国际口腔医学杂志, 2023, 50(4): 485-490 doi: 10.7518/gjkq.2023067

综述

后牙全锆冠龈边缘预备形式的研究进展

王晓晨,, 王剑,

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修复科 成都 610041

Research progress on preparation forms for the margin of monolithic zirconia crowns in posterior teeth

Wang Xiao-chen,, Wang Jian.,

State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China

通讯作者: 王剑,教授,博士,Email:ferowang@hotmail.com

编委: 骆筱秋

收稿日期: 2022-11-11   修回日期: 2023-03-25  

Received: 2022-11-11   Revised: 2023-03-25  

作者简介 About authors

王晓晨,硕士,Email:15645470267@163.com

摘要

氧化锆是近年来应用最为广泛的陶瓷材料,由第2代氧化锆制作的全锆冠具有美观、强度高的优势,即使在厚度仅有0.5 mm的情况下,也可承担后牙的咀嚼压力,在后牙全冠修复中广泛应用。后牙全锆冠的龈边缘预备形式多样,包括刃状边缘、凹槽边缘、肩台边缘等。后牙全锆冠由于机械强度较高,龈边缘预备形式与玻璃基全瓷冠有所区别,但仍缺乏统一标准。本文拟对后牙全锆冠的龈边缘预备形式进行归纳总结,探讨不同龈边缘预备形式牙冠的应力分布、机械性能、边缘适合性以及对基牙和牙周组织的影响,为后牙全锆冠龈边缘牙体预备提供临床操作参考。

关键词: 后牙全锆冠; 边缘形态; 内钝角肩台边缘; 凹槽边缘

Abstract

Zirconia is the most widely used high-strength ceramic material in recent years. Monolithic crowns made from second-generation zirconia have the advantage of being aesthetic and solid enough to withstand the masticatory pressure of posterior teeth even at a thickness of 0.5 mm. These crowns are therefore widely used in posterior full crown restoration. The margin of the crowns can be prepared using knife edge, chamfer edge, and shoulder edge. The margin preparation differs from that of glass-ceramic crowns due to the high mechanical properties of monolithic zirconia crowns, but a standard preparation procedure is not yet available. This review aims to summarize the margin preparation forms for posterior monolithic zirconia crowns and discuss the stress distribution, mechanical properties, marginal adaptation and effects on the abutment and periodontal tissues of different margin preparation forms. Results provide a clinical practice re-ference for the margin preparation of posterior monolithic zirconia crowns.

Keywords: monolithic zirconia crown; margin; round shoulder; chamfer edge

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本文引用格式

王晓晨, 王剑. 后牙全锆冠龈边缘预备形式的研究进展[J]. 国际口腔医学杂志, 2023, 50(4): 485-490 doi:10.7518/gjkq.2023067

Wang Xiao-chen, Wang Jian.. Research progress on preparation forms for the margin of monolithic zirconia crowns in posterior teeth[J]. International Journal of Stomatology, 2023, 50(4): 485-490 doi:10.7518/gjkq.2023067

氧化锆凭借其优越的美学效果、机械性能和良好的生物学相容性,成为最受欢迎的全瓷修复材料之一,被普遍应用于制作全冠修复体。无饰瓷氧化锆全冠,又称全锆冠,是通过计算机数控切削和烧结制成的修复体,其中3%氧化钇稳定的四方相氧化锆(3% yttrium-stabilized tetragonal zirconia,3Y-TZP),又称第2代氧化锆,常用于后牙全冠修复体的制作。后牙全锆冠的龈边缘预备形式多样,包括刃状边缘、凹槽边缘、肩台边缘等。后牙全锆冠具有高抗弯强度和高断裂韧性[1],龈边缘预备形式与玻璃基全瓷冠有所区别[2],但龈边缘预备形式与上饰面瓷的氧化锆全瓷冠无明显差别[3],制造商推荐使用凹槽边缘或内钝角肩台边缘,此说法缺乏大样本实验数据支撑,导致后牙全锆冠龈边缘预备形式仍缺乏统一标准。因此,本文拟对不同龈边缘预备形态后牙全锆冠的应力分布、机械性能、边缘适合性以及对基牙、牙周组织的影响进行综述,为后牙全锆冠龈边缘牙体预备提供临床操作参考。

