CN104720877A - Application of digitization technology to oral approach mandibular condylar lesion surgical excision - Google Patents
Application of digitization technology to oral approach mandibular condylar lesion surgical excision Download PDFInfo
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
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Abstract
The invention relates to application of a digitization technology to oral approach mandibular condylar lesion surgical excision. The application comprises the following steps: planting five self-tapping titanium screws into a mandible of a patient to be used as registration mark points of a navigation system in a surgery; photographing maxillofacial region CT (Computed Tomography) scanning and storing in a DICOM (Digital Imaging and Communications in Medicine) format; establishing a patient lesion three-dimension pattern; designing an osteotomy face and an osteotomy range according to a lesion boundary; introducing navigation software in an STL (Standard Template Library) format to reestablish a three-dimensional geometrical model; mounting a navigation reference frame, and registering by using a navigation positioning probe and the mark points; setting an incision and dissecting and separating a joint capsule under an endoscope view to expose a condylar process; searching an osteotomy face position by using the positioning probe and calibrating a coordinate of a bone saw; adjusting the bone saw to the position of the osteotomy face and the cutting angle; and under the guidance of the incision stretched endoscope probe and a navigation positioning image, carrying out condylar osteotomy by holding the bone saw via a surgery doctor. By the aid of the application, the surgery doctor can accurately cut off condylar tumors according to preoperative plans, so the ideals of minimally invasive surgery and accurate surgery are uniformed.
Description
Technical field
The present invention relates to a kind of Computer assisted surgery field, especially relate to the application of a kind of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy.
Background technology
In prior art, it is the important anatomical structure of Maxillary region that condyle is dashed forward, and Condylar morphology and function complete ensures that mandibular bone is opened to remain silent and the key of masticatory movement.Condyle is prominent to be made up of cortical bone and spongy bone, surface coverage cartilaginous element.Betide the tumor of bone structure and cartilaginous tissue, the diseases such as such as osteochondroma, also can betide condyle and dash forward.The neoplastic disease that condyle is dashed forward often can cause the pain of remporomandibular joint, joint function disturbance and Facial asymmetry and occlusion disorder.Its main Therapeutic Method is by surgery operating removing tumor, even excises the condyle involved and dashes forward.And the approach of conventional surgical method usually needs to adopt preauricular incision or postauricular incision, to expose tumor, excise.But these otch and approaches often have facial nerve injury risk, and cause face scar, affect aesthetic after operation in patients.Along with the development of social economy and culture, people are attractive in appearance deeply concerned all the more to self looks.Increasing patient can not accept larger operation wound and face scar and externally to have attractive appearance the impact seen.In recent years, Minimally Invasive Surgery has become a surgery development trend.The use of endoscopic technic, can make operative doctor process as structure of temporomandibular articulation so like this deeply anatomical structure time, good illumination and local field of view clearly also can be provided.Due to the restriction of endoscopic technic self, only two-dimensional field of view can be put forward.Although endoscopic probe can the clear details showing topography enlargedly, can not lead to and overall stereo vision is provided.Owing to can not carry out operation technique under direct-view, operative doctor only relies on the local field of view of scope, the more difficult locus accurately determining operation technique and operating theater instruments.
Summary of the invention
The object of the invention is for prior art weak point and the application of a kind of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy is provided.The method provides a bridge connecting practical operation in preoperative planning and art, greatly increases the accuracy of operation, accuracy and predictability, adds operative doctor to the controllability of operation and self-confidence.Meanwhile, also achieve the effect of Wicresoft, decrease operation wound, avoid face scar.
