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下颌阻生第三磨牙(impacted mandibular third molar,IMTM)拔除术是牙槽外科最常见的手术之一,拔除IMTM时医师通常会选择术前行口腔曲面断层片检查,用以判断阻生牙的位置、牙根情况,以及牙根与下牙槽神经管的影像学关系等[1]。若术前未进行充分评估,则可能导致断根、下牙槽神经受损、下唇麻木等并发症[2]。如何通过口腔曲面断层片较准确地评估下牙槽神经管管壁是否有损伤风险,目前对此方面研究仍较少,本研究就此问题作一探讨。
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IMTM拔除术中共探及损伤下牙槽神经管壁38例(损伤组),术后出现下唇麻木4例(2.07%),其中3例在术后1个月内恢复,仅1例病人3个月后麻木无好转,且随访1年仍无改善;未损伤下牙槽神经管壁155例(未损伤组),均未出现下唇麻木。2组IMTM是否弯根、神经管上下壁是否清晰、Pell & Gregory分类、IMTM距管上壁距离、IMTM与MSM长轴夹角差异均有统计学意义(P < 0.01),2组IMTM阻生侧差异无统计学意义(P>0.05)(见表 1)。
指标 损伤组
(n=38)未损伤组
(n=155)χ2 P IMTM阻生侧 右侧
左侧19(50.00)
19(50.00)75(48.39)
80(86.45)0.03 >0.05 IMTM是否弯根 是
否28(73.68)
10(26.32)21(13.55)
134(86.45)58.26 <0.01 神经管上下壁是否清晰 上下均清晰 8(21.05) 127(81.94) 上壁不清晰、下壁清晰 28(73.68) 26(16.77) 53.82 <0.01 上下壁均不清晰 2(5.26) 2(1.29) Pell & Gregory分类 高位 6(15.79) 74(47.74) 中位 23(60.53) 64(41.29) 13.69 <0.01 低位 9(23.68) 17(10.97) IMTM距管上壁距离/mm -1.01±1.31 1.81±2.03 -10.51* <0.01 IMTM与MSM长轴夹角/(°) 46.26±34.37 23.08±34.89 3.68* <0.01 *示t′值 表 1 相关指标在损伤组与未损伤组病人间比较[n;百分率(%)]
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将单因素分析中有统计学意义的变量纳入logistic回归分析(赋值见表 2),结果显示,IMTM是否弯根、神经管上下壁是否清晰、IMTM距管上壁距离、IMTM与MSM长轴间夹角均为IMTM拔除术中损伤下牙槽神经管壁的独立危险因素(P < 0.05~P < 0.01)(见表 3)。
因素 变量名 赋值 是否弯根 X1 否=0,是=1 IMTM距管上壁的距离/mm X2 连续性变量 IMTM与MSM长轴间夹角/(°) X3 连续变量 上下壁清晰情况 X4 上下壁均不清晰=1,上壁不清晰、下壁清晰=2,上下壁均清晰=3 Pell & Gregory分类 X5 低位=1,中位=2,高位=3 下牙槽神经管损伤 Y 管壁不受损=0,管壁受损=1 表 2 IMTM拔除术中下牙槽神经管损伤影响因素赋值
变量 B SE Waldχ2 P OR(95%CI) 是否弯根 — — — — — 否* — — — — 1 是 -4.543 0.969 21.976 < 0.01 0.011(0.002~0.071) IMTM距管上壁距离 1.537 0.392 15.340 < 0.01 4.649(2.155~10.030) IMTM与MSM长轴间夹角 -0.034 0.014 5.678 < 0.05 0.967(0.941~0.994) 上下壁清晰情况 — — 8.807 < 0.05 — 上下壁均不清晰* — — — — 1 上壁不清晰、下壁清晰 -0.240 2.543 0.009 >0.05 0.787(0.005~115.009) 上下壁均清晰 2.218 2.631 0.711 >0.05 9.191(0.053~1 594.954) Pell & Gregory分类 — — 2.341 >0.05 — 低位* — — — — 1 中位 -1.312 0.891 2.170 >0.05 0.269(0.047~1.543) 高位 -1.429 1.256 1.296 >0.05 0.239(0.020~2.805) 以*为参考 表 3 IMTM拔除术中下牙槽神经管损伤的logistic回归分析
口腔曲面断层片评估下颌第三磨牙拔除术中神经管损伤的影响因素分析
Analysis of the influencing factors of neural tube injury in mandibular third molar extraction by panoramic tomography
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摘要:
目的在曲面断层片上测量下颌阻生第三磨牙(impacted mandibular third molar,IMTM)周围相关指标,分析IMTM拔除术中下牙槽神经管损伤的影响因素。 方法对拟拔除IMTM病人108例行术前曲面断层片检查,测量IMTM周围的相关指标,包括下牙槽神经管清晰度、阻生牙距下牙槽神经管上壁的距离、阻生牙的Pell & Gregory分类等。按照标准拔除阻生牙手术操作步骤拔除IMTM,拔牙术后利用钝头探针检查拔牙创底有无神经管损伤,分析IMTM拔除术中下牙槽神经管损伤的影响因素。 结果108例病人共拔除193颗IMTM,术中探及下牙槽神经管壁损伤38例,术后出现下唇麻木4例,麻木率2.07%;下牙槽神经管壁无损伤155例,均未出现下唇麻木。损伤与未损伤病人在IMTM是否弯根、神经管上下壁是否清晰、Pell & Gregory分类、IMTM距管上壁距离、IMTM与MSM长轴夹角方面差异均有统计学意义(P < 0.01)。Logistic回归分析结果显示,IMTM是否弯根、神经管上下壁是否清晰、IMTM距管上壁距离、IMTM与MSM长轴间夹角均为IMTM拔除术中损伤下牙槽神经管壁的独立危险因素(P < 0.05~P < 0.01)。 结论通过口腔曲面断层片可以较好的评估IMTM拔除术中下牙槽神经管损伤的危险因素,本研究所观察的指标对临床指导拔除下颌阻生牙有一定的指导意义。 