1  后牙全锆冠龈边缘预备形式

玻璃陶瓷全瓷冠龈边缘预备形态一般采用1.0 mm深凹槽或内钝角肩台边缘[4-5]。全锆冠机械性能高于玻璃陶瓷,冠边缘厚度可以较玻璃陶瓷冠更小,相应的基牙龈边缘预备深度也可以减小[6]。上饰面瓷的氧化锆全冠也可采用刃状边缘[7]、凹槽边缘、肩台边缘[3]。后牙全锆冠龈边缘按照预备方式划分,可分为有明显边缘的水平牙体预备和无明显边缘的垂直牙体预备,后者也称为刃状边缘[2,7-8]。水平牙体预备的龈边缘形态可分为凹槽边缘、肩台边缘等。其中,凹槽边缘根据其宽度分为浅凹槽边缘和深凹槽边缘;肩台边缘一般指90°直角肩台边缘,根据肩台内线角的圆钝与否,可分为内锐角肩台边缘和内钝角肩台边缘[4];在刃状边缘的基础上,Loi等[7]提出了生物导向牙体预备技术(biologically oriented preparation technique,BOPT),包括重新确定釉牙骨质界的位置,采用刃状边缘,同时去除部分龈沟内组织(图1)。后牙全锆冠龈边缘按照与牙龈的位置关系划分,可分为龈上边缘、平龈边缘、龈下边缘。

图1

图1   后牙全锆冠不同龈边缘预备形态

Fig 1   Different gingival edge preparation forms of full zirconium crown in posterior teeth


凹槽边缘和内钝角肩台边缘因其适应证广泛、操作简便、容易辨认、密合性好、长期美学效果佳、保留更多健康牙体组织和粘接剂易于排出等特点在后牙全锆冠中得到广泛应用。有学者[9]认为,刃状边缘有助于减少牙体和牙冠之间的间隙,从而减少细菌微渗漏,在后牙全锆冠中是具有潜在优势的龈边缘形态。BOPT主要用于旧全冠修复体更换时,需要再次完善牙体预备的基牙[10],同时重塑牙龈轮廓,改善牙周组织的美观性[7,10-12],但牙体预备技术要求较高,需要更长的椅旁学习时间。与龈上、平龈边缘相比较,龈下边缘更容易对牙周组织健康产生不利影响,却可以实现良好的美学修复效果[13],一般要求修复体边缘距离龈沟底至少0.5 mm[4]

2  后牙全锆冠龈边缘的应力分布

全瓷冠最常见的并发症之一是冠的折裂,咀嚼过程中的高应力集中部位易产生微裂纹并进一步扩展,直至全瓷冠碎裂。有学者[14-15]发现,后牙全锆冠近边缘位置应力高于𬌗面应力,因此薄弱的边缘可能是导致牙冠折裂的原因。然而,在临床使用中,也可由于后牙全锆冠𬌗面应力集中,裂缝从𬌗面扩展至薄弱边缘[16]。因此,边缘形态可以影响后牙全锆冠颈部应力分布。Miura等[17]对比后牙全锆冠内锐角肩台边缘、内钝角肩台边缘、凹槽边缘的应力分布,认为内锐角肩台边缘应力最为集中,内钝角肩台边缘和凹槽边缘表现出更有利的几何形状,可改善后牙全锆冠的力学性能,最大限度地减少咬合应力,且内钝角肩台边缘应力值最小。根据以上文献报道,后牙全锆冠边缘可能成为应力集中的薄弱环节,为避免边缘应力集中,可以认为内钝角肩台边缘是后牙全锆冠牙体预备的最佳选择。

3  后牙全锆冠龈边缘的机械性能

后牙全锆冠边缘的机械性能影响其远期修复效果及临床使用寿命,不同边缘形态在机械性能上有所差异。由于计算机辅助设计/计算机辅助制造 (computer aided design/Computer aided manufacturing,CAD/CAM)过程中,尤其是烧结和冷却过程中,修复体边缘可能发生碎裂。因此,制造商对于不同机械性能的全锆冠均建议使用无锐边的1.0 mm凹槽边缘或内钝角肩台边缘,同时认为这两种边缘具有最佳的精度和美观性[18]

