保存10 mm髁突头及关节附件的下颌骨切除重建方法探讨

中国口腔颌面外科杂志 ›› 2016, Vol. 14 ›› Issue (2): 144-148.

保存10 mm髁突头及关节附件的下颌骨切除重建方法探讨

白果^{1, #}, 杨驰^{1, *}, 郑志伟^{2, #}, 方一鸣^{2, *}

1.上海交通大学医学院附属第九人民医院·口腔医学院口腔外科,上海市口腔医学重点实验室,上海 200011;
2.温州医科大学附属第一医院口腔颌面外科,浙江温州 325000

收稿日期:2015-08-22 出版日期:2016-03-20 发布日期:2016-04-06
通讯作者: 杨驰,E-mail:yangchi63@hotmail.com;方一鸣,E-mail:fangyiming2003@sina.com。 ^*共同通信作者
作者简介:白果（1989-）,男,住院医师,E-mail:surgeonb@163.com;郑志伟（1989-）,男,住院医师,E-mail:516578221@qq.com。#并列第一作者
基金资助:
上海市科学技术委员会科研计划项目（14DZ2294300）; 上海市科学技术委员会学科带头人计划（13XD1402300）

Mandible resection and reconstruction with preservation of 10 mm condyle and temporomandibular joint attachment

BAI Guo¹, YANG Chi¹, ZHENG Zhi-wei², FANG Yi-ming²

1.Department of Oral Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology. Shanghai 200011; 2. Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Wenzhou Medical University. Wenzhou 325000, Zhejiang Province, China

Received:2015-08-22 Online:2016-03-20 Published:2016-04-06

摘要/Abstract

摘要： 目的:探讨颞下颌关节保存性手术治疗未累及髁突头的下颌骨病变的效果。方法:下颌骨巨大成釉细胞瘤患者1例,采用计算机辅助设计技术确定瘤体边界及与髁突关节面的关系,模拟测量并设计截骨方法,制作数字化导板,于术中指导截骨。利用肋骨配合重建钛板连接保存的髁突头及下颌支残端,维持盘-髁关系和咬合稳定。通过术中对重要结构的保护、术后关节-颌骨-咬合评价及影像学随访,评价颞下颌关节保存性外科技术的治疗效果。结果:术中截骨导板就位顺利,指导术者沿肿瘤边界分块截骨后将瘤体连同累及骨质一并取出。保存下牙槽神经血管束,保留髁突头10 mm及关节盘等附件,用肋骨连接髁突头并行下颌骨残端关节重建。术后CT显示,成釉细胞瘤累及骨质被彻底切除,保留的髁突头与肋骨愈合良好。术后随访1年肿瘤无复发,关节功能维持良好、面型对称且咬合稳定,患者面部无麻木等异常感觉。结论:在未累及髁突关节面的下颌骨病变中,应用颞下颌关节保存性外科理念,辅以数字化导板,可在精确实现病灶切除的基础上保护髁突头及关节附件,有利于关节功能的保存,维持关节-颌骨-咬合三位一体的关系,术后疗效稳定。

关键词: 颞下颌关节, 保存性手术, 数字化导板, 成釉细胞瘤

Abstract: PURPOSE: To explore the effect of temporomandibular joint (TMJ) preservation surgery in the treatment for a giant mandibular ameloblastoma with healthy condylar head. METHODS: For 1 case of a giant mandibular ameloblastoma, computer-assisted technology was applied to determine the margins of the tumor and its relationship with the condylar head. Then anatomical measurements and virtual osteotomy simulation were performed based on which digital templates were made to guide intra-operative osteotomy. The condylar head was preserved and connected to the remaining ramus by costochondral graft, fixed with a reconstructive titanium plate, in order to keep the original condyle-disc relationship and a stable occlusion. The clinical effects were evaluated by intra-operative preservation of important anatomical structures, postoperative joint function, joint-jaw-occlusion relationship, as well as results of imaging follow-ups. RESULTS: Digital osteotomy templates were smoothly positioned and attached to bone surface and guided the resection of the affected region along the pre-designed margin of the ameloblastoma. The inferior alveolar nerve bundle had been well preserved; TMJ disc and normal condylar head with a height of 10 mm was also saved for mandible reconstruction with costochondral graft. Postoperative CT showed complete elimination of the ameloblastoma and its affected mandible region. The preserved condylar head and rib graft grew into each other well. One-year follow-up CT showed no recurrence of the tumor, and the patient had satisfactory functional TMJ, symmetrical facial appearance as well as stable occlusion. No facial numbness or other complications occurred. CONCLUSIONS: In the treatment of mandibular benign lesion with healthy condylar head, the concept of TMJ preservation surgery should be advocated with the facilitation of digital templates. In this way, accurate resection of the affected bone with preservation of the condylar head as well as TMJ attachments could be realized. This procedure could help maintain TMJ function and three-dimensional joint-jaw-occlusion relationship with stable post-operative outcomes.

