Application and progress of mandibular reconstruction

doi:10.3969/j.issn.2095-4344.2017.28.020

Abstract

Abstract:

BACKGROUND: There are various methods used for mandibular reconstruction, but some problems still need to be solved.
OBJECTIVE: To summarize the methods, research progress, and existing problems of mandibular reconstruction, and forecast the future development.
METHODS: The “mandibular reconstruction, bone tissue engineering, prosthesis device, operative complications” in English and Chinese served as the keywords to search the articles related to the research progress of mandibular reconstruction published from 1985 to 2017 in PubMed, WanFang and CNKI databases. The classification of mandibular defects, reconstruction methods were summarized, and the existing difficulties and development direction were explored.
RESULTS AND CONCLUSION: Totally 48 eligible articles were enrolled. Considering that mandibular defects are complicated, an appropriate classification method is crucial for mandibular reconstruction and treatment. Immediate reconstruction is recommended for mandibular defects caused by tumor resection, which has been shown to be available for the recovery of facial appearance and function. Non-vascularized and vascularized bone grafts are commonly used for mandibular reconstruction, but large surgical trauma, complications and difficulty in occlusal relationship still trouble clinical surgeons. Those emerging technologies, such as rapid prototyping, computer aided design and computer aided manufacture, not only enhance the surgical precision, but also remarkably reduce the operation time, further achieving satisfactory reconstructive effects. Tissue engineering is a promising method in the reconstruction of mandibular defects, and its combination with computer aided design and computer aided manufacture can perfectly restore the mandibular function and morphology. However, the long-term efficacy in the repair of mandibular defects needs to be studied in depth.

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

Key words: Mandible, Bone Remodeling, Computer-Aided Design, Tissue Engineering

CLC Number:

R318

Ma Cheng, Huang Xuan-ping. Application and progress of mandibular reconstruction[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(28): 4550-4555.

Figures/Tables 2

2.2 下颌骨缺损重建的原则与时机下颌骨缺损重建不仅需要恢复下颌骨的连续性与面部外形，还要恢复患者的咀嚼、吞咽、言语等基本生理功能，包括牙槽骨的高度、牙弓形态与宽度、周围咀嚼肌附着，以及感觉功能恢复和咬合功能重建等。成功植骨的前提主要包括[12]：①受区组织健康；②移植骨与宿主骨广泛接触；③术区血供良好；④移植骨固定持久可靠。对于下颌骨缺损修复重建的时机，尤其是对恶性肿瘤患者，传统观点认为应当延期修复，以便检测肿瘤复发。如何在保证肿瘤最大程度根治的前提下，充分利用整复手段恢复患者下颌骨的外形与功能是手术考虑的重要因素。随着颌面整复技术与显微外科技术的发展，特别是血管化游离组织瓣移植的广泛应用，外科手术不但能够保证肿瘤的广泛切除，而且还能恢复患者的面部外形与功能。与延期修复相比，即刻修复具有更多优点：①有利于保护重要组织与器官，减少术后并发症的发生；②有利于患者尽早解除心里障碍；③有利于早期恢复患者的面部外形与基本生理功能。因此，越来越多的学者认为即刻修复应当作为下颌骨的缺损重建的首选[13]。 2.3 下颌骨缺损重建的方法目前下颌骨缺损重建的常用方法主要包括非血管化骨移植、带蒂骨肌皮瓣移植，成型钛板重建以及血管化游离骨皮瓣移植等。非血管化游离骨移植虽然手术过程简单，耗费时间少，但移植成活依赖于受植区的血供，易发生感染，导致愈合时间长，且不能修复软组织的缺损[14]。带蒂骨肌皮瓣可同时提供软组织修复肌肉、口腔黏膜和皮肤缺损，缺陷是在不影响自身血供的情况下难以塑形，易造成修复后的下颌骨外形欠佳[15]。游离腓骨瓣移植是目前应用最为广泛的修复方法[16-17]：游离腓骨瓣长度适宜，最长可达25 cm，骨量充足，血供来源于骨膜和骨内腓动脉，因此可对其进行多次截骨满足各种形状的三维立体塑形需求，且腓骨皮质骨较厚，更利于种植体的植入。血管直径为1.5-3.0 mm，为颈部血管的吻合提供了有利的条件。近年来随着计算机技术与影像学的快速发展，快速成型技术、计算机辅助设计与制造(CAD/CAM)技术与骨移植、个体化钛支架植入相结合修复下颌骨缺损已经进入临床治疗阶段，且取得了理想的效果[18]。其优点是可以在术前模拟各种手术方案，进行数字化导板、重建钛板、钛螺钉固定位置的设计，优化修复体的生物力学，简化手术过程，缩短了手术时间[19-20]。快速成型技术在下颌骨缺损修复上的基本流程：首先利用MRI或螺旋CT对患者下颌骨进行扫描从而获得数字化数据，为保证仿真生物模型的精确度，目前选择的扫描层距为1.0 mm或者小于1.0 mm[21]。再利用逆向工程镜像还原技术模拟出患者缺损部位的下颌骨三维图像，然后以STL数据格式输出，控制快速成型机完成下颌骨仿真模型的制作，临床医生即可根据图像进行手术部位、重建钛板、固位和稳定等方面的设计，直至满意为止[22]。Foley等[23]在利用快速成型技术分别对8例下颌骨缺损患者进行修复的报告中，术前进行手术模拟，确定截骨范围，设计并制造了引导装装置，术后通过与术前模拟数据进行对比，分析发现利用快速成型技术制作手术导板修复下颌骨缺损是一种精确的修复方法。张新凤等[24]使用快速成型技术结合腓骨皮瓣修复80例下颌骨缺损的患者，术前在计算机软件上模拟病变切除及腓骨移植修复重建的手术操作，通过快速成型技术打印出修复后的实体模型及指导截骨和移植骨塑形的数字化导板，并根据模型进行重建钛板的预弯，术中根据术前制作的手术导板进行固位与塑形，术后患者均获得满意面容。将实际手术与模拟手术截除的下颌骨各个部位的长度进行对比，发现快速成型技术在血管化腓骨移植修复下颌骨缺损方面可获得较高的精度(表1)。"

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