国际口腔医学杂志 ›› 2020, Vol. 47 ›› Issue (3): 318-327.doi: 10.7518/gjkq.2020043

• 综述 • 上一篇    下一篇

膜龈手术在牙龈乳头保留与重建中的应用

柳佳美,吴燕岷()   

  1. 浙江大学医学院附属第二医院口腔内科 杭州 310009
  • 收稿日期:2019-08-06 修回日期:2020-02-06 出版日期:2020-05-01 发布日期:2020-05-08
  • 通讯作者: 吴燕岷
  • 作者简介:柳佳美,学士,Email:liu-jm@zju.edu.cn
  • 基金资助:
    浙江省科学技术厅公益研究计划(LGF18H140003)

Application of periodontal plastic surgery in the preservation and reconstruction of gingival papilla

Liu Jiamei,Wu Yanmin()   

  1. Dept. of Oral Medicine, The Second Affiliated Hospital, Medical College of Zhejiang University, Hangzhou 310009, China
  • Received:2019-08-06 Revised:2020-02-06 Online:2020-05-01 Published:2020-05-08
  • Contact: Yanmin Wu
  • Supported by:
    Public Welfare Research Program of Science and Technology Department of Zhejiang Province(LGF18H140003)

摘要:

牙周组织丧失所导致的前牙牙龈乳头退缩是影响口腔美学的重要原因。牙龈乳头退缩还会引起食物嵌塞、牙龈乳头炎症,甚至影响发音。牙龈乳头退缩的治疗包括手术治疗与非手术治疗。膜龈手术中保留牙龈乳头的切口设计能避免龈乳头高度丧失,上皮下结缔组织移植术结合特殊的翻瓣术式是重建牙龈乳头的重要途径。牙龈乳头保留或重建成功的关键在于良好的血供。本文就膜龈手术方式在保留和重建牙龈乳头中的作用作一综述,以期为临床诊疗提供借鉴。

关键词: 牙龈乳头保留, 牙龈乳头重建, 上皮下结缔组织移植术

Abstract:

Papilla loss due to periodontal tissue defects could lead to aesthetic problems, food impaction, gingivitis, and pronunciation problems. Periodontal surgery and non-surgical treatment are the major solutions to preserve or reconstruct the gingival papilla. Relative periodontal surgery includes special surgical incisions to reduce papilla loss and application of soft tissue grafts or substitutes for papilla reconstruction. Sufficient blood supply is the key to successful periodontal mucogingival surgery. This article aims to review the specific role of periodontal surgery in the preservation and reconstruc-tion of gingival papilla.

Key words: gingival papilla preservation, gingival papilla reconstruction, subepithelial connective tissue graft

中图分类号: 

  • R781.4 +5

图 1

保留牙龈乳头切口示意图 A:保留牙龈乳头切口;B:改良的保留牙龈乳头切口;C:简化的保留牙龈乳头切口。虚线示沟内切口。"

表 1

膜龈手术的保留牙龈乳头切口设计"

