摘要
依Amsterdam 1974牙周補綴的定義:針對重度牙周病的治療過程中,適當且絕對必要的補綴治療。而面臨重度牙周炎,囊袋深度≧７mm，臨床症狀除了牙齦發炎出血、牙周膿腫、口臭、牙縫增大甚至為牙齒動搖度增加、冠根比例不當併發次級性咬合傷害、咬合崩潰、不良咬合平面、少數殘存齒列、牙齒異位、造成咬合不穩定等情況發生。在施行任何復形和補綴治療之前，首重牙周炎控制及創傷性咬合的去除。牙周炎控制：包括了手術及非手術的治療。 手術性的治療：從傳統性的齦下刮除術、瓣膜翻開術、植骨手術及引導牙周再生手術。非手術性的治療：主要以超音波洗牙治療。 而手術及非手術的療效，根據Kaldahl 1990 結論，就短期內手術治療可以降低較多的牙周囊袋深度，但就長期而言，不管手術及非手術對於牙周囊袋深度(probing depth)及臨床附著(clinic attachment level)並無顯著差異。 創傷性咬合治療方式：主要包括咬合調整、咬合板治療、矯正治療、splinting、贋復治療。而牙周補綴的設計包括了：固定義齒、傳統可撤式活動義齒、覆蓋式義齒、套疊式義齒及植牙。 本論文提出9個病例報告(可參考病例摘要表)。患者除了動機明確願意配合外，均教導積極性的口腔衛教及牙周炎基本治療（包括結石刮除術、牙齦下刮除術及根面整平術及齲齒復形、根管治療及拔除癒後不良牙齒）(Walter B. Hall 1998)。病例一、二、三、七的缺牙區或牙齒動搖區皆予以治療性臨時義齒或金屬矯正線以樹脂光聚合固定，藉以重建患者顎間關係及咬合高度，並有二次固定動搖牙齒功效及重新分配力量，重新打造一有利牙周復原的環境。在徹底基本治療後四個禮拜重新評估(Polson 1981)其牙周情況。此依Lindhe 1982牙周囊袋超過5 mm以上，BOP乃予以翻瓣手術治療(病例一、七、八)。嚴重骨缺損，有殘餘二面至三面骨壁且骨下缺損超過4 mm (Laurell 1998) 給予骨粉(病例八)或基質蛋白(病例一)以利修復或牙周再生。牙齦下牙冠缺損以牙冠增長術露出健康的牙冠邊緣齒質(病例四、五、七)，維持基本生物寬度3 mm(Gargiulo 1961)。根叉侵犯達二、三級，且牙根外展度足夠且有保留價值的牙齒進行牙根分離及切除術(病例一、三、八) ，使得口腔清潔易維持並能保持齒槽嵴高度。病理性位移(病例二、三、四、五、七)造成牙齒擁擠、咬合干擾、咬合平面喪失、食物淤塞、空間分配不當及齒軸不佳乃藉由矯正方式改善(病例二、三、四、五、七)。附著牙齦不足，予以結締組織移植，用以維持牙周穩定及防止牙齦發炎和萎縮(病例四)。至於前牙因長期缺損時間過久，造成牙嵴塌陷，則以結締組織作牙嵴豐隆術，維持前牙美觀(病例四)。 牙周補綴方面，依支台齒數目的多寡(Ante's law l926)及美觀經濟考量來設計補綴物是固定或活動式義齒。至於牙周支持不良的牙齒，則以薄蓋冠，降低冠根比例、減少側方力量、防止二次創傷性咬合，之後以覆蓋式義齒(病例三、四)或雙重冠義齒(病例一、二、五、六、七)，讓咬合一體化，可防止傳統牙鉤(clasp)式的活動義齒易造成義齒及天然牙行使咀嚼功能非等量下陷問題。缺牙區以植體贋復後，可避免天然齒修磨、黏膜刺激、齒槽嵴的維持、固位性高(Patrick .J. Steven 2000)、咀嚼速率增加(Jemt et. al. 1985)、下顎運動範圍增加(Lundgren et. al.1987)，及最大咬力增加(Judith et.al.2000) (病例四、九)。另外植體本身對後牙喪失，提供錨定來源及垂直高度的支撐，並防止前牙外翻，讓整個齒列可以重新分配空間，維持整個牙弓的完整、穩定性(病例四)。 總之，牙周補綴是跨多科性的治療，而不能簡單區分為單純的牙周治療或單純的補綴治療，牙醫師應衡量每種補綴設計的優缺點，配合病患經濟考量予以最適當的治療，以期維持患者長期健康、功能、美觀的需求。
並列摘要
The definition of Periodontal prosthesis according to the Amsterdam 1974: the process of prosthetic therapy is appropriate and absolute necessity at advanced periodontitis.But the probing depth exceed 7 mm in advanced periodontitis,the clinical condition besides gingival bleeding、 gingival inflammation、periodontal abcess、halitosis、increasing interdental space、increasing tooth mobility、improper crown to root ratio inducing secondary occlusal trauma、bite collapse、uneven occlusal table 、residual dentition、pathologic migration、and unstable occlusion.The most important is plaque control and elimination of occlusal trauma before any restorative and prosthetic treatment.The control of periodontitis included: surgical and non-surgical therapy. Surgical therapy : subgingival curettage、flap operation、bone graft and regenerative surgery.Non-surgical therapy: primarily with ultrasonic treatment. According to the conclusion of Kaldahl 1990, the short-term treatment of surgical treatment can decrease more probing depth than non-surgical treatment, But there are no statistic difference for probing depth and clinical attachment in the long-run.The therapy of traumatic occlusion included occlusal adjustment、occlusal plate、orthodontic treatment、splinting and prosthetic treatment,then periodontal prosthesis covered fixed bridge、traditional removable denture、overdenture、double crown restoration and implant. This thesis brings up 9 case reports (please refer to the table of case summary). Besides active motivation and well coordination,patients were taught good oral hygiene control and basic periodontal therapy including