磨牙位点保存后进行种植修复及软组织增量的1例报告

赵丽萍， 詹雅琳， 胡文杰△， 王浩杰， 危伊萍， 甄 敏， 徐 涛， 刘云松

(北京大学口腔医学院·口腔医院， 1. 牙周科， 2. 修复科，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， 北京 100081)



·病例报告·

磨牙位点保存后进行种植修复及软组织增量的1例报告

赵丽萍1， 詹雅琳1， 胡文杰1△， 王浩杰1， 危伊萍1， 甄 敏1， 徐 涛1， 刘云松2

(北京大学口腔医学院·口腔医院， 1. 牙周科， 2. 修复科，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， 北京 100081)

外科手术，微创性；拔牙；牙种植；牙修复体；软组织增量

临床上，常规拔牙后牙槽骨的自然愈合存在不同程度的牙槽骨吸收[1]，影响未来的种植体植入修复位置，角度及软、硬组织处理。研究表明，采取微创拔牙和位点保存技术可以减少牙槽骨吸收，显著保留牙槽嵴宽度及高度[2-3]，减少或避免种植治疗同期实施复杂的植骨手术。另有文献指出，种植体周围至少需要2 mm的角化龈及1 mm的附着龈，方能维护种植体周围组织健康，获得长期稳定疗效。本研究完整展示了1例针对牙周-牙髓联合病变磨牙的病情分析，采取微创拔牙结合位点保存和游离龈移植术创造良好软、硬组织条件，获得最终较好种植修复效果的具体实施步骤，积累了针对此类问题的临床经验。

1 病史及临床检查

1.1 病史

患者，女，57岁，2013年6月以主诉“右下后牙牙龈肿包20天”于外院对症处理后就诊于北京大学口腔医院牙周科，患者6年前曾于本院行患牙冠修复，数年前行牙周洁治，未定期复查。患者全身健康，无过敏史，否认吸烟，刷牙2次/d，横、竖结合。

1.2 口腔检查

患者46烤瓷冠修复，颊侧牙龈近根方可见一瘘管，红肿、溢脓，与牙周袋相通，牙周袋探诊深度(probing depth，PD)于颊侧中央达10 mm，舌侧中央7 mm，余位点3～5 mm；松动Ⅱ度。X线片显示：根管内高密度充填影，欠填，根分叉处大面积低密度影，根尖区有小范围低密度影；47存在冠缘悬突，48近中水平阻生(图1)。

患者口腔卫生状况差，牙石++，色素沉着，前牙PD 2～3 mm、出血指数(bleeding index，BI)1～2；后牙PD散在3～5 mm、BI 3～4, 附着丧失可及。17、26、36、47冠修复，27缺失。

1.3 诊断

患者诊断为：46牙周-牙髓联合病变，慢性牙周炎，上颌牙列缺损，48水平阻生，47不良修复体。

2 病情分析及治疗计划

针对口腔卫生状况差，去除病因，控制炎症，恢复全牙列牙周健康。46局部对症处理控制炎症后，微创拔牙同期进行位点保存，保留并创造良好的骨组织三维形态，拟择期种植修复。为确保微创拔牙位点保存区域严密缝合导致的前庭沟变浅，必要时进行前庭沟加深和角化龈增宽。择期拔除48。

3 治疗过程及结果

3.1 46微创拔牙同期进行位点保存术

46局部冲洗上药，全口牙周基础治疗恢复牙周健康，创造手术条件。46微创拔牙同期进行位点保存术(图2)。

46采取沟内切口，离断嵴顶纤维，涡轮裂钻分根，微创拔除46，于47近中及45远中轴角处附加纵切口，翻开粘骨膜瓣，彻底清除肉芽组织，暴露新鲜骨面，见46颊侧骨板薄，中央及近中呈“V”形缺损，于拔牙窝内植入Bio-Oss(Geistlich, Wolhusen, Switzerland, 0.5 g, 0.25～1 mm)，使植骨材料与近、远中骨嵴顶高度和宽度平齐，表面覆盖修剪好的Bio-Gide膜(Geistlich, Wolhusen, Switzerland, 25 mm×25 mm)，颊侧采取骨膜减张切口松弛龈瓣，颊侧龈瓣冠向复位后严密缝合，完全关闭创口。

