同期神经化血管化髂骨瓣修复下颌骨及神经缺损  

Simultaneous innervated and vascularized iliac bone flap for reconstructing mandible and nerve defects

作　　者：王磊[1] 史敬存 WANG Lei;SHI Jingcun(The Ninth People's Hospital of Shanghai Jiaotong University School of MedicineSchool of Stomatology,Oral and MaxillofacialHead and Neck Oncology Department,National Clinical Medical Research Center for Oral Diseases,Shanghai Laboratory of Stomatology,Shanghai Institute of Stomatology,Shanghai 200011,China)

机构地区：[1]上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科,国家口腔医学中心,国家口腔疾病临床医学研究中心,上海市口腔医学重点实验室,上海市口腔医学研究所,上海200011

出　　处：《口腔疾病防治》2023年第9期609-617,共9页Journal of Prevention and Treatment for Stomatological Diseases

基　　金：国家自然科学基金项目(81970907,81771046)。

摘　　要：颌骨大型缺损的功能性重建是口腔颌面外科临床的重点问题,自体骨移植是主要的方法。然而,自体骨移植后的骨质易吸收,即使通过吻合血管,移植骨的自发性疏松化仍然严重影响牙种植及功能恢复。因此,血管化自体骨移植的疏松化成为颌骨重建的重要并发症之一,尚无预防措施。血供充足的自体骨无法避免自身疏松化的问题提示:血供之外被长期忽略的神经等系统因素可能调控移植骨内环境。笔者基于前期神经微环境调控间充质干细胞的系列研究,通过构建神经化血管化髂骨瓣动物模型及尸体解剖,提出了同期神经支配的血管化髂骨瓣修复下颌骨缺损的新术式。神经化血管化髂骨瓣移植是在髂骨瓣(骨肌皮瓣)植入受区并行血管吻合后,对同时获取的支配髂骨的髂腹股沟神经(传统方法一般忽略并牺牲)与下牙槽神经近心端及颏神经行显微缝合。笔者团队通过开展临床回顾性研究和前瞻性随机对照试验,证实同期神经化血管化髂骨瓣移植的新方法不仅抵御骨质吸收,而且能够恢复唇等周围软组织的感觉,可解决颌骨重建后感觉缺失及疏松化的关键问题,保证了牙种植义齿的成功,并提出“血供+神经”双系统骨移植的新理念。The functional reconstruction of large maxillofacial defects is a major issue in oral and maxillofacial surgery,and autologous bone transplantation is the main method.However,bone is readily absorbed following an autologous bone transplant.Even with vascular anastomosis,spontaneous osteoporosis of transplanted bone is still serious,which affects dental implantation and functional recovery.Therefore,osteoporosis of the grafted bone has become one of the main complications of jaw reconstruction,and there is no preventive measure.The problem that autologous bone with sufficient blood supply cannot avoid osteoporosis suggests that systemic factors such as nerves,which have been neglected in traditional methods,may regulate the internal environment of the transplanted bone.Based on previous studies on the regulation of mesenchymal stem cells by the neural microenvironment,we initiated a new surgical procedure for innervated and vascularized iliac bone flaps based on animal model and cadaver studies.In the innervated and vascularized iliac bone flap,vascular microanastomosis was performed in conjunction with microneuronal anastomosis between the simultaneously harvested ilioinguinal nerve(which innervates the iliac bone and is usually sacrificed and neglected in the conventional vascularized iliac bone flap)and the inferior alveolar nerve proximally and with the mental nerve distally.By conducting clinical retrospective studies and prospective randomized controlled trials,we proved that the novel method of simultaneous innervated iliac bone transplantation can not only prevent bone resorption but also restore the sensation of adjacent soft tissues such as the lip.This may solve the key problems of sensory loss and osteoporosis after mandibular reconstruction,ensure the success of dental implant dentures,and put forward the new concept of"blood supply+innervation"bi-system bone transplantation.

关 键 词：下颌骨缺损 下颌骨重建 游离髂骨瓣 血管化 旋髂深动静脉 髂腹股沟神经 下颌神经 颏神经 神经支配 骨质疏松症 感觉 

分 类 号：R78[医药卫生—口腔医学]