手术术式 切口设计 操作步骤 主要适用手术
沟内 龈乳头 垂直
切口 切口 切口
保留牙龈乳 保留牙龈乳头切口 + - - 绕邻牙一周作沟内切口,在腭侧作弧形切 引导组织再生术(牙间隙
头切口 口,将完整保留的龈乳头连在唇瓣上 充分时)
改良的保留牙龈乳头切口 + - - 绕邻牙一周作沟内切口,在唇侧作弧形切
口连接邻牙近中轴角,将完整保留的龈乳
头连在腭瓣上
简化的保留牙龈乳头切口 + + - 绕邻牙一周作沟内切口,在牙间龈乳头上作 引导组织再生术(牙间隙
一牙颊侧近中轴角向邻牙邻面中点的切口 不充分时)
“鲸尾”技术 “鲸尾”技术 + - + 在骨缺损累及的2颗患牙的远缺损处,沿远 引导组织再生术(前牙区
中轴角各作一垂直切口,垂直切口延伸至 垂直骨缺损)
膜龈联合,其终点作水平切口相连,绕邻
牙一周作沟内切口,龈乳头保留在唇瓣上
改良 “鲸尾”技术 + - + 在骨缺损累及的2颗患牙的远缺损处,沿远
中轴角作2个半月形切口代替垂直切口和水
平切口至膜龈联合处
全牙龈乳头 + - + 在颊侧做沟内切口,然后在远离患牙骨缺 引导组织再生术(后牙区
保留技术 损处作一垂直切口,翻开全厚瓣,用显微 垂直骨缺损)
器械分离骨缺损处牙龈乳头,提升完整的
牙龈乳头
非牙龈乳头 - - - 仅作一颗患牙颊侧根方的水平切口,切口 引导组织再生术(颊侧骨
切口 尽可能远离骨缺损和龈缘,冠向翻起黏骨 壁吸收)
膜瓣
隧道技术 + - + 沿患牙颈部作沟内切口,然后在非直视下 根面覆盖
利用隧道专用显微器械分离颊侧半厚瓣至
膜龈联合处

图 2

“鲸尾”技术切口示意图 A:“鲸尾”技术;B:改良“鲸尾”技术。虚线示沟内切口。"

图 3

全牙龈乳头保留技术示意图 A:全牙龈乳头保留技术的切口设计;B:翻瓣后龈乳头仍保留。虚线示沟内切口,黄色箭头示窄深骨缺损处,黑色箭头示翻瓣方向。"

图 4

非牙龈乳头切口示意图"

图 5

隧道技术示意图 A:隧道技术唇侧示意图,线段状虚线示沟内切口,点状阴影示隧道;B:隧道技术矢状面示意图,虚线示隧道。"

图 6

种植二期保留牙龈乳头切口示意图 A:U形切口;B:H形切口;C:十字形切口;D:S形切口。虚线同心圆示种植体。"

图 7

Beagle术式示意图 A:Beagle术式腭侧示意图;B、C:Beagle术式矢状面示意图;D:改良Beagle术式唇侧示意图;E、F:改良Beagle术式矢状面示意图。虚线示沟内切口。"

