颧骨“L”型截骨降低术的数字化分析与解剖学研究
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摘要
研究目的
颧骨“L”型截骨降低术在临床上已被广泛应用近20年,但对于这一术式的研究却非常少。本课题旨在通过以下几个方面对其进行探索性研究：
1.分别对三维CT影像以及颧弓位X线影像进行测量和分析,研究颧骨“L"型截骨降低术前后颅面骨性结构的变化；
2.建立关于颧骨“L”型截骨降低术的三维有限元模型,探讨该术式在生物力学方面的特点；
3.评估患者术后颧面部的感觉功能受到影响的程度；
4.对颧骨“L”型截骨降低术所涉及的颧面孔相关神经、血供进行解剖学研究,探讨颧面部相关神经之间的关系。
研究方法
1.分别对24例接受颧骨“L”型截骨降低术患者术前与术后的CT数据,运用三维选点法、三维配准法进行测量和分析,采取前后自身对照的方法,分析手术前后患者颅面结构的变化情况。
2.根据头影测量学的原则,设计、研制颧弓位头影测量定位摄影椅,辅助患者拍摄颧弓位X线片时摆放体位。
3.分别对17例患者术前与术后的颧弓位X线影像进行头影测量和数字图像处理,分析手术前后患者颅面结构的变化情况。
4.选取高颧骨患者男女各1例,采集术前CT数据,通过三维重建、手术模拟、划分网格、材料赋值等步骤,建立颧骨“L”型截骨降低术三维有限元模型,模拟术中为形成颧弓根部的青枝骨折而对颧骨颧弓进行按压,通过有限元分析法研究颧骨颧弓的形变、应力分布特点。
5.通过对34例患者术前与术后10天颧面部感觉进行测量和调查,采取前后自身对照的方法,评估患者颧面部感觉功能的变化。
6.分别以26例干性颅骨标本及6例新鲜头颅标本,分别对颧面孔分布特点、颧面神经、颧颞神经、眶下神经、面神经的颞支和颧支,以及颧面动脉等与颧骨“L”型截骨降低术相关的结构的分布、走行进行解剖研究。
研究结果：
1.使用三维选点法测量发现：颧骨“L”型截骨降低术后5项指标与术前相比,差异有统计学意义。其分别是：前面宽(zp-zp)、颧突点与颧弓点间弧长的中点间距(mpy-mpy)、颧突距(po-zp)、颧突角(∠n-zp-po)、前面宽指数(zp-zp/ft-ft)。
2.使用三维配准法显示：所有患者在接受颧骨“L”型截骨降低术,手术区域骨性结构变化呈现一共同趋势：颧颌缝的外侧存在一较小区域差值最大；以该区域为圆心,差值变化向外上方逐渐减小；至A区(颧弓根部区域),差值逐渐减小至公差范围。
3.使用颧弓位X线片头影测量发现：颧骨“L"型截骨降低术前后5对测量项目的变化具有统计学意义。其分别是：颧骨体最前点到X轴的距离(3-X)、颧突点到X轴的距离(4-X)、颧突点到Y轴的距离(4-Y)、颧突点与颧弓点弧长的中点到Y轴的距离(5-Y)、颧突根角：颧突点与颧弓根点的连线和X轴的夹角(∠4-7-X)
4.通过对手术前后的颧弓位二维影像的图像处理分析显示,所有接受颧骨“L”型截骨降低术患者,配准术前与术后的颧弓位影像显示出颧骨颧弓共同的内收、降低的变化趋势：该变量一般从颧弓的中部开始,向前方逐渐增大,至颧突区其变化量达到最大,再向前方则逐渐减小。术后颧骨颧弓的轮廓线的较之术前更趋于平滑,其弯曲的程度减小。
5.通过应用数字化技术,利用三维的CT数据合成了较为清晰的二维颧弓位X线影像。对两种颧弓位影像,用同样头影测量方法所得到的测量数据明显无统计学差异。
6.建立了2个颧骨“L”型截骨降低术的三维有限元模型,形变分析显示：颧骨颧弓向内发生形变位移,从颧弓根部至颧骨的前份位移量逐渐增大,颧骨截骨端顶点是位移量最大。应力分析显示：在颧弓的根部出现一个单一独立的应力明显集中区域。
7.术前与术后10天的测量评估,未发现颧骨“L”型截骨降低术后患者颧面部感觉有明显变化。
8.面神经、眶下神经、颧颞神经与颧面神经之间关系密切,相邻的神经之间存在交通支。
9.颧面动脉骨外段分为深、浅两支：深支在骨膜上紧贴,沿颧弓向后方走行,浅支则一直与颧面神经的各分支紧密伴行。
10.国人的颧面动脉、颧颞动脉的来源是上颌动脉的颞深动脉前支。
结论
1.颧骨“L”型截骨降低术前后骨性结构发生明显的变化：颧骨体的突度、宽度变化最为明显,颧弓前中部明显内收、宽度降低,但颧弓的根部保持稳定,其宽度无明显改变。
2.颧弓位X线头影测量和图像分析方法,满足常规类型的颧骨美容手术的临床诊疗、随访的一般需要。
3.颧骨“L”型降低截骨术中,对颧骨颧弓的按压能够在颧弓根部产生一个单一的应力集中区域,从而使颧弓根部发生青枝骨折,致使颧骨、颧弓发生向内的形变。
4.颧骨“L”型截骨降低术通常不会对患者颧面部感觉造成明显影响。
5.颧面神经与眶下神经、颧颞神经、面神经之间存在复杂的交通、相邻关系,它们在代偿颧面神经功能中可能均有作用。面神经在颧面区、眶下区感觉功能有重要意义。
Objective
1. The Reduction Malarplasty with L-shaped Osteotomy has been widely used in clinical practice for nearly20years, but research on this is very rare.In our exploratory study, we aimed at the following aspects:
2. To compare the morphology changes of the craniofacial structures before and after the Reduction malarplasty with L-shaped osteotomy, based on measurements and analysis of the three-dimensional CT imaging and submentovertex view radiograph.
3. To establish three dimensional finite element model of the Reduction Malarplasty with L-shaped Osteotemy, and to explore biomechanical characteristics of the surgery.
4. To evaluate the extent of the sensory function of the zygomatic facial area affected by the surgery.
5. To study the anatomy relationships among the nerves and blood supplies which related with the zygomaticofacial foramen.
Methods
1. Preoperative and postoperative CT data of24patients who received the Reduction Malarplasty with L-shaped Osteotomy were measured and analyzed to find the morphology changes of the craniofacial structures with the three-dimensional selected points method and the three-dimensional registration method.
2. Based on the cephalometrics principles, we designed and manufactured a cephalometer chair for submentovertex view radiograph positioning.
3. Preoperative and postoperative submentovertex view cephalometric radiographs of17patients who received the Reduction Malarplasty with L-shaped Osteotomy were measured and Image processed to compare the morphology changes of the craniofacial structures.
4. Followed by the three dimensional reconstruction and L-shaped osteotemy simulation remeshing, and material properties assignment, the3D finite element model of the Reduction Malarplasty with L-shaped Osteotemy was established, which were based2patients' CT data. The FEA model was carried out biomechanical analysis under the load of simulated zygomatic pressure.
5. The sensation measurements and surveys were done to the34patients preoperative and postoperative10days respectively, to assess the changes of the sensory function in zygomaticfacial area.
6.26dry skull specimens and6fresh skull specimens were respectively anatomical studied to find the Reduction Malarplasty with L-shaped Osteotomy related structures connections and distribution characteristics, which is like the zygomatic foramen, zygomaticofacial nerve, zygomaticotemporal nerve, infraorbital nerve, temporal branch and zygomatic branch of facial nerve, zygomaticofacial artery etc.