The object of the invention is to be realized by following measures: the application of a kind of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy, is characterized in that: step is as follows:
On mandibular bone, implant self tapping titanium through mandibular bone lip side mucosa before step one, operation in patients and follow closely 5,5 self tapping titaniums nail position is respectively between infradentale root, between bilateral canine tooth and frist premolar root, bilateral the or two is ground one's teeth in sleep between root, as navigation system registration marks point in art;
Step 2, patient take Maxillary region CT scan, sweep limits be on to calvarium, down to hyoid bone level, Scan slice thickness is 1.25mm, and scan-data is preserved in dicom format;
Step 3, patient CT scan figure is imported surgical planning software, in coronalplane, sagittal plane and transverse section, dash forward pathological changes or abnormal portion bit boundary of condyle is retouched and drawn, set up patient's upper jaw bone, mandibular bone and condyle and to dash forward pathological changes graphics;
Step 4, according to the pathological changes boundary design osteotomy surface of described patient's pathological changes graphics and osteotomy scope, described osteotomy surface is that the condyle blocked is dashed forward pathological changes or the part between abnormal position and the separating surface blocking rear surplus mandibular portions, and 3-D geometric model and the Osteotomy at patient's upper jaw bone, mandibular bone and condyle are dashed forward pathological changes or abnormal position are preserved with STL form;
Step 5, by described osteotomy surface with STL form import navigation software, the 3-D geometric model of reconstruction patients head;
Step 6, settle navigational reference frame in center, mandible chin portion, use navigator fix probe by the real image of patient on operating-table and the point of the registration marks in step one registration;
Step 7, at patient's Ipsilateral mandibular bone anterior border of ramus place to offside first molar root side vestibule trench culture otch, cut the sudden and violent surface of bone of mucosa, along Ipsilateral ramus of mandible upwards, the auxiliary lower dissection temporalis of scope exposes coronoid process, coronoid process is blocked according to preoperative plan under navigation, continue anatomical isolation joint capsule under the help in the scope visual field, expose condyle and dash forward;
Step 8, use position probe seek osteotomy surface position by navigation picture, are pressed from both sides by the instrument tracer of navigation system and assemble bone saw, demarcate coordinate be convenient to location tracking thereafter by the tool calibration device of navigation system to bone saw;
Step 9, under navigation system orientation direction, bone saw can be adjusted to position, the cutting angle of described osteotomy surface by operative doctor exactly;
Step 10, the endoscopic probe stretched at described otch, provide illumination and surgical field of view, and by under the guiding of navigation positioning images, operative doctor hand-held bone saw under the guiding of osteotomy surface carries out condyle and to dash forward osteotomy.
The transverse section of form in planning software, coronalplane and sagittal plane that the growth pattern that the retouching of described step 3 divides into according to tumor, form and border and normal condyle are dashed forward are seen in 2 dimension scanograms of each level, trace out by the scope of tumor.
The osteotomy surface of described step 4 or for plane or for be made up of multiple folding face.
The 3-D geometric model of the reconstruction patients head of described step 5 is the high gray-value image shown in CT imaging according to highdensity skeleton, automatically selected bone portion.Then by computerized algorithm, the contours connection in every one deck two dimensional image is got up, form 3-D view.
Compared with prior art, have employed the application of a kind of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy that the present invention proposes, tool has the following advantages: 1) according to the three-dimensional digital model of patient CT data's reconstruction patients head, Precise spraying osteotomy surface and osteotomy scope; 2) adopt endoscopic technic, carry out condyle through Intraoral incision approach and to dash forward tumor resection, avoid the postoperative scar that facia incision causes, thus avoid the impact of operation on aesthetic after operation in patients, achieve condyle and to dash forward the Wicresoft of operation, attractive in appearanceization and hommization; 3) by navigation and endoscope is clear determines surgical instrument position accurately, adjustment bone saw cutting angle and cut coverage.Operative doctor can be dashed forward tumor according to preoperative planning excision condyle accurately in the present invention, the morphosis that the damage condyle of minimum degree is prominent, thus farthest retain the function of remporomandibular joint, the theory of minimally invasive surgery and accurate surgery is obtained unified, and can realize simultaneously.
Accompanying drawing explanation
Fig. 1 is the abnormal image figure feature of a tumor patient on CT image in certain aspect that the present invention provides.
Fig. 2 shows frame of reference and is fixed on the position of mandibular bone and is fixed on the navigation registration nail of mandibular bone.
Fig. 3 operative doctor is according to endoscopic image and navigation instruction operation.
