牙周病手术治疗 - Shandong University
Transcript of 牙周病手术治疗 - Shandong University
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宋爱梅
2015-12-22
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掌握
牙周手术治疗的目的及基本原则
各类手术的适应证、手术方法的选择及手术后的愈合方式
牙龈切除术、翻瓣术的基本原则和引导性牙周组织再生(GTR)的生物学原理和操作原理;
熟悉 牙周翻瓣术和龈切术的操作要点;
了解 根分叉病变的手术治疗方式、各种膜龈手术以及牙周组织再 生性治疗的进展。
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牙周基础性手术
龈切术和翻瓣术
切除性骨手术(resective osseous surgery)
牙周再生性手术(periodontal regenerative surgery)
引导性组织再生术(Guided tissue regeneration)
植骨术(bone graft procedures)
根面处理技术(root conditioning)
釉基质蛋白(enamel matrix derivative)
多肽生长因子(growth factors)
牙周成形手术(periodontal plastic surgery)
牙冠延长术(crown lengthening surgery)
膜龈手术(Mucogingival surgery)
各类手术的适应证!!!
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切除性骨手术Resective osseous surgery
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牙槽骨的正常形态
1 牙间骨隔较高,而颊舌侧骨嵴较低,呈波浪形。
2 牙间骨形状和牙齿形状、外展隙宽度相适应。
牙齿锥度愈大,骨形态愈呈锥形;外展隙愈宽,
近远中向和颊舌向的骨愈平坦。
3 骨缘形态模拟釉牙骨质界的轮廓
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骨破坏类型:
水平型吸收: horizontal resorption
垂直型吸收: vertical resorption
凹坑状吸收: osseous crater
其 他 类 型: 外生骨疣、扶壁骨、
适应性修复
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用手术方法修整病变牙槽骨,使之恢复正常的形态和生理功能
良好的牙龈外形,利于菌斑控制
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骨成形术(osteoplasty)
在术中去除无支持作用的骨,修整骨形态
骨切除术(osteoectomy)在术中去除部分因病变而改形的、对牙齿仍有支持作用的牙槽骨,为使骨外形恢复至正常形态,骨嵴高度稍有降低
通常联合应用
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浅的一壁骨袋、宽而浅的二壁骨袋,难以有新骨修复者
邻面凹坑状吸收,骨再生可能性较小者
牙槽骨嵴圆钝肥厚或呈骨隆突状
在倾斜牙倾斜侧窄而深的骨下袋
根分叉病变区的根间骨缘,失去根间纵沟外形者
“反波浪形”牙槽骨边缘
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骨修整步骤纵向切沟:减少厚度,提供牙根的相应突度;
根面的过渡部分:是第一步的延伸,可提供光滑的、浑然一体的表面,
利于瓣的复位;
平整邻面骨:颊舌向 10-150倾斜,可防止牙龈增生。否则,
呈桥梁状,导致袋的复发。
修整骨的边缘:去除最少量的骨
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骨切除术的优点• 获得边缘骨的生理结构,使龈瓣更好地附着其
上,而且探诊深度最小。有利于改善口腔卫生
以及维护治疗
• 和非手术治疗相比,能有效去除致病
菌,牙周袋的复发减少
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牺牲骨质,骨高度降低
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引导性组织再生术(Guided tissue regeneration)
植骨术(bone graft procedures)
根面处理技术(root conditioning)
釉基质蛋白(Enamel matrix proteins)
多肽生长因子(growth factors)
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GTR的理论基础
Murphy KG 1976年提出牙周再生潜能理论 ,即只有具备产生牙骨质、牙周膜、牙槽骨的牙周韧带细胞首先附着于根面,才有可能 实现牙周组织的再生,即新附着的形成。
长上皮附着
根面吸收
根骨粘连
新附着
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新附着 再附着 New attachment:
是通过牙周组织,主要是牙周膜中的前体细胞分化和再生,在原来暴露于牙周袋内的牙根面上,重新有牙骨质形成,其中埋入新形成的牙周膜纤维,其另一端与新生的牙槽骨相连,结合上皮附着的位置也比手术前更向冠方,由此形成新的有功能的牙周支持组织。
Re-attachment:
指原来正常的牙周附着结构被急性破坏后,在短期内由原来的胶原纤维重新与没有病变的牙骨质及牙槽骨连接。例如翻瓣术中将患牙邻近的牙周组织剥离后的重新愈合。
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原理采用生物相容性膜隔离牙龈瓣
根面和膜之间的空隙
保护血凝块