[1] Batra P, Daing A, Azam I , et al. Impact of altered gingival characteristics on smile esthetics: layper-sons’ perspectives by Q sort methodology[J]. Am J Orthod Dentofacial Orthop, 2018,154(1):82-90.e2.
doi: 10.1016/j.ajodo.2017.12.010 pmid: 29957325
[2] Tarnow DP, Magner AW, Fletcher P . The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla[J]. J Periodontol, 1992,63(12):995-996.
doi: 10.1902/jop.1992.63.12.995 pmid: 1474471
[3] Jeong JS, Lee SY, Chang M . Alterations of papilla dimensions after orthodontic closure of the maxillary midline diastema: a retrospective longitudinal study[J]. J Periodontal Implant Sci, 2016,46(3):197-206.
doi: 10.5051/jpis.2016.46.3.197 pmid: 27382507
[4] 彭敏, MANDANA Hosseini, 张丰雪 . 上中切牙种植修复中种植体位置对临床冠长和龈乳头丰满度的影响[J]. 四川大学学报(医学版), 2018,49(4):656-659.
Peng M, Hosseini M, Zhang FX . Effects of implant position on clinical crown length and papilla fills in implant-supported maxillary central incisors[J]. J Sichuan Univ (Med Sci Edi), 2018,49(4):656-659.
[5] Bertl K, Gotfredsen K, Jensen SS , et al. Can hya-luronan injections augment deficient papillae at im-plant-supported crowns in the anterior maxilla? A randomized controlled clinical trial with 6 months follow-up[J]. Clin Oral Implants Res, 2017,28(9):1054-1061.
doi: 10.1111/clr.12917 pmid: 27378556
[6] Folke LE, Stallard RE . Periodontal microcirculation as revealed by plastic microspheres[J]. J Periodont Res, 1967,2(1):53-63.
doi: 10.1111/j.1600-0765.1967.tb01996.x pmid: 4229974
[7] Zhang F, Waller W, Lineaweaver WC . Growth fac-tors and flap survival[J]. Microsurgery, 2004,24(3):162-167.
[8] Fazekas R, Molnár E, Lohinai Z , et al. Functional characterization of collaterals in the human gingiva by laser speckle contrast imaging[J]. Microcirculation, 2018,25(3):e12446.
doi: 10.1111/micc.12446 pmid: 29457306
[9] Retzepi M, Tonetti M, Donos N . Comparison of gin-gival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry[J]. J Clin Periodontol, 2007,34(10):903-911.
doi: 10.1111/j.1600-051X.2007.01119.x pmid: 17850609
[10] Pradeep AR, Karthikeyan BV . Peri-implant papilla reconstruction: realities and limitations[J]. J Perio-dontol, 2006,77(3):534-544.
doi: 10.1902/jop.2006.050068 pmid: 16512769
[11] Tanaka OM, Furquim BD, Pascotto RC , et al. The dilemma of the open gingival embrasure between maxillary central incisors[J]. J Contemp Dent Pract, 2008,9(6):92-98.
pmid: 18784864
[12] Singh VP, Uppoor AS, Nayak DG , et al. Black triangle dilemma and its management in esthetic dentistry[J]. Dent Res J (Isfahan), 2013,10(3):296-301.
pmid: 24019795
[13] Sharma AA, Park JH . Esthetic considerations in interdental papilla: remediation and regeneration[J]. J Esthet Restor Dent, 2010,22(1):18-28.
[14] Ahmed AJ, Nichani AS, Venugopal R . An evaluation of the effect of periodontal biotype on inter-dental papilla proportions, distances between facial and palatal papillae in the maxillary anterior dentition[J]. J Prosthodont, 2018,27(6):517-522.
doi: 10.1111/jopr.12640 pmid: 28771895
[15] Goiato MC, de Medeiros RA, da Silva EVF , et al. Evaluation of the papilla level adjacent to implants placed in fresh, healing or healed sites: a systematic review[J]. Int J Oral Maxillofac Surg, 2017,46(11):1437-1445.
doi: 10.1016/j.ijom.2017.04.018 pmid: 28521965
[16] Kniha K, Kniha H, Möhlhenrich SC , et al. Papilla and alveolar crest levels in immediate versus delayed single-tooth zirconia implants[J]. Int J Oral Maxil-lofac Surg, 2017,46(8):1039-1044.
