摘要
當代醫學極重視『全人醫療』的概念，而牙科治療因各次專科的蓬勃發展，各項新技術的誕生，藉由科際之間的密切合作，以期達到對整個口腔環境作全方位的照護，此即「整合性全口治療」的概念。牙周補綴學之父，美國賓州大學Amsterdam教授於1974年提出「牙周補綴」的定義，他說「牙周補綴即是在嚴重牙周病治療當中，絕對必須的復形及補綴治療」；「而這些治療的概念、原則及技術亦適用於自然齒列之復形與補綴」，亦即牙周補綴的治療是必須綜合各項治療來達到維護口腔健康的目標。舉凡復形、補綴、根管及矯正均為牙周治療所用，共同協助牙周治療的完成，其角色不再只是目的，更是一種手段。所以，牙周補綴治療正是「整合性全口治療」的具體實踐。 牙周補綴的患者其齒列常是已遭中度或重度牙周病所侵犯，在咀嚼功能上、美觀上甚至病患心理層面上均已受損。所以，除了牙周病炎症的控制及牙菌斑，牙結石各種致病因子的徹底清除外，還需要適當的復形補綴來重建患者的咀嚼功能、美觀，並增加患者自信心，恢復其社交的能力，使其更有足夠動機來配合治療。在治療期間常需製作大量暫時補綴物，除材質與最終補綴物不同外，必須完全符合生理型態及功能，並滿足病患對美觀上的需求。又因裝戴期長常需修補，所以對治療者而言是一項極大的挑戰。\r 此類病患另一項特徵，根據Amsterdam教授所描述：「牙周補綴患者中，百分之九十五伴隨有後牙咬合崩塌 (posterior bite collapse)」，其結果則是產生咬合垂直高度 (vertical dimension of occlusion) 的喪失、臉型改變、下顎前移、最大牙尖對咬咬合 (MI) 偏離正中關係 (CR)、咬頭異常磨耗 (wear facet)、咬合干擾、 咬合創傷 (trauma from occlusion)、前牙前突 (flare-out) 等併發症。 在治療期必須以各種方法；如咬合板、暫時補綴物、選擇性修磨 (selective grinding) 或是矯正治療來重建其咬合高度，穩固其咬合並恢復功能，並期達到相互保護性咬合 ( mutually protected occlusion)。 治療的另一難題則是美觀上的要求如何達到，牙周病的患齒因附連喪失 (attachment loss)、牙根裸露，本就美觀不佳，又因冠根比不良，常需大量連接 (splinting) 支柱牙，以穩定咬合，因而造就了長距離跨弓連接 (long span， cross arch) 的補綴物，在製作時如何兼顧美觀及維護功能的設計，著實考驗治療者的智慧。 也由於長距離跨弓連接的補綴物設計，使每一支柱牙承擔莫大的風險，其中一支柱牙毀損，都將造成不可彌補的傷害！所以在擬定治療計劃前，對殘存齒的診斷、炎症的進行、預後的判斷 (prognosis)、治療效果的評估及支柱牙的選擇，必須力求精準，使每一支柱牙均足堪大任。 當然和病患的溝通也很重要，須使其明白補綴物是建立在某些妥協下的產物，有任何的變化均足以牽一髮而動全身；並應釐清責任，告知居家護理及定期回診的重要，千萬不要給患者過高的期望。給予適當而合理的保固 (warranty)，以取代終身的保證與承諾 (guaranty)。如此才不會造成醫病關係的緊張。 自從1977年Brånemark醫師提出骨整合 (osseointegration) 觀念，為牙科治療帶來了新的思維。近年來的各項文獻均指出種植體具備高成功率，是值得信賴的技術。種植體的應用在牙周補綴上，則是大量減少長距離跨弓連接的補綴物，保存健康牙不被修磨製備，並提供強有力的支持，尤其對遠心延伸端缺牙區 (distal extension) 的病例，提供後牙良好的支撐，回復良好的咬合並減少裝戴活動義齒之苦；對全口義齒的病例亦可提供良好的固位 (retention)，增加本體感覺，並防止無牙脊的過度吸收。實在是我們治療中的一大利器。 病例一、七、八為下顎遠心延伸端缺牙區，以種植體贗復，避免裝戴活動義齒的機會，其中病例一為全口重建之病例，上顎以六顆支柱牙支撐全口固定義齒，是屬於風險較高的設計，所幸咬合設計得宜，左右側方運動為犬齒引導 (canine guidance)，前突運動為切齒引導 (incisal guidance)，行使功能時前後牙互相保護，追蹤至今七年並無異狀。 病例三、九及十二均涉及上顎竇增高術，其中病例三、九為上顎遠心延伸端缺牙區，以種植體贗復合倂上顎竇增高術，病例三應用手骨鑽法 (osteotome technique)，病例九為開窗法 (window technique)，病例十二並取頦骨為移植骨來源，墊高上顎竇底以利將來種植體植入。 病例二為下顎全口無牙脊，施以種植體贗復固定義齒，上顎為長距離跨弓固定義齒。 病例四為早期的案例，上顎為全口義齒，下顎為覆蓋式義齒，以精密連接體ERA－OV連接自然牙支柱 (natural tooth abutments) 與全口義齒，咬合設計為全口平衡性咬合 (full mouth balanced occlusion)。 病例五幾為全口無牙脊，在上顎加植一支種植體以增加固位製做覆蓋式義齒，在下顎植四支種植體於兩頦孔間區域 (interforaminal region) 製做覆蓋式義齒，並以ERA－OV之精密連接體連接種植體和義齒。 病例六為上顎單弓無牙脊，下顎為自然齒列，上顎以四支種植體固位製作覆蓋式義齒，下顎牙冠及牙橋利用製作的順序整合於上下咬合設計中且左右均可達到平衡咬合。另為求舒適嘗試去除腭蓋，形成無腭蓋式覆蓋義齒 (roofless overdenture)。 病例八為重症牙周病患，基本治療後施以牙周齒槽骨手術 (osseous surgery) 去除骨內缺損 (infrabony defects & craters )，並配合根向重置翻瓣 (apically repositioned flap)，徹底去除牙周囊袋 病例十及十一均為牙齒斷裂施予立即性植牙手術 (immediate implant placement)。立即拔牙立即植牙可以完整保持軟組織的高度及外形，達到美觀上的高度滿意度，其中應用的是特殊的手骨鑽技巧，在病例報告中有詳述。 本病例集所彙整之病例大多為重度牙周病，缺牙數目多，常牽涉到咬合重建的問題。如病例一、二、三、四、五、六。其中咬合垂直高度的重建，正中關係 (CR) 紀錄的獲得，及咬合計劃 (occlusal scheme)的建立，均需整合在治療計劃當中。尤其病例六的咬合設計更要精準，以免造成綜合症候群 (combination syndrome)。原則上在覆蓋式義齒的咬合計劃等同於全口義齒，即全口平衡性咬合 (full mouth balanced occlusion；cross arch，cross tooth)，而全口固定義齒之咬合計劃務必達到相互保護性咬合 (mutually protected occlusion)，當下顎作側方及前突運動時，足以避免後牙異常的磨耗。關於這一點，雖然Amsterdam教授表示，在他的經驗中，平衡性咬合存在與否和牙齒健康沒有絕對關係；百分之九十的人其正中關係 (CR）和最大牙尖對咬咬合關係（MI，maximum intercuspation）均不一致，而不會出現任何症狀。然而因為補綴上任何咬合的改變（和原先的咬合相較），若患者神經肌肉系統無法適應，則任何咬點的改變都有可能變成干擾（interference），只有穩定且可重複再現的正中關係位置才是可靠的。這其中還牽涉到醫療責任的問題，也正如Amsterdam教授所述：「不可治療了一個問題，而產生了另一個問題。」此點吾人不可不慎！筆者所遵循的原則是：全口義齒的咬合型式為全口平衡性的咬合；全口固定義齒的咬合型式為相互保護性咬合。這些原則在所彙整的病例中可以得到驗証。
並列摘要
Contemporary medical science emphasizes on ‘total patient care’. With the development of specializations, new technologies and inter-disciplinary cooperation, the concept of ‘integrated oral care’ (all-in-one care of oral environment) can finally be realized. The father of periodontal prosthesis, professor Amsterdam of the University of Pennsylvania, defined the periodontal prosthesis in 1974 as the ‘necessary restorations and prostheses in severe periodontal treatment’. And the technology and treatment principle involved are universally applicable to the natural dentition. Periodontal prosthesis combines multiple treatments to maintain oral health. Since periodontal treatment