基于三维数字化技术的先天性颅缝早闭症整复外科治疗

发布时间：2018-08-09 13:51

【摘要】：目的1基于三维数字化技术,探索对颅缝早闭症患者的骨组织、软组织以及大脑容积的客观测量方法,客观定量化评价额眶前移的手术术式和疗效。2基于三维数字化设计和制造技术,根据术前手术模拟设计及导航导板,以期达到个性化精准颅颌面整复手术治疗的目的。3建立颅缝早闭畸形三维有限元分析模型,分析畸形形成及颅眶截骨术后及模拟牵引的生物力学特征及变化,为内置式牵引器的临床应用奠定理论基础。方法1选取2010年1月至2017年3月就医手术的颅缝早闭症患者12例,根据术前、术后、及随访时头颅CT的DICOM数据重建头颅的骨性、软组织、脑组织结构,并进行定量化分析。2选取2014年8月至2016年12月就治于颌面整形外科中心的颅缝早闭症患者3例,利用CT数据进行术前设计手术截骨方案,确定骨瓣复位位置,预制术中使用的复位导板并用于引导术中骨瓣的复位,比较各颅骨标志点术前术后的移动距离差,以及各标志点术前模拟情况及术后实际情况。3利用三维数字化技术,进行颅缝早闭症患儿的头颅有限元建模,对颅缝早闭骨化畸形病理发生过程进行机制探讨;对额眶前移术后的解剖结构进行三维有限元生物力学分析,并在额眶前移截骨基础上进行了牵引力模拟加载。结果1、颅底结构患侧与健侧具有统计学差异:术前患侧的前颅窝测量指标(CSX∧、CX、SX)以及中颅窝测量指标(XSM∧、S-Pt、XM、SM)随访时与术前有统计学差异。前颅对称指数,前颅窝偏斜角,额角,额面角,患侧颞角,颞面角。术前大脑容积与对照组具有统计学差异指标;术后及随访时大脑容积与对照组无统计学差异;骨瓣前移变化测量:双侧额眶前移较单侧额眶前移可以更好的使颞部向前外侧方向扩展;单侧额眶前移在纠正颞部畸形上效果不及双侧额骨瓣。2、利用三维打印的复位导板辅助术中骨瓣复位,缩短了手术时间,复位时间约为0.5小时至1小时;术中即刻直视下,额眶两侧对称性形态相近;手术区域各标志点的术后与手术模拟之间的位移差效果类似。3、建立了 4节点一阶四面体单元的头颅三维有限元模型(静态应力分析模型)、单侧及双侧额眶前移截骨模拟有限元模型(荷载动态应力分析模型),通过应力分析结果显示:在患侧额部、左侧颞部及左侧顶部可见多个应力集中区域,提示患侧额眶塌陷后缩的阻力来源于早闭骨化的冠状缝;前颅窝及中颅窝的应力分布比较集中,提示骨化的冠状缝及其向颅底延伸缝的早闭骨化所形成的阻力,导致前颅凹后缩浅小。而额眶前移模拟截骨有限元模型提示:我们所采用的手术术式可以解除阻力、降低颅底的应力,有利于颅底、颌面部在大脑、眼球生长推动力作用下,在三维空间上生长发育。在额部及颞部施加牵引力后,眼眶可出现向前向下的移位,得出最佳的牵引力大小及牵引距离。结论1、颅缝早闭症患儿颅底、颅骨及颞部的骨组织及软组织存在畸形,大脑容积低于正常,经额眶前移术后畸形得到改善;双侧额眶前移较单侧额眶前移更好改善颞部畸形。2、数字化技术辅助颅缝早闭症的术前手术模拟,复位导板制作应用,可以提高手术精确性及安全性。3、建立了颅缝早闭症的头颅有限元模型及额眶前移模拟截骨有限元模型,可以了解畸形的病理发生机制;进行更加精细的手术模拟及安全的手术;明确额眶前移对颅面和颅底形态及发育的影响,在额眶前移截骨基础上进行牵引力模拟加载,优化牵引方向及牵引力大小,为后期牵引器的设计奠定理论基础。
[Abstract]:Objective 1 to explore the objective measurement of bone tissue, soft tissue and brain volume in patients with craniofacial early closure based on three-dimensional digital technology. Objective and objective quantitative evaluation of the surgical procedure and effect of frontal and orbital motion..2 based on three-dimensional digital design and manufacturing technology, according to pre operation simulation design and navigation guide plate, in order to achieve individualized precision. Objective.3 to establish a three-dimensional finite element analysis model of craniofacial early closure deformity for the objective of craniofacial reconstruction. The biomechanical characteristics and changes of the deformity formation and craniotomy and simulated traction were analyzed in order to lay a theoretical foundation for the clinical application of the built-in tractor. Method 1 the craniotomy early closure from January 2010 to March 2017 was selected. In 12 cases, 3 cases of craniotomy with craniotomy in maxillofacial plastic surgery center were selected from August 2014 to December 2016 by quantitative analysis of the bone, soft tissue, and brain structure of the skull based on the preoperative, postoperative, and DICOM data of the head CT, and the quantitative analysis of.2 was used to select the osteotomy program of the preoperative design and determine the bone with the CT data. The position of the reposition of the valve, the reduction guide plate used in prefabrication and the reduction of the bone flap in the operation, the difference of the moving distance between the cranial markers and the preoperative simulation and the actual situation after the operation, and the three-dimensional digital technique of.3 were used to make the craniofacial closure of the cranial seture. The mechanism of the pathological process of the deformity was discussed. The three-dimensional finite element biomechanical analysis of the anatomic structure after frontal orbital preshift was carried out and the traction simulated loading was carried out on the fronto orbital anterior truncation. Results 1, there were statistical differences between the affected side of the skull base and the healthy side: the measurement index of the anterior cranial fossa (CSX, CX, SX) before