下颌阻生智齿拔除手术的可预期微创化

登辉 段; 恩博 王; 念晖 崔; 新利 翟; 宇 刘; 娟红 孟; 伟 张; 益 张

doi:10.19723/j.issn.1671-167X.2020.02.033

. 2020 Apr 18;52(2):395–403. [Article in Chinese] doi: 10.19723/j.issn.1671-167X.2020.02.033

下颌阻生智齿拔除手术的可预期微创化

登辉段 ^1,^△, 恩博王 ¹, 念晖崔 ¹, 新利翟 ¹, 宇刘 ¹, 娟红孟 ¹, 伟张 ¹, 益张 ¹

PMCID: PMC7433448

下颌阻生智齿拔除是口腔颌面外科最经典,最基础的手术之一,但因其术野受限,邻近重要解剖结构,阻生程度和牙根形态变异较大,下颌阻生智齿拔除手术较为复杂,术后并发症多.近年来,随着以腔镜^[1,2],介入技术^[3,4,5]为代表的微创外科的发展,微创的理念渗入至牙槽外科领域,微创拔牙越来越受到患者和业界的接受^[6,7].然而,对于下颌阻生智齿可否进行微创拔牙,如何进行微创拔牙,如何评价微创拔牙等,目前尚无一致意见.本文结合临床工作,提出"可预期微创化"的概念,进一步完善下颌阻生智齿微创拔牙的内涵.

1. 下颌阻生智齿拔除手术的现状

下颌阻生智齿拔除手术较为复杂,术后并发症多.手术器械主要有圆凿,牙挺,拔牙钳和高速涡轮手机等.在围手术期存在如下问题:(1)患者术前的焦虑状态未受重视,口服,吸入和静脉给药的镇静技术临床应用不充分.(2)医生术中和术后的疼痛控制意识不强,高速涡轮手机截冠的过程中出现的酸痛被认为是正常现象;术后反应性疼痛以及干槽症引起的疼痛不进行事前干预,往往在疼痛出现后进行事后补救,如给予镇痛药和搔刮拔牙窝等.(3)抗生素的使用不规范,切开翻瓣的阻生智齿拔除术后,往往常规使用口服甚至静脉输入抗生素^[8,9].(4)术后面颈部的间隙感染时有发生,病情长期迁延不愈,常常需要在面颊部进行切开引流,影响患者美观;感染严重时影响患者的吞咽和呼吸,甚至危及患者生命^[10],需住院治疗.(5)手术步骤个性化,针对同一阻生智齿的拔除,是否切开翻瓣,是否增隙,是否使用高速涡轮手机截冠分根,拔牙窝是否放置植入材料等,手术医生会有较强的个人倾向,缺乏统一的标准化的操作流程.(6)术后肿胀疼痛与术后出血的控制不容易兼顾,针对埋伏阻生智齿,由于手术创伤较大,切口严密缝合可以避免术后出血,但是往往导致术后出现明显肿胀疼痛,不严密缝合可以减轻术后肿胀疼痛,但又有术后出血的风险^[11].(7)敲锤增隙普遍使用,使患者产生恐惧害怕心理,容易直接损伤下牙槽神经(图1A),牙根根尖移位间接压迫损伤下牙槽神经^[12], 或者将智齿敲出拔牙窝移位进入舌侧间隙^[13,14](图1B).(8)手术可预期性差,关于手术时间,即便是非常有经验的医生在回答患者这一问题时往往都会很笼统;关于下牙槽神经和舌神经损伤问题,医生往往不能在术前,术中甚至术后准确预估神经是否损伤,以及损伤后的恢复情况.

左下颌阻生智齿拔除术后麻木两年,敲锤增隙时,圆凿直接损伤下牙槽神经,挺松过程中圆凿折断(A);右下颌水平阻生智齿,敲锤增隙过程中,牙齿舌向移位,进入咽旁间隙(B)

随着人们生活水平的提高,微创医学或精准医学的发展,目前下颌阻生智齿拔除手术的的一些观念或手术操作需要改变,使之符合医学发展的方向.

