趙麗萍， 詹雅琳， 胡文杰△， 王浩杰， 危伊萍， 甄 敏， 徐 濤， 劉云松

(北京大學口腔醫(yī)學院·口腔醫(yī)院， 1. 牙周科， 2. 修復科，口腔數(shù)字化醫(yī)療技術和材料國家工程實驗室 口腔數(shù)字醫(yī)學北京市重點實驗室， 北京 100081)

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·病例報告·

磨牙位點保存后進行種植修復及軟組織增量的1例報告

趙麗萍1， 詹雅琳1， 胡文杰1△， 王浩杰1， 危伊萍1， 甄 敏1， 徐 濤1， 劉云松2

(北京大學口腔醫(yī)學院·口腔醫(yī)院， 1. 牙周科， 2. 修復科，口腔數(shù)字化醫(yī)療技術和材料國家工程實驗室 口腔數(shù)字醫(yī)學北京市重點實驗室， 北京 100081)

外科手術，微創(chuàng)性；拔牙；牙種植；牙修復體；軟組織增量

臨床上，常規(guī)拔牙后牙槽骨的自然愈合存在不同程度的牙槽骨吸收[1]，影響未來的種植體植入修復位置，角度及軟、硬組織處理。研究表明，采取微創(chuàng)拔牙和位點保存技術可以減少牙槽骨吸收，顯著保留牙槽嵴寬度及高度[2-3]，減少或避免種植治療同期實施復雜的植骨手術。另有文獻指出，種植體周圍至少需要2 mm的角化齦及1 mm的附著齦，方能維護種植體周圍組織健康，獲得長期穩(wěn)定療效。本研究完整展示了1例針對牙周-牙髓聯(lián)合病變磨牙的病情分析，采取微創(chuàng)拔牙結(jié)合位點保存和游離齦移植術創(chuàng)造良好軟、硬組織條件，獲得最終較好種植修復效果的具體實施步驟，積累了針對此類問題的臨床經(jīng)驗。

1 病史及臨床檢查

1.1 病史

患者，女，57歲，2013年6月以主訴“右下后牙牙齦腫包20天”于外院對癥處理后就診于北京大學口腔醫(yī)院牙周科，患者6年前曾于本院行患牙冠修復，數(shù)年前行牙周潔治，未定期復查。患者全身健康，無過敏史，否認吸煙，刷牙2次/d，橫、豎結(jié)合。

1.2 口腔檢查

患者46烤瓷冠修復，頰側(cè)牙齦近根方可見一瘺管，紅腫、溢膿，與牙周袋相通，牙周袋探診深度(probing depth，PD)于頰側(cè)中央達10 mm，舌側(cè)中央7 mm，余位點3～5 mm；松動Ⅱ度。X線片顯示：根管內(nèi)高密度充填影，欠填，根分叉處大面積低密度影，根尖區(qū)有小范圍低密度影；47存在冠緣懸突，48近中水平阻生(圖1)。

患者口腔衛(wèi)生狀況差，牙石++，色素沉著，前牙PD 2～3 mm、出血指數(shù)(bleeding index，BI)1～2；后牙PD散在3～5 mm、BI 3～4, 附著喪失可及。17、26、36、47冠修復，27缺失。

1.3 診斷

患者診斷為：46牙周-牙髓聯(lián)合病變，慢性牙周炎，上頜牙列缺損，48水平阻生，47不良修復體。

2 病情分析及治療計劃

針對口腔衛(wèi)生狀況差，去除病因，控制炎癥，恢復全牙列牙周健康。46局部對癥處理控制炎癥后，微創(chuàng)拔牙同期進行位點保存，保留并創(chuàng)造良好的骨組織三維形態(tài)，擬擇期種植修復。為確保微創(chuàng)拔牙位點保存區(qū)域嚴密縫合導致的前庭溝變淺，必要時進行前庭溝加深和角化齦增寬。擇期拔除48。

3 治療過程及結(jié)果

3.1 46微創(chuàng)拔牙同期進行位點保存術

46局部沖洗上藥，全口牙周基礎治療恢復牙周健康，創(chuàng)造手術條件。46微創(chuàng)拔牙同期進行位點保存術(圖2)。

46采取溝內(nèi)切口，離斷嵴頂纖維，渦輪裂鉆分根，微創(chuàng)拔除46，于47近中及45遠中軸角處附加縱切口，翻開粘骨膜瓣，徹底清除肉芽組織，暴露新鮮骨面，見46頰側(cè)骨板薄，中央及近中呈“V”形缺損，于拔牙窩內(nèi)植入Bio-Oss(Geistlich, Wolhusen, Switzerland, 0.5 g, 0.25～1 mm)，使植骨材料與近、遠中骨嵴頂高度和寬度平齊，表面覆蓋修剪好的Bio-Gide膜(Geistlich, Wolhusen, Switzerland, 25 mm×25 mm)，頰側(cè)采取骨膜減張切口松弛齦瓣，頰側(cè)齦瓣冠向復位后嚴密縫合，完全關閉創(chuàng)口。

