下颌骨缺损分类及数字化血管化骨瓣修复效果观察

Classification of mandibular defects and outcome of digital mandibular reconstruction with vascularized bone flaps

目的 对下颌骨缺损患者根据缺损范围进行分类并选择不同数字化血管化骨瓣修复方案,观察下颌骨缺损修复的效果。方法 49例下颌骨病变患者均行下颌骨切除,记录患者下颌骨缺损范围,根据缺损累及区间数(Ⅰ、Ⅱ、Ⅲ、Ⅳ类)及缺损中心位置(a、b、c、d亚类)进行分类,并依据分类采用不同数字化血管化骨瓣修复方案进行修复,观察手术方案完成情况及术后骨瓣存活情况。随访1~50个月,观察咬合关系及下颌骨形态恢复情况。结果 49例患者中2例Ⅰb型患者采用髂嵴朝向牙槽突的髂骨瓣修复;1例Ⅱa型患者采用单层腓骨瓣修复;24例Ⅱb型患者中采用髂嵴朝向下颌骨下缘的髂骨瓣修复9例,髂嵴朝向牙槽突的髂骨瓣修复5例,单层腓骨瓣修复9例,双层腓骨瓣修复1例;1例Ⅱc型患者采用髂嵴朝向下颌骨下缘的髂骨瓣修复;4例Ⅲa型患者中采用单层腓骨瓣修复3例,双层腓骨瓣修复1例;1例Ⅲa-型患者采用髂嵴朝向下颌骨下缘的髂骨瓣修复;4例Ⅲc-型患者采用髂嵴朝向下颌骨下缘的髂骨瓣修复;6例Ⅳa型患者采用单层腓骨瓣修复;5例Ⅳb型患者中采用单层腓骨瓣修复4例,双层腓骨瓣修复1例;1例Ⅳb-型患者采用髂嵴朝向下颌骨下缘的髂骨瓣修复。49例患者手术均按照术前数字化设计方案顺利完成,术后骨瓣均存活;术后中位随访时间22个月,下颌骨形态恢复均满意,咬合关系维持稳定。结论 下颌骨缺损患者采用数字化血管化骨瓣修复时,根据缺损累及区间数及缺损中心位置进行分类并采用相应修复方法,下颌骨形态恢复满意,咬合关系稳定。

Objective To classify the mandibular defects by the extent of the defects,to decide the specific digital design of mandibular reconstruction with vascularized bone flaps accordingly,and to observe the treatment outcomes.Methods Forty-nine patients with mandibular lesions underwent mandibular resection.The extent of defects was recorded for classification based on the involved intervals(class Ⅰ,Ⅱ,Ⅲ,Ⅳ) and the center of the defect(subclass a,b,c,d).Different digital designs were provided for each class to achieve mandibular reconstruction with vascularized bone flaps.The treatment outcomes were measured by whether the procedure was successful,as well as postoperative survival of bone flaps.A follow-up was conducted for 1 to 50 months to evaluate the occlusion and restoration of mandibular morphology.Results Of these 49 patients,2 patients with class Ⅰb defects used an iliac bone flap at the iliac crest orienting towards the alveolar process;1 with class Ⅱa defects underwent reconstruction with a single-layer fibular flap;24 with class Ⅱb defects underwent an iliac bone flap at the iliac crest orienting towards the inferior mandibular border in9 patients,an iliac bone flap orienting towards the alveolar process in 5,a single-layer fibular flap in 9,and a double-layer fibular flap in 1;1 with class Ⅱc defects used an iliac bone flap orienting towards the inferior mandibular border;4 with class Ⅲa defects had a single-fibular flap in 3 and double-layer fibular flap in 1;1 with class Ⅲb defects was repaired with an iliac bone flap orienting towards the inferior mandibular border;4 with class Ⅲc defects used an iliac bone flap orienting towards the inferior mandibular border;6 with class Ⅳa defects used a single-layer fibular flap;5 with class Ⅳb defects used a single-layer fibular flap in 4 and a double-layer fibular flap in 1;1 with class Ⅳb defects underwent reconstruction with an iliac bone flap orienting towards the inferior mandibular border.All procedures went smoothly according to the preoperative digital designs,and all bone flaps survived after the operations.With a median follow-up for 22 months postoperatively,all patients got satisfactory morphological restoration and good occlusal stability of their mandibles.Conclusion For patients with mandibular defects undergoing digital reconstruction using vascularized bone flaps,it is recommended to classify the defects according to the involved intervals and the center of the defect and to decide an appropriate procedure so as to ensure a satisfactory restoration of mandibular morphology and occlusal stability.