Detailed description of the invention
Below in conjunction with accompanying drawing, detailed description of the invention is elaborated: the application of a kind of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy, is characterized in that: step is as follows:
On mandibular bone, implant self tapping titanium through mandibular bone lip side mucosa before step one, operation in patients and follow closely 5,5 self tapping titaniums nail position is respectively between infradentale root, between bilateral canine tooth and frist premolar root, bilateral the or two is ground one's teeth in sleep between root, as navigation system registration marks point in art.
Step 2, patient take Maxillary region CT scan, sweep limits be on to calvarium, down to hyoid bone level, Scan slice thickness is 1.25mm, and scan-data is preserved in dicom format.In this step, after patient implants titanium nail, shooting Maxillary region CT scan, DICOM form contains definition and the network service agreement of File Format, its application agreement based on TCP/IP, and contacts each system with TCP/IP.Between the Medical Instruments that two can accept DICOM form, by the archives of DICOM form, can receive and exchange image and patient data.
Step 3, patient CT scan figure is imported surgical planning software, in coronalplane, sagittal plane and transverse section, dash forward pathological changes or abnormal portion bit boundary of condyle is retouched and drawn, set up patient's upper jaw bone, mandibular bone and condyle and to dash forward pathological changes graphics.In this step, existing multiple surgical planning software is available, and the software that the present invention adopts is SurgiCase CMF 5.0-Materialise, NV Leuven, Belgium.The described transverse section of form in planning software that the growth pattern, form and border and the normal condyle that divide into according to tumor dash forward, coronalplane and the sagittal plane retouched is seen in 2 dimension scanograms of each level, traces out by the scope of tumor.
Specific practice is such: because tumor is abnormal structure, so tumor and condyle are dashed forward, normal configuration is have obvious marginal on CT image, in every layer of CT image, uses the dividing function in software, is coated with by tumor section and draws.As, in Fig. 1 1.1 gives patient and to dash forward transverse section sectional drawing at the condyle of certain level, in figure, T is tumor region, simultaneously, check the scope of drawing further at coronalplane, sagittal plane, 1.2 in Fig. 1,1.3 is respectively condyle prominent coronalplane sectional drawing, sagittal plane sectional drawing, and the T in figure is tumor region, can determine further in three planes like this, improve the accuracy retouched and draw.Then, software is traced by successively to scribble, and auto Segmentation is set up and drawn upper jaw bone, mandibular bone and condyle and to dash forward the 3-D geometric model of tumor section.The 3-D geometric model that 1.4 condyles in Fig. 1 are prominent.In figure, 1.1 is the sectional drawing of coronalplane, and 1.2 is transverse section sectional drawing, and 1.3 is sagittal plane sectional drawing, 1.4 these 3-D views.T in figure: tumor region, CS are: osteotomy surface.
Step 4, according to the pathological changes boundary design osteotomy surface of described patient's pathological changes graphics and osteotomy scope, described osteotomy surface is that the condyle blocked is dashed forward pathological changes or the part between abnormal position and the separating surface blocking rear surplus mandibular portions, and 3-D geometric model and the Osteotomy at patient's upper jaw bone, mandibular bone and condyle are dashed forward pathological changes or abnormal position are preserved with STL form; Described osteotomy surface or be plane or for be made up of multiple folding face.In this step, can first in surgical simulation software, the position of simulating cut and scope, be presented as osteotomy surface, use after osteotomy surface carries out Virtual cropping, dash forward tumor section or part condyle of the condyle that can obtain amputating is dashed forward, its divisional plane with remaining mandibular portions is exactly osteotomy surface.In the operation of reality, patient's pathological changes may not be simple plane, completely the pathological changes of patient can be carried out retouching with multiple folding face and draw under digitized condition, is beneficial to farthest to retain condyle and to dash forward profile and organizational structure.Equally, osteotomy scope refers to leave the certain distance of lesion region, accomplishes both to remove diseased region, protects original tissue as much as possible again.
