上颌窦囊性改变的影像分类诊断及 上颌窦提升术的探讨

锥形束CT影像上常常可以发现上颌窦囊性改变的存在,这种改变是否影响上颌窦提升术的实施呢?这对临床医生造成了一定的困惑。本文结合临床上常见的各种囊性改变的锥形束CT影像表现,对上颌窦囊性改变的影像分类诊断进行介绍,并探讨囊性改变时上颌窦提升术的实施可行性、手术方式及术后黏膜的影像学改变等,以帮助临床医生作出正确判断。     

上颌窦囊性改变的影像分类诊断及上颌窦提升术的探讨

锥形束CT影像上常常可以发现上颌窦囊性改变的存在,这种改变是否影响上颌窦提升术的实施呢?这对临床医生造成了一定的困惑。本文结合临床上常见的各种囊性改变的锥形束CT影像表现,对上颌窦囊性改变的影像分类诊断进行介绍,并探讨囊性改变时上颌窦提升术的实施可行性、手术方式及术后黏膜的影像学改变等,以帮助临床医生作出正确判断。     

两方向法经嵴顶提升倾斜型上颌窦底的临床效果研究

目的 观察两方向法经嵴顶提升倾斜型上颌窦底的临床效果.方法 对6例拟行上颌后牙区种植修复的病例,用两方向法经嵴顶提升倾斜型上颌窦底.1个种植位点从2个方向进行经嵴顶提升,先行非植入方向骨凿冲顶窦底提升,将较低处黏膜提起,再行常规的植入方向骨凿冲顶窦底提升和种植体植入手术.结果 术后拍摄锥形束CT证实6例患者均获得了良好的上颌窦底提升效果,种植体与邻牙位置关系适当,种植体尖端有黏膜覆盖,术后鼻腔无血性分泌物,无明显疼痛,术后6个月内无种植体脱落.结论 对倾斜型上颌窦底可以考虑使用两方向法经嵴顶提升上颌窦底.     

上颌窦底提升自体骨与异种骨移植延期种植的临床疗效评价

目的 评价经上颌骨前外侧壁的上颌窦底提升植骨延期种植术的长期临床效果,并比较两种不同的骨移植材料在种植修复不同时期的变化.方法 对2002年1月至2008年12月牙列缺损患者18例(21侧)上颌窦行经上颌骨前外侧壁的上颌窦底提升植骨延期种植术.延期(6～8个月)植入共46枚种植体.将牙列缺损区域剩余牙槽骨高度＜4 mm的患者分为两组:①混合材料组(自体骨+异种骨)5例6侧;②单纯异种骨组(Bio-Oss)13例15侧.在3个时间点(植骨术后即刻、种植体负荷即刻、＞12个月随访)拍摄曲面体层X线片,评估骨吸收率及种植体存留率.结果 在植入的46枚种植体中,除1枚因感染取出外,其余种植体骨结合良好并完成修复.在平均54个月随访期内,种植体存留率为98％ (45/46).3个时间点的X线片测量比较,移植骨量两组均减少,混合材料组(10.88％和7.77％),总吸收率18.65％;单纯异种骨组(4.40％和-2.47％),总吸收率1.93％.骨量变化的差异有统计学意义.结论 上颌窦底提升植骨的临床效果是可以预期的;单纯异种骨移植的骨吸收率低于自体骨+异种骨混合材料的骨吸收率.     

上颌窦开窗植骨种植修复的远期效果评价

目的:探讨上颌窦开窗植骨种植修复在上颌后牙区骨量不足患者中的临床应用效果。方法:2002年1月—2006年11月,使用上颌窦开窗植骨种植修复上颌后牙缺失40例,其中3例行双侧手术。男29例,女11例,平均年龄51.4岁(28～66岁)。共植入84颗种植体。采用埋入式愈合方式。种植体平均愈合11.8个月(8～19个月)后行永久修复。随访期为62.3个月(47～84个月)。结果:植入的84颗种植体在愈合和随访期内均未发生松动脱落,留存率达100%。4侧上颌窦黏膜在手术过程中发生穿破,但未发生上颌窦炎等并发症。随访期X线片显示种植体颈部骨吸收平均值为(0.63±0.33)mm。结论:上颌窦开窗植骨种植修复技术安全可行,是解决上颌后牙区骨高度不足区种植修复难题的有效方法。     

