Dynamisk navigationssystem i realtid til præcis quad-zygomatisk implantatplacering hos en patient med en alvorligt atrofisk maxilla
Summary
Her præsenterer vi en protokol for at opnå præcis quad-zygomatisk implantatplacering hos patienter med alvorligt atrofisk maxilla ved hjælp af et dynamisk navigationssystem i realtid.
Abstract
Zygomatiske implantater (ZI’er) er en ideel måde at løse tilfælde af en alvorligt atrofisk edentulous maxilla og maxilla defekter, fordi de erstatter omfattende knogleforstørrelse og forkorter behandlingscyklussen. Der er dog risici forbundet med placeringen af ZI’er, såsom penetration af orbitalhulen eller infra-temporal fossa. Desuden gør placeringen af flere ZI’er denne operation risikabel og vanskeligere at udføre. Potentielle intraoperative komplikationer er ekstremt farlige og kan forårsage uoprettelige tab. Her beskriver vi en praktisk, gennemførlig og reproducerbar protokol for et kirurgisk navigationssystem i realtid til præcis placering af quad-zygomatiske implantater i den alvorligt atrofiske maxilla hos patienter med resterende knogle, der ikke opfylder kravene til konventionelle implantater. Hundredvis af patienter har modtaget ZI’er på vores afdeling baseret på denne protokol. De kliniske resultater har været tilfredsstillende, de intraoperative og postoperative komplikationer har været lave, og nøjagtigheden indikeret ved infusion af det designede billede og postoperative tredimensionelle billede har været høj. Denne metode bør anvendes under hele den kirurgiske procedure for at sikre ZI-placeringssikkerhed.
Introduction
I 1990’erne introducerede Branemark en alternativ teknik til knogletransplantation, det zygomatiske implantat (ZI), som også er blevet kaldt zygomaticus armatur1. Det blev oprindeligt brugt til behandling af traumeofre og patienter med tumorresektion, hvor der var en defekt i den maksillære struktur. Efter maxillektomi bevarede mange patienter kun forankring i zygomaens krop eller i frontforlængelsen af den zygomatiske knogle 1,2,3.
For nylig er ZI-teknikken blevet udbredt hos edentulous- og dentatpatienter med en alvorligt resorberet maxilla. Hovedindikationen for ZI-implantater er en atrofisk maxilla. Brugen af fire ZI’er i et øjeblikkeligt belastningssystem (fast protese) er praktisk for kirurger med bred klinisk erfaring, og det ser ud til at repræsentere en fremragende alternativ metode til knogletransplantatteknikker 2,4. Der er dog risici ved at placere ZI’er, enten ved frihånd eller ved hjælp af en kirurgisk skabelon til vejledning. Risici omfatter unøjagtig placering i alveolus, penetration af orbitalhulen eller infra-temporal fossa og uhensigtsmæssig placering inden for den zygomatiske fremtrædende plads5. Placeringen af flere ZI’er gør denne operation risikabel og vanskelig at udføre. Derfor er forbedring af præcisionen af ZI-placering afgørende for dets kliniske anvendelse og sikkerhed.
Det kirurgiske navigationssystem i realtid giver en anden tilgang. Det giver realtid og fuldstændigt visualiserede baner gennem analyse af præoperative og intraoperative computertomografibilleder. Med navigationssystemet i realtid er både præcision og sikkerhed blevet forbedret med sofistikeret kirurgi og behandling 5,6. En praktisk, gennemførlig og reproducerbar protokol blev udviklet ved hjælp af det kirurgiske navigationssystem i realtid til præcist at placere ZI’er i den alvorligt atrofiske maxilla 5,7,8,9,10. Med denne protokol har vi behandlet hundredvis af patienter med tilfredsstillende kliniske resultater 5,6,7,8,9,10. Her præsenterer vi protokollen med de detaljerede oplysninger om behandlingsproceduren.
Protocol
Representative Results
Discussion
Rekonstruktiv rehabilitering af den atrofiske maxilla ved hjælp af transplantater er vanskelig, fordi det kræver god kirurgisk teknik, dækning af blødt væv af høj kvalitet over transplantatet, en betydelig mængde patientsamarbejde og patienter med sundhed, der er gunstig for den endelige restaurering17,18. Placeringen af tandimplantater til rekonstruktion hos patienter med maksillær atrofi udgør en betydelig klinisk udfordring. Mønsteret af ansigtsbenre…
Disclosures
The authors have nothing to disclose.
Acknowledgements
Forfatterne takker Dr. Shengchi Fan for venligt at yde værdifuld navigationsteknisk support. Denne case-rapport blev finansieret af nøgleprojektet fra Kinas ministerium for videnskab og teknologi (2017YFB1302904), Natural Science Foundation of Shanghai (nr. 21ZR1437700), den kliniske forskningsplan for SHDC (SHDC2020CR3049B) og det kombinerede ingeniør- og medicinske projekt fra Shanghai Jiao Tong University (YG2021QN72).
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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