Abstract:ObjectiveTo measure the relevant data of impacted mandibular third molar(IMTM) by panoramic radiography, and analyze the influencing factors of inferior alveolar tube injure during extraction of IMTM. MethodsThe preoperative curved radiograph examination in 108 patients with IMTM were implemented, and the relevant indexes around IMTM, which included the clarity of inferior alveolar nerve canal; distance between impacted tooth from upper wall to inferior alveolar nerve and Pell & Gregory classification of impacted teeth, were measured.The IMTM were removed according to the standard surgical procedure.After the extraction of teeth, a blunt head probe was used to detect a nerve tube damage, and the influencing factors of inferior alveolar tube injure during extraction of IMTM were analyzed. ResultsA total of 193 IMTM in 108 patients were extracted, 38 cases with inferior alveolar nerve injury and 4 cases with numbness in lower lip(the numbness rate for 2.07%) were found.One hundred and fifty-five cases without inferior alveolar nerve injury and numbness in the lower lip were identified.The differences of the curved root of IMTM, clear upper and lower wall of neural tube, Pell & Gregory classification, distance from IMTM to upper wall of neural tube and angle between IMTM and MSM on the long axis were statistically significant between patients with and without injury(P < 0.01).The results of logistic regression analysis showed that the curved root of IMTM, clear upper and lower wall of neural tube, Pell&Gregory classification, distance from IMTM to upper wall of neural tube and angle between IMTM and MSM on the long axis were the independent risk factor of lower alveolar nerve wall injury during IMTM extraction(P < 0.05 to P < 0.01). ConclusionsThe oral surface tomography can better evaluate the risk factors of inferior alveolar neural tube injury during the extraction of IMTM.The indicators have certain guiding significance for the clinical guidance of the extraction of IMTM. -
Key words:
- impacted mandibular third molar /
- panoramic tomography /
- inferior
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表 1 相关指标在损伤组与未损伤组病人间比较[n;百分率(%)]
指标 损伤组
(n=38)未损伤组
(n=155)χ2 P IMTM阻生侧 右侧
左侧19(50.00)
19(50.00)75(48.39)
80(86.45)0.03 >0.05 IMTM是否弯根 是
否28(73.68)
10(26.32)21(13.55)
134(86.45)58.26 <0.01 神经管上下壁是否清晰 上下均清晰 8(21.05) 127(81.94) 上壁不清晰、下壁清晰 28(73.68) 26(16.77) 53.82 <0.01 上下壁均不清晰 2(5.26) 2(1.29) Pell & Gregory分类 高位 6(15.79) 74(47.74) 中位 23(60.53) 64(41.29) 13.69 <0.01 低位 9(23.68) 17(10.97) IMTM距管上壁距离/mm -1.01±1.31 1.81±2.03 -10.51* <0.01 IMTM与MSM长轴夹角/(°) 46.26±34.37 23.08±34.89 3.68* <0.01 *示t′值 表 2 IMTM拔除术中下牙槽神经管损伤影响因素赋值
因素 变量名 赋值 是否弯根 X1 否=0,是=1 IMTM距管上壁的距离/mm X2 连续性变量 IMTM与MSM长轴间夹角/(°) X3 连续变量 上下壁清晰情况 X4 上下壁均不清晰=1,上壁不清晰、下壁清晰=2,上下壁均清晰=3 Pell & Gregory分类 X5 低位=1,中位=2,高位=3 下牙槽神经管损伤 Y 管壁不受损=0,管壁受损=1 表 3 IMTM拔除术中下牙槽神经管损伤的logistic回归分析
变量 B SE Waldχ2 P OR(95%CI) 是否弯根 — — — — — 否* — — — — 1 是 -4.543 0.969 21.976 < 0.01 0.011(0.002~0.071) IMTM距管上壁距离 1.537 0.392 15.340 < 0.01 4.649(2.155~10.030) IMTM与MSM长轴间夹角 -0.034 0.014 5.678 < 0.05 0.967(0.941~0.994) 上下壁清晰情况 — — 8.807 < 0.05 — 上下壁均不清晰* — — — — 1 上壁不清晰、下壁清晰 -0.240 2.543 0.009 >0.05 0.787(0.005~115.009) 上下壁均清晰 2.218 2.631 0.711 >0.05 9.191(0.053~1 594.954) Pell & Gregory分类 — — 2.341 >0.05 — 低位* — — — — 1 中位 -1.312 0.891 2.170 >0.05 0.269(0.047~1.543) 高位 -1.429 1.256 1.296 >0.05 0.239(0.020~2.805) 以*为参考 -
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