Key words: Temporomandibular joint, Preservative surgery, Digital template, Ameloblastoma

中图分类号:

R782.6

白果, 杨驰, 郑志伟, 方一鸣. 保存10 mm髁突头及关节附件的下颌骨切除重建方法探讨[J]. 中国口腔颌面外科杂志, 2016, 14(2): 144-148.

BAI Guo, YANG Chi, ZHENG Zhi-wei, FANG Yi-ming. Mandible resection and reconstruction with preservation of 10 mm condyle and temporomandibular joint attachment[J]. China J Oral Maxillofac Surg, 2016, 14(2): 144-148.

参考文献

[1] Xie Q, Yang C, He D, et al. Is mandibular asymmetry more frequent and severe with unilateral disc displacement [J]. J Craniomaxillofac Surg, 2015, 43(1): 81-86.
[2] Karagoz H, Eren F, Sever C, et al. Mandibular reconstruction after hemimandibulectomy [J]. J Craniofac Surg, 2012, 23(5): 1373-1374.
[3] Ruiz Valero CA, Duran-Rodriguez G, Solano-Parra N, et al. Immediate total temporomandibular joint replacement with TMJ concepts prosthesis as an alternative for ameloblastoma cases [J]. J Oral Maxillofac Surg, 2014, 72(3): 646.e1-12.
[4] Rodrigues DB, Wolford LM, Malaquias P. Concomitant treatment of mandibular ameloblastoma and bilateral temporomandibular joint osteoarthritis with bone graft and total joint prostheses [J]. J Oral Maxillofac Surg, 2015, 73(1): 63-74.
[5] 陈传俊, 陈晓阳, 王军民, 等. 口腔肿瘤患者下颌骨保存性外科方法的探讨 [J]. 中国口腔颌面外科杂志, 2010, 8(2):139-143.
[6] Fregnani ER, da Cruz Perez DE, de Almeida OP, et al. Clinicopathological study and treatment outcomes of 121 cases of ameloblastomas [J]. Int J Oral Maxillofac Surg, 2010, 39(2): 145-149.
[7] Torres-Lagares D, Infante-Cossío P, Hernández-Guisado JM, et al. Mandibular ameloblastoma. A review of the literature and a presentation of six cases [J]. Med Oral Patol Oral Cir Bucal, 2005, 10(3): 231-238.
[8] Tamme T, Tiigimäe J, Leibur E. Mandibular ameloblastoma: a 28-years retrospective study of the surgical treatment results [J]. Minerva Stomatol, 2010, 59(11-12): 637-643.
[9] Chaine A, Pitak-Arnnop P, Dhanuthai K, et al. A treatment algorithm for managing giant mandibular ameloblastoma: 5-Year experiences in a Paris university hospital [J]. Eur J Surg Oncol, 2009, 35(9): 999-1007.
[10] Zemann W, Feichtinger M, Kowatsch E, et al. Extensive ameloblastoma of the jaws: surgical management and immediate reconstruction using microvascular flaps [J]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007, 103(2): 190-196.
[11] Verma A, Yadav S, Singh V. Overgrowth of costochondral graft in temporomandibular joint ankylosis: an unusual case [J]. Natl J Maxillofac Surg, 2011, 2(2): 172-174.
[12] Siavosh S, Ali M. Overgrowth of a costochondral graft in a case of temporomandibular joint ankylosis [J]. J Craniofac Surg, 2007, 18(6):1488-1491.
[13] Baek RM, Song YT. Overgrowth of a costochondral graft in reconstruction of the temporomandibular joint [J]. Scand J Plast Reconstr Surg Hand Surg, 2006, 40(3):179-185.
[14] Huang D, Chen M, He D, et al. Preservation of the inferior alveolar neurovascular bundle in the osteotomy of benign lesions of the mandible using a digital template [J]. Br J Oral Maxillofac Surg, 2015, 53(7): 637-641.

