口腔內自體結締組織移植之文獻回顧及臨床應用

Oral Autogenous Connective Tissue Graft: Clinical Application and Literature Review

鄭凱駿(Kai-Chun Cheng) ； 許嘉文(Chia-Wen Hsu)

《南臺灣醫學雜誌》 16卷2期 (2020/12) Pp. 59-71

https://doi.org/10.6726/MJST.202012_16(2).0002

摘要

自體結締組織移植（autogenous connective tissue graft）被大量運用於各種牙周手術中，目的是增加受植區角化牙齦的量、以及牙齦外型的美觀性。本文回顧針對自體結締組織移植術的原理、適應症、優缺點、供給區手術方式分類、臨床應用範圍、以及與游離牙齦移植術（free gingival graft）做比較。成功的自體結締組織移植，可以在受植區達到血漿循環與再血管化，並進而增加受植區之角化牙齦的寬度，自體結締組織手術取得部位包含了上顎腭側、上腭粗隆、下顎臼齒區等部位，應用範圍涵蓋牙齦萎縮的治療、牙周翻瓣清創、齒脊保存術、增加植體周圍角化牙齦…等。自體結締組織移植之優點為，受植區是以第一級方式達到癒合，傷口癒合較快，患者不適感較低，且術後美觀性佳。然而自體結締組織之手術方式較困難，須同時在口內製造移植區及受植區兩個傷口，且須小心避開腭大動脈這一個重要的解剖構造。此外在手術後也要注意可能產生的併發症，例如過量出血、腭部組織的壞死、腫脹及瘀斑等。游離牙齦移植也是臨床常見增加角化牙齦的術式，而自體結締組織相較於游離牙齦移植，應用於牙周組織重建，從術後受植區的美觀度、供給區之癒合及患者滿意度評估手術方式，則自體結締組織移植會優於游離牙齦移植。自體結締組織取得的數量有限，近年出現有關於替代材料的研究，替代材料取得的數量和範圍不受患者條件的限制，而且免除了第二手術區，對於這種的臨床效果仍需要長期追蹤。在不同的文獻中，學者們使用各種手術方法從移植區取得自體結締組織，可根據切線的位置、數量、以及皮瓣設計方式等作分類，而手術選擇的考量在於切線範圍及數量，切線範圍越大，術後血流供應越差；切線範圍越小，需要的手術技巧越高。手術選擇有所不同，其最終目的在於追求能夠達成患者滿意的軟硬組織外觀以及將術後併發症機率降至最低。

關鍵字

牙齦疾病 ； 結締組織移植 ； 游離牙齦移植

並列摘要

Autogenous connective tissue graft (CTG) was widely used in various kind of periodontal surgery. The purpose of CTG surgery improve the volume of keratinized gingiva of recipient side and promote the aesthetics of soft tissue. This review article was aim to discuss the following subjects: principles of connective tissue graft, indication, advantages and disadvantages, classification of techniques for harvesting connective tissue graft, clinical application, comparing with free gingival graft (FGG). Plasmatic circulation and revascularization at the recipient side can lead to a success autogenous connective tissue graft surgery, and also increase the keratinized gingiva. The common donor sides of connective tissue are upper palate, upper tuberosity, and lower retromolar area. CTG can be applicated for the treatment of gingival recession, periodontal flap debridement surgery, ridge preservation, and increasing the keratinized gingiva around implant abutment etc. The advantages of connective tissue graft are primary healing at the recipient side, less healing time, less discomfort, and better aesthetics. However, the CTG surgery is relatively difficult due to creating recipient side and donor side wounds during the surgery, which means two wounds at the same time. Also, we must avoid injuring the important anatomy like greater palatine artery. Post-operative complication including excessive bleeding, necrosis of palatal tissue, swelling, and ecchymosis etc. Free gingival graft (FGG) is also a common surgery for increasing keratinized gingiva. However, when applied to periodontal reconstruction, CTG is better than FGG when considering aesthetic outcome of recipient side, healing procedure of donor side, and patient's satisfaction. Considering the limitations of CTG, the study for the autograft substitutes was applied. The volume of the substitutes won't be limited by the patient's condition. and also avoid creating another wound during surgery. More studies and long-term follow up are required for this autograft substitutes. According to different studies, in which the authors used different methods to obtain CTG from donor sides. Those methods can be classified to the position and amount of incision lines, and the different flap designs. We must take into account that the wider of the surgery area leads to poorer blood supply; the narrower of the area takes more skillful technique. No matter what which method was applied, the purposes are the same: achieving more satisfied soft and hard tissue appearance, as well as less post-operation complications.

並列關鍵字

Gingiva diseases ； connective tissue graft ； free gingiva graft