Results
1. By using the three-dimensional selected points method measurement, significant differences were found in five indicators before and after the Reduction Malarplasty with L-shaped Osteotomy, and they were:the distance between the bilateral zygomatic process (zp-zp), the distance between the bilateral midpoint of the zp and zy (mpy-mpy), the bilateral distance from zygomatic process to porion (po-zp), the zygomatic process angle (∠n-zp-po), and the zygomaticofrontal index (zp-zp/ft-ft).
2. By using the three-dimensional registration method measurement, a common trend of morphology changes of the craniofacial structures was showed:the maximum difference was located just outside of the zygomaticomaxillary suture; from this area to the superolateral area, the difference was gradually decreases like a series of concentric circles. Till the root of the zygomatic arch, the difference decreases to the tolerance.
3. By using the submentovertex view cephalometric radiographs,significant differences were found in five pairs of indicators before and after the Reduction Malarplasty with L-shaped Osteotomy, and they were:the distance from the Most forward point of the zygomatic body to the X-axis distance (3-X), the distance from the zygomatic process point to the X-axis (4-X), the distance from the zygomatic process point to the Y-axis(4-Y), the distance from the midpoint of the zygomatic process point and the zygionto to the Y-axis (5-Y), the zygomatic process root angle: the angle between the line connected with the zygomatic process point to the point of the root of the zygomatic arch and the X-axis (∠4-7-X).
4. By using Image processing and analysis of the two-dimensional image of the submentovertex radiographs, a common trend of change was showed:the variable starting from the middle of the zygomatic arch, gradually increasing to the anterior part, and to the zygomatic process, the change reaches the maximum, and then to the anterior area,it gradually decreases. The postoperative zygomatic contour tends to be more smooth, and its degree of bending is reduced compared with the preoperative ones.
5. Through the application of digital technology, the use of three-dimensional CT data synthesis clear two-dimensional submentovertex radiographs image. There is no obviously significant difference in the measurement data obtained with the same cephalometric from the two kinds of submentovertex radiographs images.
6. The two3D finite element models were established. The deformation analysis revealed that:from the root of the zygomatic arch to the anterior of the zygomatic body, the inward displacement gradually increasing;the maximum amount of displacement were on the zygomatic osteotomy end vertex. Stress analysis revealed that:a single independent stress was concentrated in the root of the zygomatic arch area.
7. From the sensation measurements and surveys, there is no significant changes were found preoperative and postoperative10days in the zygomaticfacial area.
8. There were complicate relationship among the zygomaticofacial nerve and the zygomaticotemporal nerve, infraorbital nerve, facial nerve. There were communications between the ones adjacent each other.
9. The out-bone segment of the zygomatic facial artery is divided into a deep branch and superficial branch:the deep branch close and beyond the periosteum, towards the rear along the zygomatic arch; the superficial branch were closely accompany with the branch of the zygomaticofacial nerve.
10. The zygomaticofacial artery and the zygomaticotemporal artery originate from the anterior branch of the deep temporal artery of the maxillary artery in Chinese people.
Conclusion
1. Significant craniofacial morphology changes can be found post the Reduction Malarplasty with L-shaped Osteotomy:the changes of the protrution and width of the zygomatic body were the most obvious, the inward displacement of the anterior and middle part of the zygomatic arch were also very obvious. But the root of the zygomatic arch almost remained stable, and there is no significant changes on their width.
2. The submentovertex radiographs cephalometric and image processing methods can meet the general needs of the clinical diagnosis, treatment and the follow-up of the ordinary cosmetic surgery of the zygomatic complex.
3. Pressing the zygoma in the Reduction Malarplasty with L-shaped Osteotemy can lead to an expected greenstick fracture just on the root of the zygomatic arch, which result in an inward and lower deformation.
4. The Reduction Malarplasty with L-shaped Osteotomy is usually not cause significant impact on patients'zygomaticofacial sensation function.
5. The Zygomaticofacial nerve has very complicate communication and adjacent relationship with the infraorbital nerve, the zygomaticotemporal nerve, and the facial nerve. They may have some compensatory function for the zygomaticofacial nerve. The facial nerve maybe play a significant role of sensory function in the zygomaticfacial and the infraorbital area.
