下颌骨病变术后病理性骨折的临床分析

目的 分析下颌骨病变术后病理性骨折的发生特点与治疗要点.方法 收集13例下颌骨病变术后病理性骨折病例资料,分析导致病理性骨折发生的潜在病变、骨折发生的诱因、时间、部位、症状、骨折发生处的刺余骨质情况,讨论下颌骨病变术后病理性骨折发生特点争治疗方法的选择.结果 1997-2007年问共诊治13例下颌骨病变术后病理性骨折患者,导致病理性骨折发生的主要病因依次是下颌骨方块截骨术、下颌骨巨大囊性肿物制治术、放射性骨髓交.病理性骨折最好发的部位是方块截骨后端、下颌骨角前切迹处.12例患者接受手术治疗,其中5例为小钛板固定.7例重建钛板固定.6例手术固定后顺利愈合.结论 下颌骨病变术后病理性骨折好发于下颌角前,手术复位内固定效果良好.应选择重建钛板坚固固定.     

下颌骨髁突保存对头颈癌患者治疗失败的影响

该文旨在研究保留髁突的下颌骨节段性切除术对头颈癌患者术后肿瘤局部复发的影响，对1994-2003年间54例接受下颌骨节段性切除的头颈癌患者进行回顾性研究，所有患者先前未行治疗，截骨范围自颏孔至下颌骨后方，36例保留髁突及下颌骨的连续性。18例行髁突及下颌支切除，未行下颌骨重建。     

全颌曲面断层片预测下颌第三磨牙拔除致下颌角骨折风险的研究

目的：利用全颌曲面断层片预测下颌第三磨牙拔除致下颌角骨折的风险。方法：筛选2009年6月，2010年6月期间我科186张（共347颗下颌第三磨牙）全颌曲面断层片，计算下颌第三磨牙区剩余骨高度（b）与下颌骨高度（a）的比值（b／a值），分析该比值在人群中的分布情况。结合6例智齿拔除致下颌角骨折病例的b／a值，分析该比值用于预测下颌第三磨牙拔除术致下颌角骨折风险的临床意义。结果：347颗第三磨牙区b／a值符合正态分布，比值低于0．3的病例2例，占0．58％；分析文献中6例智齿拔除术致下颌角骨折病例b／a值均小于0．3，符合第三磨牙区b／a值的人群分布特征，属于小概率事件。结论：下颌第三磨牙拔除术后剩余骨高度与该区下颌骨高度的比值低于0．3者有较高下颌角骨折风险，全颌曲面断层片可以作为提示此风险的一种有效手段。     

重建板坚强内固定治疗下颌骨粉碎性骨折45例报告

目的：总结下颌骨粉碎性骨折的手术治疗方法。方法：对45例下颌骨粉碎性骨折采用口内或口外广泛切开,充分暴露骨折区全貌,并进行下颌骨的解剖复位,采用重建板坚强内固定。结果：45例下颌骨粉碎性骨折术后44例伤口一期愈合,骨折复位愈合良好,咬合关系恢复良好,张口度正常;1例术后下颌前庭沟黏膜处钛板小部分外露,经局部治疗,保持口腔卫生、预防感染,8个月后手术取出固定钛板螺钉,骨折处对位愈合良好,咬合关系良好,无骨感染、骨不连发生。结论：广泛切开能凊楚显露下颌骨粉碎性骨折的骨折线全貌,方便在直视下准确复位固定各骨折块、恢复下颌骨的解剖结构,获得良好的咬合关系。重建板固定骨折具有良好的稳定性和可靠性,适用于下颌骨粉碎性骨折。     

下颌骨陈旧性骨折的内固定治疗

本文复习了304例下颌骨陈旧性骨折病例，对各种类型骨折的诊治提出了自己的看法。强调在下颌骨粉碎性骨折的一期清创术中，不但要保留有软组织附丽的骨块，而且应尽量保留完全游离的骨块，以免造成术后下颌骨的骨质缺损、牙弓缩窄和严重的咬合紊乱。有骨缺损的陈旧性骨折，应尽量修复骨缺损，方能维持内固定的稳定性，加快骨愈合，获得良好、稳定的咬合关系。颌间牵引固定作为一种辅助手段，在错位愈合骨折的切开复位内固定中，有着重要作用。     

小型钛板坚强内固定治疗下颌骨骨折

目的 总结小型钛板坚强内固定治疗下颌骨骨折的临床效果。方法 对106例下颌骨骨折患者行小型钛板坚强内固定术，其中64例单发骨折者，单纯骨内固定59例，骨内固定辅以颌间牵引5例；42例下颌骨多发性骨折行小型钛板坚强内固定复位术加颌间牵引。结果 106例下颌骨骨折均获得良好的疗效，恢复正常咬合功能。结论 小型钛板坚强内固定术治疗下颌骨单发性骨折大都能达到良好复位作用；下颌骨多发性骨折在小型钛板坚强内固定术后辅以颌间牵引同样能恢复正常咬合功能。     