Step 5, by described osteotomy surface with STL form import navigation software, the 3-D geometric model of reconstruction patients head.STL form is a kind of data mode that can record morphosis and locus, use derivation and the importing of STL form, the condyle that amputation is fallen can be dashed forward the three-dimensional digital model of tumor section and remaining these two parts of mandibular portions when ensureing that locus and morphosis are all constant by us, transfers in navigation software.Just surgery planning can be seen accurately at navigation software.The navigation software adopted in this step embodiment is Intellect Cranial Navigation System (Stryker, Freiburg, Germany), iPlan (BrainLab, Westchester, IL.Patient's upper jaw bone, mandibular bone and condyle are dashed forward in the 3-D geometric model at pathological changes or abnormal position and osteotomy surface data importing software, the high gray-value image that software shows in CT imaging according to highdensity skeleton, automatically selected bone portion.Then by computerized algorithm, the contours connection in every one deck two dimensional image is got up, form 3-D view.
Step 6, settle navigational reference frame in center, mandible chin portion, use navigator fix probe by the real image of patient on operating-table and the point of the registration marks in step one registration.See in Fig. 2, figure, RF:Reference Frame navigational reference frame; RS:Register Screw navigation registration screw.
Step 7, at patient's Ipsilateral mandibular bone anterior border of ramus place to offside first molar root side vestibule trench culture otch, cut the sudden and violent surface of bone of mucosa, along Ipsilateral ramus of mandible upwards, the auxiliary lower dissection temporalis of scope exposes coronoid process, coronoid process is blocked according to preoperative plan under navigation, continue anatomical isolation joint capsule under the help in the scope visual field, expose condyle and dash forward.Be provided with otch in this step, carry out condyle through Intraoral incision approach and to dash forward tumor resection, the postoperative scar that facia incision causes can be avoided.Otch cuts mandibular bone chin portion lip side mucoperiosteum, exposes chin portion surface of bone.Use tapping screw to be fixed on mandible by navigational reference frame, ensure that the relative position relation of frame of reference and mandibular bone is firmly constant.Frame of reference is mainly fixed on chin portion is partial to patient health side mandibular bone.In this step, scope adopts the endoscope lens of 4mm diameter angulation 30 °, and in endoscope lens per os, mucosal membrane incisions and approach enter, and camera lens points to the real-time visual field that operation technique region is provided by scope, can to dash forward anatomical structure by clear display condyle, be convenient to operative doctor and carry out corresponding operation technique.
Step 8, use position probe seek osteotomy surface position by navigation picture, are pressed from both sides by the instrument tracer of navigation system and assemble bone saw, demarcate coordinate be convenient to location tracking thereafter by the tool calibration device of navigation system to bone saw.Position probe is a metal rigidity probe comprising navigation tracer, can pass through navigation system in real time, determine the locus of probe and probe pinpoint.After missing device folder upper assembling bone saw, bone saw can use after need demarcating with the apparatus calibration tool that navigation system is supporting.
Step 9, under navigation system orientation direction, bone saw can be adjusted to position, the cutting angle of described osteotomy surface by operative doctor exactly.After position probe and bone saw positioning and demarcating, probe tip can be utilized easily to give directions the locus of the region of anatomy, determine osteotomy line position.Because bone saw have also been made the demarcation of association, navigation system can show the real space position of saw blade in preoperative calculated osteotomy surface and art simultaneously, thus guided operation doctor adjusts angle of saw blade and direction, provide the spatial relation that bone saw and mandible and condyle are prominent in real time, accurately carry out operation technique according to operation plan.
