虚拟手术联合三维打印导板在下颌骨良性肿瘤切除和颌骨缺损修复重建中的应用

Application of virtual surgery combined with three-dimensional guide plate in the surgery of mandibular benign tumors resection and bone defect repairation

目的探讨虚拟手术联合三维(3D)打印导板在下颌骨良性肿瘤切除和颌骨缺损修复重建中的应用效果。方法2013年6月至2020年12月,郑州大学第一附属医院口腔颌面外科行数字化技术辅助下颌骨良性肿瘤切除,同期游离腓骨肌皮瓣修复重建颌骨缺损患者全部纳入该研究,临床资料不全者排除。根据是否在术中使用下颌骨和腓骨截骨导板,分为导板组和非导板组。导板组术前3D打印下颌骨及腓骨截骨导板,术中使用导板完成肿瘤切除和腓骨塑形操作,非导板组仅依据虚拟手术方案和预成钛板完成相应操作。记录腓骨瓣制备情况、手术时间、腓骨瓣临床成活情况,术后1周颌面部螺旋CT影像评价腓骨骨段间及腓骨与下颌骨间密合程度、预成形钛板与腓骨及下颌骨间密合程度和髁状突位置,术后半年视觉模拟评分法(VAS)调查患者术后面部外形满意度。采用SPSS 21.0软件对数据进行统计学分析,手术时间、术后面部外形评价比较采用独立样本t检验,髁突位置、腓骨及下颌骨段间密合程度、钛板与骨段密合程度比较采用卡方检验,P<0.05为差异有统计学意义。结果共纳入30例患者,男性17例,女性13例,中位年龄24岁(16~64岁)。腓骨瓣制备过程顺利,术中所需腓骨长度(14.1±1.9)cm(5.7~18.1 cm),腓骨塑形段数(2.9±0.6)段(2~4段)。12例下颌骨缺损以单层腓骨修复,7例以血管化折叠腓骨修复,11例以血管化复合非血管化腓骨修复。导板组与非导板组手术时间比较[(335.9±64.0)min vs.(470.7±140.5)min],差异具有统计学意义(P<0.05)。术后随访9~23月,平均11个月,所有腓骨瓣均成活。术后1周颌面部螺旋CT影像评价腓骨骨段间、腓骨与下颌骨间密合程度、预成形钛板与腓骨及下颌骨间密合程度及髁状突位置较好的患者,导板组分别为15例、15例和13例,非导板组分别为10例、13例和11例。导板组与非导板组腓骨骨段间及与下颌骨间密合程度比较(15/15 vs.10/15)差异具有统计学意义(P<0.05)。术后半年2组患者对术后面部外形均比较满意,导板组与非导板组VAS评分比较[(9.6±0.5)分vs.(9.3±0.5)分],差异无统计学意义(P>0.05)。结论虚拟手术联合3D打印导板可以进一步缩短手术时间,提高下颌骨良性肿瘤切除颌骨缺损游离腓骨瓣修复重建的精准度。

Objective To explore the potential of integrating virtual surgery with three-dimensional(3D)printed guides in the surgical management of mandibular benign tumors and subsequent reconstruction of bone defects.Methods A retrospective analysis was conducted on the clinical data of patients who underwent computer-assisted resection and vascularized fibular flap reconstruction for benign mandibular tumors at the Department of Oral and Maxillofacial Surgery,First Affiliated Hospital of Zhengzhou University,from June 2013 to December 2020.According to the utilization of guide plates for mandibular and fibular osteotomy during surgical procedures or not,the patients were categorized into two cohorts:a guide plate cohort and a non-guide plate cohort.In the guide plate group,custom-designed gudie plates based on virtual surgical plans were fabricated using 3D printing technology and employed intraoperatively;In the non-guide plate group,surgery was exclusively performed based on virtual surgical plan and prebent titanium plate without any supplementary plating.The measured outcomes included fibular flap osteotomy,operation duration,and clinical flap survival.Computed tomography images obtained one week post-surgery were utilized to assess the intersegmental commissure degree between fibular segments as well as between fibular segments and mandible,commissure degree between fibular segments and prebent titanium plate,and condyle position.The satisfaction of patients with their facial appearance was evaluated 6 months after the surgery using a visual analogue scale.Statistical analysis was conducted using SPSS 21.0 software.Independent sample t-tests was utilized to compare the duration of operation and and postoperative evaluation of facial appearance,the Chi-square tests was utilized for condyle position,commissure degrees among interactions involving fibular segments,prebent titanium plates,bone segments(P<0.05 denoted statistical significance).Results A total of 30 patients were enrolled,comprising 17 males and 13 females,with a median age of 24 years(16-64 years).The preparation process of fibular flaps proceeded smoothly.The required length of fibula was measured as(14.1±1.9)cm(5.7-18.1 cm),while the number of fibular segments ranged from 2 to 4,averaging at approximately 2.9±0.6.The mandibular defects were repaired using a single-layer fibula in 12 cases,a vascularized folded fibula in 7 cases and a combination of vascularized and non-vascularized fibula in 11 cases.The operation time for the guide plate group was recorded as(335.9±64.0)min(240-433 min),while it was observed to be(470.7±140.5)min(280-680 min)for the non-guide plate group.The postoperative follow-up duration ranged from 9 to 23 months,with an average period of 11 months.All fibular flaps demonstrated clinical survival.The number of patients with good commissure degree between fibular and mandibular segments,between prebent titanium plate and fibular and mandibular segments and the position of condyle were 15,15 and 13 cases in guide plate group,10,13 and 11 cases in non-guide plate group respectively.The statistical analysis revealed a significant difference(P<0.05)in the degree of commissure between the fibular and the mandibular segments(15/15 vs.10/15)in the two groups.Both groups exhibited high levels of satisfaction regarding their postoperative facial appearance at the 6 months follow-up,observed to be 9.6±0.5 and 9.3±0.5 respectively,and the statisticla analysis revealed non-significant difference(P>0.05).Conclusion The integration of virtual surgery with 3D printed guide plates can effectively reduce operative time and improve precision in the repair and reconstruction of free-fibular flaps following resection of benign tumors of the mandible.