2. 下颌阻生智齿拔除手术的可预期微创化

针对下颌阻生智齿拔牙手术存在的上述问题,业界提出微创拔牙的概念,进而医生的医疗行为发生了一些改变,如高速涡轮手机代替劈冠术,超声骨刀代替敲锤增隙,微创牙挺的使用等^{[15,16,17,18,19,20]},这一系列的改变减少手术创伤,减轻术后反应,降低术后并发症发生率,从而改善患者的手术体验;但是,下颌阻生智齿微创拔牙的内涵不应该仅仅局限于手术器械的变革,应该针对目前手术存在的问题提出完整的微创解决方案,因此,本文以"可预期微创化"的概念试图阐述下颌阻生智齿微创拔牙的内涵,此概念包括围手术期的镇静和镇痛,顺牙根长轴的拔牙方法,手术决策树和术后充分引流四部分内容.

2.1. 围手术期的镇静和镇痛

阻生智齿患者拔牙术前焦虑恐惧的心理在临床实际工作中常常被忽视,手术操作的复杂性也导致患者产生非常不好的手术体验和感受,因此,需要口服,静脉或吸入镇静药物改变患者的意识状态,让患者获得良好的手术体验^{[21,22,23,24,25,26]},其中一氧化二氮/氧气混合吸入镇静技术操作简便,镇静深度易控制,患者苏醒迅速,并发症少.对于中重度焦虑,咽反射严重,埋伏位置较深手术复杂的患者,使用一氧化二氮/氧气混合吸入镇静技术可获得良好的舒适体验,从而达到心理上的微创^[24,25,26].

术后的反应性疼痛可口服非甾体类止痛药获得良好的镇痛效果,而术中的镇痛由于下牙槽神经位置深在,传统的下牙槽神经阻滞麻醉的麻醉程度偏浅,术中的麻醉效果有时不理想,表现为高速涡轮手机截冠,挺松牙根(尤其是伴有根尖病变)时出现一定程度的疼痛.为了提高麻醉深度,在下牙槽神经阻滞麻醉的基础上,智齿周围进行局部浸润麻醉,同时在牙周膜内持续正压注射,或采用计算机辅助麻醉进行牙周膜内注射,一般可以达到良好的麻醉效果.术中完全充分的镇痛不仅仅可改善患者的手术体验,还可有效预防手术并发症.当截冠过程中的高速车针接近下牙槽神经或舌神经,气体进入舌侧间隙,挺松牙根压迫下牙槽神经时,患者常常会有疼痛反应.如果术中镇痛不充分,将不能有效区分疼痛产生的原因是由于麻醉深度不够还是由于上述操作不当导致的疼痛,错误的手术操作不能得到及时发现和纠正,导致发生严重的神经损伤和气肿等并发症.

2.2. 顺牙根长轴的拔牙方法

下颌智齿由于受到周围软/硬组织的阻挡,往往萌出不全,手术时需要切开翻瓣,利用高速涡轮手机去骨截冠,解除周围软组织,骨组织和邻牙阻力,然后进行敲锤增隙扩大牙周膜间隙,再以下颌智齿颊侧或近中牙槽嵴为支点使用牙挺挺松牙齿.如果智齿的牙根为锥形的单根,增隙后挺松的效果预期性较好,而非锥形单根牙由于牙根弯曲肥大,多牙根之间相互制衡,颊侧的骨皮质较厚等,增隙后挺松效果往往可预期性差,因此,有人使用种植机或超声骨刀将牙根周围的大部分牙槽骨壁磨除,扩大牙周膜间隙,再挺松牙齿,这些操作不可避免会产生较大的手术创伤,因此,要让弯曲肥大牙根,多牙根可预期地顺利脱位,同时更多地保留牙槽窝骨壁的完整性,需要根据智齿的阻生类型和牙根的解剖形态解除牙根周围组织的阻力,让每个牙根顺着牙根长轴方向脱位,此时脱位所需克服的阻力为牙周韧带的拉力.