Step 10, the endoscopic probe stretched at described otch, provide illumination and surgical field of view, and by under the guiding of navigation positioning images, operative doctor hand-held bone saw under the guiding of osteotomy surface carries out condyle and to dash forward osteotomy.In this step, by the scope visual field, by illumination and the enlarging function of scope, carefully can be separated protection art district important anatomy structure, show the real-time condition of art district operation on the other hand simultaneously.It combines with airmanship, the true visual field, art district that the operating theater instruments location relying on navigation system to provide and endoscopic technic provide, and operative doctor can complete tumor amputation operation smoothly without the need to obtaining the direct-view visual field.See Fig. 3.In Fig. 3 3.1 relative position relation of anatomical structure such as to dash forward, in figure: SM is bone saw display model in navigation system for coronalplane cross section display bone saw and condyle; 3.2 the relative position relation of anatomical structure such as to dash forward, in figure: SM is bone saw display model in navigation system for sagittal plane section display bone saw and condyle; 3.3: cross section, transverse section display bone saw and condyle such as to be dashed forward at the relative position relation of anatomical structure; In figure: SM is bone saw display model in navigation system; 3.4 the relative position relation of anatomical structure such as to dash forward for showing surgical planning and bone saw and condyle in 3-D view, and in figure, T is: Tumor tumor, and SM is bone saw display model in navigation system, and CS is: Cutting Surface osteotomy surface; 3.5 is scope view display local true scene in real time, and in figure: EV is the image that the scope visual field is taken the photograph, S is bone saw.Operative doctor is according to navigation instruction in endoscopic image and art, and accurate adjustment saw blade position, accurately carries out osteotomy according to preoperative plan.As mentioned above, navigation system can show the relative position relation of bone saw and patient anatomy in real time, as the relative position relation of condyle of mandible etc.Operative doctor can adjust the position of bone saw further according to the gap of the real time position of bone saw and bone saw and preoperative plan.When bone saw reaches the position of preoperative osteotomy surface in the works, under the good illumination provided at endoscope system and magnification field help, operative doctor carries out accurate osteotomy.In Fig. 3 3.6 is the photo in operation, and operative doctor operational circumstances in display art, in figure.En is scope, NS is the auxiliary bone saw of navigation; RF is navigational reference frame.
Equally, above-mentioned same method also can be taked to process for jaw fracture patient, first, according to the three-dimensional digital model of patient CT data's reconstruction patients head, the scope of locking fracture segment, analog reset fracture segment; Secondly, adopt endoscopic technic, incision site is set, through the endoscopic probe that otch stretches into, provide illumination and surgical field of view, again, by under the guiding of navigation positioning images, determine surgical instrument position used accurately, determine whether fracture segment moves and reset to correct locus.Like this, adopt digitizing technique, allow patient obtain best treatment.
Describe embodiments of the present invention by reference to the accompanying drawings above, the structure that embodiment provides is not construed as limiting the invention, and in this area, those skilled in the art make various distortion within the scope of the appended claims or revise all in protection domain.
Claims (4)
1. the application of digitizing technique in intraoral approach condyle of mandible pathological changes surgical discectomy, is characterized in that: step is as follows:
On mandibular bone, implant self tapping titanium through mandibular bone lip side mucosa before step one, operation in patients and follow closely 5,5 self tapping titaniums nail position is respectively between infradentale root, between bilateral canine tooth and frist premolar root, bilateral the or two is ground one's teeth in sleep between root, as navigation system registration marks point in art;
Step 2, patient take Maxillary region CT scan, sweep limits be on to calvarium, down to hyoid bone level, Scan slice thickness is 1.25mm, and scan-data is preserved in dicom format;
Step 3, patient CT scan figure is imported surgical planning software, in coronalplane, sagittal plane and transverse section, dash forward pathological changes or abnormal portion bit boundary of condyle is retouched and drawn, set up patient's upper jaw bone, mandibular bone and condyle and to dash forward pathological changes graphics;
Step 4, according to the pathological changes boundary design osteotomy surface of described patient's pathological changes graphics and osteotomy scope, described osteotomy surface is that the condyle blocked is dashed forward pathological changes or the part between abnormal position and the separating surface blocking rear surplus mandibular portions, and 3-D geometric model and the Osteotomy at patient's upper jaw bone, mandibular bone and condyle are dashed forward pathological changes or abnormal position are preserved with STL form;
Step 5, by described osteotomy surface with STL form import navigation software, the 3-D geometric model of reconstruction patients head;
Step 6, settle navigational reference frame in center, mandible chin portion, use navigator fix probe by the real image of patient on operating-table and the index point registration in step one;
Step 7, at patient's Ipsilateral mandibular bone anterior border of ramus place to offside first molar root side vestibule trench culture otch, cut the sudden and violent surface of bone of mucosa, along Ipsilateral ramus of mandible upwards, the auxiliary lower dissection temporalis of scope exposes coronoid process, coronoid process is blocked according to preoperative plan under navigation, continue anatomical isolation joint capsule under the help in the scope visual field, expose condyle and dash forward;
Step 8, use position probe seek osteotomy surface position by navigation picture, are pressed from both sides by the instrument tracer of navigation system and assemble bone saw, demarcate coordinate be convenient to location tracking thereafter by the tool calibration device of navigation system to bone saw;
Step 9, under navigation system orientation direction, bone saw can be adjusted to position, the cutting angle of described osteotomy surface by operative doctor exactly;
Step 10, the endoscopic probe stretched at described otch, provide illumination and surgical field of view, and by under the guiding of navigation positioning images, operative doctor hand-held bone saw under the guiding of osteotomy surface carries out condyle and to dash forward osteotomy.
