国际口腔医学杂志

国际口腔医学杂志 ›› 2022, Vol. 49 ›› Issue (5): 497-505.doi: 10.7518/gjkq.2022084

• 专家笔谈 •    下一篇

美学区种植骨增量与邻牙慢性根尖周病的联合治疗策略（上）：应用基础及适应证

满毅1,黄定明2()   

  1. 1.口腔疾病研究国家重点实验室;国家口腔疾病临床医学研究中心;四川大学华西口腔医院种植科 成都 610041
    2.口腔疾病研究国家重点实验室;国家口腔疾病临床医学研究中心;四川大学华西口腔医院牙体牙髓病科 成都 610041
  • 收稿日期:2022-04-01 修回日期:2022-06-16 出版日期:2022-09-01 发布日期:2022-09-16
  • 通讯作者: 黄定明
  • 作者简介:<named-content content-type="corresp-name">满毅</named-content>，教授，四川大学华西口腔医院种植科主任，博士研究生导师。中华口腔医学会种植专业委员会副主任委员，国际种植学会（International Team for Implantology）中国分会候任主席， 国际骨再生基金（Osteology Foundation） 中国区执行委员会（NOG China） 会长，口腔数字化产业分会副会长，四川省口腔种植专业委员会主任委员。2007 年毕业于四川大学华西口腔医学院获博士学位。2010—2012 年被美国Tufts大学牙学院聘为临床讲师，2011—2012 年为美国哈佛大学访问学者。主要研究改良多种种植外科和修复技术，并已发表在国际种植学、外科学和修复学杂志。主编专著3本，获得4 项国家发明专利，并实现转化。多次受邀在国际、国内会议上发表演讲，发表临床论文和科研论文50 余篇，主持多项国际、国家、省部级课题。|<named-content content-type="corresp-name">黄定明</named-content>，口腔医学博士，四川大学华西口腔医院教授，博士研究生导师。中华口腔医学会牙体牙髓专业委员会常务委员，老年口腔医学专业委员会常务委员，四川省口腔医学会牙体牙髓专业委员会主任委员，国家口腔医学中心牙体牙髓专科联盟主任委员。《国际口腔医学杂志》常务编委、《北京口腔医学杂志》编委、Molecular Oral Microbiology副主编。一直从事牙体牙髓根尖周病病因及现代诊治技术研究、教学和临床工作，利用现代理论知识和技术创新诊疗方法解决临床疑难问题。主持国家级、省部级科研项目10项，参编国家规划本科教材《牙体牙髓病学》和研究生教材《牙髓病学》《实用牙体牙髓病治疗学》《牙体牙髓科诊疗与操作规范》等专著10部，在国内外本领域顶级期刊发表牙体牙髓病诊治相关论文100余篇，获得国家科技进步二等奖1项、省部级科技进步一等奖3项、中华医学科技三等奖1项。
  • 基金资助:
    四川省科技厅重点研发项目(2021YFS0030);四川大学华西口腔医院探索与研发项目(LCYJ2019-19)

Combined treatment strategy of oral implantology and endodontic microsurgery for bone augmentation and en-dodontic diseases in aesthetic area (part 1): application basis and indications

Man Yi1,Huang Dingming2()   

  1. 1.State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Implantology, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
    2.State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cariology and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
  • Received:2022-04-01 Revised:2022-06-16 Online:2022-09-01 Published:2022-09-16
  • Contact: Dingming Huang
  • Supported by:
    Key Research and Development Project of the Science and Technology Department of Si-chuan Province(2021YFS0030);Exploration and Research and Development Project of West China Hospital of Stomatology, Sichuan University(LCYJ2019-19)

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摘要：

在口腔种植治疗的临床实践中，种植相关治疗术区骨量不足同时合并邻牙慢性根尖周炎的临床现象特殊而又普遍，邻牙慢性根尖周炎可成为骨增量手术中潜在的感染源而引起早期治疗失败/或延伸至种植体根尖周引起逆行性种植体周炎。不同于传统分科诊疗的模式，笔者基于两个学科的发展基础，提出了邻牙显微根尖手术与种植相关治疗同期完成的联合治疗新模式。目的是在实施种植相关手术同期消除邻牙潜在感染源；同时根尖手术中保留的自体骨可以避免种植相关骨增量手术中开辟第二术区取骨，大大提高了手术效率，并进一步减小了患者创伤，节省了医疗费用。本文针对这一新的联合治疗策略的应用基础及临床适应证进行探讨。

关键词: 口腔种植, 引导骨再生, 显微根尖外科手术, 引导组织再生, 逆行性种植体周炎

Abstract:

In the clinical practice of dental implants, the implant-related surgery in areas with proximity to a periapical lesion of adjacent teeth was relatively particular but not uncommon. Chronic apical periodontitis of adjacent teeth could become a potential source of infection in bone augmentation surgery and cause early surgery failure/or extend to the apical area of the implant and cause retrograde peri-implantitis. Unlike the traditional treatment modality, a novel digital treatment modality involves the performance of implant-related surgery in conjunction with endodontic microsurgery of the adjacent tooth during one process to control the potential risk originating from apical periodontitis, completely remo-ving the infection from the apex of adjacent teeth and establishing sufficient apical sealing. This combined surgery aimed to eliminate the potential source of infection of adjacent teeth during implant-related surgery. Meanwhile, the autologous bone retained in the apical surgery could avoid a second operating area for bone harvesting in bone augmentation surgery, significantly improving the efficiency of surgery and thus further reducing patient trauma and saving medical costs. This article discussed the application basis and clinical indications of this novel combined treatment strategy.

Key words: dental implant, guided bone regeneration, endodontic microsurgery, guided tissue regeneration, retrograde peri-implantitis

中图分类号: 

  • R 78

图 1

种植治疗术区合并邻牙慢性根尖周炎示例a、b 示例1：邻牙根尖区暗影（黄色箭头）穿通颊侧皮质骨板（a），邻牙为根管治疗后慢性根尖周炎邻近种植治疗术区（b）；c、d 示例2：邻牙根管完全钙化伴有慢性根尖周炎（c），慢性根尖周炎邻近种植治疗术区（d）；e、f 示例3：邻牙根尖区暗影（黄色箭头）位于腭侧未与皮质骨板连通（e），慢性根尖周炎邻近种植治疗术区（f）；g、h 示例4：邻牙冠修复伴根管治疗后慢性根尖周炎（g），慢性根尖周炎邻近种植治疗术区（h）。"

图 2

来自邻牙的根尖周感染导致种植位点出现感染风险a~c示例：11根尖周感染波及邻近21位点种植体，发生逆行性种植体周炎：CBCT冠状面（a）和矢状面（b）显示种植体根尖区低密度暗影（黄色箭头），11矢状面显示根尖超充（红色圆圈）伴有低密度影（c）。"

图 3

放大设备、超声骨刀等器械在口腔种植和牙体牙髓病中的应用a、b：种植治疗上颌窦提升中利用超声骨刀进行侧壁开窗；c：借助内镜放大设备辅助观察上颌窦黏膜完整性；d：牙体牙髓科显微根尖外科手术中利用超声骨刀进行皮质骨开窗；e：高倍放大下完成根尖超声倒预备；f：高倍放大下完成根尖倒充填。"

图 4

种植同期骨增量临床程序中联合手术策略的数字化设计及实现a：邻牙显示慢性根尖周炎，设计根尖（红线）下3 mm定位及零度切除斜面（蓝线）；b：联合手术导板设计，基板为种植导板，为了进一步减小翻瓣范围，附件下界指示根尖下3 mm（白色箭头），近中界指示与邻牙保持安全距离，远中界与上界开窗；c：打印后的联合手术导板（基板+附件）就位于模型；d：术中导板引导下完成根尖切除；e：基板为种植导板实现种植窝洞预备；f、g：联合手术后邻牙矢状面（f）及冠状面（g）观。"

图 5

分阶段骨增量临床程序中联合手术策略的数字化设计及实现a：邻牙显示慢性根尖周炎，设计根尖下3 mm定位及零度切除斜面（蓝线）及根方取骨范围（红线）；b：根尖区骨窗的三维显示；c：联合手术导板，附件下界指示根尖下3 mm零度切除及取骨范围； d：术中导板引导下完成根尖切除及取骨线标记；e：使用骨凿分离骨块与基骨后进行根尖区清创；f：获取的自体骨块进行体外清创。"