颧骨“L”型截骨降低术在临床上已被广泛应用近20年,但对于这一术式的研究却非常少。本课题旨在通过以下几个方面对其进行探索性研究：
1.分别对三维CT影像以及颧弓位X线影像进行测量和分析,研究颧骨“L"型截骨降低术前后颅面骨性结构的变化；
2.建立关于颧骨“L”型截骨降低术的三维有限元模型,探讨该术式在生物力学方面的特点；
3.评估患者术后颧面部的感觉功能受到影响的程度；
4.对颧骨“L”型截骨降低术所涉及的颧面孔相关神经、血供进行解剖学研究,探讨颧面部相关神经之间的关系。
研究方法
1.分别对24例接受颧骨“L”型截骨降低术患者术前与术后的CT数据,运用三维选点法、三维配准法进行测量和分析,采取前后自身对照的方法,分析手术前后患者颅面结构的变化情况。
2.根据头影测量学的原则,设计、研制颧弓位头影测量定位摄影椅,辅助患者拍摄颧弓位X线片时摆放体位。
3.分别对17例患者术前与术后的颧弓位X线影像进行头影测量和数字图像处理,分析手术前后患者颅面结构的变化情况。
4.选取高颧骨患者男女各1例,采集术前CT数据,通过三维重建、手术模拟、划分网格、材料赋值等步骤,建立颧骨“L”型截骨降低术三维有限元模型,模拟术中为形成颧弓根部的青枝骨折而对颧骨颧弓进行按压,通过有限元分析法研究颧骨颧弓的形变、应力分布特点。
5.通过对34例患者术前与术后10天颧面部感觉进行测量和调查,采取前后自身对照的方法,评估患者颧面部感觉功能的变化。
6.分别以26例干性颅骨标本及6例新鲜头颅标本,分别对颧面孔分布特点、颧面神经、颧颞神经、眶下神经、面神经的颞支和颧支,以及颧面动脉等与颧骨“L”型截骨降低术相关的结构的分布、走行进行解剖研究。
研究结果：
1.使用三维选点法测量发现：颧骨“L”型截骨降低术后5项指标与术前相比,差异有统计学意义。其分别是：前面宽(zp-zp)、颧突点与颧弓点间弧长的中点间距(mpy-mpy)、颧突距(po-zp)、颧突角(∠n-zp-po)、前面宽指数(zp-zp/ft-ft)。
2.使用三维配准法显示：所有患者在接受颧骨“L”型截骨降低术,手术区域骨性结构变化呈现一共同趋势：颧颌缝的外侧存在一较小区域差值最大；以该区域为圆心,差值变化向外上方逐渐减小；至A区(颧弓根部区域),差值逐渐减小至公差范围。
3.使用颧弓位X线片头影测量发现：颧骨“L"型截骨降低术前后5对测量项目的变化具有统计学意义。其分别是：颧骨体最前点到X轴的距离(3-X)、颧突点到X轴的距离(4-X)、颧突点到Y轴的距离(4-Y)、颧突点与颧弓点弧长的中点到Y轴的距离(5-Y)、颧突根角：颧突点与颧弓根点的连线和X轴的夹角(∠4-7-X)
4.通过对手术前后的颧弓位二维影像的图像处理分析显示,所有接受颧骨“L”型截骨降低术患者,配准术前与术后的颧弓位影像显示出颧骨颧弓共同的内收、降低的变化趋势：该变量一般从颧弓的中部开始,向前方逐渐增大,至颧突区其变化量达到最大,再向前方则逐渐减小。术后颧骨颧弓的轮廓线的较之术前更趋于平滑,其弯曲的程度减小。
5.通过应用数字化技术,利用三维的CT数据合成了较为清晰的二维颧弓位X线影像。对两种颧弓位影像,用同样头影测量方法所得到的测量数据明显无统计学差异。
6.建立了2个颧骨“L”型截骨降低术的三维有限元模型,形变分析显示：颧骨颧弓向内发生形变位移,从颧弓根部至颧骨的前份位移量逐渐增大,颧骨截骨端顶点是位移量最大。应力分析显示：在颧弓的根部出现一个单一独立的应力明显集中区域。
7.术前与术后10天的测量评估,未发现颧骨“L”型截骨降低术后患者颧面部感觉有明显变化。
8.面神经、眶下神经、颧颞神经与颧面神经之间关系密切,相邻的神经之间存在交通支。
9.颧面动脉骨外段分为深、浅两支：深支在骨膜上紧贴,沿颧弓向后方走行,浅支则一直与颧面神经的各分支紧密伴行。
10.国人的颧面动脉、颧颞动脉的来源是上颌动脉的颞深动脉前支。
结论
1.颧骨“L”型截骨降低术前后骨性结构发生明显的变化：颧骨体的突度、宽度变化最为明显,颧弓前中部明显内收、宽度降低,但颧弓的根部保持稳定,其宽度无明显改变。
2.颧弓位X线头影测量和图像分析方法,满足常规类型的颧骨美容手术的临床诊疗、随访的一般需要。
3.颧骨“L”型降低截骨术中,对颧骨颧弓的按压能够在颧弓根部产生一个单一的应力集中区域,从而使颧弓根部发生青枝骨折,致使颧骨、颧弓发生向内的形变。
4.颧骨“L”型截骨降低术通常不会对患者颧面部感觉造成明显影响。
5.颧面神经与眶下神经、颧颞神经、面神经之间存在复杂的交通、相邻关系,它们在代偿颧面神经功能中可能均有作用。面神经在颧面区、眶下区感觉功能有重要意义。
Objective
1. The Reduction Malarplasty with L-shaped Osteotomy has been widely used in clinical practice for nearly20years, but research on this is very rare.In our exploratory study, we aimed at the following aspects:
2. To compare the morphology changes of the craniofacial structures before and after the Reduction malarplasty with L-shaped osteotomy, based on measurements and analysis of the three-dimensional CT imaging and submentovertex view radiograph.
3. To establish three dimensional finite element model of the Reduction Malarplasty with L-shaped Osteotemy, and to explore biomechanical characteristics of the surgery.
4. To evaluate the extent of the sensory function of the zygomatic facial area affected by the surgery.
5. To study the anatomy relationships among the nerves and blood supplies which related with the zygomaticofacial foramen.
Methods
1. Preoperative and postoperative CT data of24patients who received the Reduction Malarplasty with L-shaped Osteotomy were measured and analyzed to find the morphology changes of the craniofacial structures with the three-dimensional selected points method and the three-dimensional registration method.
2. Based on the cephalometrics principles, we designed and manufactured a cephalometer chair for submentovertex view radiograph positioning.
3. Preoperative and postoperative submentovertex view cephalometric radiographs of17patients who received the Reduction Malarplasty with L-shaped Osteotomy were measured and Image processed to compare the morphology changes of the craniofacial structures.
4. Followed by the three dimensional reconstruction and L-shaped osteotemy simulation remeshing, and material properties assignment, the3D finite element model of the Reduction Malarplasty with L-shaped Osteotemy was established, which were based2patients' CT data. The FEA model was carried out biomechanical analysis under the load of simulated zygomatic pressure.
5. The sensation measurements and surveys were done to the34patients preoperative and postoperative10days respectively, to assess the changes of the sensory function in zygomaticfacial area.
6.26dry skull specimens and6fresh skull specimens were respectively anatomical studied to find the Reduction Malarplasty with L-shaped Osteotomy related structures connections and distribution characteristics, which is like the zygomatic foramen, zygomaticofacial nerve, zygomaticotemporal nerve, infraorbital nerve, temporal branch and zygomatic branch of facial nerve, zygomaticofacial artery etc.
