及随访监测 下颌前突畸形矫治后的术后评估,主要包括硬组织及软组织的术前术后对比,对于颌骨和牙齿的术后以及正畸后的改变,现今已有许多的评估系统,测量方法也从一开始的硫酸纸描迹,到计算机软件定点,以及现在的三维头影测量,精确度得到了明显的提高。 但是,关于软组织的手术评估方面,直到三维扫描技术的逐步开展,才取得了实质性的进展。数字化三维扫描技术能够快速、准确地获取实体组织的表层图像,并以三维立体结构呈现。在对下颌前突畸形的临床患者进行头面部扫描获得的数据,能协助进行人体软组织测量,是真正意义上的软组织重建。通过三维扫描技术,可以实现对下颌前突畸形患者术前、术后以及长期随访过程中的无创检查,精准、有效的评估面部软组织的形态变化。 自1970年起,双颌手术逐渐被运用于治疗严重的下颌前突畸形当中[39],但鼻翼的变宽、上唇的扁平化一直是其术后的并发症之一[40-41]。因而上唇以及鼻的术后改变评估也一直为各学者所重视,但却一直缺乏一个三维上的数据比较,直到三维激光扫描技术及三维光学扫描技术逐渐被运用到医学上,鼻与上唇的术后改建才有了更为直观、精确的比较分析[42-43]。 Yamada等[44]通过三维激光扫描对12例行双颌手术的患者术前术后的软组织进行扫描,从而对软组织各标志点进行线性分析、角度比较以及图像叠加后的视觉定性分析,从三维上评估得出,发现患者鼻翼在上颌骨术后呈变宽的趋势,但上唇未出现明显扁平化的现象。 Alves等[5]通过将术前术后的额部做为校准[13],比较得出正颌术后软组织的变化是从中线向鼻翼两旁逐渐减小,颏部变化趋势是从颏前点向两侧呈半球形逐渐减小。 Suh等[45]对69例骨性Ⅲ类错牙合畸形患者术前术后软组织进行扫描分析,发现其水平向位移变化不明显。 彭菊香等[46]运用结构光三维扫描技术,对8例骨性Ⅲ类错牙合畸形患者正畸正颌联合治疗的术前术后软组织进行扫描,认为骨性Ⅲ类错牙合畸形术后变化方向主要集中于垂直向与前后向,角度等变化主要发生在唇部,颏部体积变化最为显著,其次是上颌。同时,通过术前术后的软组织对比,三维扫描技术还能对术后的软组织复发率进行定量的计算[5],通过术后不同时期的软组织对比,还能得出组织的术后肿胀的减小率,可以为术前的软组织预估提供数据支持。 Kau等[47]对12例患者进行术后软组织扫描后进行分析,发现患者在术后1个月的组织肿胀消减率最大,约为60%,而双颌手术相较单颌手术的术后的体积变化更为明显。 Verzé等[48]在Tucker等[4]研究的基础上,在对骨性Ⅲ类畸形患者,运用三维扫描技术评估正颌术后的随访中,发现面部的软组织在微笑、扮鬼脸等动态的面部位移率长期随访结果未见统计学意义。"
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