颈横切口在下颌骨多发性骨折治疗中的应用

目的：评价颈横切口治疗下颌骨多发性骨折的临床效果。方法：选取8例多发性或粉碎性超过一侧的下颌骨骨折病例。选择距甲状软骨上缘1．5cm的颈上线作切口，由中线向两侧延伸直至双侧下颌角。翻开颈阔肌瓣，清理、暴露以及复位固定下颌骨骨折断端。术后随诊6个月-1年。结果：骨折断端暴露、复位、固定良好，术后获得了良好的功能及美学效果。结论：单一的颈横切口能够最大限度地暴露下颌骨多发性骨折的各个部位，是一种下颌骨多发性骨折较好的手术径路。     

下颌骨骨折后并发骨髓炎的临床探讨

目的 探讨下颌骨骨折后并发骨髓炎的原因以及治疗方法。方法 对18例因下颌骨骨折所并发的骨髓炎采用以手术为主的综合治疗，观察其疗效。结果 术后切口一期愈合有16例，2例术后感染致骨不愈合。15例经1－3年随访，口腔功能恢复良好，X线检查已骨性愈合。结论 下颌骨骨折并发骨髓炎，主要病因为伤情复杂，专科诊治延误等。以手术为主的综合治疗方法对创伤性骨髓炎可取得较好疗效，主要并发症有术后感染，骨不愈合等。     

膜引导辅助弹力牵引成骨重建节段缺失下颌骨的实验研究

目的利用膜引导骨再生技术促进记忆合金牵引器弹力自动牵引成骨进程。方法手术截除杂种犬一侧下颌骨2．5-4．0cm骨段，按bi-focal牵引成骨原理安置记忆合金牵引固定装置，并将聚四氟乙烯膜覆盖于骨膜剥离的下颌骨颊侧面；术后3个月取下颌骨观察并测量骨密度和强度。结果节段缺失下颌骨得到重建，传送盘前后各形成1．5-2．5cm再生骨段；新骨高度及厚度接近正常下颌骨，骨密度和强度接近或超过正常骨半量值。结论膜引导技术可以避免骨不连，加快弹力牵引再生骨的骨化成熟过程。     

CT三维重建下探讨BSSRO术舌侧水平截骨线与骨劈开效果的关系

目的:应用CT三维重建来探讨双侧下颌骨矢状劈开截骨术舌侧水平截骨线与骨劈开效果的关系,为下颌骨矢状劈开截骨术舌侧水平截骨位置的选择提供指导。方法:选择17例双侧下颌骨前突患者(34例),经过下颌骨矢状劈开截骨术,术后应用三维重建观测水平截骨线及劈开效果。结果:只有10.87%的劈开结果理想(符合Hunsuck描述),54.35%的劈开效果较理想,32.61%的穿过了下颌管,4.35%穿过了其它部位。劈开的效果直接受水平截骨位置的影响(P<0.01)。结论:三维CT在评价下颌骨矢状劈开截骨术效果方面是有效的工具,为下颌骨矢状劈开截骨术选择舌侧水平截骨线位置提供重要数据,并能降低不良劈开的发生率。     

Zur Indikation und Morbidität der Kontinuitätsresektion des Unterkiefers beim Plattenepithelkarzinom der unteren Mundhöhlenetage

Background

Segmental resection of the mandibula in oral cancer surgery leads to both functional and aesthetic problems. The decision to preserve or resect the mandible depends on the vicinity of the lesion to the bone. Consequently, based on the rules of safety margins to all planes that are recommended for soft tissues, each lesion that is closer than 10 mm to the mandible needs resection of the bone.

Patients and methods

To establish data-based treatment modalities, a retrospective study was initiated and the results from all preoperative staging investigations of 152 patients with intraoral squamous cell carcinoma who underwent continuity or marginal resection of the mandible were evaluated. The histological outcome of the resected bone was compared to the staging results. Functional rehabilitation and long-term follow-up including survival rates were evaluated. The study reports on typical complications following segmental resection such as fracture of the reconstruction plate and demonstrates experiences with secondary microsurgical reconstructive surgery.

Results

Mainly in cases of stage T1 and T2 carcinomas which are closer than 10 mm to the bone and clinically do not show any infiltration to the mandible, a marginal resection seems to be adequate. The decision about the extension of mandibular resection can be based on intraoperative cross sectional investigation of the periosteum. The survival rate of patients with intraoral carcinomas close to the mandible who underwent marginal mandibulectomy seems to be the same as in cases of continuity resection. A more conservative management of mandibular resection seems to be adequate and a data-based concept to standardize therapy of mandibular resection is presented.     

