解决剩余骨量不足的微创骨增量技术体会

目的:牙槽嵴骨量不足是牙种植手术设计中常遇到的挑战,近年由于临床技术和骨增量材料的研究发展,牙种植术中所采用的骨增量技术正逐渐向着简单、微创和可靠的方向发展.由于大多数人工骨仅有骨传导作用,成骨效能有限,自体骨移植常是骨增量技术中不可或缺的内容.虽然随着骨增量技术的进步,在身体其它部位开辟第二术区采取自体骨的术式已逐渐少用, 已逐步局限于口腔内上下颌骨范围内采取.但是采取自体骨仍然增加了手术的难度并造成较大的创伤.最大限度改善人工骨的成骨效果,避免开辟第二术区采取自体骨,简化手术,减少创伤,历来是牙种植医师追求的目标.本报告旨在总结我们近年为实现以上目标采用的微创骨增量技术应用体会.方法:19例牙槽嵴骨量不足的的患者经微创骨增量技术解决剩余骨量不足,二期手术时观察骨增量效果,在完成修复后随访1～2年.结果:所有患者皆取得满意的临床效果,种植体同期或骨增量术后6～7月后植入,在修复完成后随访1～2年后未出现种植体失败.结论及讨论:在充分地了解骨代用品性能以及掌握引导骨再生机理的前提下,微创骨增量技术可不需开辟第二术区采取自体骨,并实现可预期的骨增量效果,本报告讨论了我们在临床实践中探索出来的骨增量技术微创化操作体会.     

骨环种植技术在口腔临床应用的研究进展

缺牙区骨量不足是口腔种植领域的技术难题。当前常用引导骨再生技术(GBR)和Onlay植骨术解决口腔种植中最具挑战的垂直向和水平向骨增量问题,但都有耗时长、需二次手术等局限性。骨环种植技术是近年融合发展的环状骨块移植骨增量术式,支持同期植入种植体,具有缩短治疗时间、避免二次手术等优势,受到口腔种植医生的青睐。本文就近年来口腔种植领域骨环种植技术的临床应用及研究进展进行综述。     

原位取骨技术在上前牙种植中的应用

上前牙种植手术中常于下颌颏部、下颌升支等处获取自体骨行骨增量,但多篇文献报道了供骨术区的并发症。于上前牙邻近区域及缺牙区原位取骨,可减少手术时间、供区并发症,增加患者对取骨手术的接受度。该文就上前牙区潜在取骨区域及取骨方式进行简单论述,为不同大小的上前牙区骨缺损原位取骨手术方案的选择提供参考和借鉴。     

前牙区软硬组织增量相关并发症及临床处理策略

上前牙区为美学关键区,历来都是种植修复的难点和热点,但因各种牙周和根尖周问题导致的拔牙,常使种植修复面临牙槽嵴水平向及垂直向骨量不足的困境。前牙区牙槽嵴骨增量的手术方法包括引导骨组织再生术、块骨移植术、骨劈开骨挤压术等,而即使采取骨增量手术后仍存在一定数量的病例出现软组织塌陷,为此临床上常采用游离结缔组织移植的方法来恢复美学区的软组织轮廓。由此而来,伴随各种复杂的软硬组织手术,不可避免地会出现一系列并发症,包括创口裂开、感染、出血、血肿,神经损伤,移植物暴露、坏死、吸收,软组织开裂,角化龈宽度、厚度不足等。文章针对上颌前牙区骨增量和软组织增量相关并发症及临床处理策略逐一介绍,并提出风险防控建议,以期降低相关术式并发症的发生率。     

下颌舌侧减张技术在骨增量中的应用研究进展

骨增量技术是解决种植位点牙槽嵴高度和宽度不足的有效方法,术区稳定无张力一期愈合是保证复杂骨增量手术成功的关键。下颌舌侧减张技术近年来逐渐在临床应用,在颊侧减张的基础上该技术能进一步降低组织瓣张力,维护术区稳定性,提升手术成功率。本文就下颌舌侧重要解剖结构、常用减张器械及下颌舌侧减张术式的临床应用作一综述。     

上颌前牙区不同骨条件种植方式的选择

目的:报告四例上颌前牙区不同骨条件下种植方式的选择方法,探讨上颌前牙区骨量对选择种植修复方式的影响.方法:选择四例上颌前牙区不同骨条件的患者.对上颌前牙区骨量无缺损的患者,行即刻拔牙同期植入种植体技术;对上颌前牙区唇侧骨板部分缺损的患者,行即刻拔牙同期植入种植体,并应用GBR技术诱导成骨;对上颌前牙区骨厚度为3mm的患者,行骨劈开后同期植入种植体技术;对上颌前牙区骨厚度约1mm的患者,一期行异体骨骨增量技术,二期植入种植体.结果:四例患者术后种植体愈合良好,修复治疗后对修复效果均满意.讨论:上前牙缺失的患者,缺牙区牙槽嵴往往较窄,常规备孔植入种植体的方法通常比较困难,而且患者对前牙美学区的种植修复效果要求较高,因此,选择合适的种植方式,是影响种植体的骨结合及最终修复效果的关键因素,通过细致的术前设计、术中操作和修复设计,可达到良好的修复效果.     

