下颌角区域应用解剖及相关三维重建测量研究
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摘要
研究背景
东方人面部轮廓传统审美标准为“瓜子脸”、“鹅蛋脸”的脸型,面下部轮廓是影响面部整体轮廓重要因素之一。如果下颌角肥大、面下部过宽,就会被视为难看的方形脸或上窄下宽的梯形脸,从而失去东方女性特有的温柔、秀美的气质。随着人们生活水平提高和审美意识的增强,要求通过下颌角肥大整形手术改变面下部轮廓的求美者日益增多。此类手术已经成为面部整形美容手术中的重要手术之一。
下颌角肥大(prominent mandibular angle or mandibular angle hypertrophy)这一概念是由Baek等人于1989年提出。下颌角肥大的病因目前仍不完全清楚,但其病理改变,即为下颌骨的生长发育异常和(或)咬肌的肥厚,目前为大多数人所接受。东方人以下颌骨的生长发育异常为多见。人体面部是强调和谐统一的,而在整个面部轮廓中,诊断下颌角肥大是一个综合性因素考虑的结果,并且受不同人种、不同文化背景等影响,因此下颌角肥大的诊断目前还没有统一的标准。利用影像学等手段,国内、外医生和学者在下颌角肥大诊断方面做了大量的研究工作,并提出各自认为较为合理的诊断标准。王侠等对下颌角X线侧位片作过统计,认为角度<110°即可诊断。陶宏炜等认为正面下颌角宽度等于或大于颧骨宽度即可诊断,下颌角<120°也可诊断。胡静等根据下颌角肥大的X线片认为下颌角肥大诊断标准主要包括：(1)下颌角部肥大。(2)下颌平面角(MP.FH夹角)小于正常。(3)在侧位X线片上,下颌角开张度变小。(4)面下1／3高度过短。(5)非对称性改变。周智等根据大量的汉族人干性头颅测量结果,认为面颌宽比(面中宽／下颌宽)男女相对集中在1.33左右,面颌宽比可作为男女下颌角肥大通用的诊断标准之一。李慧超等通过对下颌角肥大女性的颅面三维测量提出一个供临床参考的关于下颌角肥大的三维测量诊断标准：①下颌角间距与全面高比值大于0.8；②下颌角角度小于120°；③∠GoMeGo大于65°；④下颌角间距大于95mm；⑤下颌骨升支长度大于57mm；⑥下颌骨体部长度大于82mm,Ⅶ角区最大宽度大于35mm。将三维测量上具备第一条标准并符合其它任意两条标准者定义为下颌角肥大。对于下颌角肥大的分型,国内外学者也有各自的观点。Kim等将下颌角肥大分为4型：(1)轻度肥大型：面型不方,但从侧面观察可见下颌角角度变小；(2)中度肥大型：下颌角明显外展突出；(3)重度肥大型：下颌角明显外展突出并伴咬肌肥大；(4)复合型：下颌角明显外展突出伴下颏畸形。
下颌角肥大的分类及手术方案的选择：李慧超等根据肥大下颌角的形态和他们的临床工作经验将下颌角肥大分类为：Ⅰ类—外翻型：手术方案首选下颌角截骨整形术；Ⅱ类—后下突出型：手术方案首选下颌角截骨整形术；Ⅲ类—内收型：手术方案首选下颌角截骨整形术或下颌骨外板去除术；Ⅳ类—下颌角肥大伴小颏畸形：选择下颌角截骨整形术或下颌骨外板去除术,同时行颏部水平截骨颏成形术或人工合成材料隆颏术；Ⅴ类—下颌角肥大伴有咬肌肥厚：选择下颌角截骨整形术或下颌骨外板去除术,术后根据咬肌萎缩情况决定是否需要行咬肌肉毒素注射术；Ⅵ类—轻型：手术方案首选下颌骨外板去除术。
随着研究的深入和临床相关手术的开展,近年来在手术术式的选择、并发症的处理等方面都有进一步的认识和提高。下颌角肥大整形术在我国已经成为面部整形美容手术中重要的手术项目。随着此类手术的不断开展,严重的手术并发症也不断出现。严重的手术并发症中以下颌角区域主要血管、面神经分支的损伤为最常见,原因多为下颌角区域的主要血管、神经解剖结构的认识不足,对于这些重要解剖结构的保护不到位所致。由于缺乏对于面部整体轮廓的认识,造成截骨量过多或不足,从而使面部比例关系失调。由于对于影响下颌骨轮廓的解剖结构认识不足,从而不能很好的解决正面和侧面的轮廓流畅问题,手术效果欠佳。如第二下颌角、双侧不对称、正面宽度缩窄量不够或过度、侧面轮廓不流畅、“马脸”畸形等。这些并发症都在某种程度上制约此类手术的进一步开展,增加了医生和求美者之间的纠纷几率。
目的和意义
通过本课题的研究,进一步认识下颌角区域解剖结构特征,探讨正常成年女性头面部骨性轮廓正面的比例关系,下颌角相关角度及其与下颌角间宽(面下宽)相关性,明确影响下颌骨轮廓的解剖结构及对其进行三维重建相关测量,完善下颌角肥大的相关诊断标准,提出较为合理的预防手术并发症的注意事项和方法。本课题从下颌角区域应用解剖和下颌角相关三维重建测量两方面进行相关研究,研究结果将为减少和预防手术并发症,提高手术安全性和有效性提供解剖依据和理论基础,并为进一步提高手术效果提供帮助。
方法
1.1下颌角区域应用解剖学研究
1.1.1下颌角区域解剖层次观察
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,详细观察下颌角区域从浅入深的解剖层次。
1.1.2下颌角区域主要血管的应用解剖
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。进行大体和显微解剖与观察测量。观察面动脉、面静脉、下颌后静脉的走行特点；测量面动脉、面静脉、下颌后静脉各自与下颌角点的位置关系。
1.1.3下颌角区域主要神经的应用解剖
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。进行大体和显微解剖与观察测量。观察面神经下颌缘支、面神经颈支走行和分支特点,测量面神经下颌缘支、面神经颈支出腮腺处与下颌角点的位置关系,测量和观察面神经下颌缘支与下颌骨下缘的位置关系等。
1.1.4下颌管与下颌角、下颌骨下缘(或下颌骨升支后缘)的位置关系
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。将下颌骨表面结构从骨膜剥除,以下颌角点和第三磨牙为主要标志点做标志线。各标志线为A：第三磨牙外侧至下颌骨升支后缘的垂线。B：第三磨牙外侧至下颌角点连线。C：第三磨牙外侧至下颌骨下缘的垂线。D、E：线C和线F之间三等分,分别设定标志线为D、E。F：过颏孔后缘至下颌骨下缘的垂线。沿各标志线锯开下颌骨,测量各横断截面上下颌管下缘与下颌角、下颌骨下缘(或下颌骨升支后缘)的距离,观察下颌管与下颌骨内外侧骨板的位置关系。
1.2下颌角相关螺旋CT三维重建测量研究
1.2.1头面部骨性轮廓正面比例测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就头面部骨性轮廓正面比例相关的7个测量项目进行测量,并计算相关比例。
1.2.2下颌角相关角度测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就下颌角相关角度的8个测量项目进行测量。通过SPSS13.0软件分析各角度之间的相关性以及相关角度与下颌角间宽(面下宽)的相关性。
1.2.3影响下颌骨轮廓解剖结构三维重建测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就影响下颌骨轮廓(正面、侧面)的四个区域(下颌骨升支后缘区、下颌角区、下颌骨下缘区、斜线区)分别定点,A点：下颌骨升支后缘区与下颌角区过渡点上2cm(沿下颌骨升支后缘方向)；B点：下颌骨升支后缘区与下颌角区过渡点上1cm(沿下颌骨升支后缘方向)；C点：下颌骨升支后缘区与下颌角区过渡点；D点：下颌角点；E点：下颌角区与下颌骨下缘过渡点；F点：下颌角区与下颌骨下缘区过渡点前lcm(沿下颌骨下缘方向)；G点：下颌角区与下颌骨下缘区过渡点前2cm(沿下颌骨下缘方向)；H点：斜线与下颌骨下缘相融合点；Ⅰ点：斜线与下颌骨下缘相融合点前1cm(沿下颌骨下缘方向)；J点：斜线与下颌骨体融合点；K点：H点与J点的中点(沿斜线方向)。测量各点下颌骨的厚度及下颌骨外板的骨质厚度。数据合并统计得到影响下颌骨轮廓的四个区域的下颌骨平均厚度、下颌骨外板平均厚度。
1.3统计学处理
将测量结果输入SPSS13.0软件,首先Kolomogorov-Smirnov正态分布假设检验,证实所得各项测量指标的计量数据符合正态分布,然后计算结果的平均值、标准差,分析头面部轮廓比例关系、下颌角相关角度及下颌角间宽(面下宽)之间的线性相关性。左右侧数据进行配对t检验,若P>0.05表示无显著性差异；若P<0.05表示存在显著性差异。
1.4面下部轮廓整形术术式的回顾性分析
以我院行面下部轮廓整形术患者95例为研究对象。在全面检查的基础上结合下颌角肥大诊断标准等对患者面下部轮廓情况进行分类,并根据分类选择手术方法。
结果
2.1下颌角区域的解剖层次特点
解剖层次由浅入深依次是皮肤、皮下脂肪、SMAS筋膜及颈阔肌、包裹腮腺、咬肌的腮腺咬肌筋膜、咬肌、下颌骨骨膜。在皮肤、SMAS筋膜及颈阔肌和腮腺咬肌筋膜之间可观察到宽大的颈阔肌耳韧带、篱笆状咬肌皮肤韧带。面动脉、面静脉、下颌后静脉、面神经下颌缘支、面神经颈支位于同一解剖层次,此层次位于腮腺咬肌筋膜之下。
2.2下颌角区域重要血管的应用解剖特点
面动脉起自颈外动脉的前壁,经茎突舌骨肌、二腹肌后腹和舌下神经的深面,至颏下三角,经下颌下腺后上方的面神经沟后,至咬肌附着前缘处,绕下颌体下缘至面部。在下颌体下缘处面静脉与面动脉伴行,80%(16侧)的面动脉位于面静脉的前方,20%(4侧)的面动脉位于面静脉的前深方。面静脉在颌下区走向外下与下颌后静脉汇合成面总静脉。平下颌骨下缘处,面动、静脉位置表浅,浅面有面神经下颌缘支、颈阔肌、薄层皮下脂肪、皮肤；深面紧贴下颌骨骨膜。面动脉跨过下颌骨下缘处与下颌角点的距离为(30.06±4.25)mm、面静脉跨过下颌骨下缘处与下颌角点的距离(沿下颌骨下缘方向)为(27.55±4.02)mm。
下颌后静脉由颞浅静脉和上颌静脉于下颌骨颈的后方汇合而成,穿入腮腺,在外耳门前方下行于颈外动脉的浅面。下颌后静脉与面神经或其主要分支近于十字形交叉,它们之间很少有腮腺组织分隔,多直接相贴。下颌后静脉与下颌骨升支后缘几乎平行走形,此处管壁较薄,管径较粗,仅隔骨膜或薄层腮腺组织与下颌骨升支后缘相贴。穿出腮腺下极后,分为前后两支16侧(占80%)；前支行向前下注入面静脉,后支与耳后静脉汇合成颈外静脉。4侧(占20%)不分前后支直接和面静脉汇合成颈外静脉。下颌后静脉与下颌角的关系分为2种类型：①紧密结合型：下颌后静脉及其属支形成的弧形结构与下颌角紧密相贴,距离较近8侧占40%；②松散结合型：下颌后静脉及其属支形成的弧形结构与下颌角有一定距离12侧占60%。观察发现下颌角越往后下突出,下颌后静脉与下颌角距离越近。下颌后静脉与下颌骨升支后缘水平距离为(3.00±0.56)mm、下颌后静脉与下颌角点水平距离为(12.20±1.09)mm。