術后即刻口服布洛芬緩釋膠囊(0.3 g)和阿莫西林膠囊(0.5 g)，術后7天口服阿莫西林膠囊(0.5 g，每日3次)，0.12%(體積分數(shù))醋酸氯己定溶液含漱(10 mL，每日2次，4周)。術后即刻進行平行投照根尖片和錐形束CT(cone-beam computer tomography, CBCT)檢查(圖3)。

3.2 46種植治療

46微創(chuàng)拔牙和位點保存6個月后進行種植修復。拍攝平行投照根尖片及CBCT，了解骨形成情況。影像學顯示術后6個月拔牙窩內(nèi)植骨材料保持一定的量，部分失去原有顆粒狀形態(tài)，但仍可分辨出與周圍自體骨的分界(圖4)。

A, buccal view; B, peri-apical film.

圖1 46去冠后術前及根尖片

Figure1 The pre-treatment information of tooth 46 following removal of the crown

A, buccal view after minimally invasive tooth extraction; B, occlusal view after minimally invasive tooth extraction; C, post-extraction alveolus filled with Bio-Oss particle; D, graft covered with a collagen membrane; E, occlusal view after suture; F, buccal view after suture.

圖2 46微創(chuàng)拔牙及位點保存術

Figure2 The ridge-perseveration procedure with Bio-Oss and Bio-Gide

3A, parallel periapical X-ray image at baseline; 3B and 3C, sagittal section of cone-beam computed tomography at baseline; 4A, parallel periapical X-ray image at 6 months; 4B and 4C, sagittal section of cone-beam computed tomography at 6 months.

圖3 46術后即刻平行投照根尖片及錐形束CT矢狀截面 圖4 46術后6個月平行投照根尖片及錐形束CT矢狀截面

Figure3 Parallel periapical X-ray image and representative cone-beam computed tomography of ridge-perseveration procedure with Bio-Oss and Bio-Gide at baseline Figure 4 Parallel periapical X-ray image and representative cone-beam computed tomography of ridge-perseveration procedure with Bio-Oss and Bio-Gide at 6 months

種植術前根據(jù)研究模型和CBCT結(jié)果進行分析。由修復科醫(yī)生制作手術導板，選擇Straumann軟組織水平種植體系統(tǒng)(Straumann, 瑞士)4.8 mm×10.0 mm 寬頸(wide neck, WN)種植體。46嵴頂位置從45遠中向47近中縱切口，翻開粘骨膜瓣，測得牙槽嵴頂中央處頰舌向?qū)挾葹?.5 mm，通過導板定位，專用鉆序列預備植入床，并收集自體骨屑備用。植體植入后，頰側(cè)遠中位于骨嵴頂冠方0.5～1.0 mm，余位置與骨嵴頂平齊。安裝愈合基臺WN 3 mm，將自體骨屑置于頰側(cè)遠中覆蓋植體暴露區(qū)，復位齦瓣后對位縫合，即刻測量植體初期穩(wěn)定性，測得種植體穩(wěn)定性系數(shù)(implant stability quotient, ISQ)為49。術后X線片顯示植體位置準確，近、遠中骨高度密度良好，植體根方約2 mm位于自體骨內(nèi)(圖5)。

3.3 46角化齦增寬和前庭溝加深術

術后6個月復查，患者口腔衛(wèi)生情況一般，菌斑軟垢中等，植體穩(wěn)定，近、遠中骨高度良好，與前后鄰牙相應牙槽骨協(xié)調(diào)，46角化齦缺如，前庭溝稍淺，45、47角化齦3～3.5 mm。

自47近中軸角垂直切口，冠方沿齦乳頭頰側(cè)膜齦聯(lián)合處延伸至45遠中軸角，與47同理行垂直切口。分別在切口起止處做縱切口，小心分離半厚瓣，翻瓣形成冠根向達8 mm的梯形受植區(qū)，受植區(qū)冠方寬約12 mm，根方寬約18 mm，將牙槽黏膜與骨膜縫合達到根向復位固定，使前庭溝加深。

自24～27距齦緣3 mm處按受植區(qū)大小取帶少量結(jié)締組織的游離齦瓣，修整后置于46頰側(cè)受植區(qū)與受植區(qū)冠方及近、遠中角化齦邊緣對位嚴密縫合，游離齦瓣根方與骨膜縫合固定。游離齦瓣近中、中央、遠中3處自其根方骨膜分別圍繞45、46、47牙冠或植體十字縫合，交叉固定齦瓣，充分貼合受植床，避免血腫，供瓣區(qū)佩戴牙合墊壓迫止血(圖6)。