可注射壳聚糖温敏水凝胶对犬骨髓基质细胞生物学行为的影响

目的:探讨可注射壳聚糖(chitosan,CS)基温敏水凝胶对犬骨髓基质细胞(bone marrow stromal cells,BMSCs)生物学活性的影响。方法:利用密度梯度离心法获得犬BMSCs,含10%胎牛血清的L-DMEM培养液进行原代培养并进行初步鉴定。合成壳聚糖温敏水凝胶,光镜下观察BMSCs在凝胶中的存活情况。制备凝胶浸提液,检测其对细胞增殖分化的影响。采用SPSS13.0软件包对实验数据进行单因素方差分析。结果:犬BMSCs可在壳聚糖温敏凝胶中存活。壳聚糖浸提液组对BMSCs的增殖与正常培养液组相比,无显著性差异;但在培养第1、4、7天时,矿化培养液组和矿化浸提液组的细胞增殖率明显低于未矿化的完全培养液组和壳聚糖浸提液组,第10天时,4组间无显著性差异。壳聚糖矿化浸提液组碱性磷酸酶和骨钙素活性明显提高。结论:制备的壳聚糖温敏水凝胶具有良好的生物相容性,可进行水凝胶复合BMSCs的体内外实验研究。     

黄金比例在上颌窦外提升术及同期种植体植入术中的应用评价

目的： 评价黄金比例在上颌窦外提升术及同期种植体植入术中的应用效果。方法： 选择2016年7月—2017年10月青岛大学附属医院西海岸院区种植科上颌磨牙缺失且剩余牙槽骨高度（residual bone height,RBH）约2.0～5.0 mm的患者15例,进行上颌窦外提升术。采用黄金比例确定种植体长度为11～12 mm,行同期种植体植入术,追踪其术后3～6个月愈合及骨结合情况。结果： 15例患者共植入21颗种植体,患者自我感觉良好。影像学检查可见种植体与周围骨组织结合良好,无1例患者发生上颌窦炎、种植体松动、脱落或种植体周围炎等并发症。术后6个月行种植修复,所有患者均能正常行使咀嚼功能,种植体周围软组织色泽、形态、质地无改变。结论： 运用黄金比例在上颌窦外提升术后同期植入种植体,可有效解决上颌后牙区RBH严重不足问题,为种植体长度选择提供依据。     

基因强化组织工程骨用于上颌窦底提升的动物实验

目的 评价骨形态生成蛋白2( bone morphogenetic protein-2,BMP-2)基因强化骨髓间充质干细胞(bone marrow stromal cells,BMSC)复合Bio-Oss骨在上颌窦底提升术中的效果.方法 抽取12只犬髂部骨髓体外分离扩增BMSC,分别加入含BMP-2基因、绿色荧光蛋白(green fluorescent protein,GFP)基因的腺病毒载体共培养,观察转染效率,并植入裸鼠皮下观察成骨情况.将BMP-2基因强化BMSC-Bio-Oss复合骨随机植入犬一侧上颌窦底提升形成的空腔中为实验组,另一侧植入BMSC-Bio-Oss复合骨为空白对照组.分别于术后30、60、120 d行大体观察、CT检查、组织学检查和新生骨量分析.结果 裸鼠皮下可见新生骨,荧光显微镜示踪可见BMSC.犬上颌窦底提升30 d后,大体观察和CT检查示少量新骨形成,120 d后上颌窦内新骨生成致密,仅有少量Bio-Oss骨.新生骨量分析显示,与空白对照组[(19.67 ±5.73) mm2]相比,实验组新生骨量[(24.74±6.33) mm2]显著增多(P＜0.05).结论 BMP-2基因强化BMSC-Bio-Oss复合骨应用于上颌窦底提升术可获得良好的成骨效果.     

盐酸米诺环素微球凝胶的制备及对大鼠实验性牙龈炎的抑制作用

目的:制备含盐酸米诺环素微球的功能性壳聚糖温敏凝胶,并观察载药凝胶对大鼠牙龈炎模型的抑菌效果。方法:将小分子药物盐酸米诺环素先制备成微球,共混于温敏凝胶中,观察其理化性质及释药性能;建立大鼠的实验性牙龈炎模型,观察载药凝胶对实验性牙龈炎模型的消炎效果。结果:实验制得的缓释凝胶,T50%可延长至4.24d;动物实验初步结果显示,与对照组相比实验组的牙龈指数和探诊深度有明显的减少,炎症细胞浸润数量少,毛细血管扩张程度轻。结论:加载盐酸米诺环素的缓释凝胶对大鼠实验性牙龈炎有一定的消炎作用。     

