数字化外科在正颌外科术前设计中的应用

doi:10.12016/j.issn.2096-1456.2018.11.001

摘要/Abstract

摘要：

正颌外科手术的成功不仅取决于术者的手术技巧,而且依赖于科学、正确的手术设计与计划。数字化外科的应用极大地改变了正颌外科术前计划的模式。与传统方法相比,数字化外科辅助的正颌外科术前设计与计划存在诸多不同,它免除了术前石膏模型外科并具有更高的牙合板设计精确度的优势。本文着重对应用数字化虚拟工具进行正颌外科术前设计的工作流程作一述评,以向临床上需要将数字化外科纳入正颌外科术前设计的外科医生提供虚拟手术操作流程参考。

关键词: 正颌外科, 数字化外科, 术前计划, 虚拟骨切开, 牙合板设计

Abstract:

The success of orthognathic surgery depends not only on surgical techniques but also on accurate and scientific surgical design and planning. The adoption of digital surgery has created a paradigm shift in surgical planning. However, compared with traditional methods, digital surgery-assisted planning of an orthognathic operation differs fundamentally from planning using traditional methods, including the elimination of plaster dental model surgery and of the increase in splint design accuracy. This article focuses on the application of digital virtual tools for pre-operative design of orthognathic surgery to provide a virtual surgical procedure reference for surgeons who need to incorporate digital surgery into orthognathic surgery.

Key words: Orthognathic surgery, Digital surgery, Surgical planning, Virtual osteotomy, Splint design

中图分类号:

R782

刘显文,艾伟健. 数字化外科在正颌外科术前设计中的应用[J]. 口腔疾病防治, 2018, 26(11): 681-687.

Xianwen LIU,Weijian AI. Application of digital surgery for orthognathic surgical planning[J]. Journal of Prevention and Treatment for Stomatological Diseases, 2018, 26(11): 681-687.

图/表 7

图1 数字化重建的3D模型虚拟骨切开 a：骨切开位置的个性化自主定点;b：相邻两点连线后形成骨切开六面体

Figure 1 Digital reconstruction of the 3D model of a virtual osteotomy

图2 虚拟手术模块中骨切开移动后三维头影测量数据实时显示

Figure 2 Virtually stimulated typical orthognathic surgery with measurements updated in real time during surgical simulation

图3 数字化牙合板设计 a：咬合面定点;b：计算机虚拟牙合板成型

Figure 3 Digital design of a surgical splint

图4 典型病例术前正、侧面像及头影测量分析 a：正面像;b：侧面像;c：头影测量正面像;d：头影测量侧面像

Figure 4 Photographs and cephalometric radiographs of a representative case

图5 数字化正颌外科设计 a：上颌骨骨切开线设计右侧面观、正面观、左侧面观;b：下颌骨骨切开线设计右侧面观、正面观、左侧面观

Figure 5 Digital orthognathic surgery planning

图6 术中3D打印数字化导板引导骨块就位 a：上颌骨切开导板;b：上颌骨块就位导板;c：颏成型导板

Figure 6 3D printed surgical splint used to reposition the segment at the time of surgery

图7 术后正、侧面像及头影测量分析 a：术后正面像;b：术后侧面像;c：术后头影测量正面像;d：术后头影测量侧面像

Figure 7 Postoperative photographs and cephalometric radiographs of a representative case

