锥形束CT数字成像分析牙槽嵴裂植骨修复的成骨效果

doi:10.3969/j.issn.2095-4344.2016.02.011

摘要/Abstract

摘要：

文章快速阅读：

文题释义：

锥形束CT：与传统CT相比，锥形束CT具有：①射线量极低。相比传统的多排螺旋CT，锥形束CT一次投照的剂量与投照的视窗大小有关，一般相当于传统CT的1/60-1/100放射量，仅相当于1张口腔全景片的放射量。②牙齿、颌骨成像更加清晰。锥形束CT对于牙齿或者颌骨等硬组织结构成像质量更好，层厚仅0.1 mm，甚至能显示牙根细小的裂缝，更适合口腔科的治疗，能更加清楚的显示牙齿根管数目形态，能发现变异细小根管、早期根尖炎症和牙根折裂等传统检查无法确定的病变。锥形束CT可以准确检测牙槽骨吸收的量，这样可以在无创的条件下评估牙周病的严重程度。③使用操作简单。口腔科医师完全可以按自己的意愿随意获取自己想要的牙齿或者颌骨影像，自制三维重建成像，无需CT技术人员进一步操作，既节省了人力物力，又可以避免医技沟通不便而带来的误差。

牙槽嵴：是天然牙列赖以存在的基础。其上覆盖的黏膜表层为高度角化的鳞状上皮，黏膜下层与骨膜紧密相连，故能承担较大的咀嚼压力。上下颌牙槽嵴将整个口腔分为内、外两部分。

背景：牙槽嵴裂患者植骨后骨存量目前多使用二维影像进行分析测量，结论误差较大。

目的：探讨锥形束CT评价牙槽嵴裂植骨后6个月成骨效果的应用。

方法：随机抽取25例单侧完全性牙槽嵴裂的患者，进行牙槽嵴裂髂骨移植， 6个月后采用锥形束CT进行观察。

结果与结论：牙槽嵴裂骨移植后，唇侧牙槽骨保存量较腭侧高；另外中切牙裂隙侧与正常侧的牙槽骨厚度差异有显著性意义，而尖牙缺隙侧与正常侧牙槽骨厚度在距离牙槽嵴顶0 mm处的牙槽骨厚度处差异有显著性意义，其余部位差异无显著性意义。说明牙槽嵴裂骨移植时腭侧支持骨少于唇侧，缺隙侧中切牙的支持骨也不理想，从而为牙槽骨移植和正畸治疗牙齿移动提供依据。

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

ORCID: 0000-0002-5955-3545(顾月光)

关键词: 组织构建, 组织工程, 牙槽嵴裂, 口腔, 植骨, 锥形束CT, 骨吸收, 骨形成, 唇腭裂, 髂骨, 正畸

Abstract:

BACKGROUND: In alveolar cleft patients, the amount of bone stock after alveolar bone grafting is mostly measured and analyzed by two-dimensional imaging, which can result in a large error.

OBJECTIVE: To evaluate the 6-month osteogenesis of alveolar bone graft in alveolar cleft patients using cone beam CT.

METHODS: Alveolar bone grafting was performed in 25 patients with unilateral complete alveolar cleft. The patients were followed up for 6 months after surgery and the osteogenesis of the bone graft was evaluated by CBCT.

RESULTS AND CONCLUSION: After the surgery, the labial bone support was better than the palatal one. There were significant differences in the alveolar bone thickness of the cleft region and the normal region of the central incisor as well as the alveolar bone thickness of the cleft region and the normal region of the canine tooth 0 mm distant to the alveolar crest. These findings indicate that the palatal bone support is less than the labial one, and the bone support of the central incisor is not satisfactory, which provide the basis for the tooth movement in the alveolar bone grafting and the orthodontics treatment.

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

顾月光，张来健，秦晗，徐宏志，李阳飞. 锥形束CT数字成像分析牙槽嵴裂植骨修复的成骨效果[J]. 中国组织工程研究, doi: 10.3969/j.issn.2095-4344.2016.02.011.

Gu Yue-guang, Zhang Lai-jian, Qin Han, Xu Hong-zhi, Li Yang-fei . Osteogenesis of alveolar bone graft: evaluation by cone beam CT[J]. Chinese Journal of Tissue Engineering Research, doi: 10.3969/j.issn.2095-4344.2016.02.011.

