个体化聚醚醚酮在上颌骨缺损精确重建中的应用

Application of personalized polyetheretherketone implants in the functional and accurate reconstruction of maxillary defects

目的探讨个体化定制聚醚醚酮(PEEK)在上颌骨缺损修复重建中的应用效果。方法2018年9月至2020年11月,上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科收治13例行上颌缺损的患者,男9例,女4例,年龄15~62岁,平均28.6岁。6例上颌骨良性病变及7例上颌骨肿瘤术后缺损患者,均采用个体化PEEK置入修复。13例患者术前均拍摄颌面部CT,然后三维重建获得上颌骨缺损模型,6例上颌骨良性病变患者通过虚拟手术计划制定肿瘤切除范围,获得相应的上颌骨缺损模型,并基于镜像技术进行PEEK假体的设计和制作;根据虚拟手术计划设计、制作并打印手术截骨导板。然后在截骨导板辅助下切除肿瘤,植入PEEK。7例上颌骨肿瘤术后缺损患者通过术前颌面部CT三维重建直接获得上颌骨缺损模型,然后基于镜像技术进行PEEK假体的设计和制作。术中置入PEEK,如腭部缺损则同期行股前外侧穿支皮瓣修复腭部缺损。术后定期随访,观察术后并发症、患者面部外形、咬合关系、眼球位置及活动度,统计患者满意度。术后1个月行CT扫描,将CT数据同术前虚拟手术设计数据进行拟合比较,评估PEEK置入位置的精确度;测量评估手术前、后眼球突出、上抬或内陷、下移的复位矫正情况,采用配对t检验进行统计学分析。结果13例患者均按术前设计顺利完成PEEK置入手术,其中2例患者PEEK置入时与眶下壁区缺损不完全匹配,经调磨后就位。一期重建的5例骨纤维病变患者术中行抽屉式切除术,保留了牙槽骨;7例二期重建患者中,2例为腓骨肌皮瓣修复术后利用PEEK支撑眶底改善外形,3例上颌骨缺损患者同期行股前外侧穿支皮瓣修复腭部缺损,分割口、鼻腔。术后伤口愈合良好,皮瓣全部成活。术后1个月复查时,患者面部对称性及眼球位置术后恢复良好,张口度正常,眼球运动正常无受限,患者均对手术效果满意。术后CT图像拟合显示PEEK置入位置准确,误差为(0.68±0.12)mm。6例良性肿瘤患者术后眶容积(26.37±0.94)ml,眼球高度(0.98±0.48)mm,眼球突度(1.10±0.28)mm,分别较术前的(24.06±0.85)ml、(3.83±0.81)mm、(2.53±0.67)mm明显改善,差异均有统计学意义(P值均<0.05)。7例上颌骨缺损患者术后眼球高度(0.77±0.42)mm,眼球突度(0.61±0.31)mm,较术前的(2.03±1.07)mm、(2.01±0.34)mm明显改善,差异均有统计学意义(P值均<0.05)。术后随访时间1~27个月[(12.0±7.6)个月],出现1例感染排异、1例肿瘤复发,行PEEK拆除术,其余11例未发现肿瘤复发及PEEK感染排异。结论个体化定制的PEEK,在虚拟手术计划辅助下,必要时联合软硬组织瓣,可以精确恢复上颌骨外形,支撑眶底,有效提高上颌骨缺损修复重建的精确性和安全性。

Objective To study the applicable value of personalized polyetheretherketone(PEEK)in maxillary reconstruction.Methods 6 patients with benign lesions in the maxilla and 7 patients with maxillary defects after tumor resection were repaired with personalized PEEK implant in our department from September 2018 to November 2020.In 6 patients with benign maxillary lesions,the maxillary defect models were obtained after the extent of tumor resection was established by virtual surgical design.Then,the individual PEEK was designed and produced on the base of mirroring technique.Cutting guide plates were also designed and printed according to virtual surgical planning.Then ablative surgery was performed under the guide of cutting guide,and PEEK was implanted.For 7 patients with maxillary defects,3D models of maxillary defects were directly reconstructed in the computer based on the preoperative maxillofacial CT,then the individual PEEK was designed and produced based on mirroring technique.Afterwards PEEK was implanted associated with anterolateral thigh flap to repair palatal defects if necessary.All patients were followed up at regular intervals after surgical implantation of PEEK to observe postoperative complications.And postoperative appearance and function of the patients were evaluated by clinical and CT examinations one month after surgery.Results PEEK implant operation was carried out with all of the patients according to the preoperative design.During implantation,PEEK did not match exactly with the defects in 2 patients.Then PEEK could be put into position after trimming and grinding.Three patients were performed anterolateral thigh flaps at the same time to restore the palatal defects to separate the oral and nasal cavity.The wound healed well after operation in all of the patients.All of the flaps survived,and the survival rate was 100%.Facial symmetry and eyeball location were well restored and mouth opening was recovered to normal after surgery.Image fusion showed the location of PEEK implant was accurate with an error of(0.68±0.12)mm.In 6 patients with benign lesions,postoperative orbital volume[(26.37±0.94)ml],eye vertical position[(0.98±0.48)mm]and the ratio of exophthalmos[(1.10±0.28)mm]were significantly improved compared to pre-operation[(24.06±0.85)ml,(3.83±0.81)mm,(2.53±0.67)mm].The difference were statistically significant(P<0.05).In 7 patients with maxillary defects after tumor resection,postoperative eye verticalposition[(0.77±0.42)mm]and the ratio of exophthalmos[(0.61±0.31)mm]were significantly improved compared to pre-operation[(2.03±1.07)mm,(2.01±0.34)mm].The difference were statistically significant(P<0.05).The range of postoperative follow-up was 1-27 months[(12.0±7.6)months].During follow-up,a PEEK implant was removed in one case because of implant extrusion and the other due to tumor recurrence.Conclusions With the aid of virtual surgical planning,the personalized PEEK implant combined or not with hard/soft tissue flap can accurately restore the maxillary appearance and support the orbital floor,thus effectively improving the accuracy and safety of maxillary reconstruction.