对于垂直阻生或远中阻生智齿,如果部分萌出或完全埋伏,手术需要切开翻瓣暴露牙冠牙合面,翻瓣范围需控制在角化龈区域,不超过膜龈联合.如果智齿牙根为肥大/融合根,在保证不损伤下牙槽神经和舌侧骨板的前提下,远中截冠时尽量接近根尖1/3~1/2水平,将远中根面的部分牙体组织去除,然后在近中颊角处使用牙挺顺着牙根长轴方向将牙根挺向远中牙合面脱位,此时挺出的力量主要是克服近中面和根尖下1/3~1/2水平牙周韧带的拉力(图2);如果牙根为双根分叉,首先在牙合面中央进行垂直分根至根分歧,离断后形成两个独立的锥形单根,可顺牙根长轴挺松牙根后使用牙钳拔除.

左下颌垂直阻生智齿(A),根尖片显示融合根(B),远中截冠(C),远中冠取出(D),牙挺顺牙根长轴远中牙合向脱位(E, F),近中冠根取出后的拔牙窝(G),远中截冠接近根尖1/2~1/3水平(H)

对于水平阻生或近中阻生智齿,牙冠远中面暴露不足时,需要颊侧角形翻瓣完全暴露颊侧骨面,尤其是智齿远中颊角处的骨面.去除牙冠远中面上方的骨质至釉牙骨质界处,牙冠颊侧亦可少量去骨暴露牙冠远中面即可,如果去骨过深,有可能暴露骨髓腔,导致术中出血,术后渗出较多,引起肿胀.如果牙根为肥大/融合根,在保证不损伤下牙槽神经和不穿通舌侧骨板的前提下,在牙冠远中边缘嵴前0.5 mm处(近中阻生智齿), 或牙冠外形高点前0.5 mm处(水平阻生智齿)垂直"T"形截冠,取出牙冠后在釉牙骨质界处斜行制备沟槽,沟槽内插入牙挺,并以沟槽远中的牙槽骨为支点,顺着牙根长轴方向将整个牙根推向近中脱位(图3);或者利用涡轮在远中根面打孔,使用三角挺以远中牙槽骨为支点,顺着牙根长轴方向将整个牙根挺向近中脱位(图4);如果牙根是双根分叉,垂直"T"形截冠后远中少量去骨,在釉牙骨质界处斜行截断远中根,沟槽内插入牙挺,并以沟槽远中的牙槽骨和远中根为支点,顺着牙根长轴方向将近中根推向近中脱位,然后再使用微创拔牙刀取出远中根(图5).对于舌向阻生智齿,如果舌向或远中脱位存在牙龈或骨组织的阻挡,可在舌侧或远中舌侧截冠解除阻力,尽量保留牙体组织,去除牙冠颊侧包绕的骨质至釉牙骨质界,再以釉牙骨质界为受力点,使用牙挺冲出法顺牙根长轴舌向脱位(图6).

右下颌水平阻生智齿,融合牙根与下牙槽神经相贴(A),颊侧角形翻瓣(B),垂直截冠后远中面去骨显露釉牙骨质界(C),釉牙骨质界处斜行制备沟槽(D),牙挺顺牙根长轴近中方向脱位(E),牙齿拔除后的拔牙窝(F)

右下颌水平阻生智齿,牙根肥大(A), 垂直截冠后牙根断面(B),远中根面釉牙骨质界处斜行打孔(C),三角挺顺牙根长轴挺向近中方向(D),冠根脱位(E),牙齿拔除后的拔牙窝(F)

右下颌水平阻生智齿(A),根尖片显示双根分叉(B),垂直截冠后釉牙骨质界处斜行截断远中根(C),牙挺顺牙根长轴挺向近中方向(D),截根后的牙根断面(E, F),牙齿拔除后的拔牙窝(G),离体牙显示远中截根的位置(H)