参考文献 53

[1]	王旭东 . 颅颌面坚强内固定(十九)数字化外科技术在口腔颅颌面领域中的应用[J]. 中华口腔医学杂志, 2014,49(8):506-509. DOI URL
[2]	刘筱菁 . 数字化外科学在颅颌面外科的应用[D]. 北京:中国医学科学院北京协和医学院, 2007.
[3]	刘显文, 李运峰, 刘尧 , 等. 下颌升支倒L形截骨术结合髂骨移植术矫治成年下颌发育不足畸形[J]. 口腔疾病防治, 2017,25(8):501-505. DOI URL
[4]	Choi SH, Kang DY, Cha JY , et al. Is there a difference in stability after intraoral vertical ramus osteotomy between vertically high-angle and normal-angle patients?[J]. J Oral Maxillofac Surg, 2016,74(11):2252-2260. DOI URL
[5]	Xia JJ, Gateno J, Teichgraeber JF . New clinical protocol to evaluate craniomaxillofacial deformity and plan surgical correction[J]. J Oral Maxillofac Surg, 2009,67(10):2093-2106. DOI URL PMID
[6]	Xia J, Ip HH, Samman N , et al. Computer-assisted three-dimensional surgical planning and simulation: 3D virtual osteotomy[J]. Int J Oral Maxillofac Surg, 2000,29(1):11-17. DOI URL
[7]	Xia J, Samman N, Yeung RW , et al. Computer-assisted three-dimensional surgical planing and simulation. 3D soft tissue planning and prediction[J]. Int J Oral Maxillofac Surg, 2000,29(4):250-258. DOI URL
[8]	Xia J, Wang D, Samman N , et al. Computer-assisted three-dimensional surgical planning and simulation: 3D color facial model generation[J]. Int J Oral Maxillofac Surg, 2000,29(1):2-10. DOI URL
[9]	Xia JJ, Gateno J, Teichgraeber JF . Three-dimensional computer-aided surgical simulation for maxillofacial surgery[J]. Atlas Oral Maxillofac Surg Clin North Am, 2005,13(1):25-39. DOI URL PMID
[10]	Swennen GR, Schutyser F . Three-dimensional cephalometry: spiral multi-slice vs cone-beam computed tomography[J]. Am J Orthod Dentofacial Orthop, 2006,130(3):410-416. DOI URL PMID
[11]	Gateno J, Xia JJ, Teichgraeber JF , et al. Clinical feasibility of computer-aided surgical simulation (CASS) in the treatment of complex cranio-maxillofacial deformities[J]. J Oral Maxillofac Surg, 2007,65(4):728-734. DOI URL PMID
[12]	Swennen GR, Barth EL, Eulzer C , et al. The use of a new 3D splint and double CT scan procedure to obtain an accurate anatomic virtual augmented model of the skull[J]. Int J Oral Maxillofac Surg, 2007,36(2):146-152. DOI URL PMID
[13]	Sadiq Z, Collyer J, Sneddon K , et al. Orthognathic treatment of asymmetry: two cases of "waferless" stereotactic maxillary positioning[J]. Br J Oral Maxillofac Surg, 2012,50(2):e27-e29. DOI URL PMID
[14]	Polley JW, Figueroa AA . Orthognathic positioning system: intraoperative system to transfer virtual surgical plan to operating field during orthognathic surgery[J]. J Oral Maxillofac Surg, 2013,71(5):911-920. DOI URL PMID
[15]	Bobek S, Farrell B, Choi C , et al. Virtual surgical planning for orthognathic surgery using digital data transfer and an intraoral fiducial marker: the charlotte method[J]. J Oral Maxillofac Surg, 2015,73(6):1143-1158. DOI URL PMID
[16]	Ullah R, Turner PJ, Khambay BS . Accuracy of three-dimensional soft tissue predictions in orthognathic surgery after Le Fort I advancement osteotomies[J]. Br J Oral Maxillofac Surg, 2015,53(2):153-157. DOI URL PMID
[17]	Li B, Shen SG, Yu H , et al. A new design of CAD/CAM surgical template system for two-piece narrowing genioplasty[J]. Int J Oral Maxillofac Surg, 2016,45(5):560-566. DOI URL PMID
[18]	Xia JJ, Gateno J, Teichgraeber JF , et al. Algorithm for planning a double-jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 1: planning sequence[J]. Int J Oral Maxillofac Surg, 2015,44(12):1431-1440. DOI URL PMID