involves restorations and prostheses, root canal therapy, and orthodontics, it is no longer the goal, but the means to realize ‘integrated oral care’. Patients that require periodontal prosthesis treatment are often infected with moderate or severe periodontal disease. Not only do they experience difficulty with chewing, but the appearance deficit might trigger emotional or psychological trauma. Thus besides proper procedure, tooth decay and tartar removal, periodontal treatment must also help patients regain their confidence and social ability by applying adequate filling, restorations and prostheses . A large quantity of provisional prostheses is tried before the permanent one is applied, as the result must satisfy the patient’s demand for aesthetics and functionality. Finding the best prosthetics can be quite a challenge for the treatment giver. One of the characteristics of periodontal patients of this kind, according to professor Amsterdam, is that 95% of them are accompanied by posterior bite collapse, which can result in the loss of vertical dimension of occlusion, change of facial profile, protruding mandible, discrepancy between MI and CR, wear facet, occlusal interference, trauma from occlusion, and flare-out anteriors etc. The treatment must utilize various means, such as biteplate, temporary prosthetics, selective grinding or orthodontics to rebuild proper occlusion and achieve stable and mutually protected occlusion. Another difficult task is the achievement of aesthetics. Most periodontal patients experience attachment loss and root exposure, added the long span and cross arch caused by splinting, it is a test on the surgeon’s knowledge to come up with a great design that conveys both functionality and aesthetic appeal. The long-span and cross-arch designed prosthesis imposes great risk to every abutment tooth, and damage to any one of them could turn out not repairable. Therefore, it is imperative to ensure precision and accuracy in the diagnosis, prognosis, treatment evaluation and the selection of the abutment teeth. Good communication with the patient is also crucial to the success of the prosthetic procedure. It must be understood that the procedure is a negotiated compromise. Accountability must be clearly drawn, and patients must be aware of the importance of self-care and periodic recalls for maintenance. Never give the patients false hope or over expectation. Give adequate and reasonable warranty instead of lifetime guaranty. The introduction of osseointegration by Dr. Brånemark in 1977 was a revolutionary concept in dentistry. And documented proof indicated high success rate of its implementation. Its application in prosthetics focuses on the reduction of long- span and/or cross- arch design, preventing healthy teeth from having to be prepared, and providing great abutment support. Implant placement is especially ideal for distal-extension edentulous ridge, as it provides strong posterior support and occlusion reconstruction, and reduces the inconvenience associated with removable denture. Implant placement is also an outstanding method that provides good retention, stability and proprioception for patients with overdentures. Over-resorption of the ridges could be reduced by this way. Case 1、7 and 8 were the patients with distal-extension edentulous ridge in the lower jaw. A dental implant was placed to avoid having to resort to removable denture. Case 1 was a full mouth rehabilitation case, in which six abutment teeth from the upper jaw supported the full arch fixed denture, and was more of a risky build. Fortunately occlusion was properly designed, and the lateral and anterior movements of the mandible were canine and incisal guided, respectively. This case has been seven years of good oral record up to today. Case 3、9、12 were cases involved with maxillary sinus lift procedure. Case 3、9 were the patients with distal-extension edentulous ridge in