【作者】 廖进民；

【导师】 钟世镇；

【作者基本信息】 第一军医大学 ， 人体解剖学， 2004， 博士

【摘要】 研究背景：下颌骨截骨手术不但要矫正患者的下颌骨畸形(如：下颌前突或后缩、小下颌畸形、下颌角及嚼肌良性肥大)，还涉及对其进行整形美容。常见的并发症有下牙槽神经血管损伤、骨折、出血；手术期间损伤面神经、面横血管、腮腺导管和咬肌神经血管也时有发生。究其因有多方面，不太了解下颌骨及其邻近结构是其中的重要原因之一。 本课题针对下颌骨及其邻近结构进行了应用解剖学研究，并开发修复面神经缺损的供体，旨在为临床更好地开展下颌骨截骨手术和减少并发症的发生提供应用基础理论，也为面神经缺损提供新的神经供体。 第一部分：下颌骨截骨术骨学测量及临床意义 目的：测量与下颌骨截骨术有关的指标和探讨其临床意义，为避免下颌骨截骨术并发症提供形态学基础。 材料和方法：8个经自然腐蚀后制成的骨架、10个下颌骨透明标本和100个下颌骨干燥标本，采用人体测量仪，按照人体测量手册所述及的下颌骨测量方法进行测量。 结果：下颌体长为(72.0±5.4)mm，下颌体高和厚分别为(27.7±3.3)mm、(15.0±1.7)mm，下颌联合高为(33.4±3.7)mm；下颌支高和最小宽、髁突间宽、下颌角角度、下颌角间宽分别为(61.1±5.7)mm、(32.6±3.2)mm、(120.4±6.6)mm、(124.9±7.5)°、(100.2±6.8)mm；下颌孔上缘至下颌切迹最低点距离、下颌孔后缘至下颌支后缘的宽度、茎乳孔前缘至下颌支后缘的距离和下颌角最突点至下颌管的距离分别为(15.8±2.3)mm、、(13.1±1.9)mm、(16.2±1.2)lnnl和(20.4±3.2)mm。 结论：这些数据可作为临床医生施行下颌骨各型截骨术时的参考依据，从而避免其并发症的发生。 第二部分:下领骨截骨术手术入路的应用解剖 目的:进一步探讨咬肌区浅层的组织结构，为临床行下领截骨术避免损伤咬肌区的重要结构提供解剖学基础。 材料和方法:18例头颈部标本，经双侧颈总动脉插管，加压注入红色乳胶或明胶墨汁，解剖观测下领支浅层的组织结构。 结果:咬肌区浅层由浅入深的组织层次是:皮肤、皮下组织、SMAS、腮腺咬肌筋膜、咬肌、咬肌下间隙和骨膜。咬肌表面横行结构有面神经颧支、面横动脉、面神经上颊支、腮腺导管、面神经下颊支、下领缘支和颈支，它们离下领角的距离分别为(5.8士0.5)em、(5.2士0.5)em、(5.1士0 .6)em、(4.3士0.5)cm、(3.3士0.8)cm、(0.9士0.5)em和(一0.8士0.4)em;离角前切迹的距离分别为(6.7士0.6)cm、(5.6士0.6)em、(5.6士0.7)em、(4.7士0.5)em、(3.5士0.7)em、(1.2士1.0)cm和C1.0士0.2)em。该区的动脉供应来源于颗浅动脉、面横动脉、颈外动脉、面动脉和咬肌动脉。 结论:行下领支截骨术时，应熟悉下领支浅层的组织层次及咬肌浅层横行结构的布局，以免造成误伤。 第三部分:下领骨血供及血管构筑的临床解剖 目的:探讨下领骨血供情况及血管构筑，为下领骨截骨术提供形态学基础。 材料和方法:巧例新鲜头颈部标本，其中8例经颈总动脉注入红色过氯乙烯填充剂，经腐蚀后制成头部血管铸型标本;2例去除部分骨皮质，显示下牙槽动脉的分支分布情况;其余5例注入5%明胶墨汁，经脱钙、漂白、乙醇梯度脱水和二甲苯透明后，用水杨酸甲酷继续透明和保存，观察下领骨膜和骨内的血管构筑。 结果:下领骨内部主要由下牙槽动脉供血;下领骨表面及骨膜则由下领骨骨膜动脉和肌动脉骨穿支营养;下领骨骨膜动脉和肌动脉骨穿支经过下领骨副孔穿入下领骨内，与下牙槽动脉分支互相吻合，使下领骨骨内与骨周围软组织间构成丰富的血管交通构筑。 结论:下领骨截骨手术后移动骨块和施行骨内固定时，要尽量少剥离下领骨周围的软组织，以避免下领骨发生坏死。 第四部分:激光三维扫描系统重建下领骨模型 目的:利用激光三维扫描系统，探索重建人体下领骨的新方法。 材料和方法:采用3D Digital Corpr的产品RealscanusB Model 200三维激光扫描系统，对人体下领骨标本进行表面扫描重建。 结果:用激光三维扫描系统进行通过多次、分区域扫描人体下领骨标本，并对多个局部的扫描点云文件进行拼接，建立了一个人体下领骨整体骨性表面的三维模型。 结论:此模型造型逼真，并可以适当的文件格式应用于有限元结构力学仿真分析。在生物力学仿真实验中，激光三维扫描系统可解决常规CAD方法难以建立非规则人体结构模型这一难题。 第五部分:颈横和锁骨上神经移植修复面神经缺损的应用解剖 目的:为颈横和锁骨上神经移植修复面神经缺损提供形态学基础。 材料和方法:在32侧成人标本上，观测颈丛皮神经的行程、长度、横径和血供情况。 结果:颈横神经和锁骨上内侧、中间和外侧神经的长度分别为(6.9士1.0)em、(8.9士1.7)em、(8.2士1.5)em和(7.3士1.7)em;横径分别为(1.5士0·5)mm、(2.0士0.5)nun、(1.9士0.9)nun、(1.8士0.4)nun。颈横和锁骨上神经的血供主要来源于甲状腺上动脉、颈升动脉和颈横动脉的肌皮支。 结论:颈横和锁骨上神经可作为面神经移植的一个合适而易得的理想供体，行自体神经游离移植或吻合血管神经移植用以修复各种原因所致的面?更多还原

