裂齒存活率與預後因子暨上顎後牙牙根尖與上顎竇距離之臨床牙髓病學研究

Abstract

本論文共分為五個章節，各章節針對研究關鍵成果進行探討。第一章提供兩個主要研究主題的概述：裂齒的存活及上顎後牙牙根尖與上顎竇之間的解剖關係，簡介其臨床價值與意義，並說明本論文的研究設計。

第二章專注於第一個研究問題，檢視裂齒的分布與接受不同治療方式後的存活，同時進行了系統性回顧和統合分析，以綜合過去文獻現有數據並提供有關裂齒預後因子的最新證據。本文共納入15篇具有中等誤差風險的世代研究(包括4,160位患者和4,193顆裂齒)分析，合併存活率和成功率分別為88% (95%信賴區間: 80%, 95%; I²: 91%)和87% (95%信賴區間: 80%, 94%; I²: 92%)。合併拔牙率顯示當裂齒為牙弓中末端支台齒(勝算比: 2.35; 95%信賴區間: 1.09, 5.06; I²<0.1%)和具有裂紋往牙齦下或牙根方向延伸的裂齒(勝算比: 3.47; 95%信賴區間: 1.47, 8.18; I²<0.1%)會顯著增加拔牙的風險。合併成功率顯示當裂齒具有≥5 mm牙周探測囊袋時，具有顯著較低的成功率(勝算比: 0.20; 95%信賴區間: 0.09, 0.44; I²: 10%)。

此外，本文也進行一個回顧性定量研究，收集有關裂齒的資料，包括人口學、臨床與放射線特徵，以評估裂齒的存活率，並分析結果預測因子。本研究於2014年至2018年間共檢查65位患者的77顆裂齒，裂齒主要出現在下顎大臼齒(42.86%)和具有近遠心方向上的裂紋(53顆裂齒, 68.83%, p<0.01)。裂齒顯著地具有敲擊痛(49顆裂齒, 63.64%, p<0.05)、無或僅有微小的動搖度(59顆裂齒, 76.62%, p<0.01)和具有咬痛(57顆裂齒, 74.03%, p<0.01)。裂齒的存活率在六個月、一年和兩年的追蹤分別為87.72%、76.00%和62.86%。當裂齒具有牙髓活性(p<0.01)、無觸診痛(p<0.05)、無自發性疼痛(p<0.05)和僅具有微小的動搖度(p<0.05)時呈現出顯著較佳的存活率。

第三章轉向第二個研究問題的論述，關於上顎小臼齒、大臼齒與上顎竇之間的解剖構造關係，進行另一個回顧性定量研究，以測量牙根尖與上顎竇及頰側皮質骨外緣之最短距離。本研究同時檢視牙根尖與上顎竇底部之間的水平和垂直空間關係，測量上顎竇底部皮質骨與黏膜厚度，並將數據資料與年齡、性別和牙位等變數進行相關性分析。

本研究共收集94位患者478顆上顎後牙的997個牙根錐狀射束電腦斷層掃描影像，結果發現上顎大臼齒和單牙根上顎第二小臼齒相較於上顎第一小臼齒顯著地更接近上顎竇(p<0.01)，兩牙根上顎第一小臼齒的頰側牙根顯著地最接近頰側皮質骨外緣(p<0.01)。在上顎小臼齒，上顎竇底部最低點通常位於顎側，而在上顎大臼齒，通常位於頰側和顎側牙根之間(p<0.01)。上顎小臼齒牙根大部分位於上顎竇之外，上顎大臼齒牙根通常會接觸或是延伸進上顎竇(p<0.01)。在另檢查的285個牙根中，95.79%具有正常的上顎竇底部黏膜厚度(0-2 mm)，4.21%具有中度增厚(2-10 mm)。隨著年齡的增加，上顎後牙牙根尖到上顎竇底部的距離和皮質與黏膜厚度均會增加，但是到頰側皮質骨外緣的距離會減少。男性相較於女性具有較厚的頰側皮質骨和黏膜厚度，上顎後牙牙根尖到上顎竇底部和頰側皮質骨外緣的距離在左右側顯示正相關性。

第四章總結本論文的主要發現與結論，並提出相關研究的未來展望。第五章列出與本論文相關的發表，以及其他在國際同儕審查期刊刊登之文章。

This dissertation is organized into five chapters, each addressing key aspects and outputs of the research. Chapter I provides an overview of the two primary research topics: the survival of cracked teeth and the anatomical relationship between the maxillary posterior root apices and the maxillary sinus. Outline their clinical value and significance, and introduce the research design of this dissertation.