Definition: 采用生物相容性的屏障膜,阻止龈瓣上的牙龈上皮及牙龈结缔组织与根面接触,引导牙周膜内的细胞向冠方增殖并占据根面,分化出成牙骨质细胞、成骨细胞和成纤维细胞,形成新的牙骨质、牙槽骨,并有新的牙周膜纤维埋入其中,从而形成牙周新
附着,这种手术方法称为引导性牙周组织再生术(简称GTR)
Guided tissue regeneration: GTR
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Nyman: 1982年第一次在人体应用GTR
Lindhe:
Karring:
Gottlow:
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生物相容性膜材料的发展醋酸纤维素 (Millipore): Nyman,1982
不可吸收性膜: e-PTFE(Gore-Tex)
可吸收性膜:胶原膜(Blumenthal,1988)
聚乳酸膜,乳酸-乙酸共聚膜
(Magnusson,1988)
脱细胞真皮基质:猪、牛、人来源,正海生物膜、Bio-collagen,Alloderm等
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骨下袋:三壁和窄而深的二壁骨下袋
Ⅱ度根分叉病变
Miller I类牙龈退缩
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口腔卫生不良者
吸烟者的愈合效果较差
口腔内其余牙的牙周组织未经治疗和控制
牙槽骨水平吸收或浅的二、三壁骨下袋
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瓣的设计
切口为在龈缘处的内斜切口,尽量保存颊、舌和牙间组织;
翻起全厚瓣,根方应超过膜龈联合,并充分暴露骨缺损及邻近2~3mm的骨质;
瓣复位缝合时,应将放臵的膜完全覆盖,在牙间处颊舌侧瓣应完全闭合,必要时做冠向复位。
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选择适合于覆盖骨缺损形状的膜,可适当修剪。
放置时应将缺损全部覆盖,并超过缺损边缘至少2~3mm;
膜与缺损处的根面之间保持间隙;
与缺损周围的骨质紧密贴合,避免膜的重叠。
不可吸收性膜需在术后2—4周取出
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A 患者因素:自我菌斑控制水平,吸烟,牙列中的感染牙位水平;
B 骨缺损因素:缺损的形态,根分叉病变的部位及程度;
C 与手术技术及愈合期有关的因素:膜的设计,膜的放臵,膜与根面间隙的保持,伤口的关闭,术后菌斑的控制,术后龈退缩,术后膜的暴露,可吸收膜的过早降解等因素。
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comparison of GTR and access flap(AP)
in deep intrabony defects (1990-2001)
N CAL PPD
GTR AP GTR AP
584 3.3±1.8 2.1±1.5 3.5±1.1 4.1±1.3
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牙周植骨术
采用骨或骨代用品等移植材料来修复
牙槽骨缺损,目的是恢复骨 的解剖
形态,促进软硬组织的生物性结合,
形成新附着,达到完全意义上的再生。
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二壁骨下袋
三壁骨袋效果最好
II度根分叉病变
牙龈瓣能覆盖骨面及根分叉区
缺损形态要求
软组织要求
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1 自体骨:髂骨、口腔部位取骨----osteogenic potential
2 异体骨:新鲜冷冻骨、骨髓、冻干骨、脱矿冻干骨(DFDBA,1996, Ouhayoun)----osteo-inductive potential
3 异种骨:Bio-oss
4 骨替代品:HA、TCP、PerioGlas(硅、钙、钠,磷)
Osteo-conductive potential
植骨材料的种类
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支架作用
骨诱导或骨引导作用
移植材料主要是作为生物性填充物,它们吸收缓慢,干扰正常骨愈合,并且伴随结合上皮向根方移位和结缔组织包绕。
只有自体移植物和去钙冻干骨被证明具有达到牙周再生的潜能。
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麻醉消毒
手术切口----保证完全覆盖受骨区
翻瓣、清创、根面平整(根面处理)
供骨区取骨或填入植骨材料
软组织瓣复位(冠向复位),严密覆盖植骨区
缝合---水平或垂直褥式
牙周塞治
术后护理---保证龈瓣稳定,预防感染
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Bone graft procedure
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outcome
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引导性组织再生术(Guided tissue
regeration)
植骨术(bone graft procedures)
根面处理技术(root conditioning)
釉基质蛋白(Enamel matrix proteins)
多肽生长因子(growth factors)
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根面处理剂
枸橼酸
四环素
EDTA
纤维连接蛋白(fibronectin)
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引导性组织再生术(Guided tissue
regeration)
