国际口腔医学杂志

国际口腔医学杂志 ›› 2023, Vol. 50 ›› Issue (3): 251-262.doi: 10.7518/gjkq.2023048

• 专家笔谈 •    下一篇

牙保存相关上颌窦底提升术的生物学基础

黄定明1(),张岚1,满毅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牙体牙髓病科 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种植科 成都 610041
  • 收稿日期:2022-12-07 修回日期:2023-03-02 出版日期:2023-05-01 发布日期:2023-05-16
  • 通讯作者: 满毅
  • 作者简介:黄定明，教授，博士，Email：<email>dingminghuang@163.com</email>|<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》编委、Molecular Oral Micro‐biology 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。</br><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。
  • 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);成都市重大科技应用示范项目(2021-YF09-00078-SN)

Biologic bases of nature tooth-related maxillary sinus floor elevation

Huang Dingming1(),Zhang Lan1,Man Yi2()   

  1. 1.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
    2.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
  • Received:2022-12-07 Revised:2023-03-02 Online:2023-05-01 Published:2023-05-16
  • Contact: Yi Man
  • 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);Chengdu Key Application Projects of Science and Technology(2021-YF09-00078-SN)

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摘要：

上颌后牙缺失需行种植修复时，如果骨量不足，临床上常规采取上颌窦底提升术进行骨增量，以满足种植体初期稳定性的要求。上颌后牙的根管系统非常复杂，出现牙髓根尖周疾病时，根管治疗有可能无法彻底控制根管内感染，治疗后仍可能再度发生慢性根尖周病变。上颌牙、牙槽骨、上颌窦解剖位置及其功能关系紧密，笔者将其命名为“上颌牙-牙槽骨-上颌窦复合体”。当上颌后牙发生慢性根尖周病变时，牙根进入上颌窦内或者病变扩散至上颌窦可形成牙源性上颌窦炎。采用显微根尖手术治疗这类患牙时，常通过上颌窦底提升术建立手术入路。笔者将这种为治疗牙源性上颌窦炎并保存疑难根尖周病患牙而采取的显微根尖手术联合上颌窦底提升术命名为“牙保存相关上颌窦底提升术”。该技术与牙种植相关上颌窦底提升术不同，是一种全新的治疗术式。本文通过文献回顾分析，结合临床开展该技术的经验和认识，从解剖学、病因学和病理学三方面阐述了该技术的生物学基础：上颌牙-牙槽骨-上颌窦复合体是该技术的解剖学基础，牙源性感染引起上颌窦疾病是其病因学基础，根尖周术区和上颌窦黏骨膜的感染性炎症反应是其病理学基础。本文详细解析上述三方面生物学基础，为牙保存相关上颌窦底提升术临床术式的设计、诊治流程的规范和诊疗路径的建立提供了理论依据。

关键词: 上颌牙-牙槽骨-上颌窦复合体, 上颌窦底提升术, 牙源性上颌窦炎, 感染, 炎症反应

Abstract:

When missing maxillary posterior teeth require implantation, adopting maxillary sinus floor elevation routinely provides bone augmentation to meet the initial stability of the implant due to insufficient bone volume. It is very difficult to eliminate the infection completely from the complex root canal system of maxillary posterior teeth by root canal treatment, which results in the chronic apical periodontitis after treatment. The close anatomy relationship among the maxillary posterior teeth, maxillary bone and sinus, termed as maxillary tooth-alveolar-process-sinus complex, makes it easy for the infection to spread into the maxillary sinus. When endodontic microsurgery is needed, the surgical access is often established through maxillary sinus floor elevation, which is named as tooth-related maxillary sinus floor elevation. It is necessary to put forward the tooth-related maxillary sinus floor elevation as it is different biologic basis from the traditional dental implantation-related maxillary sinus floor elevation in anatomy, etiology and pathology.

Key words: maxillary tooth-alveolar-process-sinus complex, maxillary sinus floor elevation, odontogenic maxillary sinusitis, infection, inflammation

中图分类号: 

  • R 78

图 1

牙种植相关侧壁开窗上颌窦底提升术A：术前口内像，16牙缺失；B：导板引导下进行16位点上颌窦侧壁开窗术；C：经侧壁入路，彻底剥离上颌窦黏膜，垫入胶原膜，窦内植入骨替代材料；D：同期完成种植体植入；E：使用胶原膜辅助关闭上颌窦侧壁开窗；F：龈瓣复位缝合；G：术前16缺牙位点锥形束CT（cone beam computed tomography，CBCT）冠状面观；H： 术前16缺牙位点CBCT矢状面观；I：侧壁提升同期种植后CBCT冠状面观，种植体位置理想，上颌窦提升效果良好；J：侧壁提升同期种植后CBCT矢状面观。"

图 2

上颌牙-牙槽骨-上颌窦复合体的解剖结构A：复合体模式图；B：上颌后牙区CBCT矢状面观。"

图3

上颌牙-牙槽骨-上颌窦复合体三者间垂直向关系上：根据上颌牙-牙槽骨-上颌窦CBCT冠状面分型；下：分型相对应的模式图；每幅图的左侧为颊侧，右侧为腭侧。Ⅰ型：所有根尖低于上颌窦底平面最低点且存在一段距离；Ⅱ型：上颌窦底低于颊腭根尖连线但根尖未突入上颌窦内；Ⅲ型：仅颊根尖高于窦底，且突入窦内；Ⅳ型：仅腭根尖高于窦底，且突入窦内；Ⅴ型：所有根尖突入上颌窦内。"

图4

上颌牙-牙槽骨-上颌窦复合体三者间水平向关系上：根据上颌牙-牙槽骨-上颌窦CBCT冠状面分型；下：分型相对应的模式图。Ⅰ型：上颌窦底最低处位于颊根的颊侧牙槽突内且低于根尖平面；Ⅱ型：上颌窦底最低处位于颊腭根之间的牙槽突内且低于颊腭根尖连线平面；Ⅲ型：上颌窦底最低处位于腭根的腭侧牙槽突内且低于根尖平面。箭头示窦底位置。"

图 5

上颌窦的窦黏膜A：CBCT冠状面示上颌窦外侧骨壁及窦底骨皮质薄，需行上颌窦底提升术；B：术中示经上颌窦侧壁开窗后，显示薄的上颌窦黏膜呈深蓝色。"

图 6

根尖周病损引起牙源性上颌窦炎A：根尖周病损只引起上颌窦黏膜增厚：B：根尖周炎引起上颌窦骨膜炎；C：根尖周炎引起窦底骨皮质破坏，病变组织与上颌窦黏膜直接相连。"

图7

上颌后牙根尖周病损与上颌窦底间关系分级A：Ⅰ型，根尖周病损突破上颌窦底，进入上颌窦内与施耐德膜紧密相连；B：Ⅱ型，病损与上颌窦底接触；C：Ⅲ型，窦底与上颌窦底间距离小于2 mm，但上颌窦底骨组织完整连续；D：Ⅳ型，病损与上颌窦底间距离大于2 mm。"

图 8

上颌窦黏膜增厚程度分级A：1级，窦黏膜厚度0~2 mm；B：2级，窦黏膜厚度2~4 mm；C：3级，窦黏膜厚度4~10 mm且未堵塞上颌窦开口；D：4级，窦黏膜厚度大于10 mm且未堵塞上颌窦开口；E：5级，增厚的窦黏膜堵塞上颌窦开口（箭头示）。"

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