3.4 46種植修復

角化齦增寬術后5周，由修復科醫(yī)生完成最終修復(圖7)。

3.5 46種植修復后6個月復查

患者全口口腔衛(wèi)生情況良好，患者自訴咀嚼良好。46植體穩(wěn)定，平行投照X線片顯示近、遠中骨高度良好(圖8)，頰側(cè)角化齦寬度7 mm，術后效果保持穩(wěn)定。

4 分析與討論

良好的牙槽嵴和牙齦解剖形態(tài)的保存或重建是修復體獲得滿意的美學效果和長期成功的先決條件。牙齒拔除后，在拔牙窩愈合過程中所發(fā)生的或在拔牙之前已經(jīng)存在的不同程度的牙槽骨吸收會造成種植治療時骨量不足，從而影響未來種植體植入修復的位置、角度及植體的預后和軟、硬組織的美觀[3]。因此，在拔牙同期進行拔牙窩內(nèi)生物材料移植，實現(xiàn)軟、硬組織的保存或增量，是近年來拔牙位點保存技術研究和實踐的主要目的。通過微創(chuàng)拔牙位點保存技術，創(chuàng)造種植治療長期穩(wěn)定和發(fā)揮功能的基礎條件，從而減少或避免復雜的植骨手術、減小創(chuàng)傷、縮短療程，已逐步成為共識[4]。

與位點保存的大部分研究所關注的美學區(qū)單根牙位點不同，磨牙因解剖形態(tài)復雜，牙周病變不易控制且發(fā)展迅速，導致牙槽骨嚴重吸收，在種植治療時因骨量不足通常需采用復雜的骨增量技術增加骨量。本課題組既往針對存在骨缺損的磨牙進行拔牙位點保存的臨床效果分析表明，已經(jīng)存在骨缺損的磨牙應用去蛋白牛骨基質(zhì)(Bio-Oss)與可吸收膠原膜(Bio-Gide)進行拔牙位點保存，可明顯增加頰側(cè)牙槽骨高度和牙槽嵴頂根方1 mm和4 mm處牙槽骨寬度[5]。本研究的此例患者完整展示了下頜磨牙微創(chuàng)拔除，結(jié)合同期使用Bio-Oss和Bio-Gide進行即刻移植并重建缺損牙槽嵴，6個月后牙槽嵴擁有足夠的骨寬度(9.5 mm)及高度(距離下齒槽神經(jīng)管超過13 mm)，創(chuàng)造了種植體植入良好的骨組織條件，避免了術中額外植骨，降低了種植手術的復雜性和不可預期性，正是遵循了上述思路。

磨牙拔除后位點保存的難點在于，因其創(chuàng)口近、遠中徑和頰舌徑較單根牙和前磨牙大，術后若創(chuàng)口開放，會造成植骨材料部分流失，因此，創(chuàng)口應達到嚴密關閉 Ⅰ 期愈合以保留植骨材料，本例為達到拔牙位點保存術后的軟組織 Ⅰ 期愈合，采取松弛頰側(cè)齦瓣，將齦瓣冠向復位后嚴密縫合，較好地保護了植骨材料，使得位點保存后的牙槽嵴的高度和寬度良好，解決了上述問題。需要指出的是，齦瓣冠向復位后嚴密縫合的同時也導致頰側(cè)膜齦聯(lián)合位置冠向移位，術后前庭溝變淺，角化齦缺如，這對未來種植體的長期健康和穩(wěn)定可能存在潛在影響。角化齦對于維持牙周健康的重要性已經(jīng)討論了20余年[6-7]，以往研究表明至少要有2 mm角化齦才能阻止牙周病的進展，而對于種植體周圍角化齦寬度是否關系到植體的長期健康和穩(wěn)定尚不確定，有研究指出，角化齦窄的區(qū)域更易探診出血，牙槽骨易吸收[8]；另有研究表明，缺乏足夠角化齦的植體，其菌斑指數(shù)、黏膜炎癥、探診出血及相應齦退縮增加，種植體周圍炎發(fā)生率高[9]。

5A, occlusal view before implant surgery; 5B, occlusal view after flap elevation; 5C, suturing completed; 5D, parallel periapical X-ray image of implant surgery at baseline; 6A and 6B, measurement of free gingival graft; 6C, prepare the partial thickness flap; 6D, apically displace alveolar mucosa to deepen vestibular sulcus; 6E, trapezoid recipient site; 6F, palatal donor site; 6G, free gingival graft from the palate; 6H, suturing completed.