图/表（结果） 3

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引言

材料方法

1.1 设计回顾性分析。

1.2 时间及地点试验于2013至2015年在连云港市第一人民医院口腔分院完成。

1.3 对象收集2013至2015年在连云港市第一人民医院口腔分院进行治疗的单侧牙槽嵴裂患者。

纳入标准：①诊断为非综合征性单侧完全性牙槽嵴裂。②术前均行活动性正畸治疗扩大上颌骨宽度以利于植骨。③所有手术均由同一术者进行，植骨区骨源均来自患者自己的髂骨，牙槽嵴裂植骨与髂骨取骨同时进行。④所有患者均无系统性及遗传性疾病。⑤均有清晰的三维成像。

排除标准：双侧牙槽嵴裂。未进行术前正畸的。③三维影像不清晰，无法进行测量的。

剔除标准：对已被选入本临床研究，属于以下情况之一者，作为剔除病例。①不符合纳入标准，或符合排除标准者。②无任何记录者

脱落标准：对已被选入本临床研究，属于以下情况之一者，作为脱落病例。①受试者依从性差。②受试者不愿意继续进行临床试验，向主管医生提出退出者。

最终获得25例患者，其中男13例，女12例，年龄9-14岁，平均12.5岁。

1.4 方法

1.4.1 植骨方法 ①在髂前上棘处设计切口线，长 1.5-2.0 cm，按切口线切开皮肤至骨膜并剥离骨膜，凿开骨皮质，取出适量髂骨骨松质，将其置于生理盐水中并剪成颗粒状待用。②切开裂隙侧牙龈缘及黏膜止于第一磨牙近中，并转折向上至龈颊沟，钝性剥离唇腭侧粘骨膜瓣至鼻翼基底，锐性分离裂隙中连接鼻腔黏膜和腭黏膜的结缔组织后，缝合上部粘骨膜形成鼻底，此为植骨床顶，下部粘骨膜向下与腭黏膜缝合形成植骨床底，将备用的髂骨松质骨植入裂隙的骨缺损及鼻翼基底骨凹陷处，然后将唇腭侧粘骨膜在无张力状态下缝合。

1.4.2 锥形束CT测量所有患者应用锥形束CT (NewTom VG，QR s.r.1，意大利)拍摄植骨后6个月的骨移植区，拍摄时患者采取坐位，调节设备至患者姿势自然，在扫描全过程中要求患者缓慢呼吸，保持闭嘴姿势，但不紧咬牙，不能晃动。使用锥体束单次360°旋转，扫描时间为18 s，扫描层厚为0.3 mm，获得三维图像以DICOM格式存放，数据导入Simplant pro 13.0 软件(Materialise Dental，比利时)重建，从水平面、矢状面、冠状面并结合3D成像来判断牙槽骨的高度及厚度。

1.4.3 改良的Bergland分型评价 ①垂直向牙槽骨高度：根据改良的Bergland分型：Ⅰ型为正常牙槽嵴高度；Ⅱ型为植入骨的牙槽嵴高度超过总牙槽高度的3/4；Ⅲ型为植入骨的牙槽嵴高度小于总牙槽高度的3/4；Ⅳ型为牙槽突裂间隙内无植入骨的骨桥(图1A)。②中切牙、尖牙的健侧和裂隙侧牙颈部至牙槽嵴顶的距离(图1B)。③唇向骨厚度，以双侧中切牙、尖牙为目标牙齿，测量距离牙槽嵴顶0，1，2，4 mm的牙槽骨厚度，并分别记为M0-4(图1C)。每位患者均测量3次取平均值。

1.5 结局观察指标锥形束CT的测量结果。

1.6 统计学分析数据采用SPSS16.0软件进行统计学分析。数据以x(_)±s表示。垂直向牙槽骨高度的测量采用Mann-Whitney检验进行比较。中切牙、尖牙的健侧和裂隙侧牙颈部至牙槽嵴顶的距离及两侧唇向骨厚度采用成组t检验进行比较。P < 0.05为差异有显著性意义。