scaling、root planing、subgingival curettage、restoration、root canal therapy and extration of holeless teeth ( Walter B.Hall 1998). The edentulous ridge or movable teeth in case 1,2,3,7 were performed by provisional denture or wire fixation with light curing resin in order to rebuild jaw relation、occlusal vertical dimension、secondary splinting of movable teeth and redistributing occlusal load. This therapy could provide a beneficial environment for periodontal regeneration.After thoroughly basic treatment for 4 weeks,re-evaluating the periodontal circumstance (Poson 1981).According to Lindhe 1982,the probing depth exceeded 5 mm and bleeding on probing treated with flap surgery (case 1,7,8) . Severe 2-to 3-wall bony defect exceeding 4 mm (Laurell 1998) were performed with bone grafts (case 8) or Emdogain (case 1) to repair or regeneration of periodontal tissue.The subgingival caris were treated with crown lengthening procedure to expose sound teeth structure (case 4,5,7) in order to keep biological width: 3 mm (Gargiulo 1961).The garded teeth with gradeⅡor gradeⅢfurca invasion and wide root proximity were treated by root separation (case 1,3,8) to give easy oral hygiene control and ridge height maintenance.Pathologic migration (case 2,3,4,5,7) inducing teeth crowding、occlusal interference、uneven occlusal table、food impaction and improper space distribution were corrected by orthodontic therapy (case 2,3,4,5,7).Lacking attached gingiva were organized with connective tissue grafts in order to maintain the periodontal stability then preventing gingival inflammation and gingival recession (case 4).A common consequence of tooth loss for a long–term period was ridge resorption augmented with connective tissue grafts to keep esthetics of upper anterior teeth (case 4). In the aspect of periodontal prosthesis,the design of fixed or removable denture depended on the number of abutment teeth (Ante's law l926)、esthetics and financial consideration. As for less supporting tooth structure were treated with inner coppig、crown to root ratio reduction、lateral force elimination or preventing secondary trauma from occlusion. After that, overdenture (case 3,4) or double crown restoration (case 1,2,5,6,7) made the occlusion for one-unit preventing uneven sinking between nature teeth and prosthesis of traditional clasp removable denture.Edentulous ridge restored by implants (case 4,9) avoided nature teeth preparation、mucosa irritation、alveolar ridge maintenance、denture stability ( Patrick .J. Steven 2000)、raising chewing efficiency (Jemt et. al. 1985)、increasing the border of mandibular movement (Lundgren et. al.1987)、improving maximal biting force (Judith et.al.2000).In addition,as loss of posterior supporting teeth,implants cound provide anchorage、posterior support which prevented anterior teeth flaring out、redistributing space、keeping the whole arch integration and stability. In sum up, periodontal prosthesis covers many sectional treatments and can't be simplified to pure periodontal or prosthetic treatment. Dentist must evaluate the advantage and disadvantage in each prosthetic design to give patients the most appropriate treatment depending on financial consideration, getting with health、function and beauty for the long-term period.