【Abstract】 Clinical Anatomic Study on the Plastic Surgery of the mandiblePhD. Candidate: LIAO Jinmin Supervisor: Prof. ZHONG ShizhenInstitute of Clinical Anatomy, The First Military Medical University, Guangzhou 510515Background: The mandibular deformities such as mandibular prognathism or retrognathism, micrognathia, prominent mandibular angles and masseter muscle hypertrophy, and so on, not only would be corrected, but also be carried out aesthetic plastic surgery during the mandibular osteotoctomies. However, such common complications as the injury of inferior alveolar nerve, bone fracture and bleeding would be occurred in surgical procedure, and the injuries of the facial nerve, the transverse facial vessels, parotid duct and masseteric nerve and vessels, etc. would be happened at times. It was believed that many causes had been responsible for the complications, one of the important causes was less understandings for the mandible and its adjacent structures.The aims of this study were to explore the mandible and its adjacent structures and to develop donors repairing facial nerve defects, so as to provide the applied basic theories for the mandibular osteotomy being better performed and making these complications as less happen as possible, and to provede a new nervous donors for the facial nerve defects, too. Part one:The mandible osteometry related to mandibular osteotomy and its clinical significancesObjective: To measure bony indices related to mandibular osteotomy and explore their clinical significance, so as to provide morphological data-6-for avoiding the occurrence of complications when osteotomy of mandibular ramus was clinically performed.Methods: 100 dry and 10 transplant adult mandibles, which were undamaged on their surfaces, were measured by using the human surveying instrument and referring to surveying methods described by the human surveying handbook.Results: The length, height and thickness of the mandibular body, the height of symphysis, the height and the minimum breadth of the mandibular ramus, the bicondylar breadth, the mandibular angle and the bigonial breadth were72.0?.4mm 27.7?.3mm, 15.0?.7mriK 33.4?.7mm, 61.1?.7mm 32.6?.2mnu 120.4?.6mnu 124.9?.5? 100.2?.8mm, respectively; and the distance from the superior margin of the mandibular foramen to the lowest point of the notch, the distance from the posterior margin of the mandibular foramen to the posterior margin of the ramus, the distance from the anterior margin of stylomastoid foramen to the posterior margin of the mandibular ramus, the distance from the prominent point of the mandibular angle to canal were 15.8?.3mm . 13.1?.9mm . 16.2?.2mm and 20.4?.2mm, separately.Conclusion: The bony indices not only increase anatomic data, but can provide morphological basis when osteotomy of mandibular ramus was clinically performed. Part two:The applied anatomy on the operative approach of the mandibular osteotomyObjective: Further to explore the tissue structures of the superficial face on the masseteric region of mandible and to provide anatomic basis for avoiding damage of its important structures when osteotomy of mandibular ramus was clinically performed.Methods: Red latex or carbonic black ink containing 5% gelatin was injected into the arteries on 18 adult head specimens by both common carotid artery catheterization. The tissue structures of the superficial part of the-7-mandibular ramus were observed and measured.Results: The tissue structures of the superficial part of the mandibular ramus, from superficial to deep layer, were as follows: the skin, subcutaneous tissue, the superficial musculoaponeurotic system (SMAS), parotideomasseteric fascia, masseter, spaces of submasseter and periosteum of mandible. The distances on the superficial face of the masseter from the, zygomatic branch, transverse facial artery, superior buccal branch, parotid duct, inferior buccal branch, marginal mandibular branch and cervical branch to mandibular angle were 5.80.5cnK 5.20.5cm5.1?.6cnu 4.30.5cm, 3.30.8cm 0.9?.5cm更多还原