doi: 10.1016/j.ijom.2017.02.007 pmid: 28259599
[17] Roccuzzo M, Roccuzzo A, Ramanuskaite A . Papilla height in relation to the distance between bone crest and interproximal contact point at single-tooth im-plants: a systematic review[J]. Clin Oral Implants Res, 2018,29(Suppl 15):50-61.
doi: 10.1111/clr.13116 pmid: 29498124
[18] Kniha K, Modabber A, Kniha H , et al. Dimensions of hard and soft tissue around adjacent, compared with single-tooth, zirconia implants[J]. Br J Oral Maxillofac Surg, 2018,56(1):43-47.
doi: 10.1016/j.bjoms.2017.11.005 pmid: 29179980
[19] Ramanauskaite A, Roccuzzo A, Schwarz F . A syste-matic review on the influence of the horizontal dis-tance between two adjacent implants inserted in the anterior maxilla on the inter-implant mucosa fill[J]. Clin Oral Implants Res, 2018,29(Suppl 15):62-70.
[20] Takei HH, Han TJ, Carranza FA Jr , et al. Flap techni-que for periodontal bone implants. Papilla preserva-tion technique[J]. J Periodontol, 1985,56(4):204-210.
doi: 10.1902/jop.1985.56.4.204 pmid: 3889270
[21] Zucchelli G, Mounssif, Marzadori M , et al. Conne-ctive tissue graft wall technique and enamel matrix derivative for the treatment of infrabony defects: case reports[J]. Int J Periodontics Restorative Dent, 2017,37(5):673-681.
doi: 10.11607/prd.3083 pmid: 28817131
[22] Cortellini P, Prato GP, Tonetti MS . The modified papilla preservation technique. A new surgical ap-proach for interproximal regenerative procedures[J]. J Periodontol, 1995,66(4):261-266.
doi: 10.1902/jop.1995.66.4.261 pmid: 7782979
[23] Cortellini P, Prato GP, Tonetti MS . The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures[J]. Int J Periodontics Restorative Dent, 1999,19(6):589-599.
pmid: 10815597
[24] Froum SJ, Wang WC, Hafez T , et al. Incision design and soft tissue management to maintain or establish an interproximal papilla around integrated implants: a case series[J]. Int J Periodontics Restorative Dent, 2018,38(1):61-69.
doi: 10.11607/prd.2978 pmid: 29240207
[25] Bianchi AE, Bassetti A . Flap design for guided tissue regeneration surgery in the esthetic zone: the “whale’s tail” technique[J]. Int J Periodontics Restorative Dent, 2009,29(2):153-159.
pmid: 19408477
[26] Rath A, Fernandes BA, Sidhu P , et al. Surgical mana-gement of wide intrabony defect underlying midline diastema using Whale’s tail flap technique: a case report[J]. Int J Surg Case Rep, 2018,49:166-169.
doi: 10.1016/j.ijscr.2018.07.006 pmid: 30015214
[27] Kuriakose A, Ambooken M, Jacob J , et al. Modified Whale’s tail technique for the management of bone-defect in anterior teeth[J]. J Indian Soc Periodontol, 2015,19(1):103-106.
doi: 10.4103/0972-124X.145826 pmid: 25810604
[28] Aslan S, Buduneli N, Cortellini P . Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-year results[J]. J Clin Periodontol, 2017,44(9):926-932.
doi: 10.1111/jcpe.12780 pmid: 28727170
[29] Aslan S, Buduneli N, Cortellini P . Entire papilla preservation technique: a novel surgical approach for regenerative treatment of deep and wide intrabony defects[J]. Int J Periodontics Restorative Dent, 2017,37(2):227-233.
doi: 10.11607/prd.2584 pmid: 28196163
[30] Moreno Rodriguez JA, Caffesse RG . Nonincised papillae surgical approach (NIPSA) in periodontal regeneration: preliminary results of a case series[J]. Int J Periodontics Restorative Dent, 2018,38(Suppl):s105-s111.
