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鼻腭神经移位术应用于美学区骨量不足的种植1例

2019-05-07 郭天奇 付丽 孙悦 实用口腔医学杂志

患者,男,45岁,两年前由于牙周炎合并急性咬合创伤,拔除11,12,拔除后未经修复治疗,患者否认全身系统性疾病。专科检查:开口度及开口型正常,牙周卫生情况一般,CI-S=1,DI-S=2,12及11缺失,缺牙区唇舌向牙槽嵴宽度及高度均有吸收。CBCT示:右侧上颌中切牙及侧切牙缺失,缺牙区唇舌向牙槽骨纤薄,伴有唇舌向牙槽骨骨宽度吸收,鼻腭神经管位置偏向牙槽嵴顶及腭侧(图1)。

鼻腭神经血管束走行于鼻腭神经管内,从鼻腭孔穿出上颌骨,支配双侧前牙区腭黏膜的感觉,并为该区域黏膜提供血液供应。许多患者鼻腭神经管唇侧骨质较薄,上前牙拔牙后区唇侧的骨吸收又进一步加剧了可用骨量的不足,同时种植手术中往往易伤及鼻腭神经管,致使黏膜麻木,钝痛等神经损伤症状,严重降低了患者的生活质量。
 
1.资料与方法
 
1.1病例资料
 
患者,男,45岁,两年前由于牙周炎合并急性咬合创伤,拔除11,12,拔除后未经修复治疗,患者否认全身系统性疾病。专科检查:开口度及开口型正常,牙周卫生情况一般,CI-S=1,DI-S=2,12及11缺失,缺牙区唇舌向牙槽嵴宽度及高度均有吸收。CBCT示:右侧上颌中切牙及侧切牙缺失,缺牙区唇舌向牙槽骨纤薄,伴有唇舌向牙槽骨骨宽度吸收,鼻腭神经管位置偏向牙槽嵴顶及腭侧(图1)。
 
图1 术前CBCT检查,患者局部11、12骨量严重缺失,剩余牙槽嵴宽度不足
 
 
①牙列缺损;②前牙区牙槽嵴骨吸收。
 
1.3治疗
 
术前完善牙周治疗,术区消毒,麻醉,切开牙龈,见患者术区牙槽嵴顶纤薄,鼻腭神经直接与黏骨膜粘连(图2A),小心游离鼻腭神经,将无菌纱布卷成绳索状,用生理盐水浸湿,并悬吊鼻腭神经,同时避免过度牵拉(图2B),骨劈开技术预备种植位点(图2C),并植入NobelReplace3.5mm×13mm种植体2枚(图2D),并同期植入Bio-Oss骨粉种植体与颊舌侧骨板之间的空隙内及颊侧骨板外(图2E),外覆可吸收胶原膜62.5px×50px1张,制备PRF两枚,并压成薄膜,覆在生物膜上方(图2F)进行常规GBR,对位拉拢缝合牙龈。
 
图2 手术进程。A:术中切开黏膜,发现术区牙槽嵴较窄,鼻腭神经在牙槽嵴顶端附近穿出上颌骨,与腭黏膜有粘连;B:游离神经并用生理盐水沾湿的无菌纱布条轻轻牵拉至对侧;C:骨劈开预备种植位点;D:植入NobelReplace种植体2枚;E:植入骨粉性同期GBR;F:GBR术区外附PRF2枚,作为屏障膜
 
2.结果
 
术后6个月,患者术区牙龈无红肿(图3A),前颚部软组织无不适,种植体周围颊侧骨板丰满度良好,种植体涂层全部被新生骨组织包绕,覆盖螺丝部分已经被新生骨组织覆盖(图3B)。术后1年半,复诊:触诊患者术区腭侧黏膜,患者触觉基本正常,探针用力探前腭部粘膜时有痛感,未出现前颚粘膜麻木不适等症状。


 图3 术后6个月
 
3.讨论
 
鼻腭神经管,按形态分为单一管形,双管形及Y字开口管形,其位置具有较大的变异性,仅20%的患者鼻腭神经管位于上颌骨正中,术中一旦损伤鼻腭神经管,塌陷的鼻腭神经管势必压迫鼻腭神经,导致前腭区组织麻木、钝痛,种植体若比邻管内损伤的软组织,则会导致种植体周围骨结合破坏,严重的可导致种植体脱落。该患者前牙区剩余牙槽嵴为Cawood-Howell IV类牙槽嵴,只有通过骨劈开才可能实现同期种植,鼻腭神经管的三维位置进一步限制了患者的可用骨量,常规骨劈开极易造成神经管的塌陷,进而压迫、损伤鼻腭神经血管束。而神经损伤的修复又是一个漫长且不确定的过程。
 