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

讨论

牙槽嵴裂三维空间的形态缺损所形成的裂隙，形态复杂并具有个体差异，术中制备的植骨床是四面椎体形状，椎体的顶端指向后方，椎体的内面是软骨及骨性鼻中隔，锥体的外面是上颌骨的骨面，椎体的上面为鼻腔底的粘骨膜瓣，椎体的下面是腭粘骨膜瓣^[21-30]。既往使用二维测量往往高估了牙槽嵴裂后骨移植的成功率^[^31-47^]。二维测量只是提供单一方向的影像，唇舌向的影像均叠加在一起，易造成伪影使得测量结果有偏差。而锥形束CT是由数据采集设备与图像生成设备组成，通过一次旋转获得扫描数据；该数据再通过二次重建获得三维容积图像―体数据，最后再通过三次重建获得医学图像，可以在任意一个方向获得任意层面的牙槽嵴影像，因此更适合牙槽嵴裂的测量。锥形束CT与以往使用的螺旋CT相比有以下优点：①射线量低。锥形束CT一次投照只相当于传统CT的1/30-1/40放射量。②费用低廉。相较于传统CT有更低廉的售价及维护费用。③成像清晰。锥形束CT对于骨组织成像较软组织更清晰，因此更适合于口腔方面的研究。

牙槽嵴裂患者牙槽骨高度分级中，腭侧牙槽骨高度低于唇侧牙槽骨高度，这主要与手术入路从唇侧近牙槽嵴顶处剥离粘骨膜建立植骨床充填骨质有关，而因裂隙较窄，腭侧往往不能完全充满。杨超等^[⁴⁸^]认为腭侧入路进行植骨能明显提高腭侧的剩余植骨量。但唇侧还是腭侧入路尚需进一步研究。中切牙和尖牙牙颈部到牙槽嵴顶距离发生变化，但仅中切牙区差异有显著性意义，说明裂隙侧中切牙区牙槽骨高度有明显的丧失。

裂隙侧和正常侧中切牙的牙槽骨厚度差异有显著性意义，可能由于中切牙位于牙弓最唇侧，牙槽骨薄，又靠近裂隙侧，所以中切牙附近牙槽骨更易吸收，仅M0处裂隙侧牙槽骨厚度厚于健侧，可能跟牙槽骨高度相对于厚度吸收更明显有关，裂隙侧牙槽嵴顶处牙槽骨高度吸收明显，越远离牙槽嵴顶处的牙槽骨厚度越厚。另外中切牙M1、M2、M4处健侧和裂隙侧牙槽骨厚度差异有显著性意义，表明裂隙侧中切牙自牙颈部至根尖处牙槽骨厚度均有吸收且吸收远大于健侧，因此在临床上后期正畸的时候一定要注意中切牙的控根以免出现中切牙的牙根暴露等情况。

尖牙在M0处牙槽骨厚度差异有显著性意义，而M1，M2和M4处牙槽骨厚度差异无显著性意义，这可能主要与尖牙牙冠一般向裂隙侧倾斜有关，所以，近牙颈部的牙槽骨厚度，裂隙侧明显薄于健侧，而根尖方偏离裂隙侧。因尖牙牙冠多朝近中倾斜，在后续的正畸治疗中，多需矫正尖牙的轴向，但尖牙远中牙槽厚度厚于近中牙槽骨，因此，尖牙牙根向近中正轴的时候需要注意近中牙槽骨厚度，防止近中处牙槽骨过薄。另外，因牙槽嵴裂患者多伴随侧切牙的先天缺失或因无法保留而需要拔除，侧切牙处多需做固定桥，因此，不管是中切牙还是尖牙，都需要唇腭侧有健康的牙槽骨。此外，试验仅分析6个月的牙槽嵴裂骨存量，没有进行更长时间的追踪测量。

综上，牙槽骨移植时腭侧牙槽骨高度低于唇侧牙槽骨高度，裂隙侧中切牙牙颈部至牙槽嵴顶的距离明显大于健侧，裂隙侧中切牙的牙槽骨厚度明显低于健侧，裂隙侧尖牙在牙槽嵴顶的牙槽骨厚度也明显低于健侧，从而为牙槽骨移植术和正畸治疗牙齿移动提供一定的依据。

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程