[19]	Xia JJ, Gateno J, Teichgraeber JF , et al. Algorithm for planning a double-jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 2: three-dimensional cephalometry[J]. Int J Oral Maxillofac Surg, 2015,44(12):1441-1450. DOI URL PMID
[20]	Yuan P, Mai H, Li J , et al. Design, development and clinical validation of computer-aided surgical simulation system for streamlined orthognathic surgical planning[J]. Int J Comput Assist Radiol Surg, 2017,12(12):2129-2143. DOI URL PMID
[21]	Gateno J, Xia JJ, Teichgraeber JF . New 3-dimensional cephalometric analysis for orthognathic surgery[J]. J Oral Maxillofac Surg, 2011,69(3):606-622. DOI URL
[22]	Xia JJ, Mcgrory JK, Gateno J , et al. A new method to orient 3-dimensional computed tomography models to the natural head position: a clinical feasibility study[J]. J Oral Maxillofac Surg, 2011,69(3):584-591. DOI URL PMID
[23]	Schatz EC, Xia JJ, Gateno J , et al. Development of a technique for recording and transferring natural head position in 3 dimensions[J]. J Craniofac Surg, 2010,21(5):1452-1455. DOI URL PMID
[24]	Xia JJ, Chang YB, Gateno J , et al. Automated digital dental articulation[J]. Med Image Comput Assist Interv, 2010,13(3):278-286.
[25]	Chang YB, Xia JJ, Gateno J , et al. In vitro evaluation of new approach to digital dental model articulation[J]. J Oral Maxillofac Surg, 2012,70(4):952-962. DOI URL PMID
[26]	Nadjmi N, Mollemans W, Daelemans A , et al. Virtual occlusion in planning orthognathic surgical procedures[J]. Int J Oral Maxillofac Surg, 2010,39(5):457-462. DOI URL PMID
[27]	Maal TJ, Plooij JM, Rangel FA , et al. The accuracy of matching three-dimensional photographs with skin surfaces derived from cone-beam computed tomography[J]. Int J Oral Maxillofac Surg, 2008,37(7):641-646. DOI URL PMID
[28]	Marchetti C, Bianchi A, Bassi M , et al. Mathematical modeling and numerical simulation in maxillofacial virtual surgery(VISU)[J]. J Craniofac Surg, 2006, 17(4): 661-667; 668. DOI URL PMID
[29]	Marchetti C, Bianchi A, Bassi M , et al. Mathematical modeling and numerical simulation in maxillofacial virtual surgery[J]. J Craniofac Surg, 2007,18(4):826-832. DOI URL PMID
[30]	Kim H, Jürgens P, Nolte LP , et al. Anatomically-driven soft-tissue simulation strategy for cranio-maxillofacial surgery using facial muscle template model[J]. Med Image Comput Assist Interv, 2010,13(1):61-68.
[31]	Swennen GR, Schutyser F, Barth EL , et al. A new method of 3-D cephalometry. Part I: the anatomic Cartesian 3-D reference system[J]. J Craniofac Surg, 2006,17(2):314-325. DOI URL
[32]	Li J, Yuan P, Chang CM , et al. New approach to establish an object reference frame for dental arch in computer-aided surgical simulation[J]. Int J Oral Maxillofac Surg, 2017,46(9):1193-1200. DOI URL PMID
[33]	Chang YB, Xia JJ, Gateno J , et al. An automatic and robust algorithm of reestablishment of digital dental occlusion[J]. IEEE Trans Med Imaging, 2010,29(9):1652-1663. DOI URL PMID
[34]	Xia JJ, Gateno J, Teichgraeber JF . A new paradigm for complex midface reconstruction: a reversed approach[J]. J Oral Maxillofac Surg, 2009,67(3):693-703. DOI URL PMID
[35]	Schwartz HC . Does computer-aided surgical simulation improve efficiency in bimaxillary orthognathic surgery?[J]. Int J Oral Maxillofac Surg, 2014,43(5):572-576. DOI URL PMID
[36]	Chen X, Xu L, Sun Y , et al. A review of computer-aided oral and maxillofacial surgery: planning, simulation and navigation[J]. Expert Rev Med Devices, 2016,13(11):1043-1051. DOI URL
[37]	Nilsson J, Thor A, Kamer L . Development of workflow for recording virtual bite in the planning of orthognathic operations[J]. Br J Oral Maxillofac Surg, 2015,53(4):384-386. DOI URL PMID
