实时动态导航系统，用于在严重萎缩性上颌骨患者中精确放置四颧植入物
1The 2nd Dental Center, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University,National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, 2Department of Dental Implantology, Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology
Summary
在这里，我们提出了一种协议，使用实时动态导航系统在严重萎缩性上颌骨患者中实现精确的四颧植入物放置。
Abstract
颧骨植入物（ZIs）是解决严重萎缩性无牙颌和上颌骨缺陷病例的理想方法，因为它们取代了广泛的骨增量并缩短了治疗周期。然而，放置ZI存在相关风险，例如穿透眶腔或颞下窝。此外，多个ZI的放置使这种手术有风险并且更难以执行。潜在的术中并发症非常危险，并可能导致无法弥补的损失。在这里，我们描述了一种实用，可行且可重复的实时手术导航系统方案，用于将四颧植入物精确放置在残余骨患者的严重萎缩上颌骨中，不符合常规植入物的要求。根据该协议，我们部门已有数百名患者接受了 ZI。临床结局令人满意，术中和术后并发症较低，输注设计图像和术后三维图像所指示的准确性较高。在整个手术过程中应使用此方法，以确保ZI放置安全。
Introduction
在 1990 年代，Branemark 引入了一种替代骨移植技术，即颧骨植入物 （ZI），也称为颧骨固定装置1。它最初用于治疗创伤受害者和上颌骨结构有缺陷的肿瘤切除患者。上颌骨切除术后，许多患者仅在颧骨体或颧骨的额叶延伸处保留锚定1，2，3。
最近，ZI技术已广泛用于上颌骨严重再吸收的无牙颌和齿状患者。ZI植入物的主要适应症是萎缩性上颌骨。对于具有丰富临床经验的外科医生来说，在即时负荷系统（固定修复学）中使用四个ZI是实用的，并且它似乎是骨移植技术的绝佳替代方法2，4。然而，徒手或使用手术模板进行指导放置 ZI 时存在风险。风险包括肺泡内放置不准确、眶腔或颞下窝穿透以及颧突内放置不当5.多个ZI的放置使这种手术有风险且难以进行。因此，提高ZI放置的精度对其临床使用和安全性至关重要。
实时手术导航系统提供了一种不同的方法。它通过分析术前和术中计算机断层扫描图像提供实时和完全可视化的轨迹。借助实时导航系统，通过复杂的手术和治疗提高了精度和安全性5，6。使用实时手术导航系统开发了一种实用、可行且可重复的方案，以精确地将 ZI 放置在严重萎缩的上颌骨5，7，8，9，10 中。通过该方案，我们已经治疗了数百名患者，临床结果令人满意5，6，7，8，9，10。在这里，我们提供了有关治疗程序的详细信息的协议。
Protocol
所有临床方案均由上海交通大学医学院附属第九人民医院医学伦理审查委员会批准（SH9H-2020-T29-3）。 1. 患者选择 患者纳入标准如下（表1）。确保患者呈现完全无牙颌或部分无牙颌，牙齿很少松动（图 1A-G）。 确保患者上颌骨严重萎缩，骨体积不足，无法在前上颌骨和/或后上颌骨进行常规种植…
Representative Results
入组患者是一名60岁的女性，没有任何系统性疾病（图1A-D，F）。CBCT扫描后，上颌前部的牙槽嵴小于2.9 mm，而上颌后区的残余骨高度小于2.4 mm（图1E，G和表1）。颧骨的宽度和厚度分别约为22.4-23.6毫米和6.1-8.0毫米（图2，表3）。根据颧骨解剖引导方法，前ZI的入口位于?…
Discussion
使用移植物对萎缩性上颌骨进行重建是困难的，因为它需要良好的手术技术，覆盖移植物上的高质量软组织，大量的患者合作以及有利于顶端修复的患者17，18。在上颌萎缩患者中放置用于重建的牙科植入物是一项重大的临床挑战。面部骨吸收的模式与年龄有关，在无牙颌上颌中尤其明显，在使用完全可拆卸假体的患者中尤其明显19…
Divulgations
The authors have nothing to disclose.