术中对鼻腭神经进行了游离,避免了骨劈开及骨挤压的过程对鼻腭神经管可能导致的损伤,术后患者未出现腭前部麻木不适等症状。本病例不但避免了鼻腭神经的损伤,且充分利用了前牙区的剩余骨量,相比于onlay植骨,鼻腭神经移位的优势在于其降低了患者术后的创伤,避免了第二术区的开辟,同时缩短了治疗周期,使种植体同期植入变为可能。在分离鼻腭神经时,始终保证钝性分离,对粘连的黏骨膜进行适当切割,以尽量减低黏膜牵拉对鼻腭神经的损伤,同时保证鼻腭神经的完整性,牵拉移位鼻腭神经时,尽量使用纱布缠成的粗绳,以避免牵拉时对鼻腭神经产生应力集中。
 
4.结论
 
鼻腭神经移位用于前牙区牙槽骨吸收的病例,充分应用了患者的余留骨量,同时也也避免了前牙区预备种植位点时,骨劈开导致的鼻腭神经管塌陷进而产生鼻腭神经的损伤。
 
原始出处:

郭天奇,付丽,孙悦,刘珍珍,周延民.鼻腭神经移位术应用于美学区骨量不足的种植1例[J].实用口腔医学杂志,2018,34(03):416-418.

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    2019-08-12 huangdf
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    2019-11-11 clmlylxy
  4. [GetPortalCommentsPageByObjectIdResponse(id=1776220, encodeId=3a181e7622057, content=<a href='/topic/show?id=95d3e9930fe' target=_blank style='color:#2F92EE;'>#美学#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79930, encryptionId=95d3e9930fe, topicName=美学)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sat Jan 11 06:48:00 CST 2020, time=2020-01-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1702080, encodeId=35df1e02080e8, content=<a href='/topic/show?id=04b9e4784aa' target=_blank style='color:#2F92EE;'>#种植#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74784, encryptionId=04b9e4784aa, topicName=种植)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47e130405619, createdName=huangdf, createdTime=Mon Aug 12 11:48:00 CST 2019, time=2019-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1667183, encodeId=2f46166e183c8, content=<a href='/topic/show?id=8863101899aa' target=_blank style='color:#2F92EE;'>#骨量#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101899, encryptionId=8863101899aa, topicName=骨量)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=35f026117353, createdName=clmlylxy, createdTime=Mon Nov 11 02:48:00 CST 2019, time=2019-11-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2062330, encodeId=9bc4206233037, content=<a href='/topic/show?id=59f910352e50' target=_blank style='color:#2F92EE;'>#鼻腭神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103527, encryptionId=59f910352e50, topicName=鼻腭神经)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aad0444, createdName=cmsvly, createdTime=Sun Mar 01 15:48:00 CST 2020, time=2020-03-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1803264, encodeId=aabf18032645c, content=<a href='/topic/show?id=087ce514308' target=_blank style='color:#2F92EE;'>#移位术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75143, encryptionId=087ce514308, topicName=移位术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Fri Apr 03 00:48:00 CST 2020, time=2020-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1807464, encodeId=c35e180e4643d, content=<a href='/topic/show?id=f97be993236' target=_blank style='color:#2F92EE;'>#美学区#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79932, encryptionId=f97be993236, topicName=美学区)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=yeye5224612, createdTime=Wed Jul 10 22:48:00 CST 2019, time=2019-07-10, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1776220, encodeId=3a181e7622057, content=<a href='/topic/show?id=95d3e9930fe' target=_blank style='color:#2F92EE;'>#美学#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79930, encryptionId=95d3e9930fe, topicName=美学)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sat Jan 11 06:48:00 CST 2020, time=2020-01-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1702080, encodeId=35df1e02080e8, content=<a href='/topic/show?id=04b9e4784aa' target=_blank style='color:#2F92EE;'>#种植#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74784, encryptionId=04b9e4784aa, topicName=种植)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47e130405619, createdName=huangdf, createdTime=Mon Aug 12 11:48:00 CST 2019, time=2019-08-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1667183, encodeId=2f46166e183c8, content=<a href='/topic/show?id=8863101899aa' target=_blank style='color:#2F92EE;'>#骨量#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101899, encryptionId=8863101899aa, topicName=骨量)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=35f026117353, createdName=clmlylxy, createdTime=Mon Nov 11 02:48:00 CST 2019, time=2019-11-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2062330, encodeId=9bc4206233037, content=<a href='/topic/show?id=59f910352e50' target=_blank style='color:#2F92EE;'>#鼻腭神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103527, encryptionId=59f910352e50, topicName=鼻腭神经)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aad0444, createdName=cmsvly, createdTime=Sun Mar 01 15:48:00 CST 2020, time=2020-03-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1803264, encodeId=aabf18032645c, content=<a href='/topic/show?id=087ce514308' target=_blank style='color:#2F92EE;'>#移位术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75143, encryptionId=087ce514308, topicName=移位术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1e452500029, createdName=12498568m50暂无昵称, createdTime=Fri Apr 03 00:48:00 CST 2020, time=2020-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1807464, encodeId=c35e180e4643d, content=<a href='/topic/show?id=f97be993236' target=_blank style='color:#2F92EE;'>#美学区#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79932, encryptionId=f97be993236, topicName=美学区)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=yeye5224612, createdTime=Wed Jul 10 22:48:00 CST 2019, time=2019-07-10, status=1, ipAttribution=)]
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