Onlay植骨技术在上颌前牙美学区种植修复中的应用

目的:评估Onlay植骨技术在上颌前牙美学区种植修复中的应用。方法:随机选取82例行种植修复术的患者,根据术前评估,给予患者合理的Onlay植骨技术及牙种植修复手术方案。观察患者植骨期间牙槽嵴骨量变化及美学指标变化情况,记录牙种植体存活率。结果:Onlay植骨术后3个月末牙槽嵴水平向骨量(7.84±0.42)mm、牙槽嵴垂直向骨量(11.65±0.85)mm和术后6个月末牙槽嵴水平向骨量(7.15±0.60)mm、牙槽嵴垂直向骨量(10.86±0.63)mm均显著高于植骨前骨量,P=0.035、0.039、0.035、0.040;牙种植修复术后3个月末PES(7.48±1.36)分、WES(7.56±1.09)分和术后6个月末PES(7.78±1.42)分、WES(7.82±1.51)分均显著高于术前评分水平,P=0.040、0.043、0.038、0.032;Onlay植骨术后,骨组织美观丰满,伤口愈合良好,未出现植骨坏死,种植体存活率高。结论:将Onlay植骨技术应用于上颌前牙美学区种植修复中,可显著改善种植区骨量不足的问题,骨愈合情况良好,种植体存活率高,值得推广使用。     

上颌后牙区骨量不足种植修复的研究进展

导致上颌后牙区垂直骨量不足的原因有很多,长时间缺失牙造成牙槽嵴废用性吸收、因炎症导致的病理性吸收、上颌窦的气化等,增加了种植修复难度。针对上颌后牙区垂直骨量不足,近年来国内外主要采用的几种技术大致可以分为两类：①骨增量方案,包括经牙槽嵴顶的上颌窦底提升术,经前外侧壁开窗的上颌窦底提升术,引导骨再生,块状骨移植术等;②非骨增量方案,包括单纯经牙槽嵴顶的上颌窦底提升术,短种植体,倾斜种植体等。如何选择最适合患者的手术方案,以得到满意的修复效果,一直是牙医们努力的方向。上颌窦底提升技术目前已有较深入的研究,因此本文主要专注于非骨增量方案的研究进展。     

钛网结合异体骨移植和人骨形成蛋白在上颌前牙种植前牙槽嵴骨增量中的应用研究（附1例报告）

编者按：本刊特邀美国德克萨斯健康研究中心牙学院Bing-Yan Wang副教授介绍1例在上颌前牙牙槽骨严重缺损区实现骨增量的病例。在拔牙同期用异体骨和Bio-Mend延展膜进行引导骨再生术后未获得满意骨量的情况下,无法进行种植手术,术者用钛网结合异体骨移植材料和人骨形成蛋白在种植体植入前修复上前牙区部分牙缺失部位的牙槽骨缺损,最终获得成功。通过这种方法扩大了在上前牙牙槽骨严重骨缺损区种植的适应证,为患者提供了除自体骨移植以外的另一个选择。     

血小板浓缩物在口腔种植中的应用

牙体缺失后牙槽骨骨量不足向来是口腔种植中最为棘手的问题之一,而经过长期的探索研究,自体骨移植技术、引导性骨再生技术(GBR)等一系列经典术式应运而生,可以说在一定程度上很好地解决了这一问题。其中GBR技术更是以其成骨可预期性好,长期骨吸收率低,易充填塑形,无第二术区,手术并发症少等优势得到了广大种植医生和患者的青睐。然而,随着科技的进步,血小板浓缩物这一新技术开始崭露头角,并凭借着其独有的优势在口腔种植领域的组织增量中占有一席之地,甚至向经典的GBR技术发起了挑战。本文将重点对血小板浓缩物应用在口腔种植领域,特别是组织增量方面的优势作一简要综述。     

