Doctor by Infodent 2/2016 - INFODENT Srl Editorial & Consulting Company - Str. Cassia Nord Km 86,300 01100 Viterbo - Italy - www.infodent.com
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2-2016
www.my-ray.com DenTech China ¡ 2016, 26-29 Octobrer ¡ Booth B05-06, B31-32 , Hall 1
Shanghai Wor ld Expo Exhibition and Convention Center, Shanghai, P.R. China MR_X9_DoctorOsInfoInternSept16.indd 1
Retrospective radiographic study of marginal bone changes of 88 implants placed with split crest technique in the maxillary latero-posterior area
ĺœ¨ä¸Šé˘Œĺ?Žäž§ĺˆ‡ç‰™ĺŒşç”¨ç‰™ć§˝ĺľ´ĺˆ†ĺ‰˛ćł• ç§?ć¤?了88个ç§?ć¤?体䚋ĺ?ŽďźŒç”¨X线片 čŻ„äź°čžšçź˜éŞ¨ĺ?˜ĺŒ–çš„ĺ›žéĄžć€§ç ”çŠś
27/09/16 12:30
Immediate implants in extraction sockets with periapical lesions: an illustrated review
牙çŞ?ć šĺ°–ĺ‘¨ĺ?˜ç—…çš„ĺ?łĺˆťç§?ć¤?: ä¸€çŻ‡ćœ‰ć?’ĺ›žčŻ´ć˜Žçš„čż°čŻ„
Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up
ĺ…ˇćœ‰ĺšłĺ?°č˝Źć?˘čŁ…罎的锼形ç§?ć¤?体周 ĺ›´çš„čžšçź˜éŞ¨ć°´ĺšłďźšä¸€ä¸Şéš?莿了14个 ćœˆçš„ĺ¤ščŻŠć‰€ĺ?ˆä˝œĺ›žéĄžć€§ç ”犜
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Implantbook is a trademark of Infodent Srl
EDITORIAL Reinventing Marketing - 重塑营销
China, the Place to Be
中国，必争的市场 After the great feedback from “Doctor by Infodent International” – our highly scientific publication, in English and Chinese, dedicated to a selected target of Chinese dentists, professors and scientific boards, our focus within this remaining half of the year is still Chinese… China is the great economic success story of the past 30 years, the world’s second-largest economy. Since the “reform and opening-up” policy was introduced in 1978, China has changed beyond recognition. A Soviet-styled planned economy has transformed into a vibrant market-orientated economy and 600 million people have been lifted out of poverty. Between 1985 and 2010, 70% of the world population who had been lifted out of poverty was Chinese! The first and most important thing anyone hoping to set up a business should do is find a local partner. A local partner will most often be an established Chinese-owned company, or a businessperson with good contacts in the country who can navigate the complicated regulations and legal processes and, most importantly, deal with China’s government directly. A good partner is an incorporated company that is about the same size as your firm, at least partly Chinese-owned, and well-connected in the Chinese market. Infodent has another innovative project that might support your search. Our most unique project is what we are calling the “Living Magazine”… you will find that the contents of our Infodent International Magazine are going “live” at the exhibition! How? We invite you all to visit our booth (F70-71-96-97, Hall 1) at DenTech China to see, touch and evaluate the products showcased at the booth and published in the magazine through our highlights. Furthermore a “Distributors’ Wall” will be set up at the booth with announcements of dealers and manufacturers looking for new business and contacts within the Chinese market. Our “live” magazine will be further supported by three conferences organized by the Infodent group: • 32 Dental Marketing Ideas for Successful Dentists – by Emanuele Elo Usai, Infodent International Creative Copywriter & Digital Strategist • Treatment of Aesthetic and Structural Alterations of the Mucogingival Junction (MGJ) –with the collaboration of Asadental (Italy) and Dr. Liu Shuangbin • CGF (Concentrated Growth Factors) & AFG (Autologous Fibrinogen Glue): Basic Principle and clinical Application – with the collaboration of Silfradent (Italy) and Prof. Bingzhen Huang M.D. & Ph.D. China is no longer the Wild West of business that it once was. While the rise of China is easy to acknowledge, businesses constantly need to catch up with the speed and depth of change and development in China’s large and complex market space. With our small contribution we really hope to help fulfill the needs of what the industry is looking for!
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Doctor 牙医 by Infodent•2/2016
我们的“Doctor by Infodent International”是一本英汉双语发 行的高科技性杂志，它的目标读者为中国的牙科医生、教授 和科学委员会，在本杂志发行后得到了业界的高度评价和反 馈，在剩下的半年之中，我们的目标还是聚焦在中国、、、 在过去的30年中，中国成了经济成功事迹的代表，它是世界 第二大经济体。自从1978年实行改革开放政策以来，中国的 经济情况已今非昔比。从当初一个苏联式的计划经济体如今 变成了一个充满活力的市场经济体，这个巨大的改变使6亿人 脱离了贫困。在1985年至2010年间，做到了把相当于世界人口 70%的人脱离贫困的就是中国。 任何人想要在当地开展业务，第一件要做的重要事情应该是 找到一个当地的合作伙伴。合作伙伴通常是一个成熟的公司 或是一个在国内有良好关系网的商人，因为可以由他们来应 变和处理国内各种复杂的法律法规，最重要的是，他们可以 直接应对政府部门。一个好的合作伙伴应该是一个公司的大 小与你自己的企业相当，而且公司的至少有一部分股份由中 国人持有，并且已很好地植根在中国市场内的企业。 Infodent 现有一个创新性的项目，也许这个项目可以帮助你 找到理想的合作伙伴。这是我们最独特的项目，我们把他叫 做“活杂志”、、、你将在牙科展会上发现Infodent International杂志上的内容变活了！ 如何？我们邀请你来下次10月分的中国国际口腔器材展览会 暨学术研讨会，在1号厅F70-71-96-97展位来看一看、摸一摸 并评估已在杂志上发表过并出展在展位上的产品。此外，我 们还将在展览室里建立一个“分销商的墙壁”，到时墙壁上将有 各种在中国市场内寻找新业务的经销商和制造商的广告。我 们的“活”杂志还将得到由Infodent 集团组织的以下3个研讨会 的进一步支持： • 成功牙医的32个牙科营销理念 –由Infodent International杂 志的创意文案和数字媒体战略策划者Emanuele Elo Usai主讲 • 牙龈和粘膜交界处发生美学性和结构性改变的治疗方法 –与 意大利 Asadental牙科制造商和Liu Shuangbin医师的合作 • CGF（浓缩生长因子）和AFG（字体纤维蛋白原胶）：基本 原理和临床应用–与意大利Silfradent公司和Bingzhen Huang博 士教授合作 中国已经不再是那个曾经的西部狂野式的商业时代，在很容 易地意识到中国的崛起时，企业还需要不断赶上中国庞大而 复杂的市场空间变化的速度和深度。我们真的希望能够用我 们小小的贡献来帮助和满足企业的需求。
Baldo Pipitone
CEO Infodent S.r..l. baldo.pipitone@infodent,com
CONTENTS In this Issue
Contents 目录 • Editorial 2
China, the Place to Be
中国，必争的市场
• Highlights
10-14 Our Advertisers’ Products
导引植牙术
64-65 Touch the future with Castellini; Eighty years of experience, innovation and clinical expertise concentrated into a high-class unit: Skema 6. 与Castellini一起触摸未来 。 Skema 6 是一款整合了八十年经验的新型临床专业高端设备
16 - 17 DenTag - Evolution of Species; Dentag（登泰格） – 一个物种的进化
66-67 Silfradent: CGF Concentrated Growth Factors: Protocol and characterization 68-69 Silfradent: CGF浓缩生长因子：学术方案和性质特征
• Scientific Update
74-76 Interview with G.COMM 77-80 采访G COMM
20-25 Retrospective radiographic study of marginal bone changes of 88 implants placed with split crest technique in the maxillary latero-posterior area 26-30 在上颌后侧切牙区用牙槽嵴分割法种植了88个种植体 之后, 用X线片评估边缘骨变化的回顾性研究
32-36 Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up 38-42 具有平台转换装置的锥形种植体周围的边缘骨水平： 一个随访了14个月的多诊所合作回顾性研究
44-49 Immediate implants in extraction sockets with periapical lesions: an illustrated review 50-55 牙窝根尖周变病的即刻种植: 一篇有插图说明的述评
• Industry News
56-59 Asa Dental 种植术前准备
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60-64 B&B Dental: guided implantology; B&B Dental:
Doctor 牙医 by Infodent•2/2016
• Infodent International
70 Infodent.com: since 1994 the fastest way to experience the dental industry. Infodent.com: 体验牙科行业的最快方法自 1994年以来
• Dentech Exhibition
74-76 Infodent International for Dentech China: the living magazine project Infodent International 为DenTech China开展互动杂志项目 78 The conferences program - 会议的内容
• What’s Next
80 Discover how to experience the dental industry with our magazines!
20-30 Retrospective radiographic study of marginal bone changes of 88 implants placed with split crest technique in the maxillary latero-posterior area
20
在上颌后侧切牙区用牙槽嵴分割法种植了88个种植 体之后, 用X线片评估边缘骨变化的回顾性研究 上颌牙槽骨萎缩妨碍患者接受种植的问题由来已久， 种植部位是否有足够的健康骨组织对促成骨整合种植 的成功是个至关重要的前提条件
32-42 Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up
32 44
具有平台转换装置的锥形种植体周围的边缘骨水 平：一个随访了14个月的多诊所合作回顾性研究 在临床牙科治疗中，成功地用骨整合种植体来替补丢 失的自然牙是一个很大的进步，植入疗法在成活率方 面取得了显著的改进。
44-55 Immediate implants in extraction sockets with periapical lesions: an illustrated review
牙窝根尖周变病的即刻种植: 一篇有插图说明的述评 从发表第一篇关于骨结合这一技术与其第一个临床试 验 (1、2 ) 至今，人们对对骨结合式种植修复的兴趣 已经增长了好多倍
Cover My Ray (Cefla Group) Via Bicocca, 14/C I-40026 Imola (BO) - Italy Contacts email: imaging@my-ray.com tel. +39 0542 653441
AEEDC exhibition..................................................................................................43
Henry Schein................................................................................................II cover
AIO congress...........................................................................................................71
Imetric......................................................................................................................10
Asa Dental...............................................................................................................59
Implantbook..........................................................................................1, III cover
B&B Dental..............................................................................................................63
Infodent International.......................................................................................72
Diadent......................................................................................................................3
Maco.........................................................................................................................13
Dentag................................................................................................................15,18
Mesa.............................................................................................................79
DXM..........................................................................................................................77
New Tom...............................................................................................Back cover
FDI World dental congress.............................................................................37
Shanghai Handy Medical.................................................................................11
Greater New York Dental Meeting .................................................................6
Van Max..................................................................................................................31
GNYDM Special German Show ...................................................................73
Doctor 牙医 by Infodent•2/2016
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DOCTOR BY INFODENT
Everything a top dentist needs.
每一位成功牙医 所需要的。
Doctor by Infodent is the first magazine created and written for Chinese dental specialists. ‘牙医杂志by Infodent’
是第一本专门为中国的牙科专家创建的专业杂志。 This magazine comes from the experience of two big worldwide healthcare publishing houses: Infodent international and Ariesdue.
这本杂志源自两家世界知名的医疗刊物出版社多年的成功经验: Infodent International 和 Tecniche Nuove (天诺)。 If you’re reading this, you’re taking care about your future.