Platelet-rich plasma activity on maxillary sinus floor augmentation by autologous bone

OBJECTIVES: This work aims to evaluate the regenerative potential of platelet-rich plasma (PRP) on an implant site of peculiar clinical impact, such as sinus augmentation. MATERIAL AND METHODS: Sixteen consenting patients (11 females and five males), with symmetrical maxillary sinus atrophy, underwent bilateral sinus floor augmentation, using autologous (iliac crest) bone on one side and PRP plus autologous bone contralaterally. Implants were inserted 4, 5, 6 and 7 months after surgery in the patients randomly split into four groups. Orthopantomographies, computed tomography with transverse image digital reconstructions and densitometries were used to monitor the treatment progress. A core biopsy was performed at the site of implant. RESULTS: Clinical performance across both sites showed no statistical significance (P=0.414). Densitometric values were higher at PRP sites (mean Hounsfield units approximately +57%), even if densitometry converged in the two sites 8 months after surgery. Histology documents enhanced bone activities in sites treated with PRP, 4 months after surgery. Reduced bone activity was observed in both sites 5, 6 and 7 months after surgery. Bone amount, higher in sites treated with PRP (mean trabecular bone volume approximately +37%), decreased in both sites over time. CONCLUSIONS: Our results seem to indicate a certain regenerative potential of PRP when used with autologous bone. The effect of this enhancement of bone regeneration appeared to be restricted to shorter treatment times. A progressive extinguishment of the PRP effect is recorded after an interval longer than 6-7 months.     

Bioactive glass granules as a bone adjunctive material in maxillary sinus floor augmentation

OBJECTIVES: Bilateral sinus floor augmentation procedure was performed in 17 patients to study the effect of bioactive glass (BG) granules mixed with autologous bone (AB) chips on bone regeneration. The posterior part of 17 maxillary sinus was augmented with a 1:1 mixture of BG granules (phi 800-1000 microm) and AB chips harvested from the iliac crest (BG-AB group). The anterior parts of the same sinus and the contralateral sinus, serving as a control (AB group), were filled with AB chips alone. Trephine biopsies for histological, scanning electron microscopy (SEM), and energy dispersive X-ray (EDX) analyses were taken from the posterior part of the sinus after 21-34 weeks at the time of insertion of dental implants. Additionally, six biopsies were taken from the BG-AB group and four biopsies were taken from the AB group in connection with abutment operation at 49-62 weeks. RESULTS: Histological evaluation revealed lamellar bone growth in all the specimens. Although most of the BG granules were without bone contact in the majority of the patients in the BG-AB group, the bone lamellae were thicker than observed in the AB group. In the contact areas, bone was growing along the glass surface connecting the particles together. Histomorphometrical analysis carried out from the SEM images at 21-34 weeks revealed 26% and 25% bone in the BG-AB and the AB group, respectively. Corresponding figures for 49-62 weeks were 29% for the BG-AB group and 25% for the AB group. Bone-BG complex, i.e. the granules with intimate contact with bone, occupied 34% of the area measured at 21-34 weeks and 31% at 49-62 weeks. EDX analysis showed a tight contact and chemical bonding between the glass and bone. As a sign of dissolution, a few small Si-depleted areas were present in some BG granules at 21-34 weeks, while more and larger Si-free areas were observed in the granules at 49-62 weeks. CONCLUSION: The results indicate that BG granules (S53P4) can be used together with AB chips for sinus floor augmentation procedure, thus decreasing the amount of bone needed. Further studies concerning especially the biomechanical properties of the BG-AB complex with dental implants are needed.     

关于上颌窦底提升术骨增量策略的研究进展

上颌后牙区骨高度不足是种植手术常见的问题之一。而上颌窦底提升术拓宽了上颌后牙区种植的适应证。随着临床技术的进步和口腔材料学的发展,上颌窦底提升术的植骨策略不断更新。尽管上颌窦内的成骨机制尚未完全阐明,但上颌窦底提升术不植骨已经得到了越来越多的认可,如何选择和把握适应证是该策略的关键。经典传统的骨移植材料存在不同程度的缺陷,新型骨组织工程辅助材料应运而生,部分已得到临床应用。该文就上颌窦底提升术是否植骨、骨移植材料等方面的研究进展作一综述。     

Bone reformation with sinus membrane elevation: a new surgical technique for maxillary sinus floor augmentation

