骨瓣重建颌骨区域角化黏膜增量术后软组织愈合效果分析

doi:10.19723/j.issn.1671-167X.2025.01.009

摘要/Abstract

摘要：

目的: 评估颌骨重建区域种植体周角化黏膜增量手术(keratinized mucosa augmentation, KMA)术后受区、供区伤口愈合情况，并与天然颌骨牙龈移植进行比较，以期为临床术后维护提供指导，同时分组比较临床经验对KMA术后愈合评价的影响。方法: 选择北京大学口腔医院颌面外科2020年10月至2023年4月完成颌面部肿瘤切除、腓骨瓣或髂骨瓣重建及种植修复患者的病例资料进行回顾性分析，种植体植入3个月后转诊牙周科行角化黏膜增量手术，拍摄重建区域游离龈移植术前、术后即刻、术后3周和术后3个月的口内像，拍摄腭部供区术前、术后3周的口内像。由4位低年资医师(工作经验 < 10年)和3位高年资医师(工作经验≥ 10年)作为评分者，运用早期愈合指数(early healing index, EHI)、早期伤口愈合评分(early wound healing score, EHS)及粉红美学评分(the pink esthetic score, PES)根据所得口内像对重建区域软组织愈合情况进行评价，并由高年资医师对比天然颌骨牙龈移植愈合效果作出10分制评价。结果: 26位颌骨重建患者纳入本研究，年龄(34.2±10.2)岁，男11例，女15例，其中腓骨瓣重建13例，髂骨瓣重建13例。平均每位患者种植体数目为(3.2±0.7)枚。在受区，术后3周EHS评价体系得分为7.0 (4.0, 9.0)，其子项——临床再上皮化征象(clinical signs of re-epithelialization, CSR)得分为6.0 (3.0, 6.0)，凝血情况(clinical signs of haemostasis, CSH)得分为1.5 (1.0, 2.0)，炎症表现(clinical signs of inflammation, CSI)得分为1.0 (0.0, 1.0)。这说明纳入患者术后3周受区伤口整体表现为切缘基本合并，切口处有少量纤维蛋白线同时伴有一定的红肿。EHI在受区得分为2.0 (1.5, 2.5)，表示术后3周切口基本闭合且有少量纤维蛋白线。远期愈合评价体系PES [2.5 (2.0, 3.0)]，以及其子项颜色[1.0 (1.0, 1.5)]、质地[1.5 (1.0, 2.0)]与天然颌骨周围软组织相比略有差异。在腭部供区，术后3周EHI [1.3 (1.0, 2.5)]得分较低，EHS [8.5 (6.0, 10.0)]得分较高，说明供区软组织愈合较好。在不同年资医师间，受区愈合评价中除CSI项低年资组高于高年资组，其余项为高年资组显著高于低年资组，EHS评价体系的子项CSH则在不同年资的分组比较中差异无统计学意义。高年资医师对比天然颌骨牙龈移植愈合效果进行比较的十分制评分结果为8.5 (7.5, 9.5)，表现出较高的一致性[组内相关系数(intraclass correlation coefficient, ICC): 0.892; 95%置信区间(confidence interval, CI): 0.791~0.949]，提示KMA术后愈合效果欠佳。结论: 颌骨重建区域KMA术后愈合相对较慢，需要做好患者的术后管理，临床经验对颌骨重建患者KMA术后伤口愈合评价存在一定的影响。

关键词: 游离龈移植, 角化黏膜增量手术, 颌骨重建, 愈合评价, 种植体

Abstract:

Objective: To evaluate the wound healing of recipient and donor sites following keratinized mucosa augmentation (KMA) around implants in reconstructed jaw areas and to compare these outcomes with gingival grafts in native jawbone, so as to provide clinical guidance for postoperative maintenance, and to investigate the impact of clinical experience on the evaluation of KMA postoperative healing through subgroup comparisons. Methods: This study included patients who underwent resection of maxillofacial tumors, fibular or iliac flap reconstruction, and implant placement at Peking University Dental Hospital from October 2020 to April 2023. Three months post-implant placement, the patients were referred for KMA procedures. Clinical photographs of the reconstructed area were taken preoperatively, immediately postoperatively, and 3 weeks and 3 months post-surgery. Additionally, photographs of the palatal donor site were obtained preoperatively and 3 weeks later. Wound healing was assessed by four junior and three senior clinicians utilizing the early healing index (EHI), early wound healing score (EHS), and pink esthetic score (PES).And senior clinicians evaluated the healing effect compared with gingival transplantation on natural jawbone using a 10-point scale. Results: A total of 26 patients with jawbone reconstruction were included, with an average age of (34.2±10.2) years, 11 males (42.3%) and 15 females (57.7%). Among them, 13 cases (50.0%) underwent fibula flap reconstruction, and 13 cases (50.0%) underwent iliac flap reconstruction. The average number of implants per patient was 3.2±0.7. In the recipient area, 3 weeks postoperatively, the EHS was 7.0 (4.0, 9.0), with sub-item scores as follows: Clinical signs of re-epithelialization (CSR) 6.0 (3.0, 6.0), clinical signs of haemostasis (CSH) 1.5 (1.0, 2.0), and clinical signs of inflammation (CSI) 1.0 (0.0, 1.0), indicating that the average appearance of the wound in the recipient area was characterized by generally well-approximated wound edges with minimal fibrin lines and mild erythema and swelling. The EHI for the recipient area was 2.0 (1.5, 2.5), suggesting that the incision was mostly closed with some fibrin lines 3 weeks postoperatively. The long-term healing evaluation system, PES, was 2.5 (2.0, 3.0), with sub-scores for color [1.0 (1.0, 1.5)] and texture [1.5 (1.0, 2.0)], which were slightly different from the reference values.In the palatal donor area, 3 weeks postoperatively, the EHI score was lower at 1.3 (1.0, 2.5), while the EHS score was higher at 8.5 (6.0, 10.0), indicating better soft tissue healing in the donor area compared with the recipient area. Among the clinicians with different levels of experience, the assessment of wound healing revealed that except for the CSI sub-item, where the junior group scored higher than the senior group, all other sub-items showed significantly higher scores in the senior group compared with the junior group. In the EHS evaluation system, the CSH sub-item demonstrated no significant differences between the groups with varying levels of experience. Experienced clinicians' evaluation outcomes of healing effect compared with gum graft on natural alveolar bone was 8.5 (7.5, 9.5), showing high consistency [intraclass correlation coefficient (ICC): 0.892; 95% confidence interval (CI): 0.791－0.949], suggesting slightly suboptimal healing results after KMA surgery. Conclusion: The healing process following KMA in the context of jawbone reconstruction is relatively protracted, emphasizing the necessity for comprehensive postoperative management. Moreover, clinician experience plays a significant role in the assessment of wound healing outcomes for KMA in maxillofacial reconstruction.

Key words: Free gingival graft, Keratinized mucosa augmentation, Jawbone reconstruction, Healing assessment, Dental implantology

中图分类号:

R782

聂骏男, 董佳芸, 路瑞芳. 骨瓣重建颌骨区域角化黏膜增量术后软组织愈合效果分析[J]. 北京大学学报（医学版）, 2025, 57(1): 57-64.

Junnan NIE, Jiayun DONG, Ruifang LU. Analysis of soft tissue healing after keratinized tissue augmentation in reconstructed jaws[J]. Journal of Peking University (Health Sciences), 2025, 57(1): 57-64.

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参考文献 28

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Items		Senior group，M (P₂₅, P₇₅)	Junior group，M (P₂₅, P₇₅)	P
Receiving area	EHI	2.4 (1.7, 3.3)	1.8 (1.3, 2.2)	< 0.001
	EHS	7.0 (5.2, 8.2)	5.1 (4.5, 6.0)	< 0.001
	CSR	5.0 (4.0, 5.5)	4.5 (3.8, 5.3)	0.005
	CSH	1.3 (0.9, 1.8)	1.4 (1.0, 1.8)	0.661
	CSI	0.7 (0.2, 1.0)	0.9 (0.8, 1.3)	0.006
	PES	3.2 (2.7, 3.5)	1.9 (1.6, 2.1)	< 0.001
	Color	1.3 (1.0, 1.7)	0.9 (0.6, 1.1)	< 0.001
	Texture	1.8 (1.4, 1.8)	1.1 (0.9, 1.1)	< 0.001
Supply area	EHI	1.5 (1.3, 2.5)	1.2 (1.1, 2.2)	0.006
	EHS	8.3 (6.6, 9.3)	8.4 (5.3, 8.8)	0.084
	CSR	5.3 (4.6, 6.0)	5.3 (3.7, 5.5)	0.033
	CSH	1.7 (1.1, 2.0)	1.6 (1.1, 1.8)	0.959
	CSI	1.4 (0.7, 1.7)	1.4 (0.6, 1.7)	0.270

Item	M (P₂₅, P₇₅)	ICC (95%CI)
EHI	1.3 (1.0, 2.5)	0.953 (0.898－0.984)
EHS	8.5 (6.0, 10.0)	0.913 (0.810－0.971)
CSR	6.0 (3.4, 6.0)	0.772 (0.499－0.924)
CSH	2.0 (1.0, 2.0)	0.894 (0.767－0.964)
CSI	1.0 (1.0, 2.0)	0.915 (0.813－0.972)

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