doi: 10.11607/prd.3195 pmid: 30118534
[31] Zabalegui I, Sicilia A, Cambra J , et al. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: a clinical report[J]. Int J Periodontics Restorative Dent, 1999,19(2):199-206.
pmid: 10635186
[32] Azzi R, Etienne D, Takei H , et al. Surgical thickening of the existing gingiva and reconstruction of inter-dental papillae around implant-supported restorations[J]. Int J Periodontics Restorative Dent, 2002,22(1):71-77.
pmid: 11922221
[33] Zuhr O, Fickl S, Wachtel H , et al. Covering of gingival recessions with a modified microsurgical tunnel technique: case report[J]. Int J Periodontics Restora-tive Dent, 2007,27(5):457-463.
pmid: 17990442
[34] Zuhr O, Rebele SF, Cheung SL , et al. Surgery with-out papilla incision: tunneling flap procedures in plastic periodontal and implant surgery[J]. Perio-dontol 2000, 2018,77(1):123-149.
[35] Tuttle D, Kurtzman G, Bernotti AL . Gum drop te-chnique: minimally invasive soft-tissue platelet-rich plasma grafting for marginal soft-tissue recession[J]. Compend Contin Educ Dent, 2018,39(5):e9-e12.
pmid: 29714492
[36] Llamas-Monteagudo O, Girbés-Ballester P, Viña-Almunia J , et al. Clinical parameters of implants placed in healed sites using flapped and flapless techniques: a systematic review[J]. Med Oral Patol Oral Cir Bucal, 2017,22(5):e572-e581.
doi: 10.4317/medoral.21897 pmid: 28809375
[37] Arora H, Ivanovski S . Correlation between pre-operative buccal bone thickness and soft tissue chan-ges around immediately placed and restored implants in the maxillary anterior region: a 2-year prospective study[J]. Clin Oral Implants Res, 2017,28(10):1188-1194.
doi: 10.1111/clr.12939 pmid: 27469422
[38] Beagle JR . Surgical reconstruction of the interdental papilla: case report[J]. Int J Periodontics Restorative Dent, 1992,12(2):145-151.
pmid: 1521996
[39] Sawai ML, Kohad RM . An evaluation of a periodon-tal plastic surgical procedure for the reconstruction of interdental papillae in maxillary anterior region: a clinical study[J]. J Indian Soc Periodontol, 2012,16(4):533-538.
doi: 10.4103/0972-124X.106897 pmid: 23493264
[40] Chaulkar PP, Mali RS, Mali AM , et al. A comparative evaluation of papillary reconstruction by modified Beagle’s technique with the Beagle’s surgical te-chnique: a clinical and radiographic study[J]. J In-dian Soc Periodontol, 2017,21(3):218-223.
[41] Han TJ, Takei HH . Progress in gingival papilla reconstruction[J]. Periodontol 2000, 1996,11:65-68.
doi: 10.1111/j.1600-0757.1996.tb00184.x pmid: 9567958
[42] Kaushik A, Pk P, Jhamb K , et al. Clinical evaluation of papilla reconstruction using subepithelial con-nective tissue graft[J]. J Clin Diagn Res, 2014,8(9):ZC77-ZC81.
doi: 10.7860/JCDR/2014/9458.4881 pmid: 25386529
[43] Kadkhodazadeh M, Amid R, Kermani ME , et al. A modified frenectomy technique: a new surgical ap-proach[J]. Gen Dent, 2018,66(1):34-38.
pmid: 29303760
[44] Azzi R, Etienne D, Carranza F . Surgical reconstruc-tion of the interdental papilla[J]. Int J Periodontics Restorative Dent, 1998,18(5):466-473.
pmid: 10093523
[45] Jaiswal P, Bhongade M, Tiwari I , et al. Surgical reconstruction of interdental papilla using subepi-thelial connective tissue graft (SCTG) with a coronally advanced flap: a clinical evaluation of five cases[J]. J Contemp Dent Pract, 2010,11(6):E049-E057.
pmid: 21203737