2.3下颌角区域重要神经的应用解剖特点
面神经下颌缘支为1-2支,多为1支,从面神经的面颈干发起后,均经过下颌角上方和咬肌后缘处,位置较为恒定。下颌缘支自腮腺浅出后的行径大体为走行于咬肌筋膜内,在咬肌前缘跨过面动脉、面静脉,此位置比较恒定,未发现不与面动脉交叉的情况；最后分支支配颈阔肌、降口角肌、降下唇肌、颏肌。下颌缘支出腮腺位置距离下颌角点为(10.36±0.41)mm,下颌缘支出腮腺后与下颌骨下缘的位置关系可分为三种情况：①平行走行于下颌骨下缘之上,距下颌骨下缘(6.84±0.70)mm,12侧占60%,在咬肌前缘几乎平行与面动脉交叉；②大致平下颌骨下缘,相当于下颌骨下缘与颌下腺之间的沟内行走,6侧占30%,在咬肌前缘斜向上与面动脉交叉;③呈弓状行走于下颌骨下缘以下,最低不超过1.2cm,2侧占10%,在咬肌前缘斜向上与面动脉交叉。面神经下颌缘支与面动脉交叉情况可分为三种：①下颌缘支位于面动脉浅面者16侧占80%;②位于深面者2侧占10%;③下颌缘支分两支经其浅面或深面夹持或环抱面动脉,然后合成1支,2侧占10%。观察还发现4侧占20%面神经下颌缘支与面神经下颊支存在吻合现象。面神经下颌缘支跨越面动脉位置与下颌骨下缘的距离(6.93±0.42)mm。
面神经颈支为面颈干的终末支,由腮腺下缘穿出,行经下颌角点后方(9.92±0.40)mm,在颈阔肌深面行向前下方,分支支配颈阔肌。2.4下颌管走行特点及其与下颌角、下颌骨下缘(或下颌骨升支后缘)位置关系
以下颌角点和第三磨牙为主要标志点做标志线。下颌管在各下颌骨标志线截面上下颌管下缘到下颌角、下颌骨下缘(或下颌骨升支后缘)距离分别为A：(14.52±1.21)mm；B：(16.64±0.88)mm；C：(14.14±1.00)mm；D：(12.03±0.91)mm；E：(10.26±0.98)mm；F：(15.22±1.29)mm。观察下颌管与下颌骨内外侧骨板的位置关系发现：下颌管的全长走行几乎全是紧贴着舌侧骨板前行,愈近下颌后部贴附舌侧骨板愈紧。
2.5头面部骨性轮廓正面比例的三维重建测量
三维重建图像上测量头面部骨性轮廓正面比例相关数据,颅骨最大宽：(145.13±2.95)m；面宽(颧点间宽)：(133.77±4.52)mm；下颌角间宽(下面宽)：(97.18±2.38)mm；颅骨最大宽／面宽(颧点间宽)：1.09±0.02；面宽(颧点间宽)／下颌角间宽(下面宽)：1.38±0.03；颅骨最大宽／下颌角间宽(下面宽)：1.49±0.03。颅顶点-鼻根点：(105.40±3.10)mm；鼻根点-上齿龈前点(上面高)：(69.00±2.95)mm；上齿龈前点-颏下点：(46.58±1.97)mm；鼻根点-颏下点(全面高)：(111.49±4.17)mm；颅顶点-鼻根点／鼻根点-上齿龈前点(上面高)：1.53±0.03；鼻根点-上齿龈前点(上面高)／上齿龈前点-颏下点：1.48±0.07；颅顶点-鼻根点／上齿龈前点-颏下点：2.27±0.09；鼻根点-上齿龈前点(上面高)／鼻根点-颏下点(全面高)：0.62±0.02；上齿龈前点-颏下点／鼻根点-颏下点(全面高)：0.42±0.02；颅顶点-鼻根点／鼻根点-颏下点(全面高)：0.95±0.02。颅骨最大宽／颅顶点-鼻根点：1.38±0.05；面宽(颧点间宽)／鼻根点-上齿龈前点(上面高)：1.94±0.10；下面宽(下颌角间宽)／上齿龈前点-颏下点：2.09±0.10。
2.6下颌角相关角度的三维重建测量
三维重建图像上测量下颌角相关角度,下颌角(左)：(124.10±4.03)度；下颌角(右)：(124.46±4.22)度；下颌仰角(左)：(25.42±2.17)度；下颌仰角(右)：(25.61±2.28)度；下颌角外翻角(左)：(9.23±7.72)度；下颌角外翻角(右)：(9.47±8.03)度；下颌夹角：(77.32±2.34)度；下颌切线角：(105.53±1.79)度。
下颌角相关角度及其与下颌角间宽(下面宽)之间的线性相关性分析：下颌角外翻角、下颌夹角、下颌切线角、下颌角间宽四个指标之间存在显著性正相关,r值范围(0.617-0.976),(P<0.01)。
下颌角角度与下颌角间宽、下颌夹角、下颌角外翻角、下颌切线角并无显著性相关(P=0.048,P=0.019,P=0.184,P=0.019)。下颌仰角与下颌角间宽、下颌夹角、下颌角外翻角、下颌切线角并无显著性相关(P=0.303,P=0.143,P=0.709,P=0.095)。下颌角角度与下颌仰角呈显著正相关(r=0.884,P=0.000)。
2.7影响下颌骨轮廓解剖结构的三维重建测量
三维重建图像上测量影响下颌骨轮廓各因素点：对各点分别测量下颌骨厚度和下颌骨外板厚度,左、右侧测量合并均值结果分别为A点：(7.20±0.64)mm、(3.32±0.36)mm；B点：(6.58±0.66)mm、(2.85±0.34)mm；C点(7.10±0.65)mm、(3.21±0.39)mm；E点：(7.52±0.79)mm、(3.35±0.38)mm；F点：(9.83±0.94)mm、(3.62±0.33)mm；G点：(12.72±1.01)mm、(4.54±0.37)mm；H点：(12.33±0.94)mm、(4.32±0.39)mm；Ⅰ点：(11.29±0.99)mm、(4.01±0.39)；D点下颌骨厚度：(6.66±0.85)mm、；下颌骨外板厚度J点：(6.34±0.47)mm；K点：(5.31±0.46)mm。
2.8面下部轮廓整形术术式的回顾分析
通过术前分类选择合适、综合的手术方法进行面下部轮廓整形术。以双侧下颌角肥大整形术为主,结合其他手术方式重塑面下部轮廓,临床效果满意。
结论
本课题通过对下颌角区域应用解剖的研究,探讨下颌角肥大整形术安全操作范围以及较为安全的截骨区域；通过螺旋CT三维重建的下颌角相关测量研究,探讨正常成年女性头面部骨性轮廓正面的和谐比例关系,下颌角相关角度以及下颌角间宽(面下宽)之间的相互关系,明确影响下颌骨轮廓的解剖因素及相关下颌骨厚度和下颌骨外板厚度。本课题从下颌角区域应用解剖和三维重建测量两方面入手研究,其结果将为提高下颌角肥大整形手术的安全性,如减少出血、神经损伤、下牙槽血管神经束损伤等并发症的发生；提高下颌角肥大整形手术的效果,如减少双侧不对称、第二下颌角、“马脸”畸形、截骨量过多或过少、缩窄量不足或过度等影响手术效果的并发症的发生；完善下颌角肥大临床的三维诊断标准等方面提供解剖依据和理论基础。对我院行面下部轮廓整形术手术方法进行回顾性分析。通过术前分类选择合适、综合的手术方法进行面下部轮廓整形术,取得良好的手术效果。说明通过术前对患者面下部轮廓情况进行分类,选择合适、综合的手术方法,将有利于提高手术效果。
本课题主要的创新之处在于：①针对临床下颌角肥大整形手术的出血、面神经分支损伤、下牙槽血管神经束损伤等严重并发症问题,我们对下颌角区域应用解剖进行研究,并且紧密以下颌角为中心,观察测量下颌角区域主要血管、神经及下颌管与下颌角、下颌骨下缘(或下颌骨升值后缘)的位置关系。以期为下颌角肥大整形手术安全操作区域、安全截骨范围提供解剖依据,避免上述重要结构的损伤,提高下颌角肥大整形手术的安全性。②我们将mimics软件用于标本的三维重建测量,该软件具有安装方便、要求电脑配置不高、重建和测量精度高并配有多种测量工具、很容易为临床医生掌握等优点。③通过螺旋CT三维重建测量头面部骨性轮廓正面横向、纵向、纵横向等比例,比以往研究更详细的探讨头面部骨性轮廓正面比例关系。以期发现某些横向、纵向以及纵横向比例的规律。④通过三维重建测量下颌角相关角度及对各相关角度进行统计学分析,明确下颌角各相关角度及其与下颌角间宽(面下宽)之间的相互关系。⑤通过三维重建测量和观察,明确影响下颌骨正面、侧面轮廓的主要解剖因素并对这些因素通过定点方式进行下颌骨厚度、下颌骨外板厚度的测量。为临床下颌角肥大整形手术的截骨和下颌骨外板处理等操作提供依据,为医生术前设计和术后评估手术效果提供理论基础。
综上所述,本课题的研究结果,将在一定程度上为减少下颌角肥大整形手术并发症,提高手术安全性起到积极作用；为全面认识正常成年女性头面部骨性轮廓正面比例提供帮助,为丰富下颌角肥大临床诊断,完善手术效果,提高手术满意度等方面提供理论支持。
Background
Asian facial contours traditional aesthetic standard is "oval face" or "goose egg face ".The basifacial contour is an important factor in affecting the overall facial contour. If the mandibular angle is hypertrophy or the basifacial width is too great, it will be regarded as an ugly face. Which is the square face or the trapezoidal face, and thus lose their gentle characteristic and beautiful temperament in oriental women,. With the improvement of people's living standard and the enhancement of aesthetic consciousness, the people who has mandibular angle hypertrophy call for changing basifacial contour by plastic and cosmetic surgery is increasing. Such surgery has become one important surgery of facial plastic and cosmetic surgery.
