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中华口腔医学研究杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 413 -417. doi: 10.3877/cma.j.issn.1674-1366.2023.06.007

病例分析

牙槽外科相关舌神经损伤早期诊断及治疗中磁共振神经成像技术的应用
岳志浩, 王晶, 闫子玉, 葛娜, 许向亮, 单小峰, 崔念晖†()   
  1. 北京大学口腔医学院·口腔医院口腔颌面外科，国家口腔医学中心，国家口腔疾病临床医学研究中心，口腔数字化医疗技术和材料国家工程实验室，口腔数字医学北京市重点实验室，国家卫生健康委员会口腔医学计算机应用工程技术研究中心，国家药品监督管理局口腔生物材料重点实验室，北京　100081
  • 收稿日期:2023-09-18 出版日期:2023-12-01
  • 通信作者: 崔念晖

Application of magnetic resonance neurography in early diagnosis and therapy in a case of lingual nerve injury

Zhihao Yue, Jing Wang, Ziyu Yan, Na Ge, Xiangliang Xu, Xiaofeng Shan, Nianhui Cui†()   

  1. Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology & NHC Research Center of Engineering and Technology for Computerized Dentistry & NMPA Key Laboratory for Dental Materials, Beijing 100081, China
  • Received:2023-09-18 Published:2023-12-01
  • Corresponding author: Nianhui Cui
  • Supported by:
    New Clinical Techniques and Therapies of Peking University School and Hospital of Stomatology(PKUSSNCT-22A06)
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岳志浩, 王晶, 闫子玉, 葛娜, 许向亮, 单小峰, 崔念晖. 牙槽外科相关舌神经损伤早期诊断及治疗中磁共振神经成像技术的应用[J]. 中华口腔医学研究杂志(电子版), 2023, 17(06): 413-417.

Zhihao Yue, Jing Wang, Ziyu Yan, Na Ge, Xiangliang Xu, Xiaofeng Shan, Nianhui Cui. Application of magnetic resonance neurography in early diagnosis and therapy in a case of lingual nerve injury[J]. Chinese Journal of Stomatological Research(Electronic Edition), 2023, 17(06): 413-417.

舌神经损伤是牙槽外科中较为严重的并发症之一，往往发生在下颌第三磨牙（M3M）拔除术后，发病率约0.1% ~ 22%。由于临床检查及传统影像学检查的局限性，部分重症患者在损伤发生早期未得到准确诊断和有效治疗，导致舌神经永久性损伤，大大影响生活质量。近年来，磁共振神经成像（MRN）技术逐渐用于神经损伤的检查中，多种新型磁共振成像序列对重度舌神经损伤均有很好的显像，使舌神经损伤的早期诊断及治疗成为可能。本文报道了1例拔牙所致舌神经损伤2周的患者，通过磁共振检查可见舌神经完全离断样损伤。随后进行了神经吻合术，术中观察到舌神经完全离断，证明磁共振影像与现实相符，术后随访显示舌神经功能逐步恢复。

关键词: 舌神经损伤, 神经吻合, 磁共振神经成像, 牙槽外科

Lingual nerve injury is one of the serious complications in alveolar surgery, which often occurs after the extraction of the mandibular third molar (M3M), with the incidence varying from 0.1% to 22%.Due to the limitations of clinical and conventional radiographical examinations, some severe cases do not receive accurate diagnosis and effective treatment in the early stage of injury, resulting in permanent lingual nerve injury and consequent impact on the quality of life. In recent years, magnetic resonance neurography (MRN) has been gradually used in the examination of nerve injury, and several new MRN sequences have reasonable visualization of severe lingual nerve injury, making early diagnosis and therapy possible. This article reported a patient with lingual nerve injury caused by the removal of M3M for 2 weeks, and complete disconnection of the affected lingual nerve was clearly visualized through MRN. Subsequently, a nerve anastomosis surgery was performed, and the disconnection was observed during the operation, proving the consistency of the MRN imaging and the fact. Postoperative follow-up showed gradually functional recovery of the lingual nerve.

Key words: Lingual nerve injuries, Neuroanastomosis, Magnetic resonance neurography, Alveolar surgery
图1 右下颌第三磨牙拔除术后2周右舌麻木患者口内像　A：拔牙创局部软组织愈合中；B：右侧舌乳头未见明显萎缩。
图2 右下颌第三磨牙拔除术后右舌麻木患者锥形束CT（CBCT）影像　A：轴位；B：冠状位；C：斜矢状位；箭头示舌侧骨板细长狭窄骨板缺损，靠近舌神经走行位置。
图3 右下颌第三磨牙拔除术后右舌麻木患者磁共振曲面重建（CPR）影像　黄色箭头示右侧舌神经影像不连续，近颅端呈现较高信号；蓝色箭头示左侧舌神经影像连续。
图4 右下颌第三磨牙拔除术后右舌麻木患者行舌神经损伤探查修复术　A：箭头示舌神经完全离断，缺损约3 mm；B：箭头示舌神经两侧断端行端端吻合；C：箭头示人工神经鞘管包裹神经外膜；D：术后病理切片示局部神经束排列较紊乱，伴变性表现，神经断端可见纤维组织、肌组织和神经束，散在慢性炎症细胞浸润（苏木精-伊红染色　低倍放大）。
表1 右下颌第三磨牙拔除术后右舌麻木患者行舌神经损伤探查修复术前、术后患侧舌神经感觉测试（NST）结果
时间点 感觉减退 感觉异常 病理性感觉异常 其他异常 触觉 痛觉 味觉 两点辨别觉（mm） 空间方向觉（正确次数/检查次数） MRCS评分
术前 麻木 麻刺感 刺痛、电击样痛 自发痛感、凉感；咬舌；舌体烫伤 缺失 缺失 缺失 >15 0/5 S1
术后1个月 麻木稍有改善 无 无 偶有咬舌 缺失 迟钝 缺失 7 2/5 S3+
术后7个月 麻木明显改善 无 无 偶有咬舌 迟钝 迟钝 缺失 5 9/10 S4
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