上颌窦外提升术在口腔种植术中的应用

目的:探讨上颌窦提升术在口腔种植术中的应用以扩大口腔种植术中的应用范围。方法:25例患者通过上颌窦提升术同期或延期植入种植体31枚,术中患者使用了Bio-Oss胶原质作为骨移植材料,采用非埋入式种植技术。结果:术后6个月,上颌窦底提高4-6mm,所有病例完成修复后,随访6-24各月,x线检查窦底骨质无明显吸收,种植体骨结合良好,无松动脱落,修复效果满意。结论:上颌窦提升术扩大了口腔种植术的应用范围。     

口腔种植成骨材料的研究现状及进展

随着口腔种植技术的快速发展，种植修复已逐渐成为牙列缺损和牙列缺失患者的首选治疗方案。种植区牙槽骨骨量充足是种植修复成功的前提条件及关键因素。然而，临床上种植区牙槽骨骨量不足十分常见，影响种植修复体的功能发挥、美学效果及远期疗效。口腔植骨材料配合骨增量手术是目前临床常用重建缺失骨组织，使其骨量满足种植要求的方法之一。口腔植骨材料的自身特性如生物相容性、骨传导、骨诱导及骨生成等性能对植骨成功率具有至关重要的影响。该文从植骨材料的性能、分类及临床运用三个方面重点介绍口腔种植成骨材料的研究现状及最新进展，以期为成骨材料的临床选择及种植修复成功率的提高提供理论指导。     

上颌窦底提升术

目前,种植手术已成为一种常规的技术应用于临床,随着种植体设计的改进和植入技术的日趋成熟,成功率不断提高,适应证也不断扩大,但是剩余骨高度不足仍是影响上颌后牙区种植手术的主要因素.临床上多采用上颌窦底提升术,主要包括上颌窦侧壁开窗术和冲压式上颌窦底提升术,这2种术式有效解决了上颌后牙区剩余骨高度不足的问题.本文主要介绍上颌窦的解剖结构、底壁分嵴等情况,以及口腔影像学检查方法的应用;归纳总结上颌窦底提升术的基本原则,上颌窦侧壁开窗提升术的切口设计、手术方法,以及3种改良冲压式上颌窦底提升术的比较,骨挤压器和骨冲顶器的应用,初步探讨植骨材料的选择,辅助上颌窦底提升术的特殊器械(超声骨刀和内镜)的特点,伴发上颌窦囊肿和术后并发症的处理方法.     

All-on-Four技术在口腔种植领域中的应用进展

种植修复是恢复无牙颌患者咀嚼功能和美观的有效治疗方法,但因可用骨量的不足、上颌窦和下牙槽神经血管束等解剖问题而面临巨大挑战。对该类患者行种植体植入术时,常需要进行相关的骨增量手术。All?on?Four技术是指在无牙颌前牙区植入两颗轴向种植体,在远中端植入两颗角度种植体,并即刻负重,且在4～6个月后完成最终修复的新种植修复技术。该技术避免了人工骨粉植入术及上颌窦提升术等骨增量过程,患者心理反应及术后反应较轻,同时节省了患者的时间和金钱成本。这种联合应用倾斜种植体和直种植体来共同完成无牙颌患者的固定修复治疗被认为是一种可行的治疗方式。本文将就All?on?Four概念、常规技术、评价研究以及近年来提出的一些新的观点进行阐述。     

牵张成骨和引导骨再生术在垂直骨增量上的比较研究

随着种植外科的进展,大量垂直向和水平向骨增量技术得到了发展。许多种植患者存在垂直向骨量不足的问题,需要增加垂直向骨量;但垂直向骨增量相对于水平向骨增量难度比较大,预见性较差,往往易致较多的并发症;因此,垂直向骨增量技术受到了越来越多的关注。引导骨再生技术和牵张成骨术是2类较常用的垂直向骨增量技术,在临床上已得到一定的应用,本文对其在垂直向骨增量上的研究进展作一综述。     

口腔种植中骨增量技术的应用进展

临床上,种植部位骨量不足是种植治疗常遇到的难题。为确保种植区符合种植条件,骨增量技术尤为重要。常用的骨增量技术包括骨移植术、引导骨再生技术、骨劈开术、骨挤压术、上颌窦底提升术及牵张成骨术等。本文就骨增量技术在口腔种植中的应用进展作一综述。     

帐篷钉技术在牙槽嵴骨增量中的应用研究

充足的骨量是种植修复成功的关键因素,而临床上种植区骨量不足较为常见,导致难以获得理想的种植体植入方位。因此为确保种植修复的成功和稳定,牙槽嵴的修复与重建具有重要的临床意义。随着骨增量技术的发展,基于引导骨组织再生术基本原理的帐篷钉技术在临床上获得了显著效果,可以在减少甚至不使用自体骨的情况下完成牙槽嵴缺损的修复与重建。本文回顾了帐篷钉技术的发展历史,对其应用原理及条件、临床效果、相关并发症、技术要点以及注意事项等进行综述。     