右下颌舌向阻生智齿(A),颊侧角形翻瓣(B),去骨至釉牙骨质界处显露牙冠颊侧面(C),垂直方向远中截冠(D),顺牙根长轴舌向冲出,舌侧有阻力,牙齿不松动(E),垂直方向舌侧截冠(F),顺牙根长轴舌向冲出,冠根脱位(G),牙根为双根,颊舌向分根(H),牙齿拔除后的拔牙窝(I)

顺牙根长轴拔牙方法通过截冠解除周围骨组织和邻牙的阻力,通过分根解除牙根之间相互制衡的阻力,通过远中制备沟槽创造受力支点,牙齿顺牙根长轴脱位时只需克服牙周韧带的拉力.顺牙根长轴脱位的方法要求牙龈翻瓣的范围可局限于角化龈的范围,软组织渗出液,出血较少,手术去骨的范围较小,暴露牙冠牙合面(垂直阻生和远中阻生),牙冠远中面(近中阻生和水平阻生)或牙冠颊侧面(舌向阻生)即可,可更大程度保留拔牙窝骨壁的完整性,同时骨壁表面保留薄层的牙周膜,可减少术中,术后出血,减少拔牙窝骨壁的直接暴露,降低干槽症的发生率,有利于拔牙窝的愈合;牙根脱位时都是使用牙挺或三角挺挺出,避免敲锤增隙时圆凿对神经的直接损伤,或牙根对神经的间接压迫损伤,或者将智齿敲出拔牙窝移位进入舌侧间隙;对于近中或水平阻生智齿,远中根面上方去除的少许骨质为薄层的皮质骨,骨髓腔内松质骨基本不暴露,术中无出血,远中制备沟槽后推动牙根向近中方向脱位,没有舌侧方向作用力,可有效避免舌侧骨壁的折断,因此,相对于传统的敲锤增隙法,顺牙根长轴法具有明显的临床优势.

2.3. 手术决策树

下颌阻生智齿拔除由于手术本身的复杂性,目前缺乏具有指导性的具体操作流程,手术操作步骤随意性很强,造成手术的不可预期,手术创伤较大,术后并发症多^[27,28].下颌阻生智齿手术决策树是手术操作步骤具体化,流程化,微创化和可预期的一个尝试.结合智齿的Winter分类和顺牙根长轴脱位的方向,手术决策树将阻生智齿分成4种类型,即垂直和远中阻生智齿的牙合向脱位,水平和近中阻生智齿的近中脱位,舌向阻生智齿的舌向脱位和其他脱位.根据牙根形态在牙片或曲面断层片上的表现,将其分为4种类型:单根锥形,单根肥大/融合根,双根分叉和其他类型(图7).对于智齿埋伏位置较深,牙根与下颌管位置关系显示不清,下颌管与牙根关系密切或异形根的智齿,手术前需拍摄锥形束CT,明确舌侧骨壁的厚度,有无舌侧骨倒凹,牙根形态以及牙根与下颌管的位置关系,明确涡轮钻针截冠,截根和去骨的安全边界,以利于手术中规避对下牙槽神经和舌神经的损伤,以及冠根移位进入舌侧间隙,手术决策树的具体流程如图8,9,10.

下颌智齿牙根形态分类:单根锥形(A,E),单根肥大/融合根(B,F),双根分叉(C,G),其他类型(D,H)