圖5 46種植治療過程 圖6 46游離齦移植術

Figure5 The procedure of the first-stage surgery and the apical film of the implant Figure 6 Free gingival graft of tooth 46

A, favorable esthetic and healthy results of both the buccal keratinized gingiva and gingival contour; B, note the vestibular sulcus obviously deepened from occlusal view.

圖7 46種植修復

Figure7 Implant final restoration of tooth 46

有相關研究證實，保留至少2 mm角化齦對于菌斑控制、保持植體周圍組織健康至關重要[10-12]。本研究因此針對此例患者植體頰側(cè)角化齦缺如的情況，按照游離齦移植術的基本原理，采用半厚瓣翻瓣、牙槽黏膜根向復位，創(chuàng)造良好的受植區(qū)條件，同時從上腭部取帶少量結(jié)締組織的游離齦片移植于受植區(qū)，達到了增寬角化齦、加深前庭溝的效果。經(jīng)過半年多的隨訪復查，患牙咀嚼功能良好、健康維護便利，患者十分滿意。

A, buccal occlusion; B, buccal view; C, lingual view; D, occlusal view; E, the peri-apical film, note the mesial bone and distal bone height is stable; F, the periodontal chart at 6 months after restoration.

圖8 46修復后6個月

Figure8 Favorable esthetic and healthy results at 6 months recall after final restoration

綜上所述，涉及嚴重牙周破壞的磨牙拔除后牙槽嵴軟、硬組織的保留是臨床的難點，也是對種植治療的挑戰(zhàn)。本研究圍繞牙周-牙髓聯(lián)合病變導致的病變磨牙牙周支持組織破壞的臨床處置設計，展示了微創(chuàng)拔牙、位點保存、種植外科、軟組織增量和前庭溝加深、種植修復的全過程，并觀察半年以上，取得了最終的良好療效，為此類患牙的臨床處置積累了經(jīng)驗。

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(2015-10-12收稿)

(本文編輯：任英慧)

SUMMARY For ideal implant rehabilitation, an adequate bone volume, optical implant position, and stable and healthy soft tissue are required. The reduction of alveolar bone and changes in its morphology subsequent to tooth extraction will result in insufficient amount of bone and adversely affect the ability to optimally place dental implants in edentulous sites. Preservation of alveolar bone volume through ridge preservation has been demonstrated to reduce the vertical and horizontal contraction of the alveolar bone crest after tooth extraction and reduce the need for additional bone augmentation procedures during implant placement. In this case, a patient presented with a mandible molar of severe periodontal disease, the tooth was removed as atraumatically as possible and the graft material of Bio-Oss was loosely placed in the alveolar socket without condensation and covered with Bio-Gide to reconstruct the defects of the alveolar ridge. Six months later, there were sufficient height and width of the alveolar ridge for the dental implant, avoiding the need of additional bone augmentation and reducing the complexity and unpredictability of the implant surgery. Soft tissue defects, such as gingival and connective tissue, played crucial roles in long-term implant success. Peri-implant plastic surgery facilitated development of healthy peri-implant structure able to withstand occlusal forces and muco-gingival stress. Six months after the implant surgery, the keratinized gingiva was absent in the buccal of the implant and the vestibular groove was a little shallow. The free gingival graft technique was used to solve the vestibulum oris groove supersulcus and the absence of keratinized gingiva around the implant. The deepening of vestibular groove and broadening of keratinized gingiva were conducive to the long-term health and stability of the tissue surrounding the implant. Implant installation and prosthetic restoration showed favorable outcome after six months.

Dental implantation and soft tissue augmentation after ridge preservation in a molar site: a case report

ZHAO Li-ping1, ZHAN Ya-lin1, HU Wen-jie1△, WANG Hao-jie1, WEI Yi-ping1, ZHEN Min1, Xu Tao1, LIU Yun-song2

(1. Department of Periodontology, 2. Department of Prosthodontics, Peking University School and Hospital of Stomatology & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China)

Surgical procedures, minimally invasive; Tooth extraction; Dental implantation; Dental prosthesis; Soft tissue augmentation

首都醫(yī)學發(fā)展科研專項基金(2011-4025-04)和教育部留學回國人員科研啟動基金(2012-45)資助 Supported by the Capital Foundation for Medical Research and Development (2011-4025-04) and the Scientific Research Staring Foundation for the Returned Overseas Chinese Scholars, Ministry of Education of China (2012-45)

時間：2016-1-6 10：19：59

http://www.cnki.net/kcms/detail/11.4691.R.20160106.1019.012.html

R782.1

A

1671-167X(2016)06-1090-05

10.3969/j.issn.1671-167X.2016.06.030

△ Corresponding author’s e-mail, huwenjie@pkuss.bjmu.edu.cn