the operation. The median cranial fossa measurements (XSM, S-Pt, XM, SM) were statistically different from preoperative. Anterior cranial symmetry index, anterior cranial fossa skew angle, frontal angle, frontal angle, lateral temporal angle, temporal angle. The preoperative volume of brain was statistically different from that in control group; there was no statistical difference between the cerebral volume and the control group at the postoperative and follow-up; the changes of the anterior bone flap were measured: Bilateral frontal orbitoflobes move forward more laterally than unilateral frontal orbit. Unilateral frontal orbital anterior shift is less effective than bilateral frontal bone flap.2 for correcting temporomandibular malformation. The operation time is shortened from 0.5 hours to 1 hours with a three-dimensional printing reduction guide plate assisted operation, and the reduction time is about 0.5 hours to 1 hours. The symmetry of the frontal and orbital sides was similar; the effect of the displacement difference between the postoperatively and the surgical simulation was similar to.3. The three-dimensional finite element model (static stress analysis model) of the 4 node first order tetrahedron element (static stress analysis model), the finite element model of the unilateral and bilateral frontal orbital anterior shift osteotomy (dynamic stress analysis model) were established. The results of stress analysis showed that there were many stress concentration regions in the left temporal and left sides of the affected side, suggesting that the resistance of the lateral orbital collapse was derived from the coronary suture of the early closed ossification, and the stress distribution in the anterior and middle cranial fossa was concentrated, suggesting that the coronal suture of ossification and the early closure of the extension suture to the base of the skull were formed. The resistance of the anterior cranial fossa is small. The finite element model of the frontal orbital forward simulated osteotomy suggests that the operation method we adopt can relieve the resistance, reduce the stress of the skull base, be beneficial to the skull base, the maxillofacial growth and development under the action of the brain and the growth of the eyeball. After the traction force exerted on the forehead and the temporomandibular part, the orbit is applied. Conclusion 1, the skull base, the bone and the soft tissue in the skull and the temporomandibular part of the children with craniofacial early closure are deformed, the volume of the brain is lower than that of the normal, and the deformity of the brain is improved after the frontal orbital shift, and the bilateral frontal orbit moves better than the unilateral frontal orbit to improve the.2 of the temporomandibular malformation. The preoperative simulation of craniotomy for craniotomy and the application of the reduction guide can improve the accuracy and safety of the operation. The cranial finite element model of craniotomy and the frontal and orbital anterior shift simulated osteotomy finite element model can be established to understand the pathophysiological mechanism of the deformity, and to make more detailed surgical simulation and safety.3. The effect of frontal orbit movement on the shape and development of craniofacial and skull base was determined, and the traction force was simulated on the base of frontal and orbital anterior truncation, the direction of traction and the size of traction were optimized, which laid a theoretical foundation for the design of the later tractor.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R782.2

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