Marginal and segmental mandibulectomy in patients with oral cancer: a statistical analysis of 106 cases.

PURPOSE: The treatment of oral squamous cell carcinoma may require mandibular resection to secure adequate margin. This bone resection often is segmental or marginal mandibulectomy. The purpose of this work was to evaluate the local control and survival after surgical treatment of oral cancer, according to these 2 different mandibular resection procedures. PATIENTS AND METHODS: We conducted a retrospective study of a 20-year cohort of 106 patients who underwent marginal or segmental mandibulectomy for oral cancer. All patients had a biopsy-confirmed diagnosis of squamous cell carcinoma involving either the floor of the mouth, mandibular gingiva, retromolar trigone, tongue, buccal mucosa, or oropharynx. The type of mandibular resection and treatment outcome were compared, using an univariate analysis by the Pearson chi(2) test, logistic regression model for multivariate analysis, and Kaplan-Meier method to determine survival. RESULTS: The 5-year observed survival rate was 60.35%. The presence of histologic mandibular invasion increased the local recurrence rate. Early tumor stages (P =.02) were found to be associated with decreased local recurrence rates. Our findings indicate that tumor stage and size of mandibulectomy are more important than the type of mandibulectomy in predicting histologic bone involvement. The cases treated with a greater than 4 cm bone resection showed a lower survival rate than those treated with less than 4 cm mandibulectomy (P =.01). Patients in advanced stages (P =.006) and those with surgical margin (P =.0001) or the bone (P =.003) affected by the tumor showed a statistically significant lower survival rate. However, no statistically significant differences were found between patients treated by marginal or segmental mandibulectomy. CONCLUSIONS: Among the prognostic factors studied, the status of the surgical resection margin, the bony involvement and the size of mandibulectomy affected the prognosis for oral carcinoma. Mandibular conservation surgery is oncologically safe for patients with squamous carcinoma in early stages. The marginal technique was not associated with worse prognosis.     

Influence of bone invasion and extent of mandibular resection on local control of cancers of the oral cavity and oropharynx

The aim of this paper was to evaluate the influence of bone invasion on treatment outcome among patients with cancers of the oral cavity and oropharynx and to determine whether or not outcome was influenced by the extent of mandibular resection. A review of 127 prospectively documented patients who were treated with marginal or segmental resection for oral (n = 110) and oropharyngeal (n = 17) cancers was undertaken. There were 97 males and 30 females with a median age of 61 years. Clinical T stages were: T1 17 patients, T2 33, T3 22, T4 55. Median followup was 4 years. A total of 94 patients underwent marginal resections and 33 underwent segmental resections. Histological bone invasion was present in 17 patients (16%) in the marginal resection group and 21 patients (64%) in the segmental group (P<0.05). Soft tissue surgical margins were positive in 11 patients (12%) in the marginal group and in seven patients (21%) in the segmental group (P=not significant). Local control did not correlate significantly with T stage, the extent of mandibular resection or the presence of histological bone invasion, but was significantly influenced by positive soft tissue margins (P<0.01). Among patients with bone invasion, the local control rate was higher following segmental resection when compared to marginal resections (87% vs 75%) but this was not statistically significant. Survival was significantly influenced by positive soft tissue margins but not bone invasion or the type of resection. We conclude that bone invasion alone did not predict for local control or survival rates among patients with oral and oropharyngeal cancers. Involved soft tissue margins were highly predictive of local recurrence and decreased survival. Conservative resection of the mandible is safe as long as marginal mandibulectomy does not lead to compromise of soft tissue margins. Segmental resection should be reserved for patients extensive bone invasion or those with limited invasion in a thin atrophic mandible.     

虚拟手术计划在经口内入路行下颌骨切除及精确重建中的应用：附9例报道

目的 介绍在虚拟手术计划辅助下行经口内入路下颌骨切除和血管化骨重建的经验,评价术后重建效果。方法 对9例下颌骨良性肿瘤患者术前行虚拟手术计划,设计、制作适用于口内操作的预设钉孔的导板。然后经口内入路利用截骨导板行下颌骨切除,预弯钛板及血管化骨瓣的植入和固定。术中实时导航验证新下颌骨的空间位置。术后半年,通过临床及影像学检查评价患者外形和功能;通过术后CT与术前STL模型拟合,评估下颌骨重建的精确性。采用SPSS 15.0软件包对数据进行统计学分析。结果 在虚拟手术计划辅助下,9例患者均顺利完成经口内入路下颌骨切除及血管化下颌骨重建,术中导航证实重建下颌骨位置准确。术后半年复查见患者面部对称,无面瘫及开口受限。患者对手术效果满意。图像拟合显示,截骨线位置精确,误差<1 mm[（0.72±0.15）mm],下颌骨重建位置与术前设计高度一致,误差为（1.76±1.99）mm。结论 在虚拟手术计划辅助下,利用预设钉孔的导板和预弯钛板,可以精确实施口内下颌骨切除及血管化骨重建,避免了口外切口,显著提高了下颌骨重建的精确性。     

Patterns of mandibular invasion by gingival squamous cell carcinoma.

PURPOSE: This study examined patterns of invasion of lower gingiva cancer into the mandible. Our goal was to clarify the most common routes for gingival squamous cell carcinoma to enter and spread within the mandible. PATIENTS AND METHODS: The subjects were 176 patients with lower gingival squamous cell carcinoma who underwent mandibulectomy; all tumors were examined histopathologically. The method of mandibulectomy was decided on the basis of conventional plain radiographic and computed tomographic findings. RESULTS: The tumor extended to the periosteum in 33%, to the cortical bone in 23%, and to the bone marrow in 9% of the patients who underwent mandibular resection. The remaining 35% of our patients had no evidence of mandibular invasion. CONCLUSION: The area of bone resorption on preoperative clinical and radiographic examinations often disagreed with the extent of mandibular invasion on histopathologic examination.     

口腔肿瘤患者下颌骨保存性外科方法的探讨

目的：探讨与口腔肿瘤有关的下颌骨切除过程中保存下颌骨连续性的技术、方法和价值。方法：对20例口腔癌和下颌骨成釉细胞瘤患者实施下颌骨上边缘切除、下边缘切除、下颌支前边缘切除、内侧骨板板层切除、外侧骨板板层切除,使下颌骨的连续性不中断。结果：所有患者的健侧牙列和残存牙关系得以维持,咀嚼功能基本正常,面部基本对称。随访2年无病理性骨折发生。结论：除下颌骨肿瘤外,口腔肿瘤相关性下颌骨切除都可以实行连续性不中断的保存性下颌骨切除,从而获得更好的术后功能。     

口内入路个体化三焦点圆弧牵引器修复下颌骨大型缺损

目的:根据下颌骨缺损类型,设计个体化内置式圆弧牵引器,通过三焦点牵引成骨技术修复下颌骨缺损畸形。方法:对患成釉细胞瘤行下颌骨部分切除的患者,确定手术切除范围及修复后下颌骨形态,在快速原型模型上设计个体化内置式圆弧形牵引器,应用三焦点转移盘牵引方式,在肿瘤切除同期行牵引成骨手术,牵引前间歇期7d,牵引参数为0.4 mm/次,2次/d,固定期6个月。拆除牵引器后,二期行牙列修复。结果:牵引器植入后牵引过程顺利,固定6个月后X线片显示新骨形成均良好,但2个转移盘间见纤维愈合,拆除牵引器时需行钛板内固定。牙列修复前,发现下颌骨形态略小、矢状向后缩,再次行双侧下颌支矢状劈开前移下颌骨,到达设计位置并稳定后,行覆盖义齿修复。结论:个体化内置式圆弧牵引器可以有效修复下颌骨大型缺损,避免传统骨移植手术造成的供区创伤,但在前期设计时,需要适当矫枉过正。     

Pathologic mandibular fracture after biting crab shells following ramal bone graft

The mandibular ramus is considered an appropriate choice for reconstruction of maxillofacial defects because of sufficient amounts of material and fewer donor site complications. Although bone harvesting from the mandibular ramus has many advantages, in rare cases it can result in pathologic fracture of the mandible. Here, we present a case of 59‐year‐old man who suffered a pathologic mandible fracture related to biting hard foods, such as crab shells, after a sinus bone lifting with ramal bone graft procedure performed 2 weeks prior. He underwent closed reduction by intermaxillary fixation with an arch bar over the course of 4 weeks. Three months later, the patients had a stable occlusion with normal mouth opening and sensation. To prevent this complication, the osteotomy should be performed in such a way that it is not too vertical during ramal bone harvesting. Furthermore, we wish to emphasize the importance of patients being instructed to avoid chewing hard foods for at least 4 weeks after ramal bone harvesting.     

坚硬内固定在下颌骨手术中的应用

目的　提高坚硬内固定在口腔颌面外科的临床应用水平 ,减少并发症。方法　 2 1例下颌骨骨折和肿瘤切除术后骨缺损或骨连续性中断的病人分别采用经穿颊器口内内固定术、接骨板定位后骨截开或截除内固定术。结果　术后外形两侧基本对称 ,无明显功能障碍。 1例近期创口发生感染 ,2例远期螺钉松动而导致局部感染。结论　经穿颊器行下颌骨骨折内固定避免口外切口而有利于美观 ;接骨板塑形定位后再行下颌骨截开或截除的内固定术易维持术前牙合关系和颌骨的外形 ,从而恢复良好的功能和外观?。