牙周補綴之廣泛考量與臨床應用

General consideration and clinical application in periodontal prosthesis – clinical cases report

舒瓊明(Chiung-Ming Su)

指導教授 ： 洪純正

高雄醫學大學/口腔醫學院/牙醫學研究所碩士在職專班/碩士(2006年)

摘要

牙周補綴學 (periodonta1-prosthetics) 是一門跨專科治療 , 它的目的就是對於罹患中度至重度牙周炎合併進行中或不可逆牙齒動搖的病患 ,藉著牙周治療與贋復補綴 , 來恢復穩定牙齒和牙周組織的生理性型態與功能 ; 其中也可能要加入齒髓治療、齒列矯正治療、口腔外科等其他專科治療。需要牙周補綴的患者 , 常有以下臨床特徵:
1、中度至重度牙周炎
2、進行性牙齒動搖與移位
3、後方咬合塌陷 , 併有垂直咬合空間喪失
4、不良牙冠/牙根長度比率。
5、 缺牙或牙齒排列不佳
6 、不良醫源性補綴物引起牙周及咬合病變。
7 、根叉侵犯
8 、鄰近牙根太貼近 (proximity)
9 、附著性牙齦不足或前庭過淺
10 、鄰接面有牙根凹陷 (root concavity) 或凹溝 (flute) 致使牙菌斑控制困難 , 包括牙根敏感、牙根齲齒和牙齦發炎。
11 、牙齒的排列常會造成美觀的問題
12 、缺乏穩定咬合 , 常有咀嚼困難問題
13 、臨床性牙冠長度不足 , 致使牙齒磨削修形困難
14 、磨削修形牙齒時常會造成牙髓曝露 , 引發牙髓病變
15 、磨削修形牙齒時 , 較難取得好的平行角度。
16 、有較高顳顎關節問題的比率，不良咬合功能習慣和前牙區磨耗
牙醫師依據所收集的診斷資料 , 詳細表列問題, 再依問題導向, 思考制定相對應的解決方案 , 訂定治療計劃時，必須參考患者的心理狀態 ,如果患者以前有戴假牙經驗，尚需了解他對以前義齒的觀感以及目前的需求 , 還有他的經濟能力，意願如何, 身體健康狀況 , 時間限制等因素 , 參考專科醫師意見 , 才來設計修復方式以及提出具體治療方案 , 並排定治療進程，有效率地完成治療；這個治療計劃 , 必須在臨時補綴期間 , 反覆地接受修正與檢討 , 直到確定支柱牙 (abutment)和永久性補綴的方式，這治療計劃方才定案。
本論文提出 9 個中度或重度牙周病患者需要牙周補綴進行全口或半口重建的病例 , 採用不同的治療方式；牙周治療包括非手術性與手術性治療 ( 牙周翻瓣術、牙冠增長術、游離牙齦移植術、引導骨再生術、自體齒移植術與種植體置入 ), 最終的補綴設計包括傳統固定式牙冠牙橋、植體支持牙冠牙橋、傳統或雙重冠覆蓋義齒、植體覆蓋義齒。經由專業性及整合性的牙周補綴治療，來滿足患者咀嚼功能，顏面美觀，咬合平衡，發音以及個人背景因素的需求。

關鍵字

牙周補綴學 ； 牙周翻瓣術 ； 游離牙齦移植術 ； 引導骨再生術 ； 自體齒移植術 ； 植體置入 ； K&ouml ； nus與CSC 雙重冠覆蓋式義齒 ； 傳統鉤靠可撤式義齒與覆蓋式義齒組合體 ； 植體覆蓋義齒 ； 全口重建

並列摘要

Periodontal-prosthetics is a multidisciplinary therapeutic regimen. Its goal is the reestablishment of the oral health of the patient with moderate to advance periodontitis and associated progressive and irreversible tooth mobility. The physiologic form and function of the dentition and its supporting structures are restored and stabilized by means of combined periodontal and prosthetic therapy, supplemented when required by endodontic, orthodontic, and oral surgical procedures. Such a complex therapeutic effort requires a coordinated approach to diagnosis and a carefully orchestrated treatment plan. Patients requiring periodontal-prosthetics demonstrate some combinations of the following complications:
1. Moderate to advanced marginal periodontitis
2. Progressive tooth mobility and migration
3. Collapse of posterior occlusion, frequently with concomitant loss of vertical dimension of occlusion
4. Adverse crown-to-root ratio
5. Missing and malpositioned teeth
6. Inadequate and iatrogenic restorative dentistry
superimposed on and contributory to the periodontal and
occlusal pathosis
7. Furcal invasions
8. Proximity of adjacent roots
9. Inadequate zones of attached gingival and shallow
vestibular fornices
10. Increased exposure of proximal root concavities and
flutings that predispose to inadequate plaque control,
inducing root sensitivity, root caries, and gingival
inflammation
11. Esthetic impairment
12. Absence of a stable occlusion, frequently with
difficulty in mastication
13. Difficulty in tooth preparation because of increased
clinical length
14. More frequent incidence of pulp exposure during tooth
preparation because of increased preparation length and
taper
15. Problems in achieving parallelism of preparations
16. High incidence of parafunctional habit patterns,
temporomandibular joint (TMJ) dysfunction, and occlusal
and incisal wear patterns.

From the data collection, dentists list all the problems. Base on problem thinking method, dentists try to solve all problems and get the solutions of the problems, then summarize the solutions and make treatment plan. When we are
making the treatment plan, we also need to consider the patient's mental psychological condition, previous denture experience, what kind of denture he prefers, economic ability, dental recognition, physical health condition, time
limit and specialist opinion .In the treatment plan we offer the real reconstruction design and also arranges the efficiency and effective schedule. Both the diagnosis and treatment plan mast undergo continuous reappraisal during
provisional therapy until definitive decisions are made concerning abutment selection and final prosthesis design.

In this thesis, 9 moderate to advanced periodontal prosthetic treated cases were presented. These cases are applied with many different treatment methods.The periodontal treatment includes non-surgical and surgical procedure ( open-flap curettage, free gingival graft, subepithelial connective tissue graft,
osteotome sinus lift, guided bone regeneration, autogenous transplantation and implant placement). The final prostheses contain various designs (fixed prosthesis, implant overdenture, conventional overdenture and könus or CSC telescope denture).By the integrated, multidisciplinary approach of treatment, patients have healthy periodontal condition, can perform normal chewing function, pronunciation and satisfatory esthetic appearance.

並列關鍵字

periodontal prosthesis ； K&ouml ； nus and CSC telescopic denture ； implant overdenture ； autogenous transplantation ； full mouth rehabitation

參考文獻

Wanger AG. Comparision of four methods to determine rest position of the mandible. The Journal of Prosthetic Dentistry 1971; 25(5):p. 506-514.

2. 洪純正 , 蔡正文 , 王震乾 , 李惠娥 , 洪昭民. Könus雙重套冠系統的臨床應用（I）理論篇. 台灣齒科醫學會雜誌 1988;11(2): p.389-394.

3. Köber KH. Könus krone, Das rationale telescope system Einfuhrung in klinik und technik.; 1983.

4. Igarashi Y, Ogata A., Kuroiwa A. and Wang CH. Stress distribution and abutment tooth mobility of distal-extension removable partial entires with different retainers: An vivo study. Journal of Oral Rehabilitation 1999; 26:p. 111-116.

5. Langer A. Combination of diverse retainers in removable partial dentures. The Journal of Prosthetic Dentistry 1978; 40(4): p.378-384.