Background: Various maxillary sinus floor augmentation techniques using bone grafts and bone substitutes are frequently used to enable placement of dental implants in the posterior maxilla. A previous case report demonstrated the possibility of promoting bone formation in the sinus by lifting the membrane without using a grafting material. However, the predictability of the technique is not known. Purpose: The aim of this study was to investigate whether sinus membrane elevation and the simultaneous insertion of titanium implants without additional grafting material constitute a valid technique for bone augmentation of the maxillary sinus floor. Materials and Methods: The study group comprised 10 patients in whom a total of 12 maxillary sinus floor augmentations were performed. A replaceable bone window was prepared in the lateral sinus wall with a reciprocating saw. The sinus membrane was dissected, elevated superiorly, and sutured to the sinus wall to create and maintain a compartment for blood clot formation. One to three dental implants were inserted through the residual bone and protruded at least 5 mm into the maxillary sinus. The bone window was replaced and secured with the overlying mucosa. Bone height was measured directly at each implant site at the time of insertion. Resonance frequency analysis (RFA) was performed on each implant at the time of initial placement, at abutment surgery, and after 12 months of functional loading. Computed tomography (CT) was performed in the immediate postoperative period and 6 months later, prior to exposure of the implants. Results: A total of 19 implants (Brånemark System®, TiUnite?, Nobel Biocare AB, Gothenburg, Sweden) in lengths of 10 to 15 mm were placed, with an average residual bone height of 7 mm (range, 4–10 mm). All implants remained clinically stable during the study period. Comparisons of pre‐ and postoperative CT radiography clearly demonstrated new bone formation within the compartment created by the sinus membrane elevation procedure. RFA measurements showed mean implant stability quotient values of 65, 66, and 64 at placement, at abutment connection, and after 12 months of loading, respectively. Conclusions: The study showed that there is great potential for healing and bone formation in the maxillary sinus without the use of additional bone grafts or bone substitutes. The secluded compartment created by the elevated sinus membrane, implants, and replaceable bone window allowed bone formation according to the principle of guided tissue regeneration. The precise mechanisms are not known, and further histologic studies are needed. Sinus membrane elevation without the use of additional graft material was found to be a predictable technique for bone augmentation of the maxillary sinus floor.     

Endoscopic lift of the maxillary sinus floor in beagles

The aim of this study was to introduce a modified endoscopic lift of the floor of the maxillary sinus in beagles. Twelve operations (bilateral and randomly chosen) were done in 6 beagles each in the test group (modified endoscopic operation), and the control group, in which the operation was done with an osteotome. All operations were evaluated by two indices of safety (perforation of the sinus membrane and nasal bleeding) and 3effective indices (the intraoperative height after lifting, volume of bone grafts, and dislocation of the sinus grafts). The sinus membrane was not perforated and there were no nasal bleeds in either group. The intraoperative height after lifting was 13.7 (0.8) mm in the test group and 9.1 (0.5) mm in the control group, so it was significantly higher in the test group than the control group (p=0.0001). Similarly, the volume of bone graft was 0.9 (0.04) ml in the test group and 0.5 (0.02) ml in the control group (p=0.0001). The volume of the anterior and posterior bone grafts in the implant cavity in the test group did not differ significantly (p=0.102), while there were significant differences in the control group (p=0.002). Endoscopic lifting of the floor of the maxillary sinus is a safe and effective approach based on direct observation in beagles.     

Pre-implantological bone formation in the floor of the maxillary sinus in a self-supporting space

Introduction

In edentulous patients the form and size of the maxillary sinus vary greatly. Therefore sinus floor augmentation is a standard procedure for implantological purposes. As the sinus membrane cannot be characterized as periosteum, various augmentation materials are used.

上颌窦宽度及角度预测经牙槽嵴顶上颌窦底提升术骨移植稳定性的价值

目的: 探讨通过锥形束CT（CBCT）测量上颌窦宽度及角度,评估牙槽嵴顶上颌窦底提升术骨移植稳定性的价值。方法: 选取行经牙槽嵴顶上颌窦底提升术并同期种植的78例患者为研究对象。所有患者术前、术后6个月均行CBCT检查,测量上颌窦宽度、角度及根端骨吸收量。分析影响牙槽嵴顶上颌窦底提升术骨移植稳定性的因素,评估上颌窦宽度、上颌窦角度预测牙槽嵴顶上颌窦底提升术骨移植稳定性的价值。采用SPSS 18.0软件包对数据进行统计学分析。结果: 术后6个月种植体根端骨平均吸收量为（1.81±0.26）mm,其中,49例≤1.81 mm,29例>1.81mm。Logistic多因素回归分析显示,上颌窦宽度、上颌窦角度是影响牙槽嵴顶上颌窦底提升术骨移植稳定性的独立因素（OR：3.873、4.518,95%CI：1.594~9.412、1.859~10.979,P<0.05）。ROC曲线分析显示,上颌窦宽度、上颌窦角度及两者联合预测牙槽嵴顶上颌窦底提升术骨移植稳定性的AUC分别为0.764、0.742和0.908。结论: 上颌窦宽度和角度是影响牙槽嵴顶上颌窦底提升术骨移植稳定性的指标,两者联合预测术后骨移植稳定性效能良好。     