1 Penarrocha-Diago M, Maestre-Ferrín L, Penarrocha-Oltra D, et al. Inflammatory implant periapical lesion prior to osseointegration: a case series study[J]. Int J Oral Maxillofac Implants, 2013, 28(1): 158-162.
2 Mohamed JB, Alam MN, Singh G, et al. The mana-gement of retrograde peri-implantitis: a case report[J]. J Clin Diagn Res, 2012, 6(9): 1600-1602.
3 Lefever D, van Assche N, Temmerman A, et al. Ae-tiology, microbiology and therapy of periapical lesions around oral implants: a retrospective analysis[J]. J Clin Periodontol, 2013, 40(3): 296-302.
4 Jakovljevic A, Nikolic N, Jacimovic J, et al. Prevalence of apical periodontitis and conventional nonsurgical root canal treatment in general adult population: an updated systematic review and meta-analysis of cross-sectional studies published between 2012 and 2020[J]. J Endod, 2020, 46(10): 1371-1386.e8.
5 Moy PK, Aghaloo T. Risk factors in bone augmentation procedures[J]. Periodontol 2000, 2019, 81(1): 76-90.
6 Dammaschke T, Steven D, Kaup M, et al. Long-term survival of root-canal-treated teeth: a retrospective study over 10 years[J]. J Endod, 2003, 29(10): 638-643.
7 Danesh N, Ljunggren AC, Wolf E, et al. Development of criteria for investigation of periapical tissue from root-filled teeth[J]. Acta Odontol Scand, 2019, 77(4): 269-274.
8 Zhou W, Zheng QH, Tan XL, et al. Comparison of mineral trioxide aggregate and iRoot BP plus root repair material as root-end filling materials in en-dodontic microsurgery: a prospective randomized controlled study[J]. J Endod, 2017, 43(1): 1-6.
9 Moraschini V, Poubel LA, Ferreira VF, et al. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review[J]. Int J Oral Maxillofac Surg, 2015, 44(3): 377-388.
10 McAllister BS, Masters D, Meffert RM. Treatment of implants demonstrating periapical radiolucencies[J]. Pract Periodontics Aesthet Dent, 1992, 4(9): 37-41.
11 Green TL, Walton RE, Taylor JK, et al. Radiogra-phic and histologic periapical findings of root canal treated teeth in cadaver[J]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1997, 83(6): 707-711.
12 Rowe AH, Binnie WH. Correlation between radiological and histological inflammatory changes following root canal treatment[J]. J Br Endod Soc, 1974, 7(2): 57-63.
13 Seltzer S. Long-term radiographic and histological observations of endodontically treated teeth[J]. J Endod, 1999, 25(12): 818-822.
14 Schwarz F, Derks J, Monje A, et al. Peri-implantitis[J]. J Periodontol, 2018, 89(): S267-S290.
15 Sarmast ND, Wang HH, Soldatos NK, et al. A novel treatment decision tree and literature review of retrograde peri-implantitis[J]. J Periodontol, 2016, 87(12): 1458-1467.
16 Ramanauskaite A, Juodzbalys G, Tözüm TF. Apical/retrograde periimplantitis/implant periapical lesion: etiology, risk factors, and treatment options: a syste-matic review[J]. Implant Dent, 2016, 25(5): 684-697.
17 Marshall G, Canullo L, Logan RM, et al. Histopa-thological and microbiological findings associated with retrograde peri-implantitis of extra-radicular en-dodontic origin: a systematic and critical review[J]. Int J Oral Maxillofac Surg, 2019, 48(11): 1475-1484.
18 di Murro B, Papi P, di Murro C, et al. Correlation between endodontic pulpal/periapical disease and retrograde peri-implantitis: a case series[J]. Aust Endod J, 2021, 47(2): 358-364.
19 Zhou W, Han C, Li DH, et al. Endodontic treatment of teeth induces retrograde peri-implantitis[J]. Clin Oral Implants Res, 2009, 20(12): 1326-1332.
20 Fernandez de Grado G, Keller L, Idoux-Gillet Y, et al. Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management[J]. J Tissue Eng, 2018, 9: 204173-1418776819.
21 Antoun H, Sitbon JM, Martinez H, et al. A prospective randomized study comparing two techniques of bone augmentation: onlay graft alone or associated with a membrane[J]. Clin Oral Implants Res, 2001, 12(6): 632-639.
22 Meijndert CM, Raghoebar GM, Meijndert L, et al. Single implants in the aesthetic region preceded by local ridge augmentation; a 10-year randomized controlled trial[J]. Clin Oral Implants Res, 2017, 28(4): 388-395.