术后即刻口服布洛芬缓释胶囊(0.3 g)和阿莫西林胶囊(0.5 g)，术后7天口服阿莫西林胶囊(0.5 g，每日3次)，0.12%(体积分数)醋酸氯己定溶液含漱(10 mL，每日2次，4周)。术后即刻进行平行投照根尖片和锥形束CT(cone-beam computer tomography, CBCT)检查(图3)。

3.2 46种植治疗

46微创拔牙和位点保存6个月后进行种植修复。拍摄平行投照根尖片及CBCT，了解骨形成情况。影像学显示术后6个月拔牙窝内植骨材料保持一定的量，部分失去原有颗粒状形态，但仍可分辨出与周围自体骨的分界(图4)。

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

图1 46去冠后术前及根尖片

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.

图2 46微创拔牙及位点保存术

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.

图3 46术后即刻平行投照根尖片及锥形束CT矢状截面 图4 46术后6个月平行投照根尖片及锥形束CT矢状截面

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

种植术前根据研究模型和CBCT结果进行分析。由修复科医生制作手术导板，选择Straumann软组织水平种植体系统(Straumann, 瑞士)4.8 mm×10.0 mm 宽颈(wide neck, WN)种植体。46嵴顶位置从45远中向47近中纵切口，翻开粘骨膜瓣，测得牙槽嵴顶中央处颊舌向宽度为9.5 mm，通过导板定位，专用钻序列预备植入床，并收集自体骨屑备用。植体植入后，颊侧远中位于骨嵴顶冠方0.5～1.0 mm，余位置与骨嵴顶平齐。安装愈合基台WN 3 mm，将自体骨屑置于颊侧远中覆盖植体暴露区，复位龈瓣后对位缝合，即刻测量植体初期稳定性，测得种植体稳定性系数(implant stability quotient, ISQ)为49。术后X线片显示植体位置准确，近、远中骨高度密度良好，植体根方约2 mm位于自体骨内(图5)。

3.3 46角化龈增宽和前庭沟加深术

术后6个月复查，患者口腔卫生情况一般，菌斑软垢中等，植体稳定，近、远中骨高度良好，与前后邻牙相应牙槽骨协调，46角化龈缺如，前庭沟稍浅，45、47角化龈3～3.5 mm。

自47近中轴角垂直切口，冠方沿龈乳头颊侧膜龈联合处延伸至45远中轴角，与47同理行垂直切口。分别在切口起止处做纵切口，小心分离半厚瓣，翻瓣形成冠根向达8 mm的梯形受植区，受植区冠方宽约12 mm，根方宽约18 mm，将牙槽黏膜与骨膜缝合达到根向复位固定，使前庭沟加深。

自24～27距龈缘3 mm处按受植区大小取带少量结缔组织的游离龈瓣，修整后置于46颊侧受植区与受植区冠方及近、远中角化龈边缘对位严密缝合，游离龈瓣根方与骨膜缝合固定。游离龈瓣近中、中央、远中3处自其根方骨膜分别围绕45、46、47牙冠或植体十字缝合，交叉固定龈瓣，充分贴合受植床，避免血肿，供瓣区佩戴牙合垫压迫止血(图6)。

3.4 46种植修复

角化龈增宽术后5周，由修复科医生完成最终修复(图7)。

3.5 46种植修复后6个月复查

患者全口口腔卫生情况良好，患者自诉咀嚼良好。46植体稳定，平行投照X线片显示近、远中骨高度良好(图8)，颊侧角化龈宽度7 mm，术后效果保持稳定。

4 分析与讨论

良好的牙槽嵴和牙龈解剖形态的保存或重建是修复体获得满意的美学效果和长期成功的先决条件。牙齿拔除后，在拔牙窝愈合过程中所发生的或在拔牙之前已经存在的不同程度的牙槽骨吸收会造成种植治疗时骨量不足，从而影响未来种植体植入修复的位置、角度及植体的预后和软、硬组织的美观[3]。因此，在拔牙同期进行拔牙窝内生物材料移植，实现软、硬组织的保存或增量，是近年来拔牙位点保存技术研究和实践的主要目的。通过微创拔牙位点保存技术，创造种植治疗长期稳定和发挥功能的基础条件，从而减少或避免复杂的植骨手术、减小创伤、缩短疗程，已逐步成为共识[4]。