The concept of prominent mandibular angle or mandibular angle hypertrophy was put forward by Baek et al in 1989. The cause of mandibular angle hypertrophy is still not entirely clear at present, but the pathological changes is the anormal growth of mandible and/or masseteric hypertrophy, which is currently accepted by the most people. The anormal growth of mandible is more common in mandibular angle hypertrophy of Asians. The human face is to emphasize harmony and unity, but in the whole facial contours, the diagnosis of mandibular angle hypertrophy is the results of comprehensive considerations,and which is subject to influence different ethnicity, different cultural background,and so on, so there is no uniform standards of the diagnosis of mandibular angle hypertrophy. Domestic and foreign doctors and scholars did a lot of research in the diagnosis of mandibular angle hypertrophy by imageology and other means, and put forward their reasonable diagnostic criteria. Wang Xia et al did some statistics on the lateral X-ray films of the mandibular angle and thought the angle of mandibular angle less than 110°can be diagnosed the mandibular angle hypertrophy. TAO Hong-Wei et al thought the width of mandibular angle equal to or greater than the width of the zygoma can be diagnosed the mandibular angle hypertrophy and thought the angle of mandibular angle less than 120°also can be diagnosed it. Hu Jing et al according to the X-ray film of mandibular angle hypertrophy thought that the diagnostic criteria of mandibular angle hypertrophy include:(1) The region of the mandibular angle is hypertrophy. (2) Mandibular plane angle (MP. FH angle) is less than normal. (3) In the lateral X-ray films, the opening degree of the mandibular angle become smaller than normal. (4) Lower 1/3 height of face is too short. (5) Asymmetry change. Zhou Zhi et al according to a large number of Han people dry skull measurements, thought that the ratio of facial width and mandibular width (midface width/mandibular width) for men and women are relatively concentrated around 1.33, the ratio of facial width and mandibular width can be used as one of the diagnostic criteria for male and female mandibular angle hypertrophy, Li Hui Chao et al according to the results of three-dimensional measurements of craniofacial mandibular angle hypertrophy women and proposed a clinical reference for the mandibular angle hypertrophy of diagnostic criteria on the three-dimensional measurement:①Ratio of bigonial breadth and morphological facial height is greater than 0.8;②Angle of mandibular angle is less than 120°;③∠GoMeGo is greater than 65°;④Bigonial breadth is greater than 95mm;⑤Mandibular ascending branch length is greater than 57mm;⑥Length of mandibular body is greater than 82mm,maximum width ofⅦmandibular angle region is greater than 35mm.Three-dimensional measurements with the first standard and comply with any two other standards is defined as the mandibular angle hypertrophy. The type of the mandibular angle, domestic and foreign scholars had their own point of view. Kim et al mandibular angle hypertrophy is divided into four types:(1) Mild degree:face is not square, but angle of mandibular angle was observed smaller from the side;(2) Moderate degree:mandibular angle clear abduction and predominance;(3) Severe degree:mandibular angle significant bduction and predominance associated with masseteric hypertrophy; (4) Compound type: mandibular angle significant abduction and predominance associated with microgenia deformity.
Classification and operation project of mandibular angle hypertrophy:Li Hui Chao et al according to the shape of hypertrophic mandibular angle and their clinical experience they classified mandibular angle hypertrophy:Ⅰtype -- eversion type:the preferred operation project of this type is mandibular angle osteotomy plasty;Ⅱtype---decocted later predominance:the preferred operation project of this type is mandibular angle osteotomy plasty;Ⅲtype --adduction type:the preferred operation project of this type is mandibular angle osteotomy plasty or mandibular external circumferential lamella ablation;Ⅳtype--mandibular angle hypertrophy with microgenia:the preferred operation project of this type is mandibular angle osteotomy plasty or mandibular external circumferential lamella ablation with level osteotomy genioplasty or synthetic materials chin augmentation;Ⅴtype--mandibular angle hypertrophy associated with masseteric hypertrophy:selected the osteotomy plasty or mandibular external circumferential lamella ablation, according to the condition of postoperative masseter muscle atrophy determined whether need toxin injection or not; VI type-light:the preferred operation project of this type is mandibular angle osteotomy plasty.
With the in-depth research and the launching of clinical related surgery, in recent years the choice of surgical procedures, complications treatment, and other aspects had been further understood and improved. Mandibular angle hypertrophy plasty in our country had become an important project in facial plastic and cosmetic surgery. As the launching of the operation, serious complications were also emerging. Mandibular angle region's main blood vessels and branches of the facial nerve injury were the most common in serious surgical complications, because the anatomical structure of mandibular angle region's blood vessels and nerves had no enough knowledge and had no good protection of these important anatomical structures. Due to lack of the recognition of overall facial contour., resulting in excessive or inadequate osteotomy, so that the proportional relationship was imbalance. As lack of knowledge for the anatomical structure of the influencement of mandibular contour, which could not be satisfactorily resolved the fluent problems of the frontal and lateral contours, result was ineffective. Such as the second mandibular angle, bilateral asymmetry, inadequate or excessive narrowing the frontal width,the lateral profile is not smooth, " horse face" deformity and so on. These complications restricted further development of such operations to some extent, increased the dispute chances between doctors and patients.
Purpose and Significance
Through the research of the topic,we better understood the characteristics of regional anatomy of the mandibular angle,discussed the proportional relationship of the frontal head and facial skeletal contour in normal adult female,related angles of mandibular angle and their correlation of them and bigonial breadth,identified the anatomical structure of the influencement of mandibular contour, undertook the related measurement by three-dimensional reconstruction,improved the relevant diagnostic criteria of the mandibular angle hypertrophy,put forward a more reasonable note and methods to prevent the surgical complications. The research of the topic from two aspects:applied anatomy of mandibular angle region and associated measurement of mandibular angle by three-dimensional reconstruction, The findings will provid anatomical basis and theoretical basis in reducing and preventing the surgical complications and improving safety and effectiveness of the surgery. And it will help further enhance the results of operations.
Methods
1.1 Applied anatomical research of the mandibular angle region
1.1.1 Anatomical layer observation of the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, detailed observation anatomical level of the mandibular angle region from the shallow into the deep.
1.1.2 Applied anatomy of major blood vessels in the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomy,observe and measure. Observed courser characteristics of the facial artery, facial vein, retromandibular vein; measured the position relationship between them and the mandibular angle point.
1.1.3 Applied anatomy of important nerves in the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomiy,observe and measure.Observed Courser and branch characteristics of marginal mandibular branch of facial nerve and cervial branch of facial nerve, measured the position relationship between them and the mandibular angle point when they away from the parotid gland, measured and observed the position relationship between the marginal mandibular branch of facial nerve and the inferior border of mandible.
1.1.4 Position relationship between mandibular canal and the mandibular angle,the inferior border of mandible (or the posterior border of mandibular ascending branch)
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomiy,observe and measure.The surface structure was stripped from the mandibular periosteum,mandibular angle point and third molar point were marked as the main indicator line. Separate indicator line was A:outer margin of third molar to posterior border of mandibular ascending branch,B:outer margin of third molar to mandibular angle,C:outer margin of third molar to inferior border of mandible,D, E: trisected between line C and line F and set line D and line E,F:from posterior border of mental foramen to inferior border of mandible. And sawed mandible along the indicator line, measured the distance between mandibular canal and the mandibular angle point,the inferior border of mandible (or the posterior border of mandibular ascending branch) on the transverse cross-section and observed the position relationship between the mandibular canal and inside and outside plate of mandible.
1.2 Related measurements of mandibular angle by spiral CT three-dimensional reconstruction
1.2.1 Measured the proportions of frontal head and facial skeletal contour
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, measured 7 items about the proportion of frontal head and facial skeletal contour on the image of three-dimensional reconstruction and calculated the relative proportions.
1.2.2 Measured the related angles of mandibular angle
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, measured 8 items about the mandibular angle on the image of three-dimensional reconstruction,analyzed the correlation between the various angles, the correlation of the associated angles and bigonial breadth (basifacial breadth) by SPSS13.0 statistical software.
1.2.3 Measured the anatomical structures of the influencement of mandibular contour.
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, fixed points on the four regions (the posterior border of mandibular ascending branch area, the mandibular angle area, the inferior border of mandible area,the slash area)which influenced mandibular contour (front view, lateral view) on the image of three-dimensional reconstruction, A point:2cm above the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area (along the posterior border of mandibular ascending branch direction); B point:1cm above the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area (along the posterior border of mandibular ascending branch direction); C point:the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area; D point:the mandibular angle point; E point:the transition point between the mandibular angle area and the inferior border of mandible;F points:1cm ahead the transition point between the mandibular angle area and the inferior border of mandible area (along the inferior border of mandible direction); G points:2cm ahead the transition point between the mandibular angle area and the inferior border of mandible area (along the inferior border of mandible direction); H point:the fusion point between the slash and the inferior border of mandible;Ⅰpoint:1cm ahead of the fusion point between the slash and the inferior border of mandible (along the inferior border of mandible direction) J points:the fusion point between the slash and the mandible body; K point: the mid-point of the H point and the J point (along the slash direction). All these points were measured the thickness of mandible and the thickness of outside plate of mandible. Combined analysis of data obtained the average thickness of the mandible and the average thickness of the outside plate of mandible on the four regions.
1.3 Statistical treatment
Measurement results were input SPSS13.0 software, the first to use hypothesis testing of Kolomogorov-Smirnov normal distribution, confirmed that measurement data is normally distributed, and calculated the mean, standard deviation of the results, analyzed the proportion relationship of frontal head and facial skeletal contour and analyzed the linear correlation between the various angles, the linear correlation of the associated angles and bigonial breadth (basifacial breadth). Left and right side data carry out paired-samples t test, if P> 0.05 indicated no significant difference; if P<0.05 indicated the significant differences.
1.4 Retrospective analysis of surgical options on basifacial contours plasty
We took 95 cases patients who undertook basifacial contours plasty in our hospital as research objects. We combined diagnostic criteria of mandibular angle hypertrophy on the basis of the comprehensive examination, and classified the condition of patient's basifacial contours, and choosed surgical options according to classification.
Results
2.1 The characteristic of anatomical layers of mandibular angle region
Anatomical layers are skin, subcutaneous fat, SMAS fascia and platysma, fascia parotidea masseterica,.which parcels parotid gland and masseter muscle,masseter muscle, periosteum of mandible, from the shallow into the deep. The large platysma-auricular ligament, fence-like masseteric ligament could be observed among the skin, SAMS fascia and fascia parotidea masseterica. Facial artery, facial vein, retromandibular vein, marginal mandibular branch of facial nerve and cervial branch of facial nerve are located in the same anatomical level. The level was under the fascia parotidea masseterica.
2.2 Applied atomical characteristics of major blood vessels in the mandibular angle region
Facial artery origin from the anterior wall of the external carotid artery, through the stylohyoid muscle and posterior digastric and the deep surface of the hypoglossal nerve, to the submental triangle, through facial nerve groove above submandibular gland, to the anterior border of masseter muscle, around the inferior border of mandibular body to the face. Facial vein company with facial artery on the inferior border of mandibular body,80%(16 sides) of the facial artery located in front of facial veins,20%(4 sides) of the facial artery is located in the deep and front of facial vein. Facial vein and the mandibular vein converge the common facial vein in the submandibular area. At the anterior border of mandibular, facial artery and facial vein located superficially, marginal mandibular branch of facial nerve, platysma, thin subcutaneous fat and skin on the surface of them; deep surface of them close to the periosteum of mandible. The distance between facial artery and the mandibular angle point is (30.06±4.25)mm, the distance between facial vein and the mandibular angle point is (27.55±4.02) mm at the inferior border of mandibular.
The superficial temporal vein and the maxillary vein converged the retromandibular vein behind the neck of mandible,penetrated the parotid gland, courser at the surface of the external carotid artery in front of the external acoustic pore. The retromandibular vein and the facial nerve or its main branches near a cross intersection, little parotid gland organization between them, most paste directly. The retromandibular vein and the posterior border of mandibular ascending branch is almost flat, where the wall is thin and diameter of caliber is coarse, pasted the posterior border of mandibular ascending ramus only had the periosteum,or thin-layer parotid organization between them. After the lower pole of the parotid gland,it is divided into anterior and posterior,the two branches 16 sides (80%); anterior branch injected into the facial vein, the posterior branch with posterior auricular vein merged into the external jugular vein. Four sides (20%) no anterior and posterior branch vein directly merged into facial vein. The relationship between retromandibular vein and the mandibular angle is divided into two kinds of types:①Tight connection type: retromandibular vein and its tributaries which form the arc structure is closely pasted the mandibular angle,8 sides accounted for 40%;②Loose connection type: retromandibular vein and its tributaries which form the arc structure is loosely pasted the mandibular angle,12 sides accounted for 60%. The more decoct later prominent of mandibular angle, the closer the retromandibular vein and the mandibular angle. The distance was (3.00±0.56)mm between the retromandibular vein and the posterior border of mandibular ascending branch, the distance was (12.20±1.09)mm between the retromandibular vein and the mandibular angle point.