2.4. 术后充分引流

下颌完全萌出的智齿拔除一般无明显术后反应,而下颌阻生智齿,尤其是完全埋伏的智齿术后常常伴有明显肿胀,张口受限,严重时出现化脓感染.术后的肿胀和张口受限主要与手术创面的渗血,组织渗出液引流不畅有关^[29,30].牙龈缝合后,拔牙窝骨壁和颊侧的软组织瓣的组织渗出液向前下沿着下颌骨外斜线与后牙牙槽嵴形成的骨性颊沟进入组织松软的颊间隙,或者经拔牙窝舌侧骨壁缺损处进入组织松软的翼下颌,下颌下或咽旁间隙,同时诱发明显的炎性水肿反应,导致临床中常见的面颊部或舌侧咽旁的术后肿胀.渗出的炎性因子激惹周围的咬肌,颞肌或翼内肌产生张口受限.如果不能及时治疗,术后的肿胀往往导致化脓感染,因此,手术过程中应当尽量在角化龈范围内进行牙龈翻瓣,保持骨膜和拔牙窝骨壁的完整性,从源头上控制手术创面的渗出.同时,应当改变渗出物的引流通道,使其直接通畅引流至口内.常用的方法是拔牙窝内放置引流条,缝线固定,并由第二磨牙远中或近中切口处引出(图11A), 24 h后取出引流条,或者保证无术后出血的情况下,复位牙龈组织瓣,不做切口缝合,组织渗出液能顺切口流出,牙龈可在无张力状态下原位愈合(图11B).

3. 下颌阻生智齿拔除手术可预期微创化的发展方向

手术是一把双刃剑,在解决患者病痛的同时往往伴有手术创伤,出现程度不一的术后反应和术后并发症.在牙槽外科领域,目前的现状是以解决患者的病痛为中心,而对手术相关的创伤和并发症未得到足够的重视.微创医学是在解决患者病痛的基础上,基于对疾病和医疗干预更深刻,全面的科学认知,试图降低医疗干预相关的不良反应,体现以人为本和对人性的尊重.下颌阻生智齿拔除手术的可预期微创化通过围手术期的镇静和镇痛达到心理上的微创化;通过顺牙根长轴的拔牙方法达到生理上的微创化;通过术后充分引流控制术后反应,通过手术决策树达到手术过程的标准化和流程化,最后实现下颌阻生智齿拔除时手术相关创伤的微创化,手术过程可预期和术后反应可预期,具体表现为:(1)手术体验无疼痛,无焦虑,全程舒适;(2)反应期(术后1~2 d)无出血,面颊部无肿胀,无自发痛,无张口受限,无唇舌麻木;(3)恢复期(术后2 d后)无口角糜烂,无疼痛,无需抗生素,无感染.随着微创医学的发展,拔牙相关的新理念,新技术,新设备将会不断出现,医疗干预相关的不良反应将获得很好的控制,从而提高患者对智齿手术的接受程度,更好地维护口腔健康.

References

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22.Inverso G, Dodson TB, Gonzalez ML, et al. Complications of moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. J Oral Maxillofac Surg. 2016;74(3):474–479. doi: 10.1016/j.joms.2015.10.009. [DOI] [PubMed] [Google Scholar]
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28.Cho H, Lynham AJ, Hsu E. Postoperative interventions to reduce inflammatory complications after third molar surgery: Review of the current evidence. Aust Dent J. 2017;62(4):412–419. doi: 10.1111/adj.12526. [DOI] [PubMed] [Google Scholar]
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[b1] 1.Sun Y, Pan B, Fu Y, et al. Development of a novel intelligent laparoscope system for semi-automatic minimally invasive surgery [J]. Int J Med Robo, 2019, 11(2019-11-01)[2019-11-5]. https://onlinelibrary.wiley.com/doi/abs/10.1002/rcs.2049.

[b2] 2.中国腹腔镜胃肠外科研究组(CLASS研究组). 中国腹腔镜胃肠外科研究组十年回顾与展望. 中华胃肠外科杂志. 2019;22(10):916–919. doi: 10.3760/cma.j.issn.1671-0274.2019.10.003. [DOI] [PubMed] [Google Scholar]

[b3] 3.Blanco RT, Ojala R, Kariniemi J, et al. Interventional and intraoperative MRI at low field scanner: A review. Eur J Radiol. 2000;56(2):130–142. doi: 10.1016/j.ejrad.2005.03.033. [DOI] [PubMed] [Google Scholar]

[b4] 4.Mathew MS, Oto A. MRI-guided focal therapy of prostate cancer. Future Oncol. 2017;13(6):537–549. doi: 10.2217/fon-2016-0201. [DOI] [PubMed] [Google Scholar]