然而,不同氧化钇含量的氧化锆的机械性能之间存在差异,其中,常用于后牙全锆冠制作的第2代氧化锆的弯曲强度大于900 MPa,要求全锆冠修复体最小厚度为0.4 mm。Beuer等[19]对比了不同边缘形态的0.4 mm后牙氧化锆基底冠所能承受的断裂载荷,认为内钝角肩台边缘可承载更高的断裂载荷。有学者[20]发现,后牙全锆冠凹槽边缘可承担的断裂载荷优于刃状边缘,Sorrentino等[21]的进一步实验分析不同品牌第2代氧化锆制作的后牙全冠刃状边缘的机械性能,经过1年的咀嚼模拟实验,边缘均未发生应力诱导的四方相向单斜相转变,未产生微裂纹。粘固材料可以增加全瓷冠断裂载荷并提高其寿命,其中,树脂水门汀机械性能高,可以弥补陶瓷内部缺陷,而且含有功能单体的树脂水门汀和后牙全锆冠内表面之间建立化学结合,增强后牙全锆冠的机械性能[22]。基于以上研究结果,后牙全锆冠0.4 mm的内钝角肩台边缘、凹槽边缘、刃状边缘虽然表现出机械性能上的差异,但均能够满足临床需要。

4  后牙全锆冠龈边缘适合性

边缘适合性是指预备基牙边缘与修复体边缘的密合程度,清晰的基牙边缘形态是实现后牙全锆冠边缘良好适合性的首要因素。边缘适合性的影响因素包括边缘形态、印模制取方式、切削材料等。适合性较差可能导致全锆冠边缘微渗漏、龋齿、牙髓并发症或牙周病。

全冠牙体预备不同龈边缘形态影响后牙全锆冠的边缘适合性。有学者[5]指出,凹槽边缘圆钝的内线角,除了防止应力集中,还可以实现更好的适合性。进一步对比不同厚度凹槽边缘的适合性,研究[23-25]表明0.5 mm、1.0 mm、1.2 mm的凹槽边缘均具有良好边缘适合性,其中,1.0 mm凹槽边缘适合性优于0.5 mm和1.2 mm的凹槽边缘。除此之外,Baig等[3]认为,1.0 mm凹槽边缘和内钝角肩台边缘均可实现良好的边缘适合性。相比而言,后牙全锆冠刃状边缘适合性相对较差,但其适合性仍在临床可接受的范围内[26]。综上,凹槽边缘、内钝角肩台边缘、刃状边缘均可满足后牙全锆冠对边缘适合性的要求,但为实现更好的边缘适合性,尽量避免边缘形态对牙周组织产生不良影响,临床上更推荐后牙全锆冠应用0.5~1.2 mm凹槽边缘、1.0 mm内钝角肩台边缘。

传统印模和椅旁口腔扫描数字化印模也会对后牙全锆冠边缘适合性产生影响,运用椅旁口腔扫描数字化印模制作的后牙全锆冠,凹槽边缘和内钝角肩台边缘的适合性无明显差异,而扫描常规印模制作的后牙全锆冠,内钝角肩台边缘的适合性优于凹槽边缘[27-28]

同时,后牙全锆冠的切削材料也会影响边缘适合性、边缘质量和断裂载荷。完全烧结氧化锆切削制作的边缘质量最佳,断裂载荷最高,但其制作成本高、效率低。因此,预烧结氧化锆瓷块仍是CAD/CAM制作后牙全锆冠的主要加工材料类型。无缺陷的全锆冠边缘可降低牙冠折裂的风险,提高边缘适合性,降低生物和牙体预备技术并发症的风险[29]

5  后牙全锆冠龈边缘对牙体组织的影响

后牙全锆冠具有优越的抗弯强度和断裂韧性,不需要饰瓷空间,可适当降低基牙龈边缘牙体预备宽度,减少牙体预备量[30],从而尽可能保留健康牙体组织,符合微创牙体预备的理念[24]。Borelli等[31]对比内钝角肩台边缘、凹槽边缘、刃状边缘的基牙牙体预备量,认为凹槽边缘和刃状边缘牙体预备量更少,内钝角肩台边缘的牙体预备量最大,刃状边缘牙体预备量最小。