2.3 Applied atomical characteristics of important nerves in the mandibular angle region
The marginal mandibular branch of the facial nerve is one-two, mostly one, origin from the facial cervical stem of the facial nerve after that, had undergone on the top of mandibular angle and posterior border of the masseter muscle, the location is more constant. The marginal mandibular branch of facial nerve from the parotid gland after that its courser under the masseteric fascia, cross the facial artery at anterior border of masseter muscle, the location is more constant,was not found there was no cross the facial artery; finally controlled platysma,depressor anguli oris,depressor labii inferioris, mentalis. The distance was (10.36±0.41)mm between marginal mandibular branch of the facial nerve and mandibular angle point when it was away from the parotid gland, after that its position relationship with the inferior border of mandible can be divided into three conditions:①It parallel run on the top of the inferior border of mandible,the distance was (6.84±0.70)mm between it and the inferior border of mandible,12 sides accounted for 60%, it was almost parallel crossed with facial artery at the anterior border of masseter muscle;②It generally flat the inferior border of mandible, equivalent to in thegroove between the inferior border of mandible and the submandibular gland 6 sides accounted for 30%, it was oblique crossed with facial artery at the anterior border of masseter muscle;③It run below the inferior border of mandible, the maximum of the distance between it and the inferior border of mandible was not more than 1.2cm,2 sides accounted for 10%, it was oblique crossed with facial artery at the anterior border of masseter muscle. The relationship of the marginal mandibular branch of facial nerve crossing with the facial artery can be divided into three conditions:①The marginal mandibular branch of facial nerve is located superficial to the facial artery,16 sides accounted for 80%;②It is located in the deep surface of the facial artery,2 sides accounts for 10%;③It separate two branches which retain or encircle facial artery, and then compose one branch,2 sides account for 10%. we also found that four sides,20% of the marginal mandibular branch of facial nerve anastomose with the buccal branch of facial. The distance was (6.93±0.42)mm between the marginal mandibular branch of the facial nerve and the the inferior border of mandible at the crossing of facial artery.
Cervical branch of the facial nerve is the terminal branch of the facial cervical stem of the facial nerve, away from the inferior border of the parotid gland, pass behind the mandibular angle point (9.92±0.40) mm, and run the deep surface of the platysma, finally controlled platysma.
2.4 Running characteristics of mandibular canal and the position relationship between mandibular canal and the mandibular angle, the inferior border of mandible (or the posterior border of mandibular ascending branch)
Mandibular angle point and third molar point were marked as the main indicator line. The distance between the inferior border of mandibular canal and the mandibular angle, the inferior border of mandible or the posterior border of mandibular ascending branch in each section of mandible., separately was A:(14.52±1.21) mm; B:(16.64±0.88)mm;C:(14.1±1.00)mm;D:(12.03±0.91) mm; E:(10.26±0.98) mm;F:(15.22±1.29) mm. Observed the relationship between mandibular canal and inside and outside plate of mandible and discovered:mandibular canal full-length almost run tightly to the inside plate, the more near the rear of the mandible the tighter it attached inside plate.
2.5 Measurement of the proportions of of frontal head and facial skeletal cont our by three-dimensional reconstruction
The relevant data of proportion of frontal head and facial skeletal contou r were measured on the images of head and facial three-dimensional reconstru ction:maximum cranial breadth,eu-eu:(145.13±2.95)mm;facial breadth (bizygom atic breadth),zy-zy:(133.77±4.52)mm;bigonialbreadth,go-go:(97.18±2.38)mm; eu-e u/zy-zy:1.09±0.02;zy-zy/go-go:1.38±0.03;eu-eu/go-go:1.49±0.03.v-n:(105.40±3.10) mm; upper facial height,n-sd:(69.00±2.95) mm;pr-gn:(46.58±1.97) mm; morphol ogical facial height,n-gn:(111.49±4.17)mm;v-n/n-sd:1.53±0.03;n-sd/pr-gn:1.48±0. 07; v-n/pr-gn:2.27±0.09;n-sd/n-gn:0.62±0.02;pr-gn/n-gn:0.42±0.02;v-n/n-gn:0.95±0.02.eu-eu/v-n:1.38±0.05;zy-zy/n-sd:1.94±0.10;go-go/pr-gn:2.09±0.10.
2.6 The measurement of the related angles of mandible angle by three-dimensi onal reconstruction
The related data of the mandibular angle were measured on the image of three-dimensional reconstruction,the mandibular angle (left):(124.10±4.03)°; the mandibular angle (right):(124.46±4.22)°;the mandibular elevated angle (left):(25. 42±2.17)°; the mandibular elevated angle (right):(25.61±2.28)°; the valgus angle of mandibular angle (left):(9.23±7.72)°; the valgus angle of mandibular angle (right):(9.47±8.03)°; the mandiblular included angle:(77.32±2.34)°; the tangent a ngle of mandible:(105.53±1.79)°.
The linear correlation analysis of the related angles of mandibular angle and bigonial breadth:the valgus angle of mandibular angle,bigonial breadth,the mandibluar included angle,the tangent angle of mandible showed significantly positive correlation r range(0.617～0.976),(P<0.01).
The mandibular angle with bigonial breadth,the mandiblular included angle, the valgus angle of mandibular angle and the tangent angle of mandible showed no significant correlation (P=0.048,P=0.019,P=0.184,P=0.019). The mandibular elevated angle with bigonial breadth,the mandiblular included angle, the valgus angle of mandibular angle and the tangent angle of mandible showed no significant correlation(P=0.303,P=0.143,P=0.709,P=0.095).The mandibular angle and the mandibular elevated angle showed a significantly positive correlation (r=0.884, P=0.000).
2.7 The anatomical structure measurement of the influencement of mandibular contour by three-dimensional reconstruction.
We marked points in the influencement area of mandibular contour on theimage of three dimensional reconstruction,.All these points were measured the thickness of mandible and the thickness of outer plate of mandible.The mean results of measurement right and left respectively is A point:(7.20±0.64)mm,(3.32±0.36)mm;B point:(6.58±0.66)mm,(2.85±0.34)mm;Cpoin(7.10±0.65)mm,(3.21±0.39)mm;Epoint:( 7.52±0.79)mm,(3.35±0.38)mm;Fpoint:(9.83±0.94)mm,(3.62±0.33)mm;Gpoint:(12.72±1.01)mm,(4.54±0.37)mm;Hpoint:(12.33±0.94)mm,(4.32±0.39)mmIpoint:(11.29±0.9 9)mm,(4.01±0.39);Dpoint,the thickness of the mandible:(6.66±0.85)mm;the thickness of outer plate of mandible Jpoint:(6.34±0.47)mm;K point:(5.31±0.46)mm.
2.8 Surgical options on basifacial contour plasty
Suitable and surgical compositive options on basifacial contour plasty were choosed and carried out through preoperative classification. Mandibular angle hypertrophy plasty combined with other assistant aesthetic operations were ideal methods to recontour basifacial contour. The result was satisfaction.
Conclusion
Through the study on applied anatomy of the mandibular angle region,disscussed the safe operative region and the more secure osteotomy region on mandibula rangle hypertrophy plasty;related measurrment of mandibular angle was done by spiral CT three-dimensional reconstruction and disscussed the harmonious proportional relationship of the frontal head and facial skeletal contour in normal adult female and the relationship between related angles of mandibular angle and bigonial breadth, identified the anatomical structure of the influencement of mandibular contour and associated thickness of mandible and the thickness of the outer plate of mandible. The subject ranged from applied anatomy of the mandibular angle region and the measurement of three-dimensional reconstruction to research, the results will provid anatomical basis and theoretical basis on improving safety of mandibular angle hypertrophy plasty, such as reduce bleeding, nerve damage, inferior alveolar neurovascular bundle damage and other complications; improving the effect of mandibular angle hypertrophy plasty such as reduce the bilateral asymmetry, the second mandibular angle, "horse face" deformity, excessive or too little osteotomy, insufficient or excessive narrowing of the face and other complications; improving the clinical three-dimensional diagnostic criteria of mandibular angle hypertrophy.
Throng etrospectively analyzed surgical options on basifacial contour plasty of patients. Suitable and compositive surgical options on basifacial contour plasty were choosed and carried out through preoperative classification. Mandibular angle hypertrophy plasty combined with other assistant aesthetic operations were ideal methods to recontour basifacial contour. The result was satisfactory.
The main innovations of this topic were:①Aim at bleeding, facial nerve damage, inferior alveolar neurovascular bundle damage and other serious complications in the clinical mandibular angle hypertrophy plasty, we studied the applied anatomy of the mandibular angle region and took the mandibular angle as the center, observed and measured the mandibular angle region's main blood vessel, nerve and mandibular canal and the position relationship between them and the mandibular angle (the exterior border of the mandible). With a view to provide anatomical basis for the safe operative region and the more secure osteotomy plane of the mandibular angle hypertrophy plasty,avoid to damage these important structures and improve the safety of mandibular angle hypertrophy plasty.②We used mimics software measure specimens by three-dimensional reconstruction, the software has many advantages such as easy installation, the computer configuration requirement is not high, reconstruction and high measuring accuracy and is equipped with a variety of measurement tools, it is easy for clinicians to master and so on.③by spiral CT three-dimensional reconstruction measurement of front view of the head and facial horizontal, vertical, vertical and horizontal proportion, studied the proportional relationship of head and facial skeletal contours more detail than the previous studies. With a view to find some rules of of horizontal,vertical as well as vertical and horizontal proportional relationship.④Related angles measurement of the mandibular angle by three-dimensional reconstruction and statistical analysis, identified the relationship between all relevant angle of mandibular and the bigonial breadth.⑤Measurement by three-dimensional reconstruction and observation, identified the the main anatomical influence factors of front and side contour of mandible and these factors were measured through the fixed-point method.And measured the thickness of mandible and the thickness of outer plate of mandible. Provided basises for the osteotomy and treatment operations on outside plate of mandible in mandibular angle hypertrophy plasty,provide theoretical supportfor doctors preoperative design and postoperative evaluated results of operations.
In summary, the findings of the topic will play an active role in reducing complications and improving safety of mandibular angle hypertrophy plasty to a certain extent, provide plastic surgery mandibular angle in order to to; supply helpness for a comprehensive understanding of the frontal proportions of head and facial skeletal contour in normal adult female, theoretical support for enriching the clinical diagnosis of mandibular angle hypertrophy，improving results of operations, improving surgical satisfaction and so on.