[b5] 5.Kim SH, Won KS, Choi BW, et al. Usefulness of F-18 FDG PET/CT in the evaluation of early treatment response after interventional therapy for hepatocellular carcinoma. Nucl Med Mol Imaging. 2012;46(2):102–110. doi: 10.1007/s13139-012-0138-8. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b6] 6.Donlon WC, Truta MP. Minimally invasive third molar surgery. J Oral Maxillofac Surg. 2007;65(2):359. doi: 10.1016/j.joms.2006.11.001. [DOI] [PubMed] [Google Scholar]

[b7] 7.Engelke W, Lazzarini M, Beltrán V. Hard tissue preservation in minimally invasive mandibular third molar surgery using in situ hardening TCP bone filler[J]. Biomed Res Int, 2018, 11(2018-11-11)[2019-11-01].https://www.ncbi.nlm.nih.gov/pubmed?term=Hard+tissue+preservation+in+minimally+invasive+mandibular+third+molar+surgery+using+in+situ+hardening&TransSchema=title&cmd=detailssearch.

[b8] 8.Lodi G, Figini L, Sardella A, et al. Antibiotics to prevent complications following tooth extractions[J]. Cochrane Database Syst Rev, 2012, 11(2012-11-14)[2019-11-02]. https://www.ncbi.nlm.nih.gov/pubmed?term=Antibiotics+to+prevent+complications+following+tooth+extractions&TransSchema=title&cmd=detailssearch.

[b9] 9.Menon RK, Kar Yan L, Gopinath D, et al. Is there a need for postoperative antibiotics after third molar surgery? A 5-year retrospective study. J Investig Clin Dent. 2019;10(4):e12460. doi: 10.1111/jicd.12460. [DOI] [PubMed] [Google Scholar]

[b10] 10.Hechler BL, Blakey GH. Necrotizing soft tissue infection following routine third molar extraction: Report of two cases and review of the literature. Int J Oral Maxillofac Surg. 2019;48(12):1525–1529. doi: 10.1016/j.ijom.2019.05.010. [DOI] [PubMed] [Google Scholar]

[b11] 11.Ma S, Li X, Zhang A, et al. Efficacy of secondary closure technique after extraction of third molars: A meta-analysis [J]. Br J Oral Maxillofac Surg, 2019, 9(201-09-17)[2019-11-05]. https://www.bjoms.com/article/S0266-4356(19)30347-X/fulltext.

[b12] 12.Tojyo I, Nakanishi T, Shintani Y, et al. Risk of lingual nerve injuries in removal of mandibular third molars: A retrospective case-control study [J]. Maxillofac Plast Reconstr Surg, 2019, 9(2019-09-10)[201-11-05]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733934.

[b13] 13.Oliveira MMM, de Franca Acioly R, de Souza DD, et al. Third molar displacement into submandibular space[J]. Case Rep Dent, 2019, 9(2019-09-17)[2019-11-02]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766172.

[b14] 14.Singh YK, Adamo AK, Parikh N, et al. Transcervical removal of an impacted third molar: an uncommon indication. J Oral Maxillofac Surg. 2014;72(3):470–473. doi: 10.1016/j.joms.2013.09.031. [DOI] [PubMed] [Google Scholar]

[b15] 15.Cai Y, Sun R, Zhao JH. Flapless boning to increase space by piezosurgery: A novel mini-invasive strategy for teeth extraction. A retrospective study. Medicine (Baltimore) 2018;97(27):e11398. doi: 10.1097/MD.0000000000011398. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b16] 16.杨映阳, 杜胜男, 吕宗凯. 高速涡轮机头和微创拔牙刀在下颌阻生牙拔除术中的应用效果评价. 上海口腔医学. 2015;24(4):489–492. [PubMed] [Google Scholar]

[b17] 17.Mantovani E, Arduino PG, Schierano G, et al. A split-mouth randomized clinical trial to evaluate the performance of piezosurgery compared with traditional technique in lower wisdom tooth removal. J Oral Maxillofac Surg. 2014;72(10):1890–1897. doi: 10.1016/j.joms.2014.05.002. [DOI] [PubMed] [Google Scholar]

