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中华临床医师杂志(电子版)

中华临床医师杂志(电子版) ›› 2020, Vol. 14 ›› Issue (04) : 272 -279. doi: 10.3877/cma.j.issn.1674-0785.2020.04.007

所属专题： 文献；

临床研究

口腔颌面部锥形束CT结合微创拔牙技术在下颌阻生第三磨牙拔除中的临床应用
代天国1, 邱银秀2, 刘应凯1, 冉红兵1,†()   
  1. 1. 617067　四川攀枝花，攀枝花市中心医院口腔科
    2. 617067　四川攀枝花，攀枝花市中心医院耳鼻咽喉头颈外科
  • 收稿日期:2019-12-07 出版日期:2020-04-15
  • 通信作者: 冉红兵

Clinical application of cone beam computed tomography combined with minimally invasive extraction in extraction of impacted mandibular third molars

Tianguo Dai1, Yinxiu Qiu2, Yingkai Liu1, Hongbing Ran1,†()   

  1. 1. Department of Stomatology, Head and Neck Surgery, Panzhihua Central Hospital, Panzhihua 617067, China
    2. Department of Otolaryngology, Head and Neck Surgery, Panzhihua Central Hospital, Panzhihua 617067, China
  • Received:2019-12-07 Published:2020-04-15
  • Corresponding author: Hongbing Ran
  • About author:
    Corresponding author: Ran Hongbing, Email:
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引用本文：

代天国, 邱银秀, 刘应凯, 冉红兵. 口腔颌面部锥形束CT结合微创拔牙技术在下颌阻生第三磨牙拔除中的临床应用[J]. 中华临床医师杂志(电子版), 2020, 14(04): 272-279.

Tianguo Dai, Yinxiu Qiu, Yingkai Liu, Hongbing Ran. Clinical application of cone beam computed tomography combined with minimally invasive extraction in extraction of impacted mandibular third molars[J]. Chinese Journal of Clinicians(Electronic Edition), 2020, 14(04): 272-279.

目的

研究口腔颌面部锥形束CT（CBCT）检查结合牙体分割微创拔牙技术在下颌阻生第三磨牙（IMTM）拔除中的临床应用。

方法

选取2018年1月至2019年5月四川省攀枝花市中心医院诊断为IMTM的97例（155颗）拔牙患者为研究对象。术前CBCT明确IMTM与周围重要组织的关系，术中采用转角高速涡轮机夹持长臂裂钻分割牙体，以微创的方式分块拔除IMTM。记录拔牙时间、患者满意度、术中及术后并发症等指标。采用t检验比较男、女间拔牙时间的差异，采用方差分析比较不同阻生牙类型及不同年龄段组间拔牙时间的差异。

结果

CBCT结果显示67.7%（105/155）的下颌管位于IMTM根尖的颊侧、22.6%根尖下方、9.7%舌侧，其中24.5%<1 mm；24颗（15.5%，24/155）IMTM根尖区舌侧骨板缺如，56颗牙（36.1%，56/155）<1 mm。IMTM以近中、垂直及水平向阻生最为常见，平均拔牙时间分别是（24.3±1.1）min，（15.6±1.2）min，（29.7±1.8）min，差异有统计学意义（F=23.85，P<0.001）；术中8颗牙（5.2%，8/155）下颌管暴露，无1例舌侧骨板损伤致牙根移位。术后3例少量出血，1例发生干槽症，无1例发生下唇麻木，患者满意度在95.5%以上。

结论

CBCT应作为IMTM拔除前常规的影像学检查手段。高速涡轮机牙体分割微创拔牙技术适用于各类IMTM拔除，具有创伤小、临床效率高、并发症少、患者满意度高等优点。

关键词: 锥形束CT, 下颌阻生第三磨牙, 微创, 拔牙术
Objective

To study the clinical application of cone beam computed tomography (CBCT) combined with minimally invasive extraction technology in the extraction of impacted mandible third molars (IMTM).

Methods

Ninety-seven patients (155 teeth) diagnosed with IMTM at Panzhihua Central Hospital from January 2018 to May 2019 were selected as study subjects. Before operation, CBCT was taken to clarify the relationship between IMTM and surrounding important tissues. During the operation, the teeth were segmented with a long arm split drill with high-speed turbine and IMTM was extracted in a minimally invasive way. The extraction time, patient satisfaction, and intraoperative and postoperative complications were recorded. The difference of extraction time between males and females was compared by the t-test, and the difference of extraction time between different age groups was compared by ANOVA.