东方人面部轮廓传统审美标准为“瓜子脸”、“鹅蛋脸”的脸型,面下部轮廓是影响面部整体轮廓重要因素之一。如果下颌角肥大、面下部过宽,就会被视为难看的方形脸或上窄下宽的梯形脸,从而失去东方女性特有的温柔、秀美的气质。随着人们生活水平提高和审美意识的增强,要求通过下颌角肥大整形手术改变面下部轮廓的求美者日益增多。此类手术已经成为面部整形美容手术中的重要手术之一。
下颌角肥大(prominent mandibular angle or mandibular angle hypertrophy)这一概念是由Baek等人于1989年提出。下颌角肥大的病因目前仍不完全清楚,但其病理改变,即为下颌骨的生长发育异常和(或)咬肌的肥厚,目前为大多数人所接受。东方人以下颌骨的生长发育异常为多见。人体面部是强调和谐统一的,而在整个面部轮廓中,诊断下颌角肥大是一个综合性因素考虑的结果,并且受不同人种、不同文化背景等影响,因此下颌角肥大的诊断目前还没有统一的标准。利用影像学等手段,国内、外医生和学者在下颌角肥大诊断方面做了大量的研究工作,并提出各自认为较为合理的诊断标准。王侠等对下颌角X线侧位片作过统计,认为角度<110°即可诊断。陶宏炜等认为正面下颌角宽度等于或大于颧骨宽度即可诊断,下颌角<120°也可诊断。胡静等根据下颌角肥大的X线片认为下颌角肥大诊断标准主要包括：(1)下颌角部肥大。(2)下颌平面角(MP.FH夹角)小于正常。(3)在侧位X线片上,下颌角开张度变小。(4)面下1／3高度过短。(5)非对称性改变。周智等根据大量的汉族人干性头颅测量结果,认为面颌宽比(面中宽／下颌宽)男女相对集中在1.33左右,面颌宽比可作为男女下颌角肥大通用的诊断标准之一。李慧超等通过对下颌角肥大女性的颅面三维测量提出一个供临床参考的关于下颌角肥大的三维测量诊断标准：①下颌角间距与全面高比值大于0.8；②下颌角角度小于120°；③∠GoMeGo大于65°；④下颌角间距大于95mm；⑤下颌骨升支长度大于57mm；⑥下颌骨体部长度大于82mm,Ⅶ角区最大宽度大于35mm。将三维测量上具备第一条标准并符合其它任意两条标准者定义为下颌角肥大。对于下颌角肥大的分型,国内外学者也有各自的观点。Kim等将下颌角肥大分为4型：(1)轻度肥大型：面型不方,但从侧面观察可见下颌角角度变小；(2)中度肥大型：下颌角明显外展突出；(3)重度肥大型：下颌角明显外展突出并伴咬肌肥大；(4)复合型：下颌角明显外展突出伴下颏畸形。
下颌角肥大的分类及手术方案的选择：李慧超等根据肥大下颌角的形态和他们的临床工作经验将下颌角肥大分类为：Ⅰ类—外翻型：手术方案首选下颌角截骨整形术；Ⅱ类—后下突出型：手术方案首选下颌角截骨整形术；Ⅲ类—内收型：手术方案首选下颌角截骨整形术或下颌骨外板去除术；Ⅳ类—下颌角肥大伴小颏畸形：选择下颌角截骨整形术或下颌骨外板去除术,同时行颏部水平截骨颏成形术或人工合成材料隆颏术；Ⅴ类—下颌角肥大伴有咬肌肥厚：选择下颌角截骨整形术或下颌骨外板去除术,术后根据咬肌萎缩情况决定是否需要行咬肌肉毒素注射术；Ⅵ类—轻型：手术方案首选下颌骨外板去除术。
随着研究的深入和临床相关手术的开展,近年来在手术术式的选择、并发症的处理等方面都有进一步的认识和提高。下颌角肥大整形术在我国已经成为面部整形美容手术中重要的手术项目。随着此类手术的不断开展,严重的手术并发症也不断出现。严重的手术并发症中以下颌角区域主要血管、面神经分支的损伤为最常见,原因多为下颌角区域的主要血管、神经解剖结构的认识不足,对于这些重要解剖结构的保护不到位所致。由于缺乏对于面部整体轮廓的认识,造成截骨量过多或不足,从而使面部比例关系失调。由于对于影响下颌骨轮廓的解剖结构认识不足,从而不能很好的解决正面和侧面的轮廓流畅问题,手术效果欠佳。如第二下颌角、双侧不对称、正面宽度缩窄量不够或过度、侧面轮廓不流畅、“马脸”畸形等。这些并发症都在某种程度上制约此类手术的进一步开展,增加了医生和求美者之间的纠纷几率。
目的和意义
通过本课题的研究,进一步认识下颌角区域解剖结构特征,探讨正常成年女性头面部骨性轮廓正面的比例关系,下颌角相关角度及其与下颌角间宽(面下宽)相关性,明确影响下颌骨轮廓的解剖结构及对其进行三维重建相关测量,完善下颌角肥大的相关诊断标准,提出较为合理的预防手术并发症的注意事项和方法。本课题从下颌角区域应用解剖和下颌角相关三维重建测量两方面进行相关研究,研究结果将为减少和预防手术并发症,提高手术安全性和有效性提供解剖依据和理论基础,并为进一步提高手术效果提供帮助。
方法
1.1下颌角区域应用解剖学研究
1.1.1下颌角区域解剖层次观察
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,详细观察下颌角区域从浅入深的解剖层次。
1.1.2下颌角区域主要血管的应用解剖
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。进行大体和显微解剖与观察测量。观察面动脉、面静脉、下颌后静脉的走行特点；测量面动脉、面静脉、下颌后静脉各自与下颌角点的位置关系。
1.1.3下颌角区域主要神经的应用解剖
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。进行大体和显微解剖与观察测量。观察面神经下颌缘支、面神经颈支走行和分支特点,测量面神经下颌缘支、面神经颈支出腮腺处与下颌角点的位置关系,测量和观察面神经下颌缘支与下颌骨下缘的位置关系等。
1.1.4下颌管与下颌角、下颌骨下缘(或下颌骨升支后缘)的位置关系
选取经福尔马林溶液固定、红色乳胶颈总动脉灌注的成人头颅标本10例(男7例,女3例),共20侧,逐层解剖,确定下颌角点：下颌角最向下、最向后、最突出点为下颌角测量点。将下颌骨表面结构从骨膜剥除,以下颌角点和第三磨牙为主要标志点做标志线。各标志线为A：第三磨牙外侧至下颌骨升支后缘的垂线。B：第三磨牙外侧至下颌角点连线。C：第三磨牙外侧至下颌骨下缘的垂线。D、E：线C和线F之间三等分,分别设定标志线为D、E。F：过颏孔后缘至下颌骨下缘的垂线。沿各标志线锯开下颌骨,测量各横断截面上下颌管下缘与下颌角、下颌骨下缘(或下颌骨升支后缘)的距离,观察下颌管与下颌骨内外侧骨板的位置关系。
1.2下颌角相关螺旋CT三维重建测量研究
1.2.1头面部骨性轮廓正面比例测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就头面部骨性轮廓正面比例相关的7个测量项目进行测量,并计算相关比例。
1.2.2下颌角相关角度测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就下颌角相关角度的8个测量项目进行测量。通过SPSS13.0软件分析各角度之间的相关性以及相关角度与下颌角间宽(面下宽)的相关性。
1.2.3影响下颌骨轮廓解剖结构三维重建测量
随机选取符合实验要求的60例成年女性(20岁-50岁)头颅螺旋CT数据,以DICOM格式导入mimics软件进行三维重建,在三维重建图像上就影响下颌骨轮廓(正面、侧面)的四个区域(下颌骨升支后缘区、下颌角区、下颌骨下缘区、斜线区)分别定点,A点：下颌骨升支后缘区与下颌角区过渡点上2cm(沿下颌骨升支后缘方向)；B点：下颌骨升支后缘区与下颌角区过渡点上1cm(沿下颌骨升支后缘方向)；C点：下颌骨升支后缘区与下颌角区过渡点；D点：下颌角点；E点：下颌角区与下颌骨下缘过渡点；F点：下颌角区与下颌骨下缘区过渡点前lcm(沿下颌骨下缘方向)；G点：下颌角区与下颌骨下缘区过渡点前2cm(沿下颌骨下缘方向)；H点：斜线与下颌骨下缘相融合点；Ⅰ点：斜线与下颌骨下缘相融合点前1cm(沿下颌骨下缘方向)；J点：斜线与下颌骨体融合点；K点：H点与J点的中点(沿斜线方向)。测量各点下颌骨的厚度及下颌骨外板的骨质厚度。数据合并统计得到影响下颌骨轮廓的四个区域的下颌骨平均厚度、下颌骨外板平均厚度。
1.3统计学处理
将测量结果输入SPSS13.0软件,首先Kolomogorov-Smirnov正态分布假设检验,证实所得各项测量指标的计量数据符合正态分布,然后计算结果的平均值、标准差,分析头面部轮廓比例关系、下颌角相关角度及下颌角间宽(面下宽)之间的线性相关性。左右侧数据进行配对t检验,若P>0.05表示无显著性差异；若P<0.05表示存在显著性差异。
1.4面下部轮廓整形术术式的回顾性分析
以我院行面下部轮廓整形术患者95例为研究对象。在全面检查的基础上结合下颌角肥大诊断标准等对患者面下部轮廓情况进行分类,并根据分类选择手术方法。
结果
2.1下颌角区域的解剖层次特点
解剖层次由浅入深依次是皮肤、皮下脂肪、SMAS筋膜及颈阔肌、包裹腮腺、咬肌的腮腺咬肌筋膜、咬肌、下颌骨骨膜。在皮肤、SMAS筋膜及颈阔肌和腮腺咬肌筋膜之间可观察到宽大的颈阔肌耳韧带、篱笆状咬肌皮肤韧带。面动脉、面静脉、下颌后静脉、面神经下颌缘支、面神经颈支位于同一解剖层次,此层次位于腮腺咬肌筋膜之下。
2.2下颌角区域重要血管的应用解剖特点
面动脉起自颈外动脉的前壁,经茎突舌骨肌、二腹肌后腹和舌下神经的深面,至颏下三角,经下颌下腺后上方的面神经沟后,至咬肌附着前缘处,绕下颌体下缘至面部。在下颌体下缘处面静脉与面动脉伴行,80%(16侧)的面动脉位于面静脉的前方,20%(4侧)的面动脉位于面静脉的前深方。面静脉在颌下区走向外下与下颌后静脉汇合成面总静脉。平下颌骨下缘处,面动、静脉位置表浅,浅面有面神经下颌缘支、颈阔肌、薄层皮下脂肪、皮肤；深面紧贴下颌骨骨膜。面动脉跨过下颌骨下缘处与下颌角点的距离为(30.06±4.25)mm、面静脉跨过下颌骨下缘处与下颌角点的距离(沿下颌骨下缘方向)为(27.55±4.02)mm。
下颌后静脉由颞浅静脉和上颌静脉于下颌骨颈的后方汇合而成,穿入腮腺,在外耳门前方下行于颈外动脉的浅面。下颌后静脉与面神经或其主要分支近于十字形交叉,它们之间很少有腮腺组织分隔,多直接相贴。下颌后静脉与下颌骨升支后缘几乎平行走形,此处管壁较薄,管径较粗,仅隔骨膜或薄层腮腺组织与下颌骨升支后缘相贴。穿出腮腺下极后,分为前后两支16侧(占80%)；前支行向前下注入面静脉,后支与耳后静脉汇合成颈外静脉。4侧(占20%)不分前后支直接和面静脉汇合成颈外静脉。下颌后静脉与下颌角的关系分为2种类型：①紧密结合型：下颌后静脉及其属支形成的弧形结构与下颌角紧密相贴,距离较近8侧占40%；②松散结合型：下颌后静脉及其属支形成的弧形结构与下颌角有一定距离12侧占60%。观察发现下颌角越往后下突出,下颌后静脉与下颌角距离越近。下颌后静脉与下颌骨升支后缘水平距离为(3.00±0.56)mm、下颌后静脉与下颌角点水平距离为(12.20±1.09)mm。