Results
1. By using the three-dimensional selected points method measurement, significant differences were found in five indicators before and after the Reduction Malarplasty with L-shaped Osteotomy, and they were:the distance between the bilateral zygomatic process (zp-zp), the distance between the bilateral midpoint of the zp and zy (mpy-mpy), the bilateral distance from zygomatic process to porion (po-zp), the zygomatic process angle (∠n-zp-po), and the zygomaticofrontal index (zp-zp/ft-ft).
2. By using the three-dimensional registration method measurement, a common trend of morphology changes of the craniofacial structures was showed:the maximum difference was located just outside of the zygomaticomaxillary suture; from this area to the superolateral area, the difference was gradually decreases like a series of concentric circles. Till the root of the zygomatic arch, the difference decreases to the tolerance.
3. By using the submentovertex view cephalometric radiographs,significant differences were found in five pairs of indicators before and after the Reduction Malarplasty with L-shaped Osteotomy, and they were:the distance from the Most forward point of the zygomatic body to the X-axis distance (3-X), the distance from the zygomatic process point to the X-axis (4-X), the distance from the zygomatic process point to the Y-axis(4-Y), the distance from the midpoint of the zygomatic process point and the zygionto to the Y-axis (5-Y), the zygomatic process root angle: the angle between the line connected with the zygomatic process point to the point of the root of the zygomatic arch and the X-axis (∠4-7-X).
4. By using Image processing and analysis of the two-dimensional image of the submentovertex radiographs, a common trend of change was showed:the variable starting from the middle of the zygomatic arch, gradually increasing to the anterior part, and to the zygomatic process, the change reaches the maximum, and then to the anterior area,it gradually decreases. The postoperative zygomatic contour tends to be more smooth, and its degree of bending is reduced compared with the preoperative ones.
5. Through the application of digital technology, the use of three-dimensional CT data synthesis clear two-dimensional submentovertex radiographs image. There is no obviously significant difference in the measurement data obtained with the same cephalometric from the two kinds of submentovertex radiographs images.
6. The two3D finite element models were established. The deformation analysis revealed that:from the root of the zygomatic arch to the anterior of the zygomatic body, the inward displacement gradually increasing;the maximum amount of displacement were on the zygomatic osteotomy end vertex. Stress analysis revealed that:a single independent stress was concentrated in the root of the zygomatic arch area.
7. From the sensation measurements and surveys, there is no significant changes were found preoperative and postoperative10days in the zygomaticfacial area.
8. There were complicate relationship among the zygomaticofacial nerve and the zygomaticotemporal nerve, infraorbital nerve, facial nerve. There were communications between the ones adjacent each other.
9. The out-bone segment of the zygomatic facial artery is divided into a deep branch and superficial branch:the deep branch close and beyond the periosteum, towards the rear along the zygomatic arch; the superficial branch were closely accompany with the branch of the zygomaticofacial nerve.
10. The zygomaticofacial artery and the zygomaticotemporal artery originate from the anterior branch of the deep temporal artery of the maxillary artery in Chinese people.
Conclusion
1. Significant craniofacial morphology changes can be found post the Reduction Malarplasty with L-shaped Osteotomy:the changes of the protrution and width of the zygomatic body were the most obvious, the inward displacement of the anterior and middle part of the zygomatic arch were also very obvious. But the root of the zygomatic arch almost remained stable, and there is no significant changes on their width.
2. The submentovertex radiographs cephalometric and image processing methods can meet the general needs of the clinical diagnosis, treatment and the follow-up of the ordinary cosmetic surgery of the zygomatic complex.
3. Pressing the zygoma in the Reduction Malarplasty with L-shaped Osteotemy can lead to an expected greenstick fracture just on the root of the zygomatic arch, which result in an inward and lower deformation.
4. The Reduction Malarplasty with L-shaped Osteotomy is usually not cause significant impact on patients'zygomaticofacial sensation function.
5. The Zygomaticofacial nerve has very complicate communication and adjacent relationship with the infraorbital nerve, the zygomaticotemporal nerve, and the facial nerve. They may have some compensatory function for the zygomaticofacial nerve. The facial nerve maybe play a significant role of sensory function in the zygomaticfacial and the infraorbital area.
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