Results

CBCT showed that 67.7% (105/155) of mandibular canals were located in the buccal side, 22.6% under the root tip, and 9.7% in the lingual side of IMTM, of which 24.5% was less than 1 mm. There were 24 (15.5%, 24/155) IMTM apical regions with lingual bone plate missing and 56 teeth (36.1%, 56/155) less than 1 mm. Angular, vertical, and horizontal impactions were the most common types of IMTM. The average extraction time was (24.3±1.1) min, (15.6±1.2) min, (29.7±1.8) min, respectively (F=23.85, P<0.001). Eight teeth (5.2%, 8/155) were exposed to mandibular canal during the operation, and there was no root displacement caused by lingual bone plate injury. There were three cases of bleeding and one case of dry socket. There was no case of numbness of the lower lip. The rate of patient satisfaction was more than 95.5%.

Conclusion

CBCT should be used as a routine imaging examination before IMTM extraction. High speed turbine assisted minimally invasive extraction technology is suitable for all kinds of IMTM extraction. It has the advantages of small trauma, high clinical efficiency, few complications, and high patient satisfaction.

Key words: Cone beam computed tomography, Impacted mandibular third molar, Minimally invasive, Extraction
图1 按Winter分类法分类下颌阻生第三磨牙　图a为近中阻生；图b为垂直阻生：图c为水平阻生；图d为远中阻生；图e为倒置阻生；图f为颊向阻生；图g为舌向阻生；图h为各类阻生牙例数
图2 下颌管与下颌阻生第三磨牙根尖关系　图a，a1：下颌管位于下颌阻生第三磨牙根尖颊侧<1 mm；图b，b1：下颌管位于下颌阻生第三磨牙根尖舌侧<1 mm；图c，c1：下颌管位于下颌阻生第三磨牙根尖下方<1 mm
图3 下颌阻生第三磨牙与舌侧骨板关系　图a为全景片无法显示舌侧骨板情况；图b为下颌阻生第三磨牙釉牙骨质界距舌侧骨板距离<1 mm；图c为下颌阻生第三磨牙根中份舌侧骨板开始缺如；图d为下颌阻生第三磨牙根尖区舌侧骨板完全缺如
图4 年龄对拔牙时间的影响　图a为不同年龄段平均拔牙时间比较；图b为垂直组不同年龄段平均拔牙时间比较；图c为近中组不同年龄段平均拔牙时间比较；图d为水平组不同年龄段平均拔牙时间比较
图5 下颌管暴露及颊侧骨板损伤情况　图a为下颌阻生第三磨牙呈水平阻生，下颌管与下颌阻生第三磨牙根尖关系密切；图b为下颌阻生第三磨牙拔除后下颌管暴露，但无损伤；图c、d为下颌阻生第三磨牙拔除前后颊侧骨板对比，术后骨板保留较完整
表1 拔牙并发症及患者满意度调查
项目 近中 垂直 水平 远中 舌向 颊向 倒置 合计[例（%）]
神经管暴露 2 4 2 0 0 0 0 8（5.2）
软组织损伤 0 0 1 0 0 0 0 1（0.6）
邻牙损伤 0 0 0 0 0 0 0 0（0）
器械折断 0 0 1 0 0 0 0 1（0.6）
皮下气肿 0 0 0 0 0 0 0 0（0）
出血 1 0 2 0 0 0 0 3（1.9）
术后肿胀 ? ? ? ? ? ? ? ?
? 无 11 27 1 0 0 0 0 39（25.2）
? 轻度 60 20 25 4 2 1 1 113（72.9）
? 重度 0 0 3 0 0 0 0 3（1.9）
术后疼痛时间（d） ? ? ? ? ? ? ? ?
? <1 2 14 0 0 0 0 0 16（10.3）
? 1~2 53 31 24 3 2 0 0 113（72.9）
? 2~3 10 2 2 1 0 1 1 17（11）
? >3 6 0 3 0 0 0 0 9（5.8）
干槽症 0 1 0 0 0 0 0 1（0.6）
下唇麻木 0 0 0 0 0 0 0 0（0）
满意度 ? ? ? ? ? ? ? ?
? 非常满意 65 47 28 4 2 1 1 148（95.5）
? 满意 6 0 0 0 0 0 0 6（3.9）
? 不满意 0 1 0 0 0 0 0 1（0.6）
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