随着现代粘接技术的发展,具有高强断裂韧性的陶瓷材料可以实现微创牙体预备,以防止牙体组织抗折能力的减弱、预备过程中的温度和其他刺激引起的牙髓炎症、以及预备后牙本质小管暴露引起的牙本质敏感,并且Nakamura等[32]认为边缘厚度对后牙全锆冠的断裂载荷无显著影响。因此,牙体预备量更少的龈边缘几何形状(如刃状边缘)可能是比内钝角肩台边缘更好的选择。根据微创牙体预备的理念,为保护牙颈部组织结构的健康,基牙龈边缘预备的范围应尽可能控制在牙釉质内[33-34],建议使用0.3~0.5 mm凹槽边缘或刃状边缘。

6  后牙全锆冠龈边缘对牙周组织的影响

6.1  全锆冠的生物相容性

后牙全锆冠边缘具有抛光的表面,便于患者清洁,从而可避免牙菌斑生物膜沉积,有助于维持牙周组织的健康。临床研究[35]表明,96周的随访期间,后牙全锆冠边缘对牙周组织无不良影响,表现出良好的生物相容性。根据FDI标准,全锆冠所有生物学方面评分都有较高的分数,患者满意度较高[36]。这一结果与其他研究结果一致,证明全锆冠在用于后牙修复时具有良好的生物相容性[37-38]

6.2  全锆冠边缘对牙周组织的影响

已有前瞻性、回顾性研究[39-43]证实,后牙全锆冠具有良好的临床修复效果,但部分后牙全锆冠周围探诊出血指数阳性,然而,上述研究均未提及后牙全锆冠边缘形态是否对修复体周围的探诊出血指数产生影响。Stack等[9]对73颗刃状边缘后牙全锆冠进行平均21周的随访,发现其探诊出血阳性率高于对照牙,但缺乏统计学意义。随后,一项针对0.5 mm平龈凹槽边缘后牙全锆冠的临床研究发现,经过为期5年的随访后,发现探诊出血和牙龈退缩指数显著增加,而探诊深度和菌斑指数保持稳定,并且,16.3%的后牙全锆冠出现1.0 mm或2.0 mm的牙龈退缩[44]。Paniz等[13]对比龈下刃状边缘和凹槽形边缘对牙周组织的影响,认为刃状边缘探诊出血指数更高,而牙龈退缩指数更低。

上述短期研究结果表明:虽然后牙全锆冠边缘具有良好的生物相容性,但修复体边缘形态可能对牙周组织的健康产生影响,主要表现为探诊出血和牙龈退缩。其中,刃状边缘更易出现探诊出血,但可避免后牙全锆冠牙龈退缩。另外,仍需对大量患者进行长期随机对照研究,以充分评价后牙全锆冠边缘形态对于牙周组织健康的影响。

7  总结和展望

综上所述,当临床牙冠和牙周组织健康时,在综合考虑后牙全锆冠边缘的应力分布、机械性能、适合性的前提下,临床上更推荐选用0.5~1.2 mm的凹槽边缘和1.0 mm内钝角肩台边缘。同时,应用椅旁口腔扫描数字化印模进一步确保后牙全锆冠的边缘适合性;当优先考虑微创牙体预备时,后牙全锆冠凭借其优越的机械性能,龈边缘预备选用刃状边缘、凹槽边缘较为理想,牙体预备量更少,具有保护基牙牙体组织的作用。同时,后牙全锆冠选用含有功能单体的树脂类水门汀,以提高修复体的机械性能。

对于需要更换旧修复体,伴有牙龈退缩,需要再次完善牙体预备的基牙,可采用刃状边缘并结合BOPT,是更具有前景的边缘形态,但这种边缘形态在后牙全锆冠修复中的应用仍存在一些问题与挑战:不易确定边缘位置,边缘适合性仍有待提高,对牙体预备技术要求较高。

此外,高度抛光的全锆冠边缘表现出良好的生物相容性,避免菌斑的附着和牙周袋的形成,但龈下边缘可对牙周组织健康产生影响。在将来,仍需要进一步的长期临床研究来证实后牙全锆冠不同边缘形态的临床效果及其对牙周组织健康的影响。

利益冲突声明

作者声明本文无利益冲突。


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