如果您在读这篇文章的话，您就照顾您的将来。
Be careful: the reading of Doctor by Infodent can truly increase revenues and profitability. 阅读‘牙医杂志by Infodent’有助于开拓商业机会，增长您的收入和利润。
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Doctor 牙医 by Infodent•2/2016
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Exhibit Dates: November 27-30
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Sponsored by the New York County and Second District Dental Societies
GNYDM Offers More Than 350 Scientific Programs 6 Hours Of Free CE Every Day 4 Days Of Exhibits
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Greater New York Dental Meeting™
200 West 41st Street - Ste. 800 New York, NY 10036 USA Tel: (212) 398-6922 Fax: (212) 398-6934 E-mail: victoria@gnydm.com Website: www.gnydm.com Follow Us!
DOCTOR BY INFODENT
Borders are for people, development is for humankind. 封疆为人民，发展为人类。
We want to publish your articles and share your discoveries with the best dental audience ever: read Doctor by Infodent editorial policies and send your work to scientificarticles@infodent.com
我们想把您的文章发布,把您的发现分享 跟最好的牙科观众。请看看“牙医 by Infodent”杂志的编辑政策,就给 scientificarticles@infodent.com 发您的文章。
Doctor by Infodent: information for authors
“牙医 by Infodent”杂志: 投稿信息 General Info • Doctor by Infodent’s mission is to promote the scientific discourse
within the entire domain of education and professional development in dentistry.
The magazine aims to influence the practice of dentistry at clinician, research, industry and policy-maker level on an international scale. • The articles will be classified according to the following types: clinical research (observational and epidemiological studies), literature reviews, clinical cases, professional training.
Requirements • The manuscripts can’t be offer simultaneously to others publishing
houses or published in other journals. • Authors whose manuscripts include illustrations or texts already published for another journal have to provide the permission from the copyright holder. This permission must be received in writing along with the manuscript. In the absence of it, all the material received will be considered property of the author of the work. • The publisher will provide free of charge to the publishing of the articles (scientific and professionals), for the drafting of the manuscript is excluded any sort of reward for the author. • The final drafting of the manuscript must be sent in a digital format to Doctor by Infodent headquarter, subsequent amendments will not be accepted.
Author information must include:
• full name of all authors • complete address, telephone number and mailing address for each
author • degrees (e.g. DDS, DMD, PhD) • affiliation (e.g. School of Dentistry, University of London…)
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Doctor 牙医 by Infodent•2/2016
• the permission for texts already published or images depicting pe-
ople • Send the work (text and iconography) to scientificarticles@infodent.com • Illustrations must be sent in a digital form, numbered consecutively and accompanied by their captions with specific reference in the text. • Illustrations, graphs and figures must be provided as TIFF or JPEG files with the following parameters: • line art (and tables that are submitted as a graphic) must be sized at approximately 5” x 7” and have a resolution of 1200 dpi. • gray scale/black & white figures must have a minimum size of 3.5” x 5”, and a maximum size of 5” x 7” and a minimum resolution of 300 dpi and a maximum of 400 dpi. • color figures must have a minimum size of 2.5” x 3.5”, and a maximum size of 3.5” x 5” and a minimum resolution of 300 dpi and a maximum of 400 dpi. • color photographs must be sized at approximately 3.5” x 5” and have a resolution of 300 dpi. • To offer a significant contribution to the individual authors, the maximum number of authors accepted for bibliographical works or presentation of clinical cases is 4, for clinical research and epidemiological studies the maximum is 6. • The texts must be written in English and Chinese and structured into: - Scientific title in English and Chinese - Author(s) name(s) and last name(s) and concerning professional qualifications - Structured summaries in English and Chinese including subtitles, scope of work, materials and methods, results and conclusions. - Keywords in English and Chinese, using terms listing in Index Medicus.
- Introduction with the scope of the article. - Materials and methods, described in sufficient detail to allow others to reproduce the results. The study must be done in accordance with the Declaration of Helsinki and subsequent amendments. - Results - Discussion and conclusions - Bibliography. Entries and bibliographical references must be listed in order of appearance in the text and identified by Arabic numerals in parentheses (1), square brackets [1], superscript ¹, or a combination. - Tables, graphics, illustrations and captions.
作者信息要包括:
• Approval for publication is given, within the deadline set, by the
必须条件
标准: • 线艺术 (Line Art) 及 Tables (表格) 的必须尺寸约为5” x 7”， 并有1200 dpi的分辨率。 • 灰度/黑白形象必须具有3.5” x 5”的最小尺寸，5” x 7”的最大 尺寸。再说要300 dpi的最小分辨率, 400 dpi 的最大分辨率。 • 颜色的形象必须具有2.5” x 3.5”的最小尺寸， 3.5” x 5”的最大 尺寸。另外需要300 dpi的最小分辨率, 400 dpi的最小分辨率。 • 彩色照片必须尺寸在大约3.5” x 5”，再说有300 dpi的分辨 率。 • 以提供给各个作者的一个显著的贡献, 书目文章及临床病例 文章最多的作者是4人, 临床研究及流行病学研究最多的作者 是6个人。 - 所有文章都要中英双语写。另外需要: - 科学标题要用中英双语写的。 - 每一位作者的姓, 名字, 学位, 工作都。 - 中英双语的摘要, 包括副标题, 工作的目的, 材料及方法, 结果, 结论。 - 中英双语的关键字。 - 简介与文章的目的。 - 材料及方法。 研究都必须遵循“赫尔辛基宣言” (Declaration of Helsinki) 。 - 结果 - 讨论及结论 - 参考书目必须按出场顺序排列， 另外要用阿拉伯数字在 括号（ 1 ） ，方括号[ 1] ，上标 ¹ 。
• 手稿不能同时提供给其他出版社, 刊物都。 • 如果文章中包括其他受版权保护的作品，作者必须取得著作
• 发布的核准由科学委员会委员 (Science Board Committe)，如
Science Board Committee, who can make changes to texts if deemed necessary. The proofs must be returned correct uniquely by any misprints, without any changes or modifications. • The literary property of all texts, scientific and updated articles, is up to the editor.The author(s) requiring publication in Doctor by Infodent implicitly accepts the possibility of being published by the magazine, fully or partially, in other online and print publications. To transfer the ownership of the manuscript the authors must ask to the staff and fill the copyright statement. The publisher declines any liability related to manuscripts not expressly requested by the publishing house. The opinions expressed are the opinions of the authors and do not necessarily reflect the views of Doctor by Infodent. The publishing house assumes no responsibility for any errors in the article published. •The original text is not returned.
基本信息 “牙医 by Infodent”杂志的使命是促进科学论述在牙科学之内。 这本杂志旨在影响临床医生，研修员和决策人的牙科做法在 国际范围内。 文章将根据以下类型分类: 临床研究（观察及流行病学研究)， 文献综述，临床病例，专业培训。
权人的书面许可。此许可必须与稿件一起收到。如果没有的 话，收到的所有材料都将被认为是作品的作者的财产。 • 出版商将免费发表文章 (科学及专业人士的文章)，为稿件的 写作没有回报。 • 手稿的最后起草必须以数字格式给“牙医 by Infodent”杂志的 总部发送， 随后所有的修改都将不会接受。 • 手稿的最后起草必须以数字格式给“牙医 by Infodent”杂志的 总部发送， 随后所有的修改都将不会接受。
• 所有作者都的全名 • 每一位作者都的地址,电话号码,电邮地址。 • 学位 (比如说, 硕士学位, 博士学位等等) • 人事关系 (比如说, 伦敦大学, 牙科学校等等) • 已经发表的文章或描绘人的图像的许可 • 请把所有的材料都寄去 scientificarticles@infodent.com • 插图必须以数字形式发送，连续编号和伴随着它们与文字 说明中引用的标题。
• 请把插图，图表和附图都提供为TIFF或JPEG文件用下列
有必要可以把文章更改了。证明必须由印刷错误返回正确的 唯一，没有任何变动或修改。 • 所有文章都的著作权随编者。 作者们需要通过“牙医byInfodent” 杂志出版隐含接受由杂志正 在出版的可能性，完全或部分，在其他在线和印刷出版物。 表达的观点是作者的观点，不一定体现“牙医byInfodent”杂志 的意见。对于因本期刊中任何错误或遗漏而引起的损害，编 辑与出版社不承担任何责任。 • 原文不会返回。
Doctor 牙医 by Infodent•2/2016
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HIGHLIGHTS Our Advertiser’s Products
• 我们降低了产品的价格和尺寸，但没有降低产品的精确度和性能！ 基于几十年的工业计量经验，给牙科市场提供最精确的3DSA扫描仪的瑞士生产商，研发了 两款用于牙科试验室的价格实惠和高精确度的扫描系统。 IScan L1扫描仪的标准是用于齿冠、牙桥、局部牙、义齿、嵌体和高嵌体等，除了上述标 准外，IScan L1还能用于扫描为了生产基台的种植体模型和多种植体的修复。多亏了其开 放的数据格式L1扫描仪系列兼容多种CAD软件解决方案，这给客户提供了多种选择和方案。Imetric 扫描仪支持exocad 和 DDesigner。 欢迎到https://www.youtube.com/watch?v=Nh0uaM_254I观看我们的视频剪辑 欢迎登录我们的网站www.imetric.com // 电子邮箱：info@imetric.com 来中国国际口腔器材展览会暨学术研讨会，美国的Lab Day East牙科试验室峰会拜访我们。 We reduced the price and size, but not the accuracy and performance! Based on decades of experience in industrial metrology, the provider of the most accurate scanner in the dental market, Swiss-based Imetric 3D SA, has developed two new, affordable and accurate scanning systems for use in the dental laboratory. The IScan L1 is the scanner for standard indications like crowns and bridges, partials, dentures, inlays/onlays etc. The IScan L1m is also capable of scanning implant models for the production of custom abutments and multi-implant restorations, in addition to the afore mentioned standard indications. Due to open data formats, the L1 Scanner Series is compatible with multiple CAD software solutions, providing the user with diverse options and solutions. Imetric supports exocad and DDesigner. Watch the video clip: https://www.youtube.com/watch?v=Nh0uaM_254I www.imetric.com // info@imetric.com Visit us at Dentech China, Lab Day East
The flagship scanner D105i with the ring 经典D105i系列扫描仪！
The new L1-Series 全新L1系列！
Unequalled precision for implant-based restorations
We reduced the price and size, but not the accuracy and performance!
种植修复应用中绝无仅有的高精度！
实惠的价格,更小的尺寸 , 一样的精度和性能!
... with the IScan D105i – the ultimate scanner for complex tasks Swiss-made precision technology
... Combining accuracy with reliability and simplicity
Consistent high accuracy (< 5 µm)
Swiss-made precision technology
Validated workflow solutions available
Upgradable – from Crown & Bridge to Custom Abutment & Implant Bridges Highly configurable – allows use with various CAD software solutions
Combining accuracy with reliability and simplicity Based on decades of experience in industrial metrology, the provider of the most accurate scanner in the dental market – Imetric 3D SA – has developed two new, affordable and accurate scanning systems for use in the dental laboratory.