[46] Muthukumar S, Rangarao S . Surgical augmentation of interdental papilla—a case series[J]. Contemp Clin Dent, 2015,6(Suppl 1):S294-S298.
doi: 10.4103/0976-237X.166836 pmid: 26604592
[47] Nordland WP, Tarnow DP . A classification system for loss of papillary height[J]. J Periodontol, 1998,69(10):1124-1126.
doi: 10.1902/jop.1998.69.10.1124 pmid: 9802711
[48] Carnio J, Carnio AT . Papilla reconstruction: interdi-sciplinary consideration for clinical success[J]. J Esthet Restor Dent, 2018,30(6):484-491.
doi: 10.1111/jerd.12411 pmid: 30195268
[49] Buti J, Baccini M, Nieri M , et al. Bayesian network meta-analysis of root coverage procedures: ranking efficacy and identification of best treatment[J]. J Clin Periodontol, 2013,40(4):372-386.
doi: 10.1111/jcpe.12028 pmid: 23346965
[50] Sharma E, Sharma A, Singh K . The role of subepi-thelial connective tissue graft for reconstruction of interdental papilla: clinical study[J]. Singapore Dent J, 2017,38:27-38.
doi: 10.1016/j.sdj.2017.05.001 pmid: 29229072
[51] Zuhr O, Bäumer D, Hürzeler M . The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and exe-cution[J]. J Clin Periodontol, 2014,41(Suppl 15):S123-S142.
doi: 10.1111/jcpe.12185 pmid: 24640997
[52] Henriques PG, Okajima LS, Siqueira S Jr . Surgical reconstruction of the interdental papilla: 2 case re-ports[J]. Gen Dent, 2018,66(4):e1-e4.
pmid: 29964255
[53] De Castro Pinto RC, Colombini BL, Ishikiriama SK , et al. The subepithelial connective tissue pedicle graft combined with the coronally advanced flap for restoring missing papilla: a report of two cases[J]. Quintessence Int, 2010,41(3):213-220.
pmid: 20213022
[54] Muthukumar S, Ajit P, Sundararajan S , et al. Recons-truction of interdental papilla using autogenous bone and connective tissue grafts[J]. J Indian Soc Perio-dontol, 2016,20(4):464-467.
[55] Azzi R, Takei HH, Etienne D , et al. Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts[J]. Int J Periodontics Restorative Dent, 2001,21(2):141-147.
pmid: 11829388
[56] Geurs NC, Romanos AH, Vassilopoulos PJ , et al. Efficacy of micronized acellular dermal graft for use in interproximal papillae regeneration[J]. Int J Perio-dontics Restorative Dent, 2012,32(1):49-58.
pmid: 22254225
[57] Yamada Y, Nakamura S, Ueda M , et al. Papilla re-generation by injectable stem cell therapy with re-generative medicine: long-term clinical prognosis[J]. J Tissue Eng Regen Med, 2015,9(3):305-309.
doi: 10.1002/term.1737 pmid: 23533047
[58] Ahila E, Saravana Kumar R, Reddy VK , et al. Aug-mentation of interdental papilla with platelet-rich fibrin[J]. Contemp Clin Dent, 2018,9(2):213-217.
doi: 10.4103/ccd.ccd_812_17 pmid: 29875563
[1] 罗志宾综述 曾融生, 陈卓凡审校. 牙种植体周软组织的处理[J]. 国际口腔医学杂志, 2009, 36(5): 583-585,589.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
[1] 张新春. 桩冠修复与无髓牙的保护[J]. 国际口腔医学杂志, 1999, 26(06): .
[2] 王昆润. 长期单侧鼻呼吸对头颅发育有不利影响[J]. 国际口腔医学杂志, 1999, 26(05): .
[3] 彭国光. 颈淋巴清扫术中颈交感神经干的解剖变异[J]. 国际口腔医学杂志, 1999, 26(05): .
[4] 杨凯. 淋巴化疗的药物运载系统及其应用现状[J]. 国际口腔医学杂志, 1999, 26(05): .
[5] 康非吾. 种植义齿下部结构生物力学研究进展[J]. 国际口腔医学杂志, 1999, 26(05): .
[6] 柴枫. 可摘局部义齿用Co-Cr合金的激光焊接[J]. 国际口腔医学杂志, 1999, 26(04): .
[7] 孟姝,吴亚菲,杨禾. 伴放线放线杆菌产生的细胞致死膨胀毒素及其与牙周病的关系[J]. 国际口腔医学杂志, 2005, 32(06): 458 -460 .
[8] 费晓露,丁一,徐屹. 牙周可疑致病菌对口腔黏膜上皮的粘附和侵入[J]. 国际口腔医学杂志, 2005, 32(06): 452 -454 .
[9] 赵兴福,黄晓晶. 变形链球菌蛋白组学研究进展[J]. 国际口腔医学杂志, 2008, 35(S1): .
[10] 庞莉苹,姚江武. 抛光和上釉对陶瓷表面粗糙度、挠曲强度及磨损性能的影响[J]. 国际口腔医学杂志, 2008, 35(S1): .