the upper jaw. The treatment involved implantation combined with procedure of maxillary sinus lift. In case 12, sinus augmentation with autogenous bone grafted from symphysis and single tooth implant placement would be performed later in the near future. Osteotome technique and window technique were applied respectively. Case 2: Severely periodontal infected teeth in mandible and maxilla. All teeth in the mandible were hopeless and extracted. Seven implants were placed in the residual ridge three months after the extraction and supported a full arch bridge. Six maxillary teeth were retained after periodontal therapy and used as abutments for full arch fixed denture. Case 4 was one of the earlier cases. The upper jaw was complete denture and the lower one overdenture. A precision attachment: ERA-OV, was used to connect the natural tooth abutments with the overlay denture. The occlusal scheme was full mouth balanced occlusion. Case 5 Severely resorpted residual ridge was found in the maxilla and mandible. Four implants were placed in the complete edentulous ridge of mandible, at the interforaminal region, to retain an overdenture. Another implant was placed at upper left canine region to improve retention of upper overdenture. ERA-OVs was used to connect the abutments and the dentures. Case 6: The patient was totally edentulous in the upper jaw and contained natural teeth in the lower jaw except left first molar. Four implants were used to stabilize overdenture in the upper jaw. To achieve bilaterally balanced occlusion, teeth arrangement of upper was done firstly and the wax patterns of the crowns and bridges in the lower jaw were just integrated into the occlusal scheme. The palatal portion of upper denture was removed with caution to enhance patient’s comfort. Case 8 experienced severe periodontal disease. After preliminary treatment, an osseous surgery was conducted to remove infrabony defects and craters, coupled with apically repositioned flap to completely remove pockets. Case 10 and 11 were both broken teeth that required immediate implant placement. Such immediate placement could preserve the shape and height of the soft tissue, in other words, aesthetics. This operation requires a unique osteotome technique, which is described in more detail in the case report. This compilation consisted mostly of severe cases of periodontal disease with numerous loss teeth that often required occlusion rebuild. Integrated treatment plan for cases 1 to 6 all involved the regain of vertical dimension of occlusion, acquiring of CR records, and establishing occlusal scheme. The occlusal scheme for case 6, in particular, needed to be very precise to avoid “combination syndrome”. In principle, the occlusal scheme for overdenture is the same as that of complete denture, meaning a full mouth balanced occlusion, cross arch and cross tooth. And the occlusal scheme for a full mouth fixed denture must be mutually protected occlusion to avoid abnormal wear of the posterior teeth due to mandibular movement. Although professor Amsterdam asserted that, in his experience, balanced occlusion is not directly related to dental health, 90% of the people’s CR and MI (maximum intercuspation) do not match, and have no signs of ailment. Yet any change to occlusion as a result of prosthetic procedure (when compared to the one before) could lead to interference, if the patient’s neuromuscular system could not adapt to the change. Hence the only reliable result is to reproduce the same CR. This often involves medical accountability and responsibility, and must be a subject of awareness for my fellow doctors. The principles I personally stand by are: the occlusal scheme for complete denture is a full mouth balanced occlusion with cross arch and tooth, whereas the occlusal scheme for full mouth fixed denture is mutually protected. The application of these principles can be found in the compiled case studies.