Imetric 3D SA • Le Bourg 9 • 2950 Courgenay • Switzerland • phone +41 32 471 14 09 • www.imetric.com • info@imetric.com
HIGHLIGHTS Our Advertiser’s Products
• 选择CAMLOG，选择成功 CAMLOG SCREW-LINE种植体系列 由瑞士设计，100%德国制造。 其创新 的主体设计，适应不同临床需要，简 洁独特的“管槽连接”TUBE-IN-TUBE CONNECTION是CAMLOG的专利设计。CAMLOG基台在各项耐疲劳实验 中遥遥领先于其他种植系统。 “管槽连接”可实现多种修复方案，无论哪种方 案，CAMLOG基台都显示出精确就位力，使临床医生轻易地获得“被动就位” 。 CAMLOG stands for success CAMLOG SCREW-LINE implant system is designed in Switzerland and 100% manufactured in Germany. Its innovative body design adapts to different clinical needs and the core element of the CAMLOG Implant System is its patented implant-to-abutment connection, known as CAMLOG “tube-in-tube connection”. CAMLOG abutment, during various performance tests, proved to be far ahead compared with other implant systems. “TUBE IN TUBE CONNECTION” can fulfil many kinds of repairing programs, and regardless of the type of restoration, CAMLOG Tube-in-Tube implant-abutment connection achieves good results for tight, precision fit so much so that clinicians easily get the “passive fit”. www.henryschein.com.cn
• 计算机导航种植技术：牙科界的先锋 B. & B.牙科有限公司是口腔种植业内领先的意大利企业，它是牙科种植体和骨再生材料的制造商。它 顺应了市场的需求和趋势，开发了一项基于软件的新技术，利用这个技术可以获得更快、更安全和更 准确的诊断和治疗。通过先进的计算机导航技术，患者可以事先得到一个手术计划，这个计划可以让 患者有可能只需要就诊一次就能实现把可移动式假牙变成种植体支撑的真牙齿，可以即刻完整无风险 的使用。在任何临床情况下，甚至在颌骨严重萎缩的情况下，通过计算机辅助的立体光刻获得的导航 使骨整合种植手术变成一个容易操作的技术。 此外，还有一个全新的手术工具包，其简单实用的功能已经使专业人员对其印象深刻。 B.&B. Dental还组织定期的培训课程，有意向参加课程人数的增加证明了人们对课程兴趣的提高。 （相关信息，请电邮至 commerciale@bebdental.it）。 网址www.bebdental.it //电子邮箱 info@bebdental.it Computer-guide implantology: the new frontier of dentistry B. & B. Dental S.r.l. is a leading Italian company in the field of oral implantology, manufacturer of dental implants and bone regeneration materials. Adhering to the new market needs and trends, a new software-based technique has been developed. It allows to obtain faster, safer and more precise diagnosis and treatment. Through advanced Computer-guided surgery techniques, patients may get treatment plans that turn mobile prosthetic teeth into fixed implant-supported teeth, in a single appointment, for immediate and completely risk-free use. The guides obtained through computer-aided stereolithography make osseointegrated implantology an easy-to-use technique in any clinical condition, even in case of severe atrophy of the jaw bones. Moreover, a brand new surgical kit has positively impressed the professionals for its functional simplicity. Successful courses are periodically organized by B.&B. Dental; they confirm the growing interest of an increasing number of dentists who wish to participate (for information please contact: commerciale@bebdental.it). www.bebdental.it // info@bebdental.it
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Doctor 牙医 by Infodent•2/2016
HIGHLIGHTS Our Advertiser’s Products
• DIA-PROSEALTM DIA-PROSEALTM根管封闭剂是一种环氧树脂基配方的流体，它具有以下几个优异的特点
- 具有低收缩率，是一种可以减小封闭剂和根管壁之间缝隙的理想封闭剂。 - 低溶解度使其不易随着时间的推移而被分解掉。 - 1：1的糊浆混合方法，使备制过程快速而简单，减少浪费。 - 很好的流动性使其容易到达并密封根管的侧面管道，使其特别适合热牙胶充填法。 - 提供了1个小时的工作时间和7个小时的凝固时间。 - 轻薄涂层的牙胶点与良好的膜厚度 我们的网站www.diadent.co.kr 电邮diadent@diadent.co.kr DIA-PROSEALTM, root canal sealer is an epoxy resin-based formula with outstanding flow characteristics. Benefits - The ideal root sealer with Low Shrinkage reduced gapping between the sealer and canal wall. - Low solubility makes it resistant to breaking down over time. - 1:1 paste to paste mixing system and Fast and Easy Preparation and Less Waste. - Excellent flow properties allow it to reach and seal lateral canals, making it especially suited to warm gutta-percha methods. - Offers 1 hour working time and 7-hour setting time. - Lightly coated Gutta Percha Points with a good film thickness. www.diadent.co.kr // diadent@diadent.co.kr
• MaCo Dental Care 推出两款新的种植体系列。 MaCo Dental Care公司今年也展示了其非凡的创新能力，在完成了其第十七次革新后，这个意大 利公司又准备在市场上推出两款新产品，其主要的种植体系列的内部具有内六角形链接，采用 了平台转换系统。Conical Active系列的特点是其8°的锥形链接，内部防旋转式六角形和双主螺 纹，确保了其在各种类型骨质中的稳定性。IM Macon系列是具有锥形链接的短种植体，其特征 在于非常容易使用并且能够确保假体部件在没有紧固螺丝情况下的稳定性。现在，由Maco公司 生产的种植体系列变成了8个，对于一家已经取得可靠性和多功能性的公司来说是个很大的成就。 登录我们的网站www.macointernational.com // 电子邮箱info@macointernational.com 来西班牙马德里牙科保健展访问我们，2016年3月10日至12日 MaCo Dental Care launches two new implant lines. Also this year, MaCo Dental Care unveils its ability to innovate. After a complete revolution of Seventeen, its main implant line with internal hex connection, implemented with platform switching system, the italian company is ready to launch two new implant lines on the market. Conical Active is characterized by its 8° conical connection, an internal anti-rotational hexagon and a double principle thread that ensures its stability in all types of bone. IM Macon, instead, is a short implant with tapered connection characterized by a great ease of use and the capability to ensure stability to the prosthetic components without tightening screw. In this way, implant systems manufactured by MaCo become eight, a great achievement for a company that has made reliability and versatility its strengths. www.macointernational.com // info@macointernational.com
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Doctor 牙医 by Infodent•2/2016
HIGHLIGHTS Our Advertiser’s Products
DenTag - Evolution of Species Dentag（登泰格） – 一个物种的进化 As you know, DenTag always produces surgical and dental instruments ... using stainless steel.
众所周知，DenTag一直专注生制作外科和牙科器械…… 原材料选择不锈钢。
Over the years, we have produced, for us and others, innumerable variations of instruments. We have also started the production of tools in aluminum, titanium and with inserts in hard metals but always working in the field of metals. We believe, in our little experience, to have built a recognized standard of quality and reliability. However, we always pay attention to changes and trends in the market that evolves rapidly and sometimes suddenly.
多年来，我们为我们自己和其他人，制作了无数的各种 各样的器械。我们也开始生产其他材质的器械，例如铝、 钛以及硬金属的内嵌件，但是一直还是在金属领域。我们 相信，在我们有限的经验下，去建立了一个公认的质量和 可靠性的标准。 即便如此，我们总是关注市场里因发展迅速或是突然发生 的变化和趋势。
Cyclically we receive requests for instruments lighter but at the same time as reliable as those made of stainless steel. Not being able to change the material used for the tips, to lighten the devices, we can only works on the handles. That is why we started to manufacture an entirely new line of plastic material handles.
我们经常收到订单要求仪器轻的同时，还要求原材料为 可靠的不锈钢。无法改变材料使用部份的材料，为了减轻 重量，我们只能在手柄上想办法。这就是为什么我们开始 制造一个全新的制作塑料材料手柄的新产品线。
Clearly this solution is already used by others before us so that, in the design, we started to study the state of art, trying to take advantage and, if possible, improve the positivity, correcting any errors if we found.The result of this search is an handle which has, we think for the first time, several positivity together. We are not the first to bring to market devices with plastic handle, but we tried to do it in the best way.
研究探求的结果就是我们在第一次开始研究时就考虑过的 手柄，它包含我们要求的性能。 我们不是第一个将塑料工具手柄引入在市场的公司，但 我们尽自己最大的努力使用最好的方法。
As always we are respecting our quality standards and, we are proud of, 101% Italian quality.
一直尊重并遵守我们的质量标准，我们感到非常自豪， 追求101%意大利品质。
It is known that simple dental instruments such as curettes or double probes may injure the operator’s hand or lacerate the glove (with the opposite working points). The possibility of injury is during use, handling or passing the instrument between Assistant-Dentist-Assistant while performing the procedures on the patient.
众所周知简单的牙科器械,例如刮勺或双探针可能伤害操 作者的手或割裂手套(与之相反的工作要点)。 在使用过程中是有受伤的可能性的, 虽然助理和牙医在对待 病人或和使用器械时候履行着操作程序。
Directive 2010/32/EU - prevention from sharp injuries in the hospital and healthcare sector, also it states that it’s necessary to prevent workers’ injuries caused by all medical sharps and pointed devices. Instruments with a handle 100, 105 mm are too short and the tips, even if they are turned contrary than working one, very often touch on the back of his hand.
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显然这个解决方案已经被别人在我们之前想到了，所以在 设计时，我们开始研究工艺水平，尝试利用现有的优势， 如果可能，提高产品性能，纠正我们发现任何错误。
欧盟2010/3/2 /下令——预防在医院和医疗保健领域发生的 尖锐器械伤害事故,也同时指出有必要防止来自所有医学专 用尖锐器械或锐利的设备对医务工作者造成伤害。 器械操作手柄100、105毫米太短和需要留意,即使他们工作 时一个转向与经常接触他的手相反。
Instead, what it can do as an additional preventive action is to choose, when buying or replacing, one instrument with a long handle. The longer instruments can be wrapped exactly like the other and, in the event that the dentist use cassettes or trays for sterilization of small size, it will be sufficient to put the instruments in the direction of the longer side.
然而,它能做什么额外的预防措施作为选择和提醒,当器械或 设备购买或更换时需用一个长柄器械。
That’s another reasons to choose new DenTag “EVO” family of instruments.
那也是另一个选择新的DenTag “EVO”家族系列器械的 原因。
Doctor 牙医 by Infodent•2/2016
长的手术器械可以包装的和另一个都一样精巧,如果牙医 使用类似长方磁带盒子或消毒托盘的体积较小,就足可以将 器械的长边朝着长的方向摆放。
Material: Lightweight (11 g) and resistant to stress. Use turns out to be easy, for sure grip and non-fatiguing. Tested and used in the food field, then completely non-toxic and free of potentially harmful substances. Autoclavable without change of shape and color. Form: 10.5 mm Diameter of the handle and the center of 9.0 mm to minimize the problems to carpal tunnel data from prolonged use in time. Longitudinal notches to increase the grip and the sensibility. Construction: We have inserted during molding of the handle, two stainless steel bushes suitably shaped, in which the tips are then introduced. With this procedure will eliminate the presence of an internal longitudinal metal bar with obvious reduction in weight. The tips are not glued to the plastic and so there is no risk of potentially harmful substances are released. Aesthetics: Profile simple, easy to wash and clean. Without deep grooves or notches that may cause accumulation of germs and bacteria. Since plastic is possible to color in various shades aesthetically pleasing and with advantages for the immediate recognition of the instrument.
材质：重量轻（11 g）和抗压力。结果 证明使用容易，抓握牢固以及无金属 疲劳。经食品领域测试和使用，完全 无毒，无有害物质。经受高温高压后 无形状和颜色的变化。 形状：工具手柄抓握处直径10.5毫米和 中心处9毫米，以减少由于长时间使用 而引起腕管综合症的风险。纵向的刻 痕用来增加抓握力与手的敏感性。 结构： 在工具手柄的成型阶段，我们 插入两个相配成形的不锈钢衬套，这 个衬套用于随后将工具头植入。这个 过程去除了纵向内部金属核的存在， 减少相当大的重量。工具头不是粘结 在塑料上，因此没有释放潜在的有害 物质的风险。 美学： 简单的轮廓，容易清洗，无可 能导致细菌和细菌的积累的深沟槽或 刻痕。作为塑性材质，其色彩可以是 不同的色度，美观和并拥有可以立即 辨识器械的优势。
The Evohandle It is known that simple dental instruments such as curettes or double probes may injure the operator’s hand or lacerate the glove (with the opposite working points). The possibility of injury is during use, handling or passing the instrument between Assistant-Dentist-Assistant while performing the procedures on the patient. Directive 2010/32/EU - prevention from sharp injuries in the hospital and healthcare sector, also it states that it’s necessary to prevent workers’ injuries caused by all medical sharps and pointed devices. Instruments with a handle 100, 105 mm are too short and the tips, even if they are turned contrary than working one, very often touch on the back of his hand. Instead, what it can do as an additional preventive action is to choose, when buying or replacing, one instrument with a long handle. The longer instruments can be wrapped exactly like the other and, in the event that the dentist use cassettes or trays for sterilization of small size, it will be sufficient to put the instruments in the direction of the longer side
That’s
another reason to choose new
Evofamily
of instruments! DenTag
s.r.l.
Via Maniago, 99 • 33085 Maniago (Pn) • Italy tel. + 39 0427 71561 fax + 39 0427 700666 info@dentag.com
www.dentag.com
Doctor 牙医 by Infodent•2/2016
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Scientific Update 学术文章 Ask your free subscription: In every issue you will discover scientific articles and a selection of the best dental products worldwide. 心动不如行动: 立刻免费订阅。在每一个发行， 您会发现科学文章及世界各地最好的牙科产品。 Write an email to prc@infodent.com, in Chinese or English, or visit our stand at DenTech China Shanghai (booth Hall 1 F 70 – 71 – 96 – 97). 联系邮箱：prc@infodent.com (中英文均可!)或者请参观我们在 上海口腔展 (DenTech China Shanghai) 的展位 (Hall 1 F 70 – 71 – 96 – 97)。
Doctor 牙医 by Infodent•2/2016
19
SCIENTIFIC UPDATE Split Crest Technique in the maxillary latero-posterior area
Author S. Longoni1, I. Maroni 2, A. Baldini 3, M. Sartori 4 1 Md, Dds, Contract Professor Of Prosthodontics, Milano Bicocca University Dental School, Milan, Italy 2 Md, Dmd, Private Practice, Varese, Italy 3 Dds, Phd, Phd Division Of Orthodontics, University Of Rome Tor Vergata, Rome, Italy 4 Dds, Phd, Phd In Experimental Periodontology, Contract Professor Of Prosthodontics, Milano Bicocca University Dental School, Milan, Italy KEY WORDS
Bone expansion, Bone resorption, Osteotome, Piezosurgery, Split Crest.
Retrospective radiographic study of marginal bone changes of 88 implants placed with split crest technique in the maxillary latero-posterior area
TO CITE THIS ARTICLE : Longoni S, Maroni I, Baldini A, Sartori M. Retrospective Radiographic Study of marginal Bone Changes of 88 implants placed with split CrestTechnique in the maxillary latero-posterior area. J OSSEOINTEGR 2016;8(1):8-13.
ABSTRACT
Aim This article presents a retrospective study on the behavior of implants placed with split crest technique in lateroposterior maxillary class IV atrophy. Materials and Methods Subjects who underwent implant placement following split crest technique in the maxillary latero-posterior area were enrolled in the present retrospective study. After a mean period of 6.2 years of function implant survival and success rates were assessed. Moreover, radiographic examination was made on digital periapical radiographs and by means of a specific software. Bone level changes were measured as the difference between the peri-implants crestal bone level and the implants shoulder during the last patient’s visit recall examination. Results A total of 30 patients satisfied the inclusion criteria and were included in the study; the subjects were treated with 88 implants (64 transmucosal and 24 submerged). The observation period for all patients treated with split crest technique varied between 4 and 8 years (mean 6.2 years). The implants survival rate was 96.6% and the prostheses survival rate was 100%. Bone resorption ranged between 2.3 mm and 2.7 mm. Conclusion Implants inserted in conjunction with split crest technique seems to be a promising therapy with similar results as conventional implant surgery. INTRODUCTION Maxillary alveolar atrophy is a longstanding problem that has prevented numerous patients from receiving treatment with dental implants. An adequate volume of healthy bone tissue at implants site is a fundamental prerequisite for a favorable prognosis of osseointegrated implants (1). In recent years, more awareness has been developed towards the principle of restoration-driven implants placements (2). In fact, maxillary bone atrophy and anatomic aberrations may jeopardize correct implant placement with respect to the ideal position and the final prosthetic restoration (2, 3). In Cawood and Howell class IV atrophy (4) there is insufficient bone at the ideal desired implant location. The site can be either grafted or enhanced through the use of barrier membranes (GBR) (5, 6) or titanium mesh (7-9), thus restoring the labial contour. Often, these procedures require a two staged approach to implant placement, lengthening treatment time and increasing costs. Indeed, bone grafting techniques implicate an additional operation area, general discomfort and morbidity and potential complications as the risk of infection
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Doctor 牙医 by Infodent•2/2016
and/or mucosa dehiscence. An alternative surgical technique is the split crest procedure that has provided satisfactory and predictable results for localized ridge expansion (10). The alveolar ridge recontour by means of this technique is obtained with a one stage procedure without involving additional costs and a second operation area. Tatum in 1986 originally developed the technique for the placement of the Omni root, D-shaped, transmucosal implants (10). Then, the technique has been modified for implants placement with a submerged approach (11-17). The main purpose of this study was to present the results of a retrospective study concerning the behavior of implants placed by means of split crest technique in the latero-posterior area of the upper jaw (from the canine to the first molar region). During patients recall examination, implants success following Albrektsson and Zarb criteria (absence of implants mobility, no radiolucency around implants in the radiographic control, no infection, no pain and other symptoms or
complaints referred by patients) and bone level changes were evaluated (18, 19). Also implants survival rate, prosthesis survival rate and aesthetic observations were reported. MATERIALS AND METHODS
Patients enrolled in the present retrospective study underwent implant placement with split crest technique in the maxillary latero-posterior area (from the canine to the first molar region: from 1.3 to 1.6 and from 2.3 to 2.6). The selected subjects had to meet the following inclusion criteria: - a thin maxillary ridge (Cawood and Howell IV class), ranging from 3 to 5 mm, and a corono-apical height of at least 10 mm; - a trapezoidal residual bone shape of the ridge (showed by the transaxial CT images); indeed, it reduces the possibility of fracture of the labial bone wall during the split crest procedure, in comparison with a rectangular ridge shape. Specifically, the ridge should have labial and palatal cortical plates that are not fused and are separated by cancellous bone to facilitate the introduction of instruments for ridge expansion (10, 17). Moreover, the residual crest angulation is important because expanding the external cortical plate of the maxilla in labial direction may jeopardize the correct implant placement (Fig. 1) (10); - a class 3 bone quality according to Lekholm and Zarb (20); - no contraindications for implant treatment (1, 18); - no smoking habits. Fig.1
Fig.2
The patients were given oral and written information regarding the risks of this type of surgery and their written informed consent was obtained. SURGICAL PROCEDURE
The surgical procedure was performed from 2006 to 2010. Surgery was planned using computed tomography scans (CT), casts, diagnostic waxup and surgical template. Local anesthesia was achieved by infiltration of articaine 4% plus adrenaline 1:100,000 (Ubistesin™; 3M ESPE, Seefeld, Germany). A soft tissue incision was made to create a full thickness crestal flap with relaxing periosteal incisions. Crestal bone was regularized with a surgical tungsten bur in order to obtain a flat bone surface between the palatal and buccal cortical plates to make the subsequent osteotomy procedure easier (Fig. 2). In order to control the extension of the fracture line and to prevent the invasion of the periodontal ligament of the adjacent teeth, with the first pilot drill (Ø1.5 mm) the sites of the most mesial and the most distal (if a distal tooth is present) implants were prepared as deep as possible to minimize bone stress during the split crest. Subsequently, the Piezosurgery® (Mectron S.P.A. Genoa, Italy) (Fig. 3) technique was used for the crestal bone incision trying to reach the same depth of the first pilot drill. Then, straight chisels and round osteotomes to mobilize and gradually expand the vestibular bone wall were used. The instruments size and number varied in relation to bone density, thickness and diameter of implants. Insertion and removal of chisels and osteotomes (Fig. 4) was performed in a straight path with light malleting (10). The procedure was completed when the conical osteotomes had prepared adequate implants sites. Two types of implants had been used: trasmucosal ITI® (Straumann AG, Waldenburg, Switzerland) standard implants (2.8 mm neck height) and 3i
Fig. 1 The anatomy of the ridge to be split may influence implant’s angulation and the possibility of vestibular wall fracture. Fig. 2 Bone ridge after regularization with tungsten bur. Fig. 3 Occlusal view of bone ridge after the first incision with Piezosurgery®.
Fig.3
Doctor 牙医 by Infodent•2/2016
21
SCIENTIFIC UPDATE Split Crest Technique in the maxillary latero-posterior area
Fig. 4 Sequence with larger instruments for a progressive and controlled bone expansion. Fig. 5 Split crest with submerged implants.
Biomet® (Palm Beach Gardens, Florida, USA) submerged implants. When a high density bone quality was present, it had been necessary to adjust the shape of implant bed with the corresponding implant bur especially in the case of straight non self-tapping transmucosal implants. Transmucosal implants had been positioned with the neck’s shoulder aligned at the level of the crestal bone. Submerged implants had been placed into the osteotomy until they had reached 1 mm below the level of the crestal bone (10) to compensate the amount of physiological bone resorption after the surgical phase (Fig. 5). All implants had been inserted using handpiece implant driver. Autogenous bone chips harvested during the bone drilling phases plus bone from bovine sources (Tutodent® Chips 0.25 mm–1.0 mm - Tutogen Medical GmbH RTI Biologics Company, Neunkirchen a. Br., Germany) were used to fill the space created by expansion around the implants. A resorbable membrane (Pericardium Membrane - Tutogen® Medical GmbH RTI Biologics Company, Neunkirchen a.B., Germany) had been always placed to prevent mucosal penetration into the surgical site and to allow bone regeneration. All implants had been allowed to integrate with a submerged approach, avoiding incongruous loading due to removable provisional prosthesis, if present. Primary wound closure had been achieved with interrupted polyglycolic suture (Vicryl ® 4-0, Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA). Second stage surgery had been performed after 4 months (21). A provisional fixed prosthesis was always used for 2 months with the aim of exerting a progressively increasing load on the implants (22). Subsequently definitive restorations had been delivered to the patients. All the definitive prostheses were fixed partial dentures, using an intraoral luting technique to achieve passive fit (23). Photographs documentation had been performed during surgery to show the implants shoulFig.4
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ders positioned following the protocol previously described. Radiographic examination was obtained using periapical radiographs taken with Rinn X-ray holders (Rinn®, Elgin, IL, USA) and the paralleling long-cone technique. In particular the radiographs had been performed at the 10 days recall for suture removal. The last photographic and radiographic evaluation was done during patients recall at the beginning of this retrospective study. For each implant, the radiograph obtained at sutures removal (baseline) and the most recent radiograph obtained during patient’s visit recall examination (after a mean period of 6.2 years, min 4 years-max 8 years) were digitized and stored in a commercially available computer software (Sidexis, Sirona Dental GmbH, Salzburg, Austria), allowing gray value adaptation and calculation of the magnification factor of radiograph (calibration). In particular, for each radiograph the known implant length of ITI system (10 mm, 12 mm or 14 mm) and the known implant length of 3i Biomet system (10 mm, 11.5 mm or 13 mm) were used to calibrate images prior to bone level measurements. When the implant length was not available, the measure of implants diameter was used as a reference. Only radiographs showing the implants both mesially and distally, and the ones with an adequate quality with respect to contrast, were used. Location of the first bone-implant contact point were measured starting from the implant shoulder, and the amount of bone loss around implants was expressed in millimeters. Measurements of the distance between these two reference points were performed digitally at mesial and distal aspect 3 times per implants and mean values were calculated, recorded for each implant and expressed as mean ± standard deviation (SD). The measurements were made to the nearest 0.1 mm. Implant success according to Albrektsson and Zarb (i.e. absence of implants mobility, no Fig.5
radiolucency around implants in the radiographic control, no infection, no pain and other symptoms or complaints referred by patients) (19) and survival rate were calculated. RESULTS The total number of patients enrolled in the present retrospective study was 30, aged between 30 years and 70 years (mean 50,8 years) (13 male, 17 female). They were treated with split crest technique in the latero-posterior area of the upper jaw (from the canine to the first molar region) and 88 implants were placed. In particular, 64 ITI transmucosal standard implants (2.8 mm neck height) were inserted in 20 patients with a mean observation period of 6.4 years. After 2 years from the placement of the first implants, 24 3iBiomet submerged implants were also placed in 10 patients in order to achieve an easier management of soft tissues and aesthetics: the mean observation period was 5.6 years (Fig. 6 and 7). Globally the mean observation period for all patients treated with split crest technique was for both implants systems 6.2 years. The implants survival rate was 96.6%: 3 implants were lost du-
ring the unloaded healing period at second stage surgery (Table 1). Lost implants where replaced with larger diameter implants. At the moment of recall all the prostheses were in situ, so the prostheses survival rate was 100% and the patients did not refer any major complaint. Radiographic examination of implants showed that in transmucosal implants the mean bone resorption was mesially 2.5 mm (± 0.6 mm SD) and distally 2.7 mm (± 0.5 mm SD). In submerged implants the mean bone resorption was mesially 2.4 mm (± 0.5 mm SD) and distally 2.3 mm (± 0.6 mm SD) (Table 1) (Fig. 8 and 9). DISCUSSION As described in the international literature (11, 12, 15, 17), the split crest is a reproducible technique, but it depends upon the surgeon’s technical skills and it requires an adequate learning curve. As a matter of fact, the main risk of split crest technique is the fracture of the labial cortical plate: this unlucky event may occur during the surgical phase especially if there is not cancellous bone between the reabsorbed cortical plates. Indications for bone splitting are restricted to those sites that do
Fig.6
Fig.7
Fig.8
Fig.9
Fig. 6 Detail of prosthetic restoration onto submerged implants after 6 years. Fig. 7 Detail of prosthetic restoration onto transmucosal implants after 6 years. Fig. 8 Crestal bone resorption evaluated on digitized periapical radiographs of submerged implants after 6 years. Fig. 9 Crestal bone resorption evaluated on digitized periapical radiographs of transmucosal implants after 6 years.
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SCIENTIFIC UPDATE Split Crest Technique in the maxillary latero-posterior area
ITI (TSI*)
Table Implants survival and implant success. Marginal bone resorption was measured at recall examination. *TSI = Transmucosal Standard Implants
Total number of implants
64
24
Total number of lost implants
2
1
96.9%
95.8%
Survival rate
96.6%
Global survival rate Mesial bone level change: mean
2.5
2.4
Mesial bone level change: SD
0.6
0.5
Distal bone level change: mean
2.7
2.3
Distal bone level change: SD
0.5
0.6
not require vertical ridge augmentation (Cawood and Howell class IV atrophy). The rationale of split crest choice is to expand the residual ridge obtaining quickly palatal and buccal bone walls ≥ 1 mm in order to position implants completely embedded into bone for long lasting osseointegration (1, 10). An important aspect of the split crest technique regards the difficulty to plan a prosthetically driven implant placement. In fact, implants are placed between the labial and the palatal cortical plates following the angulation of bone ridge fracture. As a consequence in prosthetics steps often it is necessary to rectify abutment angulation to achieve an ideal aesthetic and functional result. Moreover, the rationale for full thickness flap is to improve visualization of bone ridge to be expanded, better controlling the labial cortical wall during splitting to reduce the risk of fracture. In this way, it is possible to perform and, if necessary, to position biomaterials and membranes before sutures. But, there was the possibility of blood supply reduction that should is taken into consideration. In comparison with split crest technique, horizontal onlay block grafting allows to obtain a real 3D bone reconstruction with prosthetically favorable implant positioning. As reported by Aghaloo et al. in 2007, the implant survival rate positioned after onlay horizontal bone grafting is 90.4% and there are not long term follow up studies with exception of GBR (24). Also for ridge expansion techniques very few long-term, clinical studies have been published to date. Simion et al. (11) reported on 5 patients in which a split-crest technique combined with guided tissue regeneration was performed. A 5 years clinical study was carried out by Scipioni 24
3i BIOMET
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et al. (12) showing a survival rate ranging from 85% to 99%. Engelke et al. presented a clinical study placed with ridge splitting technique with micro-fixation reporting a survival rate of 86.2% after 5 years (15). Sethi et al. showed a survival rate of 97% after an observation period of 5 years (17). Bravi F. et al. reported a survival rate of 95.7% after 10 years (22). Blus et al. reported a high survival rate of 96.5% with split crest technique (25). In this retrospective study, clinical and radiographic parameters showed that this surgical technique was safe and predictable when all inclusion criteria are carefully evaluated. With 96.6% of implants survival and 100% of prosthesis survival rate, the outcomes of the present investigation were consistent with the recent papers of Garcez-Filho et al. (26) and Santagata M et al. (27), with previously cited articles and with traditional implant placement procedure. Specifically, the 3 lost implants were placed in an area where a major bone expansion was performed, and this probably reduced the possibility of achieving an optimal primary stability. Radiographic bone levels measured mesially and distally to the implants inserted with the split crest technique were in the ranges of the bone levels reported in the literature around the implants positioned with the conventional standard technique (18). Both types of implants showed similar bone resorption (range: min 2.3 mm max 2.7 mm). This resorption was probably due to bone remodeling after the surgical expansion trauma and the bone blood supply interruption between the vestibular and palatal cortical plates. As a consequence, aesthetic outcomes were different in relation to the different implant-abutment connections and therefore, due to implant neck morphology. The aesthetic behaviors were observed during patient’s recall examination when this retrospecti-
ve study started. In particular, in periodontal thin biotype the transmucosal smooth neck of implants was frequently exposed representing an aesthetic limit for the patient in comparison with submerged implants. Further research is needed to confirm these preliminary results. CONCLUSION Within the limitation of the present study, implants inserted in conjunction with split crest technique, regardless of the implant placement protocol (i.e.: transmucosal or submerged) showed good functional results.The one-stage approach should be considered predictable as long as selection of patients and surgical protocols described are carefully followed. REFERENCES 1. Misch CE. Available bone and implant dentistry. In: Misch CE. Contemporary Implant Dentistry. St. Louis, MO: Elsevier Mosby, 2008:105-129. 2. de Wijs FLJA, Cune MS.Immediate labial contour restoration for improved esthetics: a radiographic study on bone splitting in anterior single-tooth replacement. Int J Oral Maxillofac Implants 1997;12:686-696. 3. Guirado JL,Yuguero MR, Carrión del Valle MJ, Zamora GP.A maxillary ridge-splitting technique followed by immediate placement of implants: a case report. Implant Dent 2005;14:14-20. 4. Cawood JI1, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg1988;17(4):232-6. 5. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994;14:496-511. 6. Simion M, Jovanovic SA, Trisi P, Scarano A, Piattelli A. Vertical ridge augmentation around dental implants using a membrane technique and autogenous bone or allografts in humans. Int J Periodontics Restorative Dent 1998;18:8-23. 7. von Arx T, Hardt N, Wallkamm B. The TIME technique: a new method for localized alveolar ridge augmentation prior to placement of dental implants. Int J Oral Maxillofac Implants 1996;11:387394. 8. Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: a clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427-432. 9. Longoni S, Sartori M, Apruzzese D, Baldoni M. Preliminary clinical and histologic evaluation of a bilateral 3-dimensional reconstruction in an atrophic mandible: a case report. Int J Oral Maxillofac Implants 2007;22:478-483. 10. Ferrigno N, Laureti M. Surgical advantages with ITI TE implants placement in conjunction with split crest technique. 18-month results of an ongoing prospective study. Clin Oral Implants Res 2005;16:147-155. 11. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique
and guided tissue regeneration. Int J PeriodonticsRestorativeDent 1992;12:462-473. 12. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994;14:451-459. 13. Scipioni A, Bruschi GB, Calesini G, Bruschi E, De Martino C. Bone regeneration in the edentulous ridge expansion technique: histologic and ultrastructural study of 20 clinical cases. Int J Periodontics Restorative Dent 1999;19:269-277. 14. Duncan JM, Westwood RM. Ridge widening for the thin maxilla: a clinical report. Int J Oral Maxillofac Implants 1997;12:224-227. 15. Engelke WG, Diederichs CG, Jacobs HG, Deckwer I. Alveolar reconstruction with splitting osteotomy and microfixation of implants. Int J Oral Maxillofac Implants 1997;12:310-318. 16. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmentation in the maxilla. Int J Oral Maxillofac Implants 1998;13:701-5. 17. Sethi A, Kaus T. Maxillary ridge expansion with simultaneous implant placement: 5-year results of an ongoing clinical study. Int J Oral Maxillofac Implants 2000;15:491-499. 18. Misch CE. An implant is not a tooth: a comparison of periodontal indexes. In: Misch CE. Contemporary Implant Dentistry. St. Louis, MO: Elsevier Mosby, 2008:18-31. 19. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants1986;1:11-25. 20. Lekholm, U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Albrektsson T, eds. Tissue Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence Publ Co., 1985:199–209. 21. Basa S, Varol A, Turker N. Alternative bone expansion technique for immediate placement of implants in the edentulous posterior mandibular ridge: a clinical report. Int J Oral Maxillofac Implants 2004;19:554-558. 22. Bravi F, Bruschi GB, Ferrini F. A 10-year multicenter retrospective clinical study of 1715 implants placed with the edentulous ridge expansion technique. Int J Periodontics Restorative Dent 2007;27:557-565. 23. Longoni S, Sartori M, Maroni I, Baldoni M. Intraoral Luting: Modified Prosthetic Design to Achieve Passivity, Precision of Fit, and Esthetics for a Cement-Retained, Implant-Supported Metal-Resin-Fixed Complete Denture. J Prosthodont 2010;19:166-170. 24. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22 Suppl:49-70. 25. Blus C, Szmukler-Moncler S. Split-crest and immediate implant placement with ultra-sonic bone surgery: a 3-year life-table analysis with 230 treated sites. Clin Oral Implants Res 2006;17:700-707. 26. Garcez-Filho J, Tolentino L, Sukekava F, Seabra M, Cesar-Neto JB, Araújo MG. Long-term outcomes from implants installed by using split-crest technique in posterior maxillae: 10 years of follow-up. Clin Oral Implants Res 2015;26:326-31. 27. Santagata M, Guariniello L, Tartaro G. Modified edentulous ridge expansion technique and immediate implant placement: a 3-year follow-up. J Oral Implantol 2015;41:184-7. Doctor 牙医 by Infodent•2/2016
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SCIENTIFIC UPDATE
在上颌后侧切牙区用牙槽嵴分割法种植了88个种植体之后，用X线片评估边缘骨变化的回顾性研究
在上颌后侧切牙区用牙槽 嵴分割法种植了88个种植 体之后, 用X线片评估边缘 骨变化的回顾性研究 文章引自 Longoni S, Maroni I, Baldini A, Sartori M. Retrospective Radiographic Study of marginal Bone Changes of 88 implants placed with split CrestTechnique in the maxillary latero-posterior area. J OSSEOINTEGR 2016;8(1):8-13.
Author S. Longoni1, I. Maroni 2, A. Baldini 3, M. Sartori 4 1 意大利米兰比可 卡大学牙科学院口 腔修复学合约教授 2 意大利比雷泽私 人诊所有者 3 意大利罗马第二 大学口腔正畸学 博士 4 意大利米兰比可 卡大学牙科学院口 腔修复学合约教 授、牙周病学试验 博士
关键词 骨扩充；骨吸收； 骨切割；Piezosurgery 超声骨刀，牙槽嵴 分割
摘要 目的本文介绍一个在上颌后侧切牙区IV级萎缩的状态下牙槽嵴分割法种植的种植体性能的回 顾性研究。 材料和方法被纳入本次回顾性研究中的研究对象，在上颌后侧切牙区接受了牙槽嵴分割种植 法种植。在使用了平均6.2年后，进行了种植体成活率和成功率的评估。此外，还通过应用数 字根尖片和特定软件做了放射检查。测量了骨水平的变化值，就是召回患者检查时种植体周 围骨嵴水平线和种植体肩部水平线之间的距离值。 结果一共有30个患者对本次研究所得出的结论表示满意；有88根种植体用在这30个研究对象 上（64根粘膜式种植，24根浸入式种植）。所有接受了牙槽嵴分割种植法患者的观察期为4至 8年（平均观察期为6.2年）。种植体成活率为96.6%，义齿成活率为100%。骨吸收程度在2.3毫 米和2.7毫米之间。 结论分割牙槽嵴种植术似乎是个有前途的治疗方案，它的结果和常规种植手术的结果相似。 引言 上颌牙槽骨萎缩妨碍患者接受种植的问题由来 已久，种植部位是否有足够的健康骨组织对促 成骨整合种植的成功是个至关重要的前提条件 （1）。近年来，更多对推动修复性种植体放 置原则的意识得到了提高（2）。事实上上颌 骨萎缩和解剖性畸变可能会危及到把种植体正 确地放置在理想的位置上，还可能影响到永久 义齿的修复(2,3).在 Cawood 和Howell IV级萎 缩中（4），预期理想的种植位置上没有足够 的骨量。那一个部位可以用一个屏障膜(5,6)或 钛制网格(7,9)进行移植或得到加强，来恢复唇 侧的外形。通常，这些需要一个两阶段式的种 植法来种植，这种种植法既延长了治疗时间， 又增加成本。骨移植涉及到额外的手术部位，带 来全身的不适、患病率和潜在的并发症，如感染 和/或口腔粘膜开裂。另一种可替代的手术方法 就是牙槽嵴分割法，这中方法已经在局部牙槽嵴 扩充方面给出了满意度和可预见结果（10）。 用这种方法可以重塑牙槽嵴，它只需要一步 式的手术，没有额外的花费和二次手术部 位。在1986年，为了种植Omni根D形粘膜种 植体，Tatum第一次发明了这种技术（10） 。然后，这种技术还为浸入式种植而被修改 (11,17）。用牙槽嵴分割法在上颌后侧切牙区 （从尖牙到第一磨牙区）种植后，对种植体性
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能的回顾性评估，是这次研究的主要目的。患 者召回检查时，治疗结果满足了Albrektsson 和 Zarb提出的种植成功标准（种植体没有移动 现象、x线检查时种植体周围没有透亮点、无 感染、无痛和无患者提出的其它明显的不适症 状），评估了骨水平变化(18;19).报道了种植体 成活率、义齿成活率和美学观察结果。
材料和方法 在被纳入本次研究的患者上颌后侧切牙区，用 牙槽嵴分割法进行了种植（从尖牙都第一磨牙 区：从1.3到1.6和2.3到2.6）。被被选择的患者 需要满足下面的筛选标准： - 有薄的上颌骨嵴（Cawood 和Howell IV级萎 缩）在3至5毫米之间，根尖至齿冠的高度至少 达10毫米； -牙槽嵴的残留骨呈梯形(从CT横断图像判断) ，比起矩形牙槽嵴，梯形牙槽嵴在牙槽嵴分割 过程中有助于减少唇骨骨折。具体来讲，牙槽 嵴应该有没有被融合且与松质骨分开的牙龈瓣 和颚侧皮质板，以便于在牙槽嵴扩充过程中插 入仪器（10，17）。此外残余嵴的角度也很重 要，因为从唇部方向扩充上颌骨的外部骨板可 能会影响到种植体的正确放置（图1）（10）； -根据Lekholm 和 Zarb的理论，需要3级的骨质 量（20）；
-没有妨碍种植治疗的病症（1，18）； -无吸烟习惯。 给患者传达关于这类手术风险的书面和口头信 息，并获得他们的知情同意书。
手术过程 手术在2006年到2010年间进行，用计算机制作 的CT断层扫描、石膏、诊断性蜡型和外科模板 规划了手术过程。 用4%的阿提卡因和1：100000的肾上腺素浸润 进行了局部麻醉（肾上腺素Ubistesin™由德国 塞菲尔德的 3M ESPE公司生产），在软组织 上做个切口，并通过放松地切开骨膜来创建一 块牙槽嵴全层皮瓣。为了在腭皮层和颊皮层之 间获得一个骨平面，用一个外科钨钻规整牙槽 骨，这一步可以使随后的截骨过程更加容易。 为了控制骨折线的延伸，并防止伤害到相邻 牙的牙周韧带，用第一个钻头(1.5毫米的直径) 备制最近中和最远端的种植体部位，为了在分 割牙槽骨时的把骨压力减到最小，种植体的位 置要钻得尽可能深些。接下来，用 Piezosurgery (Piezosurgery超声切骨机由意大利热那亚 Mectron 有限公司研发) (图 3)超声切骨术进行 牙槽骨分割，这是为了达到第一个钻头所钻好 部位的同样深度；之后，为了软化并逐步扩大 前庭骨壁使用了直凿和圆凿。仪器尺寸的选择 根据骨的密度、厚度和种植体直径的不同而不 同，直凿和圆骨凿的插入和抽出的过程都要沿 着直径路线进行(10).用锥形凿凿出足够的种植 部位时，准备过程就完成了。 在本次研究中，用了两种不同型号的种植体： 跨黏膜（StraumannAG系列种植体由瑞士瓦尔 登堡的Straumann公司生产）常规种植体（2.8
毫米颈高）和3i Biomet（由美国弗洛里达周 的Palm Beach Gardens公司生产）浸入式种植 体。遇到高密度骨质时，需要用相应的种植钻 来调整种植床的形状，尤其是针对非自钻直黏 膜种植体时，跨黏膜种植体被放置后其颈肩在 牙槽骨的同一个水平上。浸入式种植体被放 置到牙槽嵴截骨水平下方1毫米深处（10）， 如此对术后生理性骨吸收可以起到补偿作用 （图5）。用手持型种植驱动器插入所有的种 植体。在钻骨过程中收集到的自体骨碎片加 上来自牛的骨移植材料（Tutodent® 0.25 毫 米–1.0 毫米 骨移植材料碎片由德国的 Tutogen Medical GmbH RTI 生物公司生产 ）被填充在 种植体周围扩张时造成的空间里，在所有的案 例中都放置了一片原膜（Tutogen®心包膜由 德国的GmbH RTI 生物公司生产 ），它可以 用来防止黏膜穿透到手术部位，并允许骨组织 再生。所有的种植体都可以用浸没的方法被整 合，如有临时修复体的话，此方法还能避免由 临时修复体所造成的不协调荷载。用间断聚酯 缝合线（Vicryl ® 4-0,聚酯缝合线由美国 Ethicon 公司和Johnson & Johnson公司生产）缝合 了初期伤口。在4个月的时候进行了第二步手 术（21）。为了给种植体施加递增性负荷，给 所有种植部位都用了2个月的临时临时安装的 义齿（22）。后来，把最终修复体交付给患者 之后，用侵入式被动入位法给所有最终修复体 都安装了局部义齿（23）。
图1
牙槽嵴的结构被分裂 的话，可能会影响种 植体的植入角度，还 有前庭壁也可能会 断裂 图2
用钨钻规整过的骨嵴 图3
用Piezosurgery超声骨 刀切开骨嵴后的咬合 视图
为了展示之前描述方案中的种植体肩部位置， 在手术过程中建立了照片文档。用Rinn X 线片 机（Rinn®,由美国的 Elgin公司生产）拍摄的X 光片和长轴平行线投照法进行了影像学检查。 具体来说，x光片是在术后第10天召回患者拆
Fig.1 Fig.3
Fig.2
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SCIENTIFIC UPDATE
图4
用更宽的仪器渐进可 控地进行骨扩充 图5 Split 用浸入式种植体
分割牙槽嵴
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在上颌后侧切牙区用牙槽嵴分割法种植了88个种植体之后，用X线片评估边缘骨变化的回顾性研究
除缝合线时拍摄的。最后一次摄影和放射评估 在即将开始本次研究召回患者检查时完成。 在拆除缝合线和最后一次召回患者检查（平均 时间为6.2年，最少4年，最多8年）时拍摄的每 个种植体X光片，用数据形式存入一个可商购 的计算机软件中（SIDEXIS软件由奥地利萨尔 茨堡斯诺德牙科有限公司研发）用此软件可以 调整x 光片的灰度值并计算X光片的放大倍数 （用于校准）。具体而言，已经知道ITI体 系种植体的长度为（10毫米、12毫米或14毫 米），3iBiomet体系种植体的长度分别为(10毫 米、11.5毫米或13毫米)，这个可以用于影像的 尺寸超出骨水平尺寸的校准。当无法获得种植体 长度时，用种植体的直径作为参考。在研究中只 用了那些可以很好地显示出种植体的近中和远端 部位，并且具有足够的相对质量的x 光片。 测量了从种植体的肩部至第一个骨与种植体接 触点的位置的距离，种植体周围的骨流失量的 单位用毫米来表达。每个种植体的近中部位和 远端部位的这两个点之间的距离均被测量了3 次，并算出平均值，为每个种植体作了记录， 并用平均值±标准偏差（SD）的方式表示。 测量值精确度到0.1毫米标准。根据Albrektsson 和Zarb的种植成功标准（义齿无移动现象、 在X光片检查中种植体周围没有出现透亮点、 无感染、无痛和病人无其它明显不适的抱怨） （19)，最后还作了种植体成活率计算。
结果 被纳入本次研究的患者一共有30个，患者年龄 在30岁至70岁之间（平均年龄为50,8岁), 其中13 个男性和17个女性，患者们的上颌侧切牙后区 内（从犬牙至第一颗磨牙区）用牙槽嵴分割法 种植了88个种植体。 具体情况是，20个患者植入了64个ITI跨黏膜标 准种植体（这些种植体颈高2.8毫米), 这些种植 体的平均观察期为5.6年（图6和7)。从全球范 围来讲，接受牙槽嵴分割种植修复治疗患者的 平均观察期为6.2年。本研究中的种植体成活率 为96.6%，有3个种植体在第二步手术的卸载愈 合期内丢失（表1), 后来用更大直径的种植体替 代了丢失的种植体。在最后一次召回检查时所 有义齿均在原位，所以义齿存活率为100%，病 人没有任何严重不适的反映。跨黏膜种植体X 光片检查中，近中骨吸收程度为2.5毫米(± 0.6 mm SD)，而远端骨吸收程度为2.3 毫米 (± 0.6 毫米 SD) (表 1) (图 8 和 9)。 讨论 就如一些国际性文献（11、12、15、17）所 述，牙槽嵴分割技术是一个具有可重复性的技 术，但它取决于外科医生的专业技能水平，并 且要求相应的学习曲线。 实际上，牙槽嵴分割技术的主要风险在于唇骨 骨折;特别是在再吸收性皮层板之间有非松质骨
Fig.4
Fig.5
Fig.6
Fig.7
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时，手术期间就可能发生这种不幸的情况。牙 槽嵴分割术仅适用那些无需纵向牙槽骨扩充的 部位(Cawood 和Howell IV级萎缩部位)。牙槽 骨分割术的原理是通过扩充牙槽嵴生于骨来重 建颚和颊骨壁使其 ≥ 1毫米，以便于使种植体 完全嵌入并长期持久地整合在牙槽骨中(1、10). 牙槽嵴分割术的一个重要特征是难以制定一个 装载义体的种植体放置方案；事实上种植体是 顺着骨嵴层的角度放置在唇和腭皮层之间；这 导致了放置义齿时经常需要纠正基台角度来取 得美学和功能上的理想效果。再者，全层牙龈 瓣的目的是为了在分割过程中提高被扩充骨的 可见度，并更好地控制唇侧的皮层壁，从而降 低骨折风险。用这样的办法是可以手术的，如 有必要，在缝合前需要放置生物材料和薄膜。 但是，还需要考虑到有可能会出现供血中断。 与牙槽骨分割术相比，横向嵌入体移植可以用 义体获得一个真实的3D骨重建效果图，这有 助于种植体的放置。如Aghaloo等在2007年的 报道，在横向嵌入体移植后的种植体成活率为 90.4%, 除GBR骨移植外，这些都不是长期的随 访研究。关于牙槽嵴扩充术，到目前为止也只 有非常少的长期临床研究文献发表。 Simion等（11）报道了对5个患者进行了牙槽骨 分割法结合组织引导骨再生技术； Scipioni等（12）进行了一个5年临床研究，他 们表示得到了85%至99%的成活率。
Engeike等（15）发表了一个临床研究，他们 用微固法进行了牙槽嵴分割术，得出5年后的 成活率为86.2%。Sethi等在观察了5年后得出了 97%的成活率（17）。Bravi F等报道，经过观 察10年后得出了95.7%的成活率（22）。 Blus等在一个牙槽嵴分割法研究中得到了96.5% 的高成活率（25）。 在这个回顾性研究中，临床和影像指标都显 示，在所有标准都被认真评估的情况下，该手 术技术是安全的，也是可以预见的，这个研究 中，我们取得了96.6%的种植体成活率和100% 的义齿成活率，研究结果与最近Garcez-Filho 等学者 (26) 、Santagata M 等人 (27)和常规种 植术之前引用过的文献结果有一致性。具体来 说，3个丢失的种植体被种植在骨扩充较大的 位置上，也许是这个原因降低了取得最好的初 期稳定性的可能。用牙槽骨分割法种植的种植 体周围近中和远端X光线测量出的骨水平，在 报道中提及的常规种植技术种植体周围骨水平 范围之内（18）。 两种类型的种植体都表现出相同的骨吸收程度 （在2，3毫米到2.7毫米之间）。骨吸收可能是 扩充手术创伤后的骨重塑和前庭和腭皮层之间 血液供应中断造成的。结果出现了根据种植体 基台链接的不同而导致了不同的美学效果的情 况 ，因此有可能是基于种植体的颈部形态。我
图6
义齿被放置到浸入式 种植体上6年后的咬 合视图 图7
义齿被装载到跨黏膜 种植体上6年后的咬 合视图 图8
通过根尖周x光片数字 化评估浸入式种植6年 后牙槽骨的吸收情况 图9
通过根尖周X光片， 数字化评估跨黏膜式 种植6年后牙槽骨的吸 收情况 表
Im在召回患者检查时 统计了种植体的成活 率和成功率，测量了 边缘骨的吸收程度 *TSI = 跨黏膜常规种 植体
Fig.8
Fig.9
ITI (TSI*)
3i BIOMET
种植体总数
64
24
种植体丢失总数
2
1
96.9%
95.8%
成活率
96.6%
全球性的成活率 近中骨水平变化：均值
2.5
2.4
近中骨水平变化：标准偏差
0.6
0.5
远端骨水平变化；均值
2.7
2.3
远端骨水平变化：标准偏差
0.5
0.6
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SCIENTIFIC UPDATE 在上颌后侧切牙区用牙槽嵴分割法种植了88个种植体之后，用X线片评估边缘骨变化的回顾性研究
们在开始回顾性研究之初召回患者检查时观察到了美学效 果的差异，总的来说，在较薄生物组织的牙周内，与浸入 式种植体相比，具有光滑颈部的跨黏膜种植体经常显现出 美学效果上的一些局限性。还需要进一步的研究来证实这 些初步的结果。
结论 根据本研究，牙槽嵴切割配合种植体载入术，无论是什么 种植方法（如跨黏膜种植法或浸入式种植法）都表现出了 良好的功能结果，一阶段式的方法可以被认为是可预见 的，只要认真遵循患者筛选标准和被描述的手术方法。 REFERENCES 1. Misch CE. Available bone and implant dentistry. In: Misch CE. Contemporary Implant Dentistry. St. Louis, MO: Elsevier Mosby, 2008:105-129. 2. de Wijs FLJA, Cune MS.Immediate labial contour restoration for improved esthetics: a radiographic study on bone splitting in anterior single-tooth replacement. Int J Oral Maxillofac Implants 1997;12:686-696. 3. Guirado JL,Yuguero MR, Carrión del Valle MJ, Zamora GP.A maxillary ridge-splitting technique followed by immediate placement of implants: a case report. Implant Dent 2005;14:14-20. 4. Cawood JI1, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg1988;17(4):232-6. 5. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994;14:496-511. 6. Simion M, Jovanovic SA, Trisi P, Scarano A, Piattelli A. Vertical ridge augmentation around dental implants using a membrane technique and autogenous bone or allografts in humans. Int J Periodontics Restorative Dent 1998;18:8-23. 7. von Arx T, Hardt N, Wallkamm B. The TIME technique: a new method for localized alveolar ridge augmentation prior to placement of dental implants. Int J Oral Maxillofac Implants 1996;11:387394. 8. Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: a clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427-432. 9. Longoni S, Sartori M, Apruzzese D, Baldoni M. Preliminary clinical and histologic evaluation of a bilateral 3-dimensional reconstruction in an atrophic mandible: a case report. Int J Oral Maxillofac Implants 2007;22:478-483. 10. Ferrigno N, Laureti M. Surgical advantages with ITI TE implants placement in conjunction with split crest technique. 18-month results of an ongoing prospective study. Clin Oral Implants Res 2005;16:147-155. 11. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J PeriodonticsRestorativeDent 1992;12:462-473. 30
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12. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994;14:451-459. 13. Scipioni A, Bruschi GB, Calesini G, Bruschi E, De Martino C. Bone regeneration in the edentulous ridge expansion technique: histologic and ultrastructural study of 20 clinical cases. Int J Periodontics Restorative Dent 1999;19:269-277. 14. Duncan JM, Westwood RM. Ridge widening for the thin maxilla: a clinical report. Int J Oral Maxillofac Implants 1997;12:224-227. 15. Engelke WG, Diederichs CG, Jacobs HG, Deckwer I. Alveolar reconstruction with splitting osteotomy and microfixation of implants. Int J Oral Maxillofac Implants 1997;12:310-318. 16. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmentation in the maxilla. Int J Oral Maxillofac Implants 1998;13:701-5. 17. Sethi A, Kaus T. Maxillary ridge expansion with simultaneous implant placement: 5-year results of an ongoing clinical study. Int J Oral Maxillofac Implants 2000;15:491-499. 18. Misch CE. An implant is not a tooth: a comparison of periodontal indexes. In: Misch CE. Contemporary Implant Dentistry. St. Louis, MO: Elsevier Mosby, 2008:18-31. 19. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants1986;1:11-25. 20. Lekholm, U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Albrektsson T, eds. Tissue Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence Publ Co., 1985:199–209. 21. Basa S, Varol A, Turker N. Alternative bone expansion technique for immediate placement of implants in the edentulous posterior mandibular ridge: a clinical report. Int J Oral Maxillofac Implants 2004;19:554-558. 22. Bravi F, Bruschi GB, Ferrini F. A 10-year multicenter retrospective clinical study of 1715 implants placed with the edentulous ridge expansion technique. Int J Periodontics Restorative Dent 2007;27:557-565. 23. Longoni S, Sartori M, Maroni I, Baldoni M. Intraoral Luting: Modified Prosthetic Design to Achieve Passivity, Precision of Fit, and Esthetics for a Cement-Retained, Implant-Supported Metal-Resin-Fixed Complete Denture. J Prosthodont 2010;19:166-170. 24. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22 Suppl:49-70. 25. Blus C, Szmukler-Moncler S. Split-crest and immediate implant placement with ultra-sonic bone surgery: a 3-year life-table analysis with 230 treated sites. Clin Oral Implants Res 2006;17:700-707. 26. Garcez-Filho J, Tolentino L, Sukekava F, Seabra M, Cesar-Neto JB, Araújo MG. Long-term outcomes from implants installed by using split-crest technique in posterior maxillae: 10 years of follow-up. Clin Oral Implants Res 2015;26:326-31. 27. Santagata M, Guariniello L, Tartaro G. Modified edentulous ridge expansion technique and immediate implant placement: a 3-year follow-up. J Oral Implantol 2015;41:184-7.
SCIENTIFIC UPDATE Marginal bone level around conical connection tapered implants with platform switching
Author
J. EKSTEIN1, M.TANDELICH1, J. NART2, J.L. CALVO GUIRADO3, L. SHAPIRA4 1 Department Of Periodontology, The Hebrew University – Hadassah Faculty Of Dental Medicine, Jerusalem, Israel 2 Department Of Periodontology, International University Of Cataluña, Barcelona, Spain 3 Department Of General And Implant Dentistry, Faculty Of Medicine And Dentistry, University Of Murcia, Spain 4 Professor And Chair Department Of Periodontology The Hebrew University – Hadassah Faculty Of Dental Medicine, Jerusalem, Israel KEY WORDS
Bone loss; conical connection; platfom switching; tapered implants
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Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up TO CITE IN THIS ARTICLE: Ekstein J, Tandelich M, Nart J, Calvo Guirado Jl, Shapira L Marginal Bone Level Around Conical Connection Tapered Implants With Platform Switching: A Multicenter Retrospective Study At 14 Months Follow-Up. J Osseointegr 2016;8(1):3-7.
ABSTRACT Aim The long-term success of dental implants mainly depends on marginal bone stability around the fixtures. The development of prosthetic abutments with reduced width in relation to the implant prosthetic platform (platform switching) and/or tighter implant/abutment connections seem to have a potential in reducing crestal bone resorption. The aim of the present study was to examine the effect of platform switching and conical connection design, on marginal bone loss around newly designed dental implants. Materials and Methods Subjects who underwent implant therapy in three different centers, were enrolled in the present retrospective study. Patients were rehabilitated with tapered platform-switched dental implants. To evaluate marginal bone level changes over time, the mesial and distal bone height was radiographically evaluated on the day of implant placement (baseline) and 14 months post-implantation. Results One hundred and twelve conical tapered platform-switched implants were placed in three different centers in 37 patients, with mean age of 53 years. The survival rate was 100% after an average follow-up of 14 months. During the first year, marginal bone loss was 0.67±0.45mm. No statistically significant differences were recorded between the different centers. Conclusions Within the limitations of the present retrospective study, limited marginal bone loss and 100% implant survival rate were observed over 14 months of follow-up.The results showed high crestal bone stability around the newly designed conical tapered platform-switched implants. INTRODUCTION The successful replacement of lost natural teeth by osseointegrated implants is a major advance in clinical dental treatment. Implant therapy has made a substantial improvement in terms of survival rate. Nowadays, dental implants report a high survival rate: on average, only 2.5% of all implants placed are lost before loading, and after the prosthetic reconstruction the failure rate varies between 0.5 – 1.3% per year (1). Therefore, the main focus of the dental community today is on the success rate of the dental implant and the stability of the results. The long-term success of endosseous implants depends mainly on the preservation of bone support. Indeed, maintenance of osseointegration and stability in marginal bone level are imperative to this success. Peri-implant marginal bone loss is influenced by many factors and by multiple phenomena (2). Those might include the surgical technique (3), implant positioning (4), tissue thickness (5), the presence of a micro-gap (6) at the implant-abutment interface (7), and the implant
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design (8). All of them can also influence the stability of the marginal bone crest. The criteria to define success in implant dentistry are under constant debate, but the achievement and maintenance of osseointegration are recognized as crucial factors, and marginal bone loss (MBL) is therefore a key consideration. The ubiquitous loss of up to 2 mm of bone around implant neck during the first year after functional loading has widely been considered acceptable by the dental community and has even been considered a successful outcome in some classifications and consensus statements (9,10). However, tissue stability is expected at one year after placement, and a loss of more than 0.2 mm per year is regarded as undesirable (9). Other Authors have claimed that a marginal bone loss of 1.5 mm in the first year (11), 1.8 mm (12), or 1.5–2 mm (13) represents a good outcome. A MBL of less than three threads has also been proposed as a success criterion (14,15), despite the variability in inter-thread distances among different implant systems. Implant design concepts to diminish crestal bone loss have been
developed and embedded in dental implant structure. The development of prosthetic abutments with reduced width in relation to the implant prosthetic platform (platform switching concept), and an internal conical implant-abutment connection, seem to have a potential in reducing crestal bone resorption. Implants with platform switching show a lesser crestal bone loss, improved crestal bone preservation and lead to controlled biological space reposition and to stable aesthetic outcomes (16). A recent meta-analysis revealed significantly less bone loss around implants with a platform switching configuration compared with the standard platform matching implant-abutment design (17). The aim of the present retrospective study was to examine the effect of a newly designed conical tapered platform-switched implant on the marginal bone level over 14 months of follow-up. MATERIALS AND METHODS Data collection In the present retrospective observational study were enrolled patients who underwent implant therapy in three different centers: one in Jerusalem (Israel) (LSresearch supervisor), one in Barcelona (Spain) (JN research supervisor) and one in Murcia (Spain) (JG research supervisor). All subjects were treated with tapered dental implants, with internal conical implantabutment connection and a built-in platform switching (MIS C1 Conical Connection, MIS, Israel). Inclusion and exclusion criteria Patients were included in the study according to the following criteria: 1. implant placement performed at least three months after tooth extraction; 2. medical history without any contraindications to implant therapy; 3. pre-existing bone, radiographically examined by a CT scan, adequate to allow the placement of at least 3.75-mm-diameter and 10-mm-long implants with a potential minor horizontal bone augmentation. Exclusion criteria were: 1. subjects with systemic diseases such as diabetes; 2. pregnant and lactating subjects; 3. subjects with habit of severe bruxism or clenching; 4. subjects treated with radiation to the head within the past 12 months; 5. subjects treated with bisphosphonate within the past 12 months; 6. subjects smoking more than 10 cigarettes/day. Surgical procedure All surgeries were performed by three practitioners: 2 periodontists (LS and JN) and one oral surgeon (JG). All surgeries were performed under local anesthesia, and with antibiotic premedication of 2 g of amoxicillin (Moxypen, Teva, Israel and Actimoxi, Clariana, Spain). The antibiotic medication was continued, 500 mg 3 times a day, for up to 5 days. In cases where bone was
missing around the implant’s neck, a GBR (Guided Bone Regeneration) procedure was performed using a xenograft bone substitute (Osteobiol® GenOs, Tecnoss, Torino, Italy) and a collagen membrane (Osteobiol® Evolution, Tecnoss, Torino, Italy). The patients were instructed with oral hygiene, and rinsing with 0.2% chlorhexidine solution twice a day until suture removal, starting the day of surgery. Patients were instructed with analgesic medications post-surgery as needed. Suture removal took place 7-10 days post-surgery. All implants were placed in a submerged protocol; they were reentered and exposed by elevating a mini full-thickness flap 2-4 months after implant installation. At least 2 weeks later, the implants were loaded. Following the prosthetic reconstruction, the patients were seen at least every 6 months for professional plaque control by a dental hygienist and for follow-up appointments by the prosthodontist. Radiographic examination and evaluation All implants were examined by means of radiographs taken immediately after implants placement (time point 0: T0, baseline) and radiographs obtained on average fourteen months post-implantation (time point 1: T1). The radiographs were both intraoral periapical ones, obtained using the parallel technique with film holders, or panoramics (Gendex, Hatfield, PA, USA); a digital intraoral imaging system was used (Digora phosphor plate reader, Soredex Tuusula, Finland). All the X-rays were scanned and uploaded into the computer in order to assess marginal bone level changes over time. The measurements were taken on the computer screen using the “ImageJ” software (http://rsbweb. nih.gov/ij/download.html). Only the vertical periimplant bone level was assessed; this was defined as the vertical distance between a reference point at the implant shoulder and the most coronal bone-implant contact (Fig. 1). Changes in marginal bone level were expressed as differences in the measured values on radiographs (T1-T0=∆IBL). Marginal bone loss was calculated by multiplying the actual implant length with the bone loss from a constant referral point of the implant-abutment connection (∆IBL), all divided with the implant length measured on the x-rays.
Fig. 1 Measurement of the vertical peri-implant bone level, obtained as the vertical distance between a reference point at the implant shoulder and the most coronal boneimplant contact.
Fig.1
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SCIENTIFIC UPDATE Marginal bone level around conical connection tapered implants with platform switching
Table 1 The ∆IBL + SD (standard deviation) in the three different centers. No statistical difference between the three centers. LS, Lior Shapira; JN , Jose Nart; JG, José Guirado. Fig 2 Comparison between the three different centers regarding the ∆IBL. No statistical difference was found. LS, Lior Shapira; JN , Jose Nart; JG, José Guirado; SE , Standard error; SD, Standard deviation. Table 2 ∆IBL+SD (standard deviation) for gender and smoking (<10 cigarettes/day). No statistical difference between the groups.
The calculating equation was as follows: Marginal bone loss = Actual implant length X (∆IBL) Implant length on x-ray The radiographic measurements were independently performed by a blinded periodontist, experienced with oral radiology (MT).
implants. The mean age of the patients was 53±13 years (range 29-79); ten of them were smokers (<10 cigarettes/day). Thirty implants were placed in 18 patients by LS, 36 in 7 patients by JG, and 36 in 12 patients by JN. Forty-nine implants were placed in the maxilla, while 63 in the mandible; 54 implants had “regular diameters” of 3.75 mm and 44 implants of 4.2 mm, whereas 14 implants were considered as “wide” implants (5 mm in diameter). Considering the implants’ length, 28 were 13 mm long, 51 were 11.5 mm long, 29 were 10 mm long, and 4 were 8 mm long.
Statistical methods The primary outcome variable was ∆IBL. The hypothesis tested was that the average ∆IBL values would be significantly smaller than those accepted in the literature. For statistical analysis STATISTICA v7.0 software (StatSoft, Inc.;Tulsa, OK) was used. Descriptive statistics were used to explore the demographic data of the patients. Bi-nominal patient and implant descriptive variables were defined (such as smoking, center of treatment, follow-up x-ray, etc.). T-test was utilized to describe the amount of MBL found between groups of each describing variable. Data analysis was done based on the patient mean MBL and on each implant MBL. For all statistical analysis, a P value of <0.05 indicated statistical significance.
The implants were restored with porcelain crowns up to six months from the day of implantation. None of the implants failed during the study, resulting in a survival rate of 100% after one year. Paired t test and non-parametric signed t test for paired samples showed no difference between the MBL on the mesial and on the distal aspect of the implants. The marginal bone loss from baseline to 14 months was 0.67±0.45 mm. There was no statistical difference in the measured MBL between the three centers (Table 1, Fig. 2).
RESULTS A total of 37 subjects (20 males and 17 females) were treated with 112 conical tapered platform-switched
Surgical sequence and outcome As an example, figures 3 to 10 illustrate a case treated by LS (Jerusalem center, Israel).
CENTER
LS
JG
∆IBL
0.79±0.5
0.56±0.4
JN 0.67±0.2
AVERAGE 0.67±0.45
No difference was found in marginal bone loss between male and female, and between smokers and non-smokers (Table 2).
Fig.3
Fig.4
MALE/FEMALE ∆IBL
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0.62±0.3/0.8±0.48
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SMOKER/NON SMOKER 0.54±0.33/0.77±0.41
DISCUSSION The results of the present study demonstrated limited bone level changes within the first year after implant installation. The bone loss measured around the implant neck was clinically significantly smaller than the implant success criteria of 2 mm (9, 10). The crestal bone resorption is often related to the microgap at the interface between the implant and the abutment, mainly when it is close to the surrounding bone (9, 18). This gap facilitates bacterial infiltration and colonization close to the crestal bone, causing an inflammatory process which results in bone resorption (19). Therefore, the prevention of microbial leakage at the implant-abutment connection is a major challenge for the construction of modern two-stage implant systems. The preservation of peri-implant bone is a major factor in the long-term prognosis of prosthetic rehabilitations supported by implants. The crestal
bone loss can lead to the collapse of soft tissues and adversely affect the aesthetics of the implantsupported prosthetic elements. The adverse effects of the micro-gap are greatly reduced with thicker residual bone, as the distance between the micro-gap and the crestal bone increases. Conical connections inherently keep the implant-abutment interface away from the crestal bone (a.k.a. platform switching or platform shifting), thus promoting better biologic and aesthetic results. Implants with platform switching show lesser crestal bone loss, improved crestal bone preservation, and lead to controlled biological space reposition. All of these features lead to stable aesthetic outcomes (20) and to “complications free” survival rates up to 20 years of follow up, for fixed restorations supported by conical connection implants (21). A recent metaanalysis revealed a significantly less mean bone loss around implants with a platform switching implantabutment configuration compared with the standard
Fig.5
Fig.6
Fig.7
Fig.8
Fig 3 Implants replacing teeth 24-25. Fig. 4 Guided bone regeneration with a collagen membrane. Fig. 5 Flaps are repositioned and sutured. Fig. 6 Four months later- prior to stage 2 surgery – implant exposure.
Fig.9
Fig. 7 Exposure of implants – note new bone formation.
Fig.10
FIG. 8 Healing abutment and suturing.
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SCIENTIFIC UPDATE Marginal bone level around conical connection tapered implants with platform switching platform matching implant-abutment design (17). The internal conical implant-abutment connection is considered to be mechanically more stable and tighter than flat-to-flat connections or tube-in-tube connections (22). By minimizing micro-movements at that junction, bone loss at the crestal level is reduced (23). Load distribution is also more favorable around implants that possess conical connections, thereby preserving the marginal bone (22, 23, 24, 25). The conical connection design simplifies maintenance and ensures reliability in all clinical situations (26). These qualities, also possessed by the implant system used in the present study, result in a higher ability to preserve bone (22, 24, 26). Data from several implant manufacturers showed that different implant systems yielded different results with regard to bone level changes, but always better than 2 mm of bone loss, that was historically considered acceptable (27, 28, 29). A recent metaanalysis reported mean marginal bone level changes of 0.24 mm (Astra Tech Dental Implant System), 0.75 mm (Brånemark System), and 0.48 mm (Straumann Dental Implant System) after five years of follow-up, in comparison with bone levels at the time of prosthetic loading (29). These extraordinary stable results should raise the question whether or not a stricter success criteria regarding marginal bone loss should be developed, as the tested implants can provide significantly better results. In conclusion, within the limitations of the present retrospective study, a limited marginal bone loss and 100% implant survival rate were observed over 14-months of follow-up. The results showