下颌骨重建
合集下载
相关主题
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
导板技术
Fibular Free Flap
The commonest landmark for accuracy measurements was the condyle (54%). Accuracy deviations ranged between 0 mm and 12.5 mm and between 0.9° and 17.5° Gustaaf J.C. van Baar, Tymour Forouzanfar, Niels P.T.J. Liberton, Henri A.H. Winters, Frank K.J. Leusink, Accuracy of computer-assisted surgery in mandibular reconstruction: A systematic review,Oral Oncology, Volume 84, 2018,Pages 52-60.
Iliac Crest Free Flap
下颌骨缺损与重建中的困惑
• 下颌骨重建的时机 • 放疗后可否行游离骨移植 • 下颌骨重建术后牙种植修复在的问题 • 游离植骨放疗后是否可行种植治疗
下颌骨重建的时机
• Delayed or staged reconstruction
• Immediate reconstruction
下颌骨缺损与重建
邓思敏
下颌骨缺损的原因
• Tumor therapy
• ameloblastoma/ myxoma/ carcinomas/ sarcomas
• Avulsive traumatic injury
• most commonly arise from high-velocity injuries such as firearms, industrial accidents, and occasionally motor vehicle collisions
洪明ABCD分类（1958）
HCL分类（1989）
H：Hemi-madibular L：Lateral C：Central o：osteal m：mucosal s：skin
Urken分类（1991）
C：Condylar R：Ramus B：Body S：Symphysis
基于下颌骨功能分区与生物力学的分类
Li X, Zhu K, Liu F, Li H (2014) Assessment of quality of life in giant ameloblastoma adolescent patients who have had mandible defects reconstructed with a free fibula flap. World J Surg Oncol 12:201. doi:10.1186/1477-781912-201 Boyd JB, Mullholland RS, Davidson J et al (1995) The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg 95:1018
放疗后可否行游离骨移植
• Hirsch et al.比较了发生ORN的患者，接受放疗但未发生ORN的患 者，未接受放疗的患者，在进行血管化游离骨瓣移植后，骨瓣存 活率以及术后并发症发生率均无显著差异。ORN (86 %), no ORN (87 %), and controls (90 %);
Hirsch DL, Bell RB, Dierks EJ et al (2008) Analysis of microvascular free flaps for reconstruction of advanced mandibular osteoradionecrosis: a retrospective cohort study. J Oral Maxillofac Surg 66:2545–2556
• Vascularized Free Flaps
• Fibular Free Flap • Radial Forearm Free Flap • Scapula Free Flap • Anteriolateral Thigh Flap • The Pectoralis Major Myocutaneous Flap • The Metatarsus Osteocutaneous Flap • Iliac Crest Free Flap • Clavipectoral Osteomyocutaneous Free Flap
Reconstructive Options Used for Reconstruction of Mandible
• Reconstruction Plates
• Non vascularized Bone Grafting
• Iliac Bone • Costochondral Rib • Bone Graft Substitutes
谢谢
• Immediate reconstruction significantly improves QOL and that most patients prefer immediate reconstruction.
• Boyd reported that patients who underwent reconstruction with vascularized bone flaps experienced an average of 4 days life lost for secondary procedures, compared to 35 days for patients who underwent plate and soft tissue flaps.
下颌骨重建术后牙种植修复在的问题
• 即刻种植可以避免放疗及高压氧疗的种植体骨结合的影响 • Foster等报道血管化游离骨移植术后种植成功率为99%，非血管化
游离骨移植术后种植成功率为82% • Blake F等分析了不同类型的游离骨瓣进行种植治疗之后炎症的易
感性，他们发现不同骨瓣发生相关炎症的比率不同，种植体周围 炎发生率为9-38%，口腔黏膜炎发生率为16.3-24.1%，30-70.9%未 发生炎症
Non vascularized Iliac Bone
• 手术简单，创伤小，并发症少 • 可行种植修复 • 颌骨缺损长度<6cm • 要求植入床有良好的血供 • 要求创口与口内不相通，口内
创口能严密关闭 • 有研究报道非血管化游离植骨
二期手术(90%)较一期手术(46%) 成功率高
Lawson W, Loscalzo LJ, Baek SM et al (1982) Experience with immediate and delayed mandibular reconstruction. Laryngoscope 92:5
Double barrel Fibular Free Flap
• Байду номын сангаас唇，口角塌陷 • 牙种植修复困难
改良方法: 1.平行折叠 2.垂直牵引 3.复层骨块移植 4.将腓骨移植于牙槽嵴处
Double barrel Fibular Free Flap
Double barrel Fibular Free Flap
• Inflammatory or infectious conditions
Goals of Reconstruction
• 恢复面下1/3和下颌骨原有的外形 • 保持下颌骨的连续性，恢复下颌骨和周围软组织的空间位置关系 • 重建良好的咀嚼、吞咽和语音功能 • 维持足够的通气道
下颌骨缺损分类
• 洪明ABCD分类（1958） • HCL分类（1989） • Urken分类（1991） • 基于下颌骨功能分区与生物力学的分类
Iliac Crest Free Flap
Iliac Crest Free Flap
• 足够的厚度与高度 • 皮岛较厚，活动有限，血供不可靠 • 腹内斜肌体积较小，活动度较好，血供可靠 • 天然形态与一侧下颌骨相似 • 修复缺损<9cm • 制备与塑型的难度较大，可能的供区并发症较多
Iliac Crest Free Flap
Fibular Free Flap
• 制备相对简单，供区并发症小 • 骨量充足，可切取长达20-
25cm • 双重血供，易于截开塑性 • 可植入种植体进行种植义齿修
复 • 便于2组同时手术 • 可携带肌瓣或皮岛修复软组织
缺损 • 高度不够
Fibular Free Flap
快速原型技术
Fibular Free Flap
游离植骨放疗后是否可行种植治疗
• 种植成功率与放疗剂量有关 • Raoul等指出放疗剂量大于50Gy时避免种植手术 • 关于放疗后种植治疗成功率，各项研究报道有些差异，72.5-94% • Foster等指出种植体脱落率在放疗组与非放疗组无显著差异
Raoul G, Ruhin B, Briki S, Lauwers L, Haurou Patou G, Capet JP, Maes JM, Ferri J (2009) Microsurgical reconstruction of the jaw with fibular grafts and implants. J Craniofac Surg 20(6):2105–2117. doi:10.1097/SCS.0b013e3181bec611 Salinas TJ, Desa VP, Katsnelson A, Miloro M (2010) Clinical evaluation of implants in radiated fibula flaps. J Oral Maxillofac Surg 68(3):524–529. doi:10.1016/j.joms.2009.09.104 Foster RD, Anthony JP, Sharma A, Pogrel MA (1999) Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 21(1):66–71
Foster RD, Anthony JP, Sharma A, Pogrel MA (1999) Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 21(1):66–71 Blake F, Bubenheim M, Heiland M et al (2008) Retrospective assessment of the peri-implant mucosa of implants inserted in reanastomosed or free bone grafts from the fibula or iliac crest. Int J Oral Maxillofac Implants 23:1102– 1108
Fibular Free Flap
The commonest landmark for accuracy measurements was the condyle (54%). Accuracy deviations ranged between 0 mm and 12.5 mm and between 0.9° and 17.5° Gustaaf J.C. van Baar, Tymour Forouzanfar, Niels P.T.J. Liberton, Henri A.H. Winters, Frank K.J. Leusink, Accuracy of computer-assisted surgery in mandibular reconstruction: A systematic review,Oral Oncology, Volume 84, 2018,Pages 52-60.
Iliac Crest Free Flap
下颌骨缺损与重建中的困惑
• 下颌骨重建的时机 • 放疗后可否行游离骨移植 • 下颌骨重建术后牙种植修复在的问题 • 游离植骨放疗后是否可行种植治疗
下颌骨重建的时机
• Delayed or staged reconstruction
• Immediate reconstruction
下颌骨缺损与重建
邓思敏
下颌骨缺损的原因
• Tumor therapy
• ameloblastoma/ myxoma/ carcinomas/ sarcomas
• Avulsive traumatic injury
• most commonly arise from high-velocity injuries such as firearms, industrial accidents, and occasionally motor vehicle collisions
洪明ABCD分类（1958）
HCL分类（1989）
H：Hemi-madibular L：Lateral C：Central o：osteal m：mucosal s：skin
Urken分类（1991）
C：Condylar R：Ramus B：Body S：Symphysis
基于下颌骨功能分区与生物力学的分类
Li X, Zhu K, Liu F, Li H (2014) Assessment of quality of life in giant ameloblastoma adolescent patients who have had mandible defects reconstructed with a free fibula flap. World J Surg Oncol 12:201. doi:10.1186/1477-781912-201 Boyd JB, Mullholland RS, Davidson J et al (1995) The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg 95:1018
放疗后可否行游离骨移植
• Hirsch et al.比较了发生ORN的患者，接受放疗但未发生ORN的患 者，未接受放疗的患者，在进行血管化游离骨瓣移植后，骨瓣存 活率以及术后并发症发生率均无显著差异。ORN (86 %), no ORN (87 %), and controls (90 %);
Hirsch DL, Bell RB, Dierks EJ et al (2008) Analysis of microvascular free flaps for reconstruction of advanced mandibular osteoradionecrosis: a retrospective cohort study. J Oral Maxillofac Surg 66:2545–2556
• Vascularized Free Flaps
• Fibular Free Flap • Radial Forearm Free Flap • Scapula Free Flap • Anteriolateral Thigh Flap • The Pectoralis Major Myocutaneous Flap • The Metatarsus Osteocutaneous Flap • Iliac Crest Free Flap • Clavipectoral Osteomyocutaneous Free Flap
Reconstructive Options Used for Reconstruction of Mandible
• Reconstruction Plates
• Non vascularized Bone Grafting
• Iliac Bone • Costochondral Rib • Bone Graft Substitutes
谢谢
• Immediate reconstruction significantly improves QOL and that most patients prefer immediate reconstruction.