Chapter II focuses on the first research question, examining the distribution and survival of cracked teeth under various treatments. A systematic review and meta-analysis were conducted to synthesize current data and provide contemporary evidence on the prognostic factors of cracked teeth. A total of 15 cohort studies (4,160 patients with 4,193 cracked teeth) with medium risk of bias were analyzed. The pooled survival and success rates of cracked teeth were 88% (95% confidence interval [95%CI]: 80%, 95%; I²: 91%) and 87% (95%CI: 80%, 94%; I²: 92%), respectively. The pooled extraction rate showed that cracked teeth located as terminal abutments (odds ratio [OR]: 2.35; 95%CI: 1.09, 5.06; I²<0.1%) and those with subgingival or radicular extensions (OR: 3.47; 95%CI: 1.47, 8.18; I²<0.1%) significantly increased the risk of extraction. The pooled success rate also showed that cracked teeth with a periodontal probing depth of ≥5 mm had a significantly lower success rate (OR: 0.20; 95%CI: 0.09, 0.44; I²: 10%).

Additionally, a retrospective quantitative study was conducted to collect data on cracked teeth, including demographic, clinical, and radiographic characteristics, in order to evaluate survival rates and analyze outcome predictors. A total of 77 cracked teeth from 65 patients were examined between 2014 and 2018. Cracked teeth were primarily found in mandibular molars (42.86%) and predominantly exhibited cracks in the mesiodistal direction (53 teeth, 68.83%, p<0.01). Cracked teeth were significantly associated with percussion pain (49 teeth, 63.64%, p<0.05), no or minimal mobility (59 teeth, 76.62%, p<0.01), and biting pain (57 teeth, 74.03%, p<0.01). The survival rates of cracked teeth were 87.72%, 76.00%, and 62.86% at six-month, one-year, and two-year follow-ups, respectively. Cracked teeth that were vital (p<0.01) and exhibited no palpation pain (p<0.05), no spontaneous pain (p<0.05), and minimal mobility (p<0.05) had significantly better survival rates.

Chapter III shifts focus to the second research question, which examines the anatomical and structural relationship between the maxillary premolars and molars and the maxillary sinus. Another retrospective quantitative study was conducted to measure the shortest distance between the root apex and the maxillary sinus, as well as the external buccal cortical margin. This investigation also identified the horizontal and vertical dimensional relationships between the root apex and the maxillary sinus floor, assessed the cortical bone and mucosal thicknesses of the maxillary sinus floor, and correlated these findings with variables such as age, gender, and tooth position.

We analyzed cone-beam computed tomography images of 997 roots from 478 maxillary posterior teeth in 94 patients. The results showed that maxillary molars and single-rooted second premolars were significantly nearer to the maxillary sinus than maxillary first premolars (p<0.01). The buccal root of two-rooted maxillary first premolars was significantly closest to the external buccal cortical margin (p<0.01). In maxillary premolars, the sinus floor was usually lowest on the palatal side, whereas in maxillary molars, it was between the buccal and palatal root apices (p<0.01). Maxillary premolar roots were mostly outside the maxillary sinus, whereas maxillary molar roots often contacted or intruded into it (p<0.01). Among 285 roots, 95.79% had normal mucosal thickening (0-2 mm), while 4.21% had moderate thickening (2-10 mm) of the maxillary sinus floor. Age increased the distance from the maxillary posterior root apex to the maxillary sinus floor, as well as cortical and mucosal thickness, but decreased the distance to the external buccal cortical margin. Males had thicker buccal cortical bone and mucosa than females. The distances from the maxillary posterior root apex to the maxillary sinus floor and the external buccal cortical margin showed a positive correlation between the right and left sides.

Chapter IV summarizes the main findings and conclusions of this dissertation and presents future outlooks for related research. Chapter V lists the relevant publications that have emerged from this work, as well as other articles published by the author in international peer-reviewed journals.