Acknowledgements
笔者感谢范胜驰博士提供的宝贵导航技术支持。本病例报告由国家科技部重点项目（2017YFB1302904）、上海市自然科学基金（No. 21ZR1437700）、上海交通大学临床研究计划（SHDC2020CR3049B）和上海交通大学工学与医学联合项目（YG2021QN72）资助。
Materials
| Bistoury scalpel | Hufriedy Group | 10-130-05 | |
| Branemark system zygoma TiUnite RP 35mm | Nobel Biocare AB | 34724 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 40mm | Nobel Biocare AB | 34735 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 42.5mm | Nobel Biocare AB | 34736 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 45mm | Nobel Biocare AB | 34737 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 47.5mm | Nobel Biocare AB | 34738 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 50mm | Nobel Biocare AB | 34739 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| Branemark system zygoma TiUnite RP 52.5mm | Nobel Biocare AB | 34740 | TiUnite implant with overlength to place from the maxilla to the zygoma |
| CBCT | Planmeca Oy,Helsinki, Finland | Pro Max 3D Max | |
| connection to handpiece | Nobel Biocare AB | 29081 | the accessories to connect the intrument |
| Drill guard | Nobel Biocare AB | 29162 | the accessories to protect the lips and soft tissue during the surgery |
| Drill guard short | Nobel Biocare AB | 29162 | the accessories to protect the lips and soft tissue during the surgery |
| Handpiece zygoma 20:1 | Nobel Biocare AB | 32615 | the basic instrument for implant drill |
| Instrument adapter array size L | BRAINLAB AG | 41801 | |
| Instrument adapter array size M | BRAINLAB AG | 41798 | |
| Instrument calibration matrix | BRAINLAB AG | 41874 | a special tool for drill to calibration |
| I-plan automatic image fusion software STL data import/export for I-plan VectorVision2®, (I-plan CMF software) | BRAINLAB AG | inapplicability | the software for navigation surgery planning |
| Multi-unit abutment 3mm | Nobel Biocare AB | 32330 | the connection accessory between the implant and the titanium base |
| Multi-unit abutment 5mm | Nobel Biocare AB | 32331 | the connection accessory between the implant and the titanium base |
| Periosteal elevator | Hufriedy Group | PPR3/9A | the instrument for open flap surgery |
| Pilot drill | Nobel Biocare AB | 32630 | the drill for the surgery |
| Pilot drill short | Nobel Biocare AB | 32632 | the drill for the surgery measuring the depth of the implant holes |
| Pointer with blunt tip for cranial/ENT | BRAINLAB AG | 53106 | |
| Reference headband star | BRAINLAB AG | 41877 | |
| Round bur | Nobel Biocare AB | DIA 578-0 | the drill for the surgery |
| Screwdriver manual | Nobel Biocare AB | 29149 | |
| Skull reference array | BRAINLAB AG | 52122 | a special made metal reference for navigation camera to receive the signal |
| Skull reference base | BRAINLAB AG | 52129 | |
| Suture vicryl 4-0 | Johnson &Johnson, Ethicon | VCP310H | |
| Temporary copping multi-unit titanium (with prosthetic screw) | Nobel Biocare AB | 29046 | the temporary titanium base to fix the teeth |
| Titanium mini-screw | CIBEI | MB105-2.0*9 | the mini-screw for navigation registration |
| Twist drill | Nobel Biocare AB | 32628 | the drill for the surgery |
| Twist drill short | Nobel Biocare AB | 32629 | the drill for the surgery |
| Zygoma depth indicator angled | Nobel Biocare AB | 29162 | |
| Zygoma depth indicator straight | Nobel Biocare AB | 29162 | the measurement scale for |
| Zygoma handle | Nobel Biocare AB | 29162 | the instrument for zygomatic implant placement |
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Citer Cet Article
Shen, Y., Dai, Q., Tao, B., Huang, W., Wang, F., Lan, K., Sun, Y., Ling, X., Yan, L., Wang, Y., Wu, Y. Real-Time Dynamic Navigation System for the Precise Quad-Zygomatic Implant Placement in a Patient with a Severely Atrophic Maxilla. J. Vis. Exp. (176), e62489, doi:10.3791/62489 (2021).