植骨术(bone graft procedures)
根面处理技术(root conditioning)
釉基质蛋白(Enamel matrix proteins)
多肽生长因子(growth factors)
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当前,在临床应用中,唯一可行的实现牙周再生的生物学方法就是使用釉基质蛋白(EMD or
EMPs)。已经被证明能促进新生牙骨质,牙周韧带和牙槽骨的形成。
促进新附着形成的机理:研究热点
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多肽生长分化因子:PDGF\TGF\bFGF\BMP\等
转录因子:CBFa1,OSTERIX
应用方式:与生物材料复合;基因疗法
INFUSE®
a biodegradable collagen sponge scaffold
coated with bone morphogenetic protein-2
(BMP-2),was approved for clinical treatment
of bone defects by FDA.
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自体血液
多种生长因子: PDGF, TGF,VEGF等
CD34 + 干细胞
多种形状
操作简便
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再生方法的联合应用
GTR+植骨材料+根面处理=牙周组织再生
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Good results
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骨再生的评价方法
临床:手术前后的对照(袋深、附着水平CAL)
放射学:不可靠
手术:两个缺点---需两次手术;不能反映附着类型
组织学:能确定附着的类型,但临床不现实,可应
用于动物
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牙冠延长术
膜龈手术
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临床牙冠过短,影响美观。
因龋齿,牙齿折断等因素致牙齿断缘位于龈下,影响修复。
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通过手术的方法,降低龈缘位臵,暴露健康
的牙齿结构,使临床牙冠延长,从而利于牙齿的修复或解决美观问题
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特别考虑---biological width
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确定术后龈缘的位臵,决定了切口的设计
前牙:遵循牙龈的生理外形
后牙:暴露断缘,可利用牙体结构为准
切口:若有足够的角化龈宽度,可采用龈切术方法或翻瓣术;若牙龈宽度不足,则采用根向复位瓣术
骨嵴高度位臵:在牙断端下方4~5mm处,至少3mmm;或在CEJ下方2mm,以满足美观要求,符合生物学宽度。
遵循骨修整术原则进行骨切除,术后要彻底根面平整,去除根面上的牙周膜纤维。
修剪龈瓣,原位或根向复位,使龈瓣复位至所希望的位臵,缝合。
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牙根过短,冠根比失调。
不良的骨性结构、骨壁厚薄,剩余骨高度不足者。
全身情况不允许者
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Baby teeth ,
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根长度与牙槽骨高度比例,考虑修复后的冠根比。
若牙断端多数位点位于龈下很深(>4~5mm):牵引术.
修复时机:术后4~6周,前牙最好1-2周临时冠,2月后永久修复。
定期维护:保持高水平的菌斑控制,起决定作用.
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多种牙周软组织手术的总称,涉及附着龈、牙槽粘膜、系带及前庭沟区
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增加附着龈宽度
预防/停止龈退缩
有利于控制菌斑
改善牙根过敏症状
美容
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游离龈瓣移植术(free gingival graft)
侧向转位瓣术(laterally positioned flap)
上皮下结缔组织瓣移植术(subgingival
connective tissue graft)
皮肤组织补片移植(AlloDerm)
冠向复位瓣术
根向复位瓣术
系带修整术
牙龈退缩,根面覆盖
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取材范围:上颌尖牙远中至第一磨牙近中
取材厚度
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initial
10d after
游离龈移植术
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加深前庭沟
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Recipient site
CT graft
CT suture
CT graft procedure
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10 days
Initial
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Thank you