23 Sbordone L, Toti P, Menchini-Fabris G, et al. Implant survival in maxillary and mandibular osseous onlay grafts and native bone: a 3-year clinical and computerized tomographic follow-up[J]. Int J Oral Maxillofac Implants, 2009, 24(4): 695-703.
24 Setzer FC, Shah SB, Kohli MR, et al. Outcome of endodontic surgery: a meta-analysis of the literature: part 1: comparison of traditional root-end surgery and endodontic microsurgery[J]. J Endod, 2010, 36(11): 1757-1765.
25 Friedman S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: comparison of traditional root-end surgery and endodontic microsurgery[J]. J Endod, 2011, 37(5): 577-580.
26 Kim D, Kim S, Song MJ, et al. Outcome of endo-dontic micro-resurgery: a retrospective study based on propensity score-matched survival analysis[J]. J Endod, 2018, 44(11): 1632-1640.
27 Huang SY, Chen NN, Yu VSH, et al. Long-term success and survival of endodontic microsurgery[J]. J Endod, 2020, 46(2): 149-157.e4.
28 Conejo J, Atria PJ, Schweitzer D, et al. Digital implant planning and surgical guides: tools for clinical success[J]. Compend Contin Educ Dent, 2021, 42(7): 400-401.
29 Michelinakis G, Apostolakis D, Kamposiora P, et al. The direct digital workflow in fixed implant pros-thodontics: a narrative review[J]. BMC Oral Health, 2021, 21(1): 37.
30 Buser D, Sennerby L, de Bruyn H. Modern implant dentistry based on osseointegration: 50 years of pro-gress, current trends and open questions[J]. Perio-dontol 2000, 2017, 73(1): 7-21.
31 Hawkins TK, Wealleans JA, Pratt AM, et al. Targe-ted endodontic microsurgery and endodontic microsurgery: a surgical simulation comparison[J]. Int Endod J, 2020, 53(5): 715-722.
32 Ray JJ, Giacomino CM, Wealleans JA, et al. Targe-ted endodontic microsurgery: digital workflow options[J]. J Endod, 2020, 46(6): 863-871.
33 Dianat O, Gupta S, Price JB, et al. Guided endodontic access in a maxillary molar using a dynamic na-vigation system[J]. J Endod, 2021, 47(4): 658-662.
34 Joda T, Zarone F, Ferrari M. The complete digital workflow in fixed prosthodontics: a systematic review[J]. BMC Oral Health, 2017, 17(1): 124.
35 Stanley M, Paz AG, Miguel I, et al. Fully digital workflow, integrating dental scan, smile design and CAD-CAM: case report[J]. BMC Oral Health, 2018, 18(1): 134.
36 Blatz MB, Conejo J. The current state of chairside digital dentistry and materials[J]. Dent Clin North Am, 2019, 63(2): 175-197.
37 Coachman C, Sesma N, Blatz MB. The complete digital workflow in interdisciplinary dentistry[J]. Int J Esthet Dent, 2021, 16(1): 34-49.
38 Wakimoto M, Matsumura T, Ueno T, et al. Bone quality and quantity of the anterior maxillary trabe-cular bone in dental implant sites[J]. Clin Oral Implants Res, 2012, 23(11): 1314-1319.
39 Ribeiro CG, Bittencourt TC, Ferreira CF, et al. An alternative approach for augmenting the anterior maxilla using autogenous free gingival bone graft for implant retained prosthesis[J]. J Oral Implantol, 2014, 40(2): 183-187.
40 Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla: a systematic review[J]. Int J Oral Maxillofac Implants, 2014, 29(): 186-215.
41 Cha HS, Kim JW, Hwang JH, et al. Frequency of bone graft in implant surgery[J]. Maxillofac Plast Reconstr Surg, 2016, 38(1): 19.
42 Wang J, Luo YL, Tan XL, et al. Horizontal bone augmentation of the edentulous area with simulta-neous endodontic microsurgery of the adjacent too-th: a digitally-driven multidisciplinary case report with a 1-year follow-up[J]. Int J Oral Implantol (Berl), 2021, 14(4): 435-451.
43 Daubert D, Black RM, Chrepa V, et al. Endodontic peri-implant defects: a new disease entity[J]. J Endod, 2020, 46(3): 444-448.
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[4] 王昆润. 后牙冠根斜形牙折的治疗[J]. 国际口腔医学杂志, 1999, 26(05): .
[5] 杨锦波. 嵌合体防龋疫苗的研究进展[J]. 国际口腔医学杂志, 1999, 26(05): .
[6] 王昆润. 下颔骨成形术用网状钛板固定植骨块[J]. 国际口腔医学杂志, 1999, 26(04): .
[7] 汪月月,郭莉莉. 口腔机能与老化—痴呆危险因素流行病学研究[J]. 国际口腔医学杂志, 1999, 26(04): .
[8] 丁刚. 应用硬组织代用品种植体行丰颏术[J]. 国际口腔医学杂志, 1999, 26(04): .
[9] 田磊. 局部应用脂多糖后结合上皮反应性增生的变化[J]. 国际口腔医学杂志, 1999, 26(04): .
[10] 戴青. 口腔念珠菌病的新分类[J]. 国际口腔医学杂志, 1999, 26(04): .