[38]	Yim M, Demke J . Latest trends in craniomaxillofacial surgical instrumentation[J]. Curr Opin Otolaryngol Head Neck Surg, 2012,20(4):325-332. DOI URL PMID
[39]	Liu X, Zhu S, Hu J . Modified versus classic alar base sutures after LeFort I osteotomy: a systematic review[J]. Oral Surg Oral Med Oral Pathol Oral Radiol, 2014,117(1):37-44. DOI URL PMID
[40]	Kor HS, Yang HJ, Hwang SJ . Relapse of skeletal class Ⅲ with anterior open bite after bimaxillary orthognathic surgery depending on maxillary posterior impaction and mandibular counterclockwise rotation[J]. J Craniomaxillofac Surg, 2014,42(5):e230-e238. DOI URL
[41]	Reichert I, Figel P, Winchester L . Orthodontic treatment of anterior open bite: a review article--is surgery always necessary?[J]. Oral Maxillofac Surg, 2014,18(3):271-277. DOI URL PMID
[42]	Marzouk ES, Kassem HE . Evaluation of long-term stability of skeletal anterior open bite correction in adults treated with maxillary posterior segment intrusion using zygomatic miniplates[J]. Am J Orthod Dentofacial Orthop, 2016,150(1):78-88. DOI URL PMID
[43]	谭新颖, 胡敏, 刘昌奎 , 等. 数字化虚拟手术设计辅助正颌外科手术12例临床分析[J]. 上海口腔医学, 2014, 03)( 3):322-327.
[44]	Bengtsson M, Wall G, Greiff L , et al. Treatment outcome in orthognathic surgery-a prospective randomized blinded case-controlled comparison of planning accuracy in computer-assisted two- and three-dimensional planning techniques (part Ⅱ)[J]. J Craniomaxillofac Surg, 2017,45(9):1419-1424. DOI URL PMID
[45]	Bengtsson M, Wall G, Miranda-Burgos P , et al. Treatment outcome in orthognathic surgery-a prospective comparison of accuracy in computer assisted two and three-dimensional prediction techniques[J]. J Craniomaxillofac Surg, 2017,45(19):1419-1424. DOI URL PMID
[46]	Cassi D, Magnifico M, Gandolfinini M , et al. Early orthopaedic treatment of hemifacial microsomia[J]. Case Rep Dent, 2017: 7318715. DOI URL
[47]	Chen X, Zin AM, Lin L , et al. Three-dimensional analysis of cranial base morphology in patients with hemifacial microsomia[J]. J Craniomaxillofac Surg, 2018,46(2):362-367. DOI URL PMID
[48]	Bertin H, Mercier J, Cohen A , et al. Surgical correction of mandibular hypoplasia in hemifacial microsomia: a retrospective study in 39 patients[J]. J Craniomaxillofac Surg, 2017,45(6):1031-1038. DOI URL PMID
[49]	Liu H, Zhang X, Liu L , et al. Combined bimaxillary distraction osteogenesis associated with orthognathic surgery for hemifacial microsomia in adults[J]. Aesthetic Plast Surg, 2017,41(3):650-660. DOI URL
[50]	Yu H, Wang B, Wang M , et al. Computer-assisted distraction osteogenesis in the treatment of hemifacial microsomia[J]. J Craniofac Surg, 2016,27(6):1539-1542. DOI URL PMID
[51]	Li B, Zhang L, Sun H , et al. A novel method of computer aided orthognathic surgery using individual CAD/CAM templates: a combination of osteotomy and repositioning guides[J]. Br J Oral Maxillofac Surg, 2013,51(8):e239-e244. DOI URL PMID
[52]	Zinser MJ, Sailer HF, Ritter L , et al. A paradigm shift in orthognathic surgery? A comparison of navigation, computer-aided designed/computer-aided manufactured splints, and "classic" intermaxillary splints to surgical transfer of virtual orthognathic planning[J]. J Oral Maxillofac Surg, 2013,71(12):2151.
[53]	Gander T, Bredell M, Eliades T , et al. Splintless orthognathic surgery: a novel technique using patient-specific implants (PSI)[J]. J Craniomaxillofac Surg, 2015,43(3):319-322. DOI URL PMID