2. the application process of digitizing technique according to claim 1 in intraoral approach condyle of mandible lesions treatment art, it is characterized in that: the transverse section of form in planning software, coronalplane and sagittal plane that the growth pattern that the retouching of described step 3 divides into according to tumor, form and border and normal condyle are dashed forward are seen in 2 dimension scanograms of each level, trace out by the scope of tumor.
3. the application process of digitizing technique according to claim 1 in intraoral approach condyle of mandible lesions treatment art, is characterized in that: the osteotomy surface of described step 4 or for plane or for be made up of multiple folding face.
4. the application process of digitizing technique according to claim 1 in intraoral approach condyle of mandible lesions treatment art, it is characterized in that: the 3-D geometric model of the reconstruction patients head of described step 5 is the high gray-value image shown in CT imaging according to highdensity skeleton, automatically selected bone portion; Then by computerized algorithm, the contours connection in every one deck two dimensional image is got up, form 3-D view.
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| CN111227933A (en) * | 2019-04-16 | 2020-06-05 | 北京大学第三医院（北京大学第三临床医学院） | Prediction and real-time rendering system for mandibular angle osteotomy |
| CN111227933B (en) * | 2019-04-16 | 2021-02-19 | 北京大学第三医院（北京大学第三临床医学院） | Prediction and real-time rendering system for mandibular angle osteotomy |
| CN111772727A (en) * | 2020-07-01 | 2020-10-16 | 北京和华瑞博医疗科技有限公司 | Anti-shaking control method and system for osteotomy saw blade |
| WO2022002090A1 (en) * | 2020-07-01 | 2022-01-06 | 北京和华瑞博医疗科技有限公司 | Control method and system |
| CN112641495A (en) * | 2020-11-12 | 2021-04-13 | 南京医科大学附属口腔医院 | Recording, positioning and recovering device for position relation of condyle process in mandibular branch sagittal dissection operation |
| CN113143457A (en) * | 2021-02-09 | 2021-07-23 | 席庆 | Maxillofacial operation auxiliary system and method based on MR head-mounted equipment |
| CN113317872A (en) * | 2021-05-11 | 2021-08-31 | 上海盼研机器人科技有限公司 | Intraoral incision mandible surgery space modeling method |
| CN113317872B (en) * | 2021-05-11 | 2024-05-17 | 南通罗伯特医疗科技有限公司 | Mandible operation space modeling method for intraoral incision |
| CN115607286A (en) * | 2022-12-20 | 2023-01-17 | 北京维卓致远医疗科技发展有限责任公司 | Knee joint replacement surgery navigation method, system and equipment based on binocular calibration |
| CN116883428A (en) * | 2023-07-07 | 2023-10-13 | 东北大学 | Mandible spiral CT image partition segmentation method |
| CN116883428B (en) * | 2023-07-07 | 2024-05-31 | 东北大学 | Mandible spiral CT image partition segmentation method |
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