[b18] 18.Patil C, Jadhav A, Bhola N, et al. Piezosurgery vs bur in impac-ted mandibular third molar surgery: Evaluation of postoperative sequelae. J Oral Biol Craniofac Res. 2019;9(3):259–262. doi: 10.1016/j.jobcr.2019.06.007. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b19] 19.Badenoch-Jones EK, David M, Lincoln T. Piezoelectric compared with conventional rotary osteotomy for the prevention of postoperative sequelae and complications after surgical extraction of mandi-bular third molars: a systematic review and meta-analysis. Br J Oral Maxillofac Sur. 2016;54(10):1066–1079. doi: 10.1016/j.bjoms.2016.07.020. [DOI] [PubMed] [Google Scholar]

[b20] 20.Mamoun J. Use of elevator instruments when luxating and extracting teeth in dentistry: Clinical techniques. J Korean Assoc Oral Maxillofac Surg. 2017;43(3):204–211. doi: 10.5125/jkaoms.2017.43.3.204. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b21] 21.Yu C, Li S, Deng F, et al. Comparison of dexmedetomidine/fentanyl with midazolam/fentanyl combination for sedation and analgesia during tooth extraction. Int J Oral Maxillofac Surg. 2014;43(9):1148–1153. doi: 10.1016/j.ijom.2014.03.019. [DOI] [PubMed] [Google Scholar]

[b22] 22.Inverso G, Dodson TB, Gonzalez ML, et al. Complications of moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. J Oral Maxillofac Surg. 2016;74(3):474–479. doi: 10.1016/j.joms.2015.10.009. [DOI] [PubMed] [Google Scholar]

[b23] 23.张昊, 侯亚丽, 李向军, et al. 靶控输注异丙酚和异丙酚复合瑞芬太尼镇静在小儿埋伏多生牙拔除手术中应用的比较. 华西口腔医学杂志. 2017;35(4):408–412. [Google Scholar]

[b24] 24.邵云, 王新河, 苏荣祥, et al. 氧化亚氮/氧吸入镇静在老年高血压患者拔牙术中的应用. 上海口腔医学. 2013;22(3):302–304. [PubMed] [Google Scholar]

[b25] 25.钟恬, 胡道勇. 笑气/氧气吸入镇静技术及其在儿童口腔临床中的应用. 华西口腔医学杂志. 2014;32(1):101–104. doi: 10.7518/hxkq.2014.01.024. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b26] 26.孙玉娟, 戚道一, 张炳熙, et al. 笑气吸入清醒镇静法用于拔牙术的临床研究. 中华口腔医学杂志. 1998;33(1):24–26. [Google Scholar]

[b27] 27.Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am. 2007;19(1):117–128. doi: 10.1016/j.coms.2006.11.013. [DOI] [PubMed] [Google Scholar]

[b28] 28.Cho H, Lynham AJ, Hsu E. Postoperative interventions to reduce inflammatory complications after third molar surgery: Review of the current evidence. Aust Dent J. 2017;62(4):412–419. doi: 10.1111/adj.12526. [DOI] [PubMed] [Google Scholar]

[b29] 29.齐伟, 李健男, 赵静仁, et al. 角形切口设计和愈合方式与下颌阻生智齿拔除术后并发症. 北京大学学报(医学版) 2019;51(5):949–953. [Google Scholar]

[b30] 30.Liu S, You Z, Ma C, et al. Effectiveness of drainage in mandibular third molar surgery: A systematic review and meta-analysis. J Oral Maxillofac Surg. 2018;76(8):1640–1650. doi: 10.1016/j.joms.2018.03.004. [DOI] [PubMed] [Google Scholar]

PERMALINK

下颌阻生智齿拔除手术的可预期微创化

登辉段

恩博王

念晖崔

新利翟

宇刘

娟红孟

伟张

益张

1. 下颌阻生智齿拔除手术的现状

1.