即時導航系統輔助暫時錨定裝置置入手術之準確性及安全性評估

Evaluation of accuracy and safety of real-time navigation in TAD insertion surgery

陳奕誠(Yi-Cheng Chen)

指導教授 ： 章浩宏

國立臺灣大學/醫學院/臨床牙醫學研究所/碩士(2021年)

https://doi.org/10.6342/NTU202101801

摘要

導航系統是現代生活中不可或缺的技術，隨著科技的發展已應用在醫學中。在牙科，導航系統使用於植體植入手術及根管治療等領域。利用導航系統可以協助進行治療計畫擬定、調整、決定植體位置、導引手術進行及術中即時修正。
牙科植體目前廣泛運用在人工植牙、顏面重建及矯正治療過程中。迷你骨釘為暫時性牙科植體，其為矯正治療中常用之暫時錨定裝置 (Temporary anchorage devices, TADs)。暫時錨定裝置置入必須依照矯正原理，並且手術過程中要避免傷及鄰牙牙根及下顎管等解剖構造。傳統上依據手術醫師經驗徒手放置，偶有傷及鄰牙牙根，以致鄰牙需進行根管治療或拔除之併發症。回顧至今文獻，尚無將即時導航系統運用在暫時錨定裝置之研究，為瞭解即時導航系統是否可以應用於臨床上矯正用暫時錨定裝置的置入，我們將以臨床試驗，針對導引手術應用於暫時錨定裝置置入之準確性及安全性進行評估及探討。
其方法為以患者之電腦斷層做術前規劃及術後分析。在導航軟體及手術導板軟體上設計植體，完成術前規劃。術後再次以電腦斷層確認植體之位置。資料分析方面，將以術前及術後之影像進行重疊，分析植體平台中心差距 (platform center deviation)、植體角度差距 （angular deviation）、併發症 （傷害鄰牙、牙根、下顎管或其他解剖構造） 比例。將即時導航系統輔助、手術導板輔助及徒手方法進行比較，即時導航系統輔助之植體平台中心差距平均值為2.99 ± 1.75毫米，角度差距平均值為12.49 ± 4.48度；手術導板輔助之植體平台中心差距平均值為1.17 ± 0.77毫米，度差距平均值為12.43 ± 8.32度；徒手方法之植體平台中心差距平均值為3.10 ± 1.91毫米，角度差距平均值為15.64 ± 5.94度。即時導航系統輔助在植體平台中心控制及植體角度控制，統計上沒有出現較另外兩者精確之表現 (p>0.05)。徒手方法造成牙根傷害的比例約10％，而即時導航系統輔助及手術導板輔助無出現術後立即併發症。
本研究為首篇將即時導航系統運用於暫時錨定裝置置入手術的臨床研究，並藉由合併導航系統及手術導板的特點，探討合併導航系統及手術導板的操作模式，發現其於植體平台中心差距平均值為1.75 ± 1.05毫米，植體角度差距平均值為5.5 ± 1.83度，有較理想表現的趨勢。藉由本研究之結果，我們對於導航系統的臨床應用及暫時錨定裝置植入手術提出改善指引，並探討合併方法的可能性。

關鍵字

暫時錨定裝置 ； 迷你骨釘 ； 即時導航系統 ； 手術導板 ； 合併方法 ； 植體平台中心差距 ； 植體角度差距

並列摘要

Real-time navigation assisted surgery is an important example of today's technology being applied to medicine. Real-time navigation-assisted surgery and dynamic guided surgery span a broad area.
In the dental medicine realm, dynamic guidance has been used to facilitate dental implant surgery and endodontics treatment. Dynamic guided surgery is an easy, simple and fascinating technology that allows us to scan, plan and guide implants in minutes. Furthermore, it can also minimize the risk of surgical complications.
Dental implants have been widely used in the implant-supported prosthesis, maxillofacial reconstruction, and orthodontics treatment. Dental implants used in orthodontics treatment, such as temporary anchorage devices (TADs), most used clinically are mini-screws, are temporary implants, providing adequate anchorage to fascinate tooth movement.
During TADs insertion surgery, the surgeon must pay attention to avoid injury to the adjacent tooth, root, mandibular canal, and other vital structures. Traditionally, this procedure is based on the operator's experience by free hand. Seldomly, procedure complications may encounter, leading to root canal treatment for salvage. If worst comes to worst, extraction of the affected tooth may be taken into consideration.
We had reviewed many articles, to this time, there was no research about the usage of real-time navigation in TADs insertion surgery. The purpose of this clinical trial was to evaluate the accuracy and safety of real-time navigation in TADs insertion surgery.
Material and methods we're using computer tomography for planning and data analysis. By real-time navigation software and surgical stent software, we can perform virtual surgical planning of TADs. In data analysis, the preoperative and postoperative images were superimposed to compare the difference in the platform center deviation and angular deviation of implants and evaluate the complications rate (injury to the adjacent tooth, mandibular canal, or other vital structures).
According to the current result, in the real-time navigation assisted group, the platform center deviation was 2.99 ± 1.75mm, the angular deviation was 12.49 ± 4.48°. In the surgical stent-assisted group, the platform center deviation was 1.17 ± 0.77mm; the angular deviation was 12.43 ± 8.32°. In the freehand technique group, the platform center deviation was 3.10 ± 1.91mm; the angular deviation was 15.64 ± 5.94°. Comparing experimental groups with control and negative control groups, the real-time navigation assisted TADs insertion surgery had no better performance in platform center control and angular control (p>0.05). The freehand technique had a risk of root injury of about 10%; however, there were no immediate complications in real-time navigation-assisted and surgical stent-assisted TADs insertion surgery.
This study was the first clinical study applying the real-time navigation system in TADs insertion surgery. Combining the advantages of real-time navigation and the surgical stent, we developed real-time navigation with the surgical stent combined technique. In the combined ground, platform center deviation was 1.75 ± 1.05mm; the angular deviation was 5.5 ± 1.83°. It had a tendency of better performance than other techniques. Based on the current result of our research, we proposed improving guidelines for the clinical application of real-time navigation and TADs insertion surgery. We explored the possibility of a combined technique in the future.

並列關鍵字

temporary anchorage devices ； mini-screws ； real-time navigation ； surgical stent ； combined technique ； platform center deviation ； angular deviation

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