Radiographic outcome after maxillary sinus floor augmentation with allogeneic adipose tissue-derived stem cells seeded on deproteinized bovine bone mineral. A randomized controlled experimental study

The objective was to test the hypothesis of no difference in radiographic outcome after maxillary sinus floor augmentation (MSFA) with allogeneic adipose tissue-derived stem cells (ASCs) seeded on deproteinized bovine bone mineral (DBBM) (test) compared with excipient on DBBM (control). Eighteen minipigs were assigned into three groups of six animals and euthanised after one month (T1), two months (T2), and four months (T3), respectively. Each maxillary sinus was randomly allocated to either test or control with an equal volume of graft. Computed tomography scans (CTs) after MSFA (T0) were compared with CTs after euthanasia to evaluate graft volume (GV) changes and bone density (BD) using three-dimensional measurements and Hounsfield units. GV was larger in test compared with control at T1 (P = 0.046), whereas GV was larger in control compared with test at T3 (P = 0.01). BD increased from T0 to T1-T3 (P < 0.001) with both treatments. Higher BD was observed in control compared with test at T3 (P = 0.01), while no significant difference was observed at T1 and T2. Conclusively, the present study demonstrate that allogeneic ASCs seeded on DBBM in conjunction with MSFA seemed not to improve the radiographic outcome compared with excipient on DBBM. However, radiological outcomes need to be supplemented by bone histomorphometry before definitive conclusions can be provided about the beneficial use of allogeneic ASCs seeded on DBBM in conjunction with MSFA compared with DBBM alone.     

Osteogenic efficacy of bone marrow concentrate in rabbit maxillary sinus grafting

Maxillary sinus grafting is required to increase bone volume in the atrophic posterior maxilla to facilitate dental implant placement. Grafting with autogenous bone (AB) is ideal, but additional bone harvesting surgery is unpleasant. Alternatively, bone substitutes have been used but they limit new bone formation. The strategy of single-visit clinical stem cell therapy using bone marrow aspirate concentrate (BMAC) to facilitate new bone formation has been proposed. This study aimed to assess bone regeneration capacity of autologous BMAC mixed with bovine bone mineral (BBM) in maxillary sinus grafting. Twenty-four white New Zealand rabbits were used and their maxillary sinuses were randomly assigned for grafting with 4 different materials. Rates of new bone apposition in augmented sinuses were measured and bone histomorphometry were examined. Significant increase in the quantity of nucleated cells and colony forming unit-fibroblasts were confirmed in BMAC. Mesenchymal stem cells in BMAC retained their in vitro multi-differentiation capability. Higher rates of mineral appositions in the early period were detected in BBM + BMAC and AB than BBM alone, though they are not significantly different. Graft volume/tissue volumes in BBM and BBM + BMAC were found to be higher than those in AB and sham.     

不同种植体外形设计对上颌窦提升术后种植体周围应力分布的影响

目的：比较不同种植体外形设计对上颌窦提升术后种植体周围生物力学的影响。方法：在D3型上颌骨简化模型上利用三维有限元法分析3种不同外形设计的种植体在植骨与不植骨条件下的应力分布情况。假设所有材料都是线弹性、连续材料,向种植体施加150 N的倾斜力,测量种植体周围骨组织的最大等效力（equivalent von-Mises,EQV）。采用Ansys Workbench 14.5软件包对数据进行测量分析,采用SPSS 17.0软件包对数据进行统计学分析。结果：各组应力集中区域均位于种植体颈部皮质骨区域。不同种植体外形设计对种植体周围皮质骨最大EQV值无显著影响,但锥形种植体较其他种植体的周围松质骨最大EQV值显著上升,上颌窦提升术后植骨可以降低各组种植体周围最大EQV值。结论：锥形种植体用于上颌后牙区种植修复时,可能引起种植体周围松质骨应力变大,增加种植体周围骨吸收的风险。上颌窦提升后植骨,可降低种植体周围压力负载。