• Boyd reported that patients who underwent reconstruction with vascularized bone flaps experienced an average of 4 days life lost for secondary procedures, compared to 35 days for patients who underwent plate and soft tissue flaps.
下颌骨重建术后牙种植修复在的问题
• 即刻种植可以避免放疗及高压氧疗的种植体骨结合的影响 • Foster等报道血管化游离骨移植术后种植成功率为99%，非血管化
游离骨移植术后种植成功率为82% • Blake F等分析了不同类型的游离骨瓣进行种植治疗之后炎症的易
感性，他们发现不同骨瓣发生相关炎症的比率不同，种植体周围 炎发生率为9-38%，口腔黏膜炎发生率为16.3-24.1%，30-70.9%未 发生炎症
Non vascularized Iliac Bone
• 手术简单，创伤小，并发症少 • 可行种植修复 • 颌骨缺损长度<6cm • 要求植入床有良好的血供 • 要求创口与口内不相通，口内
创口能严密关闭 • 有研究报道非血管化游离植骨
二期手术(90%)较一期手术(46%) 成功率高
Lawson W, Loscalzo LJ, Baek SM et al (1982) Experience with immediate and delayed mandibular reconstruction. Laryngoscope 92:5
Double barrel Fibular Free Flap
• Байду номын сангаас唇，口角塌陷 • 牙种植修复困难
改良方法: 1.平行折叠 2.垂直牵引 3.复层骨块移植 4.将腓骨移植于牙槽嵴处
Double barrel Fibular Free Flap
Double barrel Fibular Free Flap
• Inflammatory or infectious conditions
Goals of Reconstruction
• 恢复面下1/3和下颌骨原有的外形 • 保持下颌骨的连续性，恢复下颌骨和周围软组织的空间位置关系 • 重建良好的咀嚼、吞咽和语音功能 • 维持足够的通气道
下颌骨缺损分类
• 洪明ABCD分类（1958） • HCL分类（1989） • Urken分类（1991） • 基于下颌骨功能分区与生物力学的分类
Iliac Crest Free Flap
Iliac Crest Free Flap
• 足够的厚度与高度 • 皮岛较厚，活动有限，血供不可靠 • 腹内斜肌体积较小，活动度较好，血供可靠 • 天然形态与一侧下颌骨相似 • 修复缺损<9cm • 制备与塑型的难度较大，可能的供区并发症较多
Iliac Crest Free Flap
Fibular Free Flap
• 制备相对简单，供区并发症小 • 骨量充足，可切取长达20-
25cm • 双重血供，易于截开塑性 • 可植入种植体进行种植义齿修
复 • 便于2组同时手术 • 可携带肌瓣或皮岛修复软组织
缺损 • 高度不够
Fibular Free Flap
快速原型技术
Fibular Free Flap
游离植骨放疗后是否可行种植治疗
• 种植成功率与放疗剂量有关 • Raoul等指出放疗剂量大于50Gy时避免种植手术 • 关于放疗后种植治疗成功率，各项研究报道有些差异，72.5-94% • Foster等指出种植体脱落率在放疗组与非放疗组无显著差异
Raoul G, Ruhin B, Briki S, Lauwers L, Haurou Patou G, Capet JP, Maes JM, Ferri J (2009) Microsurgical reconstruction of the jaw with fibular grafts and implants. J Craniofac Surg 20(6):2105–2117. doi:10.1097/SCS.0b013e3181bec611 Salinas TJ, Desa VP, Katsnelson A, Miloro M (2010) Clinical evaluation of implants in radiated fibula flaps. J Oral Maxillofac Surg 68(3):524–529. doi:10.1016/j.joms.2009.09.104 Foster RD, Anthony JP, Sharma A, Pogrel MA (1999) Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 21(1):66–71
Foster RD, Anthony JP, Sharma A, Pogrel MA (1999) Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success. Head Neck 21(1):66–71 Blake F, Bubenheim M, Heiland M et al (2008) Retrospective assessment of the peri-implant mucosa of implants inserted in reanastomosed or free bone grafts from the fibula or iliac crest. Int J Oral Maxillofac Implants 23:1102– 1108