358例年轻恒切牙冠折的临床特点及预后分析

Clinical features and prognosis analysis of 358 cases of permanent immature teeth crown fracture

目的分析年轻恒切牙外伤冠折的临床特点及其预后,探究不同因素对其预后的影响,为年轻恒切牙外伤冠折的临床诊治提供参考。方法本研究通过四川大学华西口腔医院医学伦理委员会审查批准,研究对象为2011年12月至2021年12月就诊于儿童口腔科的患者,对外伤致前牙冠折且至少随访1年的年轻恒牙进行回顾性分析,其诊断为釉质折断、釉质-牙本质折断及冠折露髓的年轻恒牙,首诊治疗方案为观察、恢复牙体外形、牙髓切断术等;采集患儿的年龄、性别、外伤后就诊时间、外伤牙位及松动度、牙根发育分期、诊断及治疗方式。患牙发生牙髓感染、牙髓坏死等事件定义为临床失败,记录其是否发生临床失败及其发生时间,分析不同类型年轻恒切牙冠折预后的相关因素并对外伤牙进行生存分析。结果358例年轻恒切牙中,诊断为釉质折断50例,釉质-牙本质折断176例,冠折露髓132例。其中冠折临床治疗后总体成功率为73.7%(264/358),釉质折断、釉质-牙本质折断和冠折露髓后发生牙髓感染、牙髓坏死的发生率分别为4%(2/50)、33.3%(58/176)和25.8%(34/132)。釉质-牙本质折断患牙行间接盖髓术+覆盖断面的临床失败率显著高于釉质-牙本质折断患牙行覆盖断面和釉质-牙本质折断患牙行牙髓切断术(χ^(2)=10.077,P=0.004);冠折露髓患牙行直接盖髓术临床失败率显著高于冠折露髓患牙行牙髓切断术(χ^(2)=5.501,P=0.038);釉质折断患牙在观察、调磨锐缘、恢复外形下的临床失败率差异无统计学意义(χ^(2)=0.588,P=0.999)。患者年龄>9岁(HR=2.11,95%CI:1.1~3.9,P=0.017)、外伤后就诊时间>3 d(HR=2.3,95%CI:1~4.8,P=0.028)、外伤冠折患牙伴有松动(HR=1.95,95%CI:1.2~3,P=0.004)、行覆盖断面的釉质-牙本质折断(HR=6.89,95%CI:1.6~29.6,P=0.010)、行间接盖髓+覆盖断面的釉质-牙本质折断(HR=13.8,95%CI:3.2~58.3,P<0.001)、进行直接盖髓术的冠折露髓(HR=46.07,95%CI:8~263.8,P<0.001)是本研究人群中临床失败的危险因素。结论年轻恒切牙釉质折断采用观察、调磨锐缘或恢复外形治疗、冠折露髓患牙采用牙髓切断术后预后较好。对于存在影响其预后危险因素的冠折年轻恒切牙应密切随访。

Objective To investigate the clinical characteristics and prognosis of crown fractures in immature permanent incisors due to trauma,and identify factors affecting their prognosisto provide a reference for clinical treatment.Methods This study was approved by the Medical Ethics Committee of West China Stomatology Hospital,Sichuan University.The study subjects were patients admitted to the pediatric stomatology department from December 2011 to December 2021,and a retrospective analysis was conducted on young permanent teeth with anterior crown fracture caused by injury and followed up for at least 1 year,which were diagnosed as enamel fractures,enamel-dentin fractures,and complicated crown fracture and treated by observation,pulpotomy etc.in the first appointment.The age,sex and time elapsed from trauma to baseline visit of the patients and the location,mobility,stage of root development,diagnosis and treatments were collected.The occurrence of pulp infection,pulp necrosis,and other events in the affected tooth is defined as clinical failure.Record whether clinical failure occurred and the timing of their occurrence of the traumatized tooth.Analyze factors related to the prognosis of various types of crown fractures in young permanent incisors and performsurvival analysis on the affected teeth.Results Among 358 cases of young permanent incisors,50 cases were diagnosed with enamel fracture,176 cases with enamel-dentin fracture,and 132 cases with complicated crown fracture.The clinical success rate of crown fractures was 73.7%(264/358)in young permanent incisors.The incidence rates of clinical failure cases,including pulp infection and necrosis,were 4%(2/50)for enamel fractures,33.3%(58/176)for enameldentin fractures,and 25.8%(34/132)for complicated crown fractures respectively.The clinical failure rate of enameldentin fracture treated with indirect pulp capping and restoration was higher than restoration only and pulpotomy(χ^(2)=10.077,P=0.004).The clinical failure rate of complicated crown fractures treated with direct pulp capping was higher than pulpotomy(χ^(2)=5.501,P=0.038).The clinical failure rates between observation,smoothing edges and restoration of enamel fractures exhibit no significant differences(χ^(2)=0.588,P=0.999).Risk factors for clinical failure in this study population included patient age over 9 years old(HR=2.11,95%CI:1.1-3.9,P=0.017)、time elapsed from trauma to baseline visit greater than 3 days(HR=2.3,95%CI:1-4.8,P=0.028),traumatized teeth with mobility(HR=1.95,95%CI:1.2-3,P=0.004),enamel-dentin fractures treated with restoration(HR=6.89,95%CI:1.6-29.6,P=0.010),enamel-dentin fractures treated with indirect pulp capping and restoration(HR=13.8,95%CI:3.2-58.3,P<0.001)and complicated crown fractures treated with direct pulp capping(HR=46.07,95%CI:8-263.8,P<0.001).Conclusion Enamel fractures treated by observation,smoothing edges and restoration,and complicated crown fractures treated with pulpotomy generally had a good prognosis in young permanent incisors.Close follow-up was recommended for crown fractures in young permanent incisors with identified risk factors for poor prognosis.