2.3下颌角区域重要神经的应用解剖特点
面神经下颌缘支为1-2支,多为1支,从面神经的面颈干发起后,均经过下颌角上方和咬肌后缘处,位置较为恒定。下颌缘支自腮腺浅出后的行径大体为走行于咬肌筋膜内,在咬肌前缘跨过面动脉、面静脉,此位置比较恒定,未发现不与面动脉交叉的情况；最后分支支配颈阔肌、降口角肌、降下唇肌、颏肌。下颌缘支出腮腺位置距离下颌角点为(10.36±0.41)mm,下颌缘支出腮腺后与下颌骨下缘的位置关系可分为三种情况：①平行走行于下颌骨下缘之上,距下颌骨下缘(6.84±0.70)mm,12侧占60%,在咬肌前缘几乎平行与面动脉交叉；②大致平下颌骨下缘,相当于下颌骨下缘与颌下腺之间的沟内行走,6侧占30%,在咬肌前缘斜向上与面动脉交叉;③呈弓状行走于下颌骨下缘以下,最低不超过1.2cm,2侧占10%,在咬肌前缘斜向上与面动脉交叉。面神经下颌缘支与面动脉交叉情况可分为三种：①下颌缘支位于面动脉浅面者16侧占80%;②位于深面者2侧占10%;③下颌缘支分两支经其浅面或深面夹持或环抱面动脉,然后合成1支,2侧占10%。观察还发现4侧占20%面神经下颌缘支与面神经下颊支存在吻合现象。面神经下颌缘支跨越面动脉位置与下颌骨下缘的距离(6.93±0.42)mm。
面神经颈支为面颈干的终末支,由腮腺下缘穿出,行经下颌角点后方(9.92±0.40)mm,在颈阔肌深面行向前下方,分支支配颈阔肌。2.4下颌管走行特点及其与下颌角、下颌骨下缘(或下颌骨升支后缘)位置关系
以下颌角点和第三磨牙为主要标志点做标志线。下颌管在各下颌骨标志线截面上下颌管下缘到下颌角、下颌骨下缘(或下颌骨升支后缘)距离分别为A：(14.52±1.21)mm；B：(16.64±0.88)mm；C：(14.14±1.00)mm；D：(12.03±0.91)mm；E：(10.26±0.98)mm；F：(15.22±1.29)mm。观察下颌管与下颌骨内外侧骨板的位置关系发现：下颌管的全长走行几乎全是紧贴着舌侧骨板前行,愈近下颌后部贴附舌侧骨板愈紧。
2.5头面部骨性轮廓正面比例的三维重建测量
三维重建图像上测量头面部骨性轮廓正面比例相关数据,颅骨最大宽：(145.13±2.95)m；面宽(颧点间宽)：(133.77±4.52)mm；下颌角间宽(下面宽)：(97.18±2.38)mm；颅骨最大宽／面宽(颧点间宽)：1.09±0.02；面宽(颧点间宽)／下颌角间宽(下面宽)：1.38±0.03；颅骨最大宽／下颌角间宽(下面宽)：1.49±0.03。颅顶点-鼻根点：(105.40±3.10)mm；鼻根点-上齿龈前点(上面高)：(69.00±2.95)mm；上齿龈前点-颏下点：(46.58±1.97)mm；鼻根点-颏下点(全面高)：(111.49±4.17)mm；颅顶点-鼻根点／鼻根点-上齿龈前点(上面高)：1.53±0.03；鼻根点-上齿龈前点(上面高)／上齿龈前点-颏下点：1.48±0.07；颅顶点-鼻根点／上齿龈前点-颏下点：2.27±0.09；鼻根点-上齿龈前点(上面高)／鼻根点-颏下点(全面高)：0.62±0.02；上齿龈前点-颏下点／鼻根点-颏下点(全面高)：0.42±0.02；颅顶点-鼻根点／鼻根点-颏下点(全面高)：0.95±0.02。颅骨最大宽／颅顶点-鼻根点：1.38±0.05；面宽(颧点间宽)／鼻根点-上齿龈前点(上面高)：1.94±0.10；下面宽(下颌角间宽)／上齿龈前点-颏下点：2.09±0.10。
2.6下颌角相关角度的三维重建测量
三维重建图像上测量下颌角相关角度,下颌角(左)：(124.10±4.03)度；下颌角(右)：(124.46±4.22)度；下颌仰角(左)：(25.42±2.17)度；下颌仰角(右)：(25.61±2.28)度；下颌角外翻角(左)：(9.23±7.72)度；下颌角外翻角(右)：(9.47±8.03)度；下颌夹角：(77.32±2.34)度；下颌切线角：(105.53±1.79)度。
下颌角相关角度及其与下颌角间宽(下面宽)之间的线性相关性分析：下颌角外翻角、下颌夹角、下颌切线角、下颌角间宽四个指标之间存在显著性正相关,r值范围(0.617-0.976),(P<0.01)。
下颌角角度与下颌角间宽、下颌夹角、下颌角外翻角、下颌切线角并无显著性相关(P=0.048,P=0.019,P=0.184,P=0.019)。下颌仰角与下颌角间宽、下颌夹角、下颌角外翻角、下颌切线角并无显著性相关(P=0.303,P=0.143,P=0.709,P=0.095)。下颌角角度与下颌仰角呈显著正相关(r=0.884,P=0.000)。
2.7影响下颌骨轮廓解剖结构的三维重建测量
三维重建图像上测量影响下颌骨轮廓各因素点：对各点分别测量下颌骨厚度和下颌骨外板厚度,左、右侧测量合并均值结果分别为A点：(7.20±0.64)mm、(3.32±0.36)mm；B点：(6.58±0.66)mm、(2.85±0.34)mm；C点(7.10±0.65)mm、(3.21±0.39)mm；E点：(7.52±0.79)mm、(3.35±0.38)mm；F点：(9.83±0.94)mm、(3.62±0.33)mm；G点：(12.72±1.01)mm、(4.54±0.37)mm；H点：(12.33±0.94)mm、(4.32±0.39)mm；Ⅰ点：(11.29±0.99)mm、(4.01±0.39)；D点下颌骨厚度：(6.66±0.85)mm、；下颌骨外板厚度J点：(6.34±0.47)mm；K点：(5.31±0.46)mm。
2.8面下部轮廓整形术术式的回顾分析
通过术前分类选择合适、综合的手术方法进行面下部轮廓整形术。以双侧下颌角肥大整形术为主,结合其他手术方式重塑面下部轮廓,临床效果满意。
结论
本课题通过对下颌角区域应用解剖的研究,探讨下颌角肥大整形术安全操作范围以及较为安全的截骨区域；通过螺旋CT三维重建的下颌角相关测量研究,探讨正常成年女性头面部骨性轮廓正面的和谐比例关系,下颌角相关角度以及下颌角间宽(面下宽)之间的相互关系,明确影响下颌骨轮廓的解剖因素及相关下颌骨厚度和下颌骨外板厚度。本课题从下颌角区域应用解剖和三维重建测量两方面入手研究,其结果将为提高下颌角肥大整形手术的安全性,如减少出血、神经损伤、下牙槽血管神经束损伤等并发症的发生；提高下颌角肥大整形手术的效果,如减少双侧不对称、第二下颌角、“马脸”畸形、截骨量过多或过少、缩窄量不足或过度等影响手术效果的并发症的发生；完善下颌角肥大临床的三维诊断标准等方面提供解剖依据和理论基础。对我院行面下部轮廓整形术手术方法进行回顾性分析。通过术前分类选择合适、综合的手术方法进行面下部轮廓整形术,取得良好的手术效果。说明通过术前对患者面下部轮廓情况进行分类,选择合适、综合的手术方法,将有利于提高手术效果。
本课题主要的创新之处在于：①针对临床下颌角肥大整形手术的出血、面神经分支损伤、下牙槽血管神经束损伤等严重并发症问题,我们对下颌角区域应用解剖进行研究,并且紧密以下颌角为中心,观察测量下颌角区域主要血管、神经及下颌管与下颌角、下颌骨下缘(或下颌骨升值后缘)的位置关系。以期为下颌角肥大整形手术安全操作区域、安全截骨范围提供解剖依据,避免上述重要结构的损伤,提高下颌角肥大整形手术的安全性。②我们将mimics软件用于标本的三维重建测量,该软件具有安装方便、要求电脑配置不高、重建和测量精度高并配有多种测量工具、很容易为临床医生掌握等优点。③通过螺旋CT三维重建测量头面部骨性轮廓正面横向、纵向、纵横向等比例,比以往研究更详细的探讨头面部骨性轮廓正面比例关系。以期发现某些横向、纵向以及纵横向比例的规律。④通过三维重建测量下颌角相关角度及对各相关角度进行统计学分析,明确下颌角各相关角度及其与下颌角间宽(面下宽)之间的相互关系。⑤通过三维重建测量和观察,明确影响下颌骨正面、侧面轮廓的主要解剖因素并对这些因素通过定点方式进行下颌骨厚度、下颌骨外板厚度的测量。为临床下颌角肥大整形手术的截骨和下颌骨外板处理等操作提供依据,为医生术前设计和术后评估手术效果提供理论基础。
综上所述,本课题的研究结果,将在一定程度上为减少下颌角肥大整形手术并发症,提高手术安全性起到积极作用；为全面认识正常成年女性头面部骨性轮廓正面比例提供帮助,为丰富下颌角肥大临床诊断,完善手术效果,提高手术满意度等方面提供理论支持。
Background
Asian facial contours traditional aesthetic standard is "oval face" or "goose egg face ".The basifacial contour is an important factor in affecting the overall facial contour. If the mandibular angle is hypertrophy or the basifacial width is too great, it will be regarded as an ugly face. Which is the square face or the trapezoidal face, and thus lose their gentle characteristic and beautiful temperament in oriental women,. With the improvement of people's living standard and the enhancement of aesthetic consciousness, the people who has mandibular angle hypertrophy call for changing basifacial contour by plastic and cosmetic surgery is increasing. Such surgery has become one important surgery of facial plastic and cosmetic surgery.