与位点保存的大部分研究所关注的美学区单根牙位点不同，磨牙因解剖形态复杂，牙周病变不易控制且发展迅速，导致牙槽骨严重吸收，在种植治疗时因骨量不足通常需采用复杂的骨增量技术增加骨量。本课题组既往针对存在骨缺损的磨牙进行拔牙位点保存的临床效果分析表明，已经存在骨缺损的磨牙应用去蛋白牛骨基质(Bio-Oss)与可吸收胶原膜(Bio-Gide)进行拔牙位点保存，可明显增加颊侧牙槽骨高度和牙槽嵴顶根方1 mm和4 mm处牙槽骨宽度[5]。本研究的此例患者完整展示了下颌磨牙微创拔除，结合同期使用Bio-Oss和Bio-Gide进行即刻移植并重建缺损牙槽嵴，6个月后牙槽嵴拥有足够的骨宽度(9.5 mm)及高度(距离下齿槽神经管超过13 mm)，创造了种植体植入良好的骨组织条件，避免了术中额外植骨，降低了种植手术的复杂性和不可预期性，正是遵循了上述思路。

磨牙拔除后位点保存的难点在于，因其创口近、远中径和颊舌径较单根牙和前磨牙大，术后若创口开放，会造成植骨材料部分流失，因此，创口应达到严密关闭 Ⅰ 期愈合以保留植骨材料，本例为达到拔牙位点保存术后的软组织 Ⅰ 期愈合，采取松弛颊侧龈瓣，将龈瓣冠向复位后严密缝合，较好地保护了植骨材料，使得位点保存后的牙槽嵴的高度和宽度良好，解决了上述问题。需要指出的是，龈瓣冠向复位后严密缝合的同时也导致颊侧膜龈联合位置冠向移位，术后前庭沟变浅，角化龈缺如，这对未来种植体的长期健康和稳定可能存在潜在影响。角化龈对于维持牙周健康的重要性已经讨论了20余年[6-7]，以往研究表明至少要有2 mm角化龈才能阻止牙周病的进展，而对于种植体周围角化龈宽度是否关系到植体的长期健康和稳定尚不确定，有研究指出，角化龈窄的区域更易探诊出血，牙槽骨易吸收[8]；另有研究表明，缺乏足够角化龈的植体，其菌斑指数、黏膜炎症、探诊出血及相应龈退缩增加，种植体周围炎发生率高[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.

图5 46种植治疗过程 图6 46游离龈移植术

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.

图7 46种植修复

Figure7 Implant final restoration of tooth 46

有相关研究证实，保留至少2 mm角化龈对于菌斑控制、保持植体周围组织健康至关重要[10-12]。本研究因此针对此例患者植体颊侧角化龈缺如的情况，按照游离龈移植术的基本原理，采用半厚瓣翻瓣、牙槽黏膜根向复位，创造良好的受植区条件，同时从上腭部取带少量结缔组织的游离龈片移植于受植区，达到了增宽角化龈、加深前庭沟的效果。经过半年多的随访复查，患牙咀嚼功能良好、健康维护便利，患者十分满意。

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.

图8 46修复后6个月

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

综上所述，涉及严重牙周破坏的磨牙拔除后牙槽嵴软、硬组织的保留是临床的难点，也是对种植治疗的挑战。本研究围绕牙周-牙髓联合病变导致的病变磨牙牙周支持组织破坏的临床处置设计，展示了微创拔牙、位点保存、种植外科、软组织增量和前庭沟加深、种植修复的全过程，并观察半年以上，取得了最终的良好疗效，为此类患牙的临床处置积累了经验。

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(2015-10-12收稿)

(本文编辑：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

首都医学发展科研专项基金(2011-4025-04)和教育部留学回国人员科研启动基金(2012-45)资助 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)

时间：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