数字化辅助保存性外科治疗突入上颌窦后份的牙源性囊性病变

Digital design of conservative surgery for odontogenic cysts intruding into posterior part of maxillary sinus

目的：寻求清除病灶的同时保存上颌窦黏膜和骨组织功能性的手术方法，应用数字化软件辅助设计手术方案，治疗突入上颌窦后份的牙源性囊性病变，并评价手术方法和术后反应。方法：回顾2011年12月-2014年12月牙源性囊性病变突入上颌窦后份的21例患者。应用Mimics软件进行术前设计，根据病变体积和位置采用不同术式。术式1“开窗骨板复位法”适用于病变体积大，超过颧牙槽嵴，且上颌窦前外侧壁无明显骨质破坏者；术式2“去骨开窗法”适用于病变体积小，近颧牙槽嵴者。手术方法评价包括麻醉效果、出血情况、根据术前设计是否可顺利清除病灶以及手术时间等：术后评价包括疼痛、肿胀和骨板存活情况等。结果：15例采用开窗骨板复位法，6例采用去骨开窗法。均在20min内成功完成手术．术中出血量少，术后疼痛时间平均为3．72d；肿胀时间平均为7．67d；8例术后鼻腔渗血1-3d：1例患者术中见化脓性炎症，开窗骨板复位术后发生感染。CT复查见其余14例复位游离骨板均无明显吸收。结论：治疗牙源性上颌窦囊性病变时，应尽量保存窦腔黏膜和骨板；数字化辅助设计手术方案可以准确指导术中截骨范围：化脓性炎症者不适宜行开窗骨板复位法。

PURPOSE： To present a functional surgery for odontogenic cysts intruding into maxillary sinus to preserve the sinus mucosa and alveolar bone, and plan the surgery with assistance of digital design and evaluate postoperative outcomes. METHODS： Patients with odontogenic cysts intruding into posterior part of maxillary sinus were collected from December 2011 to December 2014 Different operations were chosen according to volume and location of the lesion with assistance of digital operative design. Method Ⅰ ＂fenestration and bone reposition＂ was suitable for large lesion exceeding zygomatic alveolar ridge but without apparent bone destruction of anterior wall of the sinus, while method Ⅱ ＂bone removal＂ was applied for small lesion near zygomatie alveolar ridge. Evaluation of operation methods included anesthetic effect, bleeding, lesion removal difficulties according to operative design and operation time. The duration of pain and swelling, and the condition of free bony wall were assessed postoperatively. RESULTS： Fifteen cases adopted method Ⅰwhile 6 underwent method Ⅱ. Operations were completed in 20 minutes smoothly. Pain disappeared in 3.72 days on average, and swelling resolved in 7.67 days on average. Nasal bleeding occurred in 8 patients lasting 1 to 3 days. Suppurative inflammation was observed in 1 patient, and infection occurred after bone reposition. Other repositioned free bony wall were without resorption on CT images. CONCLUSIONS： Sinus mucosa and bony wall should be conserved. Preoperative digital design can guide osteotomy effectively during the surgery. Bone reposition is not suitable for suppurative inflammation.