The concept of prominent mandibular angle or mandibular angle hypertrophy was put forward by Baek et al in 1989. The cause of mandibular angle hypertrophy is still not entirely clear at present, but the pathological changes is the anormal growth of mandible and/or masseteric hypertrophy, which is currently accepted by the most people. The anormal growth of mandible is more common in mandibular angle hypertrophy of Asians. The human face is to emphasize harmony and unity, but in the whole facial contours, the diagnosis of mandibular angle hypertrophy is the results of comprehensive considerations,and which is subject to influence different ethnicity, different cultural background,and so on, so there is no uniform standards of the diagnosis of mandibular angle hypertrophy. Domestic and foreign doctors and scholars did a lot of research in the diagnosis of mandibular angle hypertrophy by imageology and other means, and put forward their reasonable diagnostic criteria. Wang Xia et al did some statistics on the lateral X-ray films of the mandibular angle and thought the angle of mandibular angle less than 110°can be diagnosed the mandibular angle hypertrophy. TAO Hong-Wei et al thought the width of mandibular angle equal to or greater than the width of the zygoma can be diagnosed the mandibular angle hypertrophy and thought the angle of mandibular angle less than 120°also can be diagnosed it. Hu Jing et al according to the X-ray film of mandibular angle hypertrophy thought that the diagnostic criteria of mandibular angle hypertrophy include:(1) The region of the mandibular angle is hypertrophy. (2) Mandibular plane angle (MP. FH angle) is less than normal. (3) In the lateral X-ray films, the opening degree of the mandibular angle become smaller than normal. (4) Lower 1/3 height of face is too short. (5) Asymmetry change. Zhou Zhi et al according to a large number of Han people dry skull measurements, thought that the ratio of facial width and mandibular width (midface width/mandibular width) for men and women are relatively concentrated around 1.33, the ratio of facial width and mandibular width can be used as one of the diagnostic criteria for male and female mandibular angle hypertrophy, Li Hui Chao et al according to the results of three-dimensional measurements of craniofacial mandibular angle hypertrophy women and proposed a clinical reference for the mandibular angle hypertrophy of diagnostic criteria on the three-dimensional measurement:①Ratio of bigonial breadth and morphological facial height is greater than 0.8;②Angle of mandibular angle is less than 120°;③∠GoMeGo is greater than 65°;④Bigonial breadth is greater than 95mm;⑤Mandibular ascending branch length is greater than 57mm;⑥Length of mandibular body is greater than 82mm,maximum width ofⅦmandibular angle region is greater than 35mm.Three-dimensional measurements with the first standard and comply with any two other standards is defined as the mandibular angle hypertrophy. The type of the mandibular angle, domestic and foreign scholars had their own point of view. Kim et al mandibular angle hypertrophy is divided into four types:(1) Mild degree:face is not square, but angle of mandibular angle was observed smaller from the side;(2) Moderate degree:mandibular angle clear abduction and predominance;(3) Severe degree:mandibular angle significant bduction and predominance associated with masseteric hypertrophy; (4) Compound type: mandibular angle significant abduction and predominance associated with microgenia deformity.
Classification and operation project of mandibular angle hypertrophy:Li Hui Chao et al according to the shape of hypertrophic mandibular angle and their clinical experience they classified mandibular angle hypertrophy:Ⅰtype -- eversion type:the preferred operation project of this type is mandibular angle osteotomy plasty;Ⅱtype---decocted later predominance:the preferred operation project of this type is mandibular angle osteotomy plasty;Ⅲtype --adduction type:the preferred operation project of this type is mandibular angle osteotomy plasty or mandibular external circumferential lamella ablation;Ⅳtype--mandibular angle hypertrophy with microgenia:the preferred operation project of this type is mandibular angle osteotomy plasty or mandibular external circumferential lamella ablation with level osteotomy genioplasty or synthetic materials chin augmentation;Ⅴtype--mandibular angle hypertrophy associated with masseteric hypertrophy:selected the osteotomy plasty or mandibular external circumferential lamella ablation, according to the condition of postoperative masseter muscle atrophy determined whether need toxin injection or not; VI type-light:the preferred operation project of this type is mandibular angle osteotomy plasty.
With the in-depth research and the launching of clinical related surgery, in recent years the choice of surgical procedures, complications treatment, and other aspects had been further understood and improved. Mandibular angle hypertrophy plasty in our country had become an important project in facial plastic and cosmetic surgery. As the launching of the operation, serious complications were also emerging. Mandibular angle region's main blood vessels and branches of the facial nerve injury were the most common in serious surgical complications, because the anatomical structure of mandibular angle region's blood vessels and nerves had no enough knowledge and had no good protection of these important anatomical structures. Due to lack of the recognition of overall facial contour., resulting in excessive or inadequate osteotomy, so that the proportional relationship was imbalance. As lack of knowledge for the anatomical structure of the influencement of mandibular contour, which could not be satisfactorily resolved the fluent problems of the frontal and lateral contours, result was ineffective. Such as the second mandibular angle, bilateral asymmetry, inadequate or excessive narrowing the frontal width,the lateral profile is not smooth, " horse face" deformity and so on. These complications restricted further development of such operations to some extent, increased the dispute chances between doctors and patients.
Purpose and Significance
Through the research of the topic,we better understood the characteristics of regional anatomy of the mandibular angle,discussed the proportional relationship of the frontal head and facial skeletal contour in normal adult female,related angles of mandibular angle and their correlation of them and bigonial breadth,identified the anatomical structure of the influencement of mandibular contour, undertook the related measurement by three-dimensional reconstruction,improved the relevant diagnostic criteria of the mandibular angle hypertrophy,put forward a more reasonable note and methods to prevent the surgical complications. The research of the topic from two aspects:applied anatomy of mandibular angle region and associated measurement of mandibular angle by three-dimensional reconstruction, The findings will provid anatomical basis and theoretical basis in reducing and preventing the surgical complications and improving safety and effectiveness of the surgery. And it will help further enhance the results of operations.
Methods
1.1 Applied anatomical research of the mandibular angle region
1.1.1 Anatomical layer observation of the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, detailed observation anatomical level of the mandibular angle region from the shallow into the deep.
1.1.2 Applied anatomy of major blood vessels in the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomy,observe and measure. Observed courser characteristics of the facial artery, facial vein, retromandibular vein; measured the position relationship between them and the mandibular angle point.
1.1.3 Applied anatomy of important nerves in the mandibular angle region
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomiy,observe and measure.Observed Courser and branch characteristics of marginal mandibular branch of facial nerve and cervial branch of facial nerve, measured the position relationship between them and the mandibular angle point when they away from the parotid gland, measured and observed the position relationship between the marginal mandibular branch of facial nerve and the inferior border of mandible.
1.1.4 Position relationship between mandibular canal and the mandibular angle,the inferior border of mandible (or the posterior border of mandibular ascending branch)
Selected 10 adult head specimens by the formalin fixation, red latex carotid artery infusion (7 males and 3 females), total 20 sides, layer by layer dissected, determined the mandibular angle point:marked the most down, the most backward, the most predominance point of the mandibular angle as measurement point. Made general and microscopic anatomiy,observe and measure.The surface structure was stripped from the mandibular periosteum,mandibular angle point and third molar point were marked as the main indicator line. Separate indicator line was A:outer margin of third molar to posterior border of mandibular ascending branch,B:outer margin of third molar to mandibular angle,C:outer margin of third molar to inferior border of mandible,D, E: trisected between line C and line F and set line D and line E,F:from posterior border of mental foramen to inferior border of mandible. And sawed mandible along the indicator line, measured the distance between mandibular canal and the mandibular angle point,the inferior border of mandible (or the posterior border of mandibular ascending branch) on the transverse cross-section and observed the position relationship between the mandibular canal and inside and outside plate of mandible.
1.2 Related measurements of mandibular angle by spiral CT three-dimensional reconstruction
1.2.1 Measured the proportions of frontal head and facial skeletal contour
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, measured 7 items about the proportion of frontal head and facial skeletal contour on the image of three-dimensional reconstruction and calculated the relative proportions.
1.2.2 Measured the related angles of mandibular angle
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, measured 8 items about the mandibular angle on the image of three-dimensional reconstruction,analyzed the correlation between the various angles, the correlation of the associated angles and bigonial breadth (basifacial breadth) by SPSS13.0 statistical software.
1.2.3 Measured the anatomical structures of the influencement of mandibular contour.
Randomly selected 60 cases head spiral CT data of adult women which met the test requirements (age 20-50 years old), imported DICOM format into mimics software and carried out three-dimensional reconstruction, fixed points on the four regions (the posterior border of mandibular ascending branch area, the mandibular angle area, the inferior border of mandible area,the slash area)which influenced mandibular contour (front view, lateral view) on the image of three-dimensional reconstruction, A point:2cm above the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area (along the posterior border of mandibular ascending branch direction); B point:1cm above the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area (along the posterior border of mandibular ascending branch direction); C point:the transition point between the posterior border of mandibular ascending branch area and the mandibular angle area; D point:the mandibular angle point; E point:the transition point between the mandibular angle area and the inferior border of mandible;F points:1cm ahead the transition point between the mandibular angle area and the inferior border of mandible area (along the inferior border of mandible direction); G points:2cm ahead the transition point between the mandibular angle area and the inferior border of mandible area (along the inferior border of mandible direction); H point:the fusion point between the slash and the inferior border of mandible;Ⅰpoint:1cm ahead of the fusion point between the slash and the inferior border of mandible (along the inferior border of mandible direction) J points:the fusion point between the slash and the mandible body; K point: the mid-point of the H point and the J point (along the slash direction). All these points were measured the thickness of mandible and the thickness of outside plate of mandible. Combined analysis of data obtained the average thickness of the mandible and the average thickness of the outside plate of mandible on the four regions.
1.3 Statistical treatment
Measurement results were input SPSS13.0 software, the first to use hypothesis testing of Kolomogorov-Smirnov normal distribution, confirmed that measurement data is normally distributed, and calculated the mean, standard deviation of the results, analyzed the proportion relationship of frontal head and facial skeletal contour and analyzed the linear correlation between the various angles, the linear correlation of the associated angles and bigonial breadth (basifacial breadth). Left and right side data carry out paired-samples t test, if P> 0.05 indicated no significant difference; if P<0.05 indicated the significant differences.
1.4 Retrospective analysis of surgical options on basifacial contours plasty
We took 95 cases patients who undertook basifacial contours plasty in our hospital as research objects. We combined diagnostic criteria of mandibular angle hypertrophy on the basis of the comprehensive examination, and classified the condition of patient's basifacial contours, and choosed surgical options according to classification.
Results
2.1 The characteristic of anatomical layers of mandibular angle region
Anatomical layers are skin, subcutaneous fat, SMAS fascia and platysma, fascia parotidea masseterica,.which parcels parotid gland and masseter muscle,masseter muscle, periosteum of mandible, from the shallow into the deep. The large platysma-auricular ligament, fence-like masseteric ligament could be observed among the skin, SAMS fascia and fascia parotidea masseterica. Facial artery, facial vein, retromandibular vein, marginal mandibular branch of facial nerve and cervial branch of facial nerve are located in the same anatomical level. The level was under the fascia parotidea masseterica.
2.2 Applied atomical characteristics of major blood vessels in the mandibular angle region
Facial artery origin from the anterior wall of the external carotid artery, through the stylohyoid muscle and posterior digastric and the deep surface of the hypoglossal nerve, to the submental triangle, through facial nerve groove above submandibular gland, to the anterior border of masseter muscle, around the inferior border of mandibular body to the face. Facial vein company with facial artery on the inferior border of mandibular body,80%(16 sides) of the facial artery located in front of facial veins,20%(4 sides) of the facial artery is located in the deep and front of facial vein. Facial vein and the mandibular vein converge the common facial vein in the submandibular area. At the anterior border of mandibular, facial artery and facial vein located superficially, marginal mandibular branch of facial nerve, platysma, thin subcutaneous fat and skin on the surface of them; deep surface of them close to the periosteum of mandible. The distance between facial artery and the mandibular angle point is (30.06±4.25)mm, the distance between facial vein and the mandibular angle point is (27.55±4.02) mm at the inferior border of mandibular.