[1]	孙守福, 张莹, 赵昊明, 王文超, 魏文佳, 郭克. 数字化导板辅助下左上根折中切牙不翻瓣即刻种植即刻自体冠修复1例报告[J]. 中国口腔颌面外科杂志, 2023, 21(2): 197-202.
[2]	戴小锋, 黄昕, 李成, 王辰昕, 施乐, 余优成. 2种CAD/CAM口腔数字化导板精度的比较[J]. 中国口腔颌面外科杂志, 2023, 21(1): 29-35.
[3]	岳史婧, 赵炅, 白果, 陈敏洁, 杨驰. 标准型颞下颌关节假体置换术中保存翼外肌附着的效果评价[J]. 中国口腔颌面外科杂志, 2022, 20(6): 548-553.
[4]	李莉玫, 朱耀旻, 王昱萌, 戴娟, 张丹迪, 梁潇. 23例颞下颌关节手术联合面部除皱术临床疗效分析[J]. 中国口腔颌面外科杂志, 2022, 20(6): 554-559.
[5]	陈静, 朱敏. 稳定型咬合板联合关节灌洗术治疗颞下颌关节紊乱病的疗效评价[J]. 中国口腔颌面外科杂志, 2022, 20(6): 565-570.
[6]	张大河, 沈佩, 杨驰. 青少年颞下颌关节盘前移位患者就诊情况分析[J]. 中国口腔颌面外科杂志, 2022, 20(5): 437-442.
[7]	张大河, 沈佩, 杨驰. 青少年颞下颌关节盘前移位患者就诊情况分析[J]. 中国口腔颌面外科杂志, 2022, 20(5): 443-448.
[8]	马志贵, 沈佩, 戈旌, 谢千阳, 赵宁, 董敏俊, 杨驰. 多学科协作教学模式在颞下颌关节病实践教学中的应用[J]. 中国口腔颌面外科杂志, 2022, 20(5): 500-504.
[9]	李辉, 黄林剑, 谢千阳, 杨驰. 体外培养的兔下颌骨髁突对机械压力的反应和变化[J]. 中国口腔颌面外科杂志, 2022, 20(4): 340-346.
[10]	陈建荣, 丁水清, 陈亮, 何佳嘉, 祁荣兴. 颞下颌关节紊乱的影像学特征：锥形束CT和MRI效能比较[J]. 中国口腔颌面外科杂志, 2022, 20(3): 273-276.
[11]	范帅, 蔡斌, 何冬梅, 徐丽丽, 陆沈吉, 方仲毅. 牵伸支具对颞下颌关节盘锚固术后患者开口受限的作用评价[J]. 中国口腔颌面外科杂志, 2022, 20(1): 37-41.
[12]	何优雅, 张誉, 戴振霖, 林承重, 曹巍, 季彤. 长链非编码RNA CASC15在成釉细胞瘤中的差异表达及生物信息学分析[J]. 中国口腔颌面外科杂志, 2021, 19(5): 411-416.
[13]	王天鸽, 周志捷, 林怡君, 孙仪庭, 陈昱, 孙华, 毛丽霞, 刘加强. 术前正畸对颞下颌关节关节盘及髁突位置和形态的影响[J]. 中国口腔颌面外科杂志, 2021, 19(5): 439-444.
[14]	孙明媛, 俞蕾蕾, 顾雅洁, 夏滴. 品管圈在提高颞下颌关节紊乱患者术后功能锻炼依从性的效果评价[J]. 中国口腔颌面外科杂志, 2021, 19(4): 340-344.
[15]	贺捷, 田卓炜, 胡永杰, 王延安. 开窗刮治术治疗24例下颌骨实性成釉细胞瘤效果观察[J]. 中国口腔颌面外科杂志, 2021, 19(3): 258-261.