A randomized clinical trial to evaluate and compare implants placed in augmented versus non-augmented extraction sockets: 3-year results

Background: The alveolar ridge undergoes reabsorption and atrophy subsequent to tooth removal and thus exhibits a wide range of dimensional changes. Preservation of the alveolar crest after tooth extraction is essential to enhance the surgical site before implant fixture placement. The aim of this randomized clinical study is to investigate and compare the need for additional augmentation procedures at implant insertion, as well as the success rate and marginal bone loss for implants placed in the grafted sites versus those placed in naturally healed sites. Methods: Forty patients with ≥1 hopeless tooth were randomly allocated to: 1) a test group, receiving extraction and grafting corticocancellous porcine bone; and 2) a control group, receiving extraction without any graft. After 7 months of healing, implants were inserted in each of the sites. The implants were submerged and loaded after 4 months with metal–ceramic rehabilitation. The follow‐up included evaluation of implant diameter and length, the need for additional augmentation procedures at implant placement, implant failure, and marginal bone level changes. All patients were followed over a 3‐year period. Results: One implant failed in the control group at the second stage of surgery (6 months after placement); one implant failed in the test group after 2 years of loading. The cumulative implant success rate at the 3‐year follow‐up visit reached 95% for both groups. No statistically significant differences were detected for marginal bone changes between the two groups. Conclusions: It was concluded that implants placed into grafted extraction sockets exhibited a clinical performance similar to implants placed into non‐grafted sites in terms of implant survival and marginal bone loss. However, grafted sites allowed placement of larger implants and required less augmentation procedures at implant placement when compared to naturally healed sites.     

Frontal sinus augmentation: Preliminary results of a new approach in prosthetic orbital reconstruction

PurposeReliable application of endosseous implants for prosthetic facial reconstruction depends on the bone volume available at the defect site. Regarding the orbit, sufficient bone presentation in the medial superior orbital rim is limited due to the frontal sinus. The aim of this article is to report for the first time on the augmentation of the frontal sinus for gaining bone volume for supraorbital implant placement.Materials and methodsBetween 2007 and 2014, five patients with orbital exenteration were treated by frontal sinus augmentation using autogenous cancellous bone graft from the ilium. Extraoral implants for prosthetic orbit reconstruction were placed 4–7 months later. In advance, cadaver surgery was performed to prove the feasibility of the method. Surgical technique is described, and intraoperative images are provided.ResultsThe frontal sinus was successfully augmented in all five patients. No major complications related to the procedure were observed. A total of nine orbital implants were inserted in the augmented bone, thereof one sleeping implant. Six implants were restored prosthetically, two implants were lost at exposure. The observation period ranged from 6 to 97 months (mean: 52.8 months). Mean time for patient rehabilitation was 13 months. High patient satisfaction was achieved with the implant-retained orbital prosthesis.ConclusionThe augmentation of the frontal sinus allows implant placement by providing sufficient bone volume in the medial supraorbital rim. Considering the surgical success of this method and patient satisfaction, this new approach is concluded to be a viable option in a unique subset of patients.     

Bone augmentation techniques

BACKGROUND: The advent of osseointegration and advances in biomaterials and techniques have contributed to increased application of dental implants in the restoration of partial and completely edentulous patients. Often, in these patients, soft and hard tissue defects result from a variety of causes, such as infection, trauma, and tooth loss. These create an anatomically less favorable foundation for ideal implant placement. For prosthetic-driven dental implant therapy, reconstruction of the alveolar bone through a variety of regenerative surgical procedures has become predictable; it may be necessary prior to implant placement or simultaneously at the time of implant surgery to provide a restoration with a good long-term prognosis. Regenerative procedures are used for socket preservation, sinus augmentation, and horizontal and vertical ridge augmentation. METHODS: A broad overview of the published findings in the English literature related to various bone augmentation techniques is outlined. A comprehensive computer-based search was performed using various databases that include Medline and PubMed. A total of 267 papers were considered, with non-peer-reviewed articles eliminated as much as possible. RESULTS: The techniques for reconstruction of bony defects that are reviewed in this paper include the use of particulate bone grafts and bone graft substitutes, barrier membranes for guided bone regeneration, autogenous and allogenic block grafts, and the application of distraction osteogenesis. CONCLUSIONS: Many different techniques exist for effective bone augmentation. The approach is largely dependent on the extent of the defect and specific procedures to be performed for the implant reconstruction. It is most appropriate to use an evidenced-based approach when a treatment plan is being developed for bone augmentation cases.