The superficial temporal vein and the maxillary vein converged the retromandibular vein behind the neck of mandible,penetrated the parotid gland, courser at the surface of the external carotid artery in front of the external acoustic pore. The retromandibular vein and the facial nerve or its main branches near a cross intersection, little parotid gland organization between them, most paste directly. The retromandibular vein and the posterior border of mandibular ascending branch is almost flat, where the wall is thin and diameter of caliber is coarse, pasted the posterior border of mandibular ascending ramus only had the periosteum,or thin-layer parotid organization between them. After the lower pole of the parotid gland,it is divided into anterior and posterior,the two branches 16 sides (80%); anterior branch injected into the facial vein, the posterior branch with posterior auricular vein merged into the external jugular vein. Four sides (20%) no anterior and posterior branch vein directly merged into facial vein. The relationship between retromandibular vein and the mandibular angle is divided into two kinds of types:①Tight connection type: retromandibular vein and its tributaries which form the arc structure is closely pasted the mandibular angle,8 sides accounted for 40%;②Loose connection type: retromandibular vein and its tributaries which form the arc structure is loosely pasted the mandibular angle,12 sides accounted for 60%. The more decoct later prominent of mandibular angle, the closer the retromandibular vein and the mandibular angle. The distance was (3.00±0.56)mm between the retromandibular vein and the posterior border of mandibular ascending branch, the distance was (12.20±1.09)mm between the retromandibular vein and the mandibular angle point.
2.3 Applied atomical characteristics of important nerves in the mandibular angle region
The marginal mandibular branch of the facial nerve is one-two, mostly one, origin from the facial cervical stem of the facial nerve after that, had undergone on the top of mandibular angle and posterior border of the masseter muscle, the location is more constant. The marginal mandibular branch of facial nerve from the parotid gland after that its courser under the masseteric fascia, cross the facial artery at anterior border of masseter muscle, the location is more constant,was not found there was no cross the facial artery; finally controlled platysma,depressor anguli oris,depressor labii inferioris, mentalis. The distance was (10.36±0.41)mm between marginal mandibular branch of the facial nerve and mandibular angle point when it was away from the parotid gland, after that its position relationship with the inferior border of mandible can be divided into three conditions:①It parallel run on the top of the inferior border of mandible,the distance was (6.84±0.70)mm between it and the inferior border of mandible,12 sides accounted for 60%, it was almost parallel crossed with facial artery at the anterior border of masseter muscle;②It generally flat the inferior border of mandible, equivalent to in thegroove between the inferior border of mandible and the submandibular gland 6 sides accounted for 30%, it was oblique crossed with facial artery at the anterior border of masseter muscle;③It run below the inferior border of mandible, the maximum of the distance between it and the inferior border of mandible was not more than 1.2cm,2 sides accounted for 10%, it was oblique crossed with facial artery at the anterior border of masseter muscle. The relationship of the marginal mandibular branch of facial nerve crossing with the facial artery can be divided into three conditions:①The marginal mandibular branch of facial nerve is located superficial to the facial artery,16 sides accounted for 80%;②It is located in the deep surface of the facial artery,2 sides accounts for 10%;③It separate two branches which retain or encircle facial artery, and then compose one branch,2 sides account for 10%. we also found that four sides,20% of the marginal mandibular branch of facial nerve anastomose with the buccal branch of facial. The distance was (6.93±0.42)mm between the marginal mandibular branch of the facial nerve and the the inferior border of mandible at the crossing of facial artery.
Cervical branch of the facial nerve is the terminal branch of the facial cervical stem of the facial nerve, away from the inferior border of the parotid gland, pass behind the mandibular angle point (9.92±0.40) mm, and run the deep surface of the platysma, finally controlled platysma.
2.4 Running characteristics of mandibular canal and the position relationship between mandibular canal and the mandibular angle, the inferior border of mandible (or the posterior border of mandibular ascending branch)
Mandibular angle point and third molar point were marked as the main indicator line. The distance between the inferior border of mandibular canal and the mandibular angle, the inferior border of mandible or the posterior border of mandibular ascending branch in each section of mandible., separately was A:(14.52±1.21) mm; B:(16.64±0.88)mm;C:(14.1±1.00)mm;D:(12.03±0.91) mm; E:(10.26±0.98) mm;F:(15.22±1.29) mm. Observed the relationship between mandibular canal and inside and outside plate of mandible and discovered:mandibular canal full-length almost run tightly to the inside plate, the more near the rear of the mandible the tighter it attached inside plate.
2.5 Measurement of the proportions of of frontal head and facial skeletal cont our by three-dimensional reconstruction
The relevant data of proportion of frontal head and facial skeletal contou r were measured on the images of head and facial three-dimensional reconstru ction:maximum cranial breadth,eu-eu:(145.13±2.95)mm;facial breadth (bizygom atic breadth),zy-zy:(133.77±4.52)mm;bigonialbreadth,go-go:(97.18±2.38)mm; eu-e u/zy-zy:1.09±0.02;zy-zy/go-go:1.38±0.03;eu-eu/go-go:1.49±0.03.v-n:(105.40±3.10) mm; upper facial height,n-sd:(69.00±2.95) mm;pr-gn:(46.58±1.97) mm; morphol ogical facial height,n-gn:(111.49±4.17)mm;v-n/n-sd:1.53±0.03;n-sd/pr-gn:1.48±0. 07; v-n/pr-gn:2.27±0.09;n-sd/n-gn:0.62±0.02;pr-gn/n-gn:0.42±0.02;v-n/n-gn:0.95±0.02.eu-eu/v-n:1.38±0.05;zy-zy/n-sd:1.94±0.10;go-go/pr-gn:2.09±0.10.
2.6 The measurement of the related angles of mandible angle by three-dimensi onal reconstruction
The related data of the mandibular angle were measured on the image of three-dimensional reconstruction,the mandibular angle (left):(124.10±4.03)°; the mandibular angle (right):(124.46±4.22)°;the mandibular elevated angle (left):(25. 42±2.17)°; the mandibular elevated angle (right):(25.61±2.28)°; the valgus angle of mandibular angle (left):(9.23±7.72)°; the valgus angle of mandibular angle (right):(9.47±8.03)°; the mandiblular included angle:(77.32±2.34)°; the tangent a ngle of mandible:(105.53±1.79)°.
The linear correlation analysis of the related angles of mandibular angle and bigonial breadth:the valgus angle of mandibular angle,bigonial breadth,the mandibluar included angle,the tangent angle of mandible showed significantly positive correlation r range(0.617～0.976),(P<0.01).
The mandibular angle with bigonial breadth,the mandiblular included angle, the valgus angle of mandibular angle and the tangent angle of mandible showed no significant correlation (P=0.048,P=0.019,P=0.184,P=0.019). The mandibular elevated angle with bigonial breadth,the mandiblular included angle, the valgus angle of mandibular angle and the tangent angle of mandible showed no significant correlation(P=0.303,P=0.143,P=0.709,P=0.095).The mandibular angle and the mandibular elevated angle showed a significantly positive correlation (r=0.884, P=0.000).
2.7 The anatomical structure measurement of the influencement of mandibular contour by three-dimensional reconstruction.
We marked points in the influencement area of mandibular contour on theimage of three dimensional reconstruction,.All these points were measured the thickness of mandible and the thickness of outer plate of mandible.The mean results of measurement right and left respectively is A point:(7.20±0.64)mm,(3.32±0.36)mm;B point:(6.58±0.66)mm,(2.85±0.34)mm;Cpoin(7.10±0.65)mm,(3.21±0.39)mm;Epoint:( 7.52±0.79)mm,(3.35±0.38)mm;Fpoint:(9.83±0.94)mm,(3.62±0.33)mm;Gpoint:(12.72±1.01)mm,(4.54±0.37)mm;Hpoint:(12.33±0.94)mm,(4.32±0.39)mmIpoint:(11.29±0.9 9)mm,(4.01±0.39);Dpoint,the thickness of the mandible:(6.66±0.85)mm;the thickness of outer plate of mandible Jpoint:(6.34±0.47)mm;K point:(5.31±0.46)mm.
2.8 Surgical options on basifacial contour plasty
Suitable and surgical compositive options on basifacial contour plasty were choosed and carried out through preoperative classification. Mandibular angle hypertrophy plasty combined with other assistant aesthetic operations were ideal methods to recontour basifacial contour. The result was satisfaction.
Conclusion
Through the study on applied anatomy of the mandibular angle region,disscussed the safe operative region and the more secure osteotomy region on mandibula rangle hypertrophy plasty;related measurrment of mandibular angle was done by spiral CT three-dimensional reconstruction and disscussed the harmonious proportional relationship of the frontal head and facial skeletal contour in normal adult female and the relationship between related angles of mandibular angle and bigonial breadth, identified the anatomical structure of the influencement of mandibular contour and associated thickness of mandible and the thickness of the outer plate of mandible. The subject ranged from applied anatomy of the mandibular angle region and the measurement of three-dimensional reconstruction to research, the results will provid anatomical basis and theoretical basis on improving safety of mandibular angle hypertrophy plasty, such as reduce bleeding, nerve damage, inferior alveolar neurovascular bundle damage and other complications; improving the effect of mandibular angle hypertrophy plasty such as reduce the bilateral asymmetry, the second mandibular angle, "horse face" deformity, excessive or too little osteotomy, insufficient or excessive narrowing of the face and other complications; improving the clinical three-dimensional diagnostic criteria of mandibular angle hypertrophy.
Throng etrospectively analyzed surgical options on basifacial contour plasty of patients. Suitable and compositive surgical options on basifacial contour plasty were choosed and carried out through preoperative classification. Mandibular angle hypertrophy plasty combined with other assistant aesthetic operations were ideal methods to recontour basifacial contour. The result was satisfactory.
The main innovations of this topic were:①Aim at bleeding, facial nerve damage, inferior alveolar neurovascular bundle damage and other serious complications in the clinical mandibular angle hypertrophy plasty, we studied the applied anatomy of the mandibular angle region and took the mandibular angle as the center, observed and measured the mandibular angle region's main blood vessel, nerve and mandibular canal and the position relationship between them and the mandibular angle (the exterior border of the mandible). With a view to provide anatomical basis for the safe operative region and the more secure osteotomy plane of the mandibular angle hypertrophy plasty,avoid to damage these important structures and improve the safety of mandibular angle hypertrophy plasty.②We used mimics software measure specimens by three-dimensional reconstruction, the software has many advantages such as easy installation, the computer configuration requirement is not high, reconstruction and high measuring accuracy and is equipped with a variety of measurement tools, it is easy for clinicians to master and so on.③by spiral CT three-dimensional reconstruction measurement of front view of the head and facial horizontal, vertical, vertical and horizontal proportion, studied the proportional relationship of head and facial skeletal contours more detail than the previous studies. With a view to find some rules of of horizontal,vertical as well as vertical and horizontal proportional relationship.④Related angles measurement of the mandibular angle by three-dimensional reconstruction and statistical analysis, identified the relationship between all relevant angle of mandibular and the bigonial breadth.⑤Measurement by three-dimensional reconstruction and observation, identified the the main anatomical influence factors of front and side contour of mandible and these factors were measured through the fixed-point method.And measured the thickness of mandible and the thickness of outer plate of mandible. Provided basises for the osteotomy and treatment operations on outside plate of mandible in mandibular angle hypertrophy plasty,provide theoretical supportfor doctors preoperative design and postoperative evaluated results of operations.
In summary, the findings of the topic will play an active role in reducing complications and improving safety of mandibular angle hypertrophy plasty to a certain extent, provide plastic surgery mandibular angle in order to to; supply helpness for a comprehensive understanding of the frontal proportions of head and facial skeletal contour in normal adult female, theoretical support for enriching the clinical diagnosis of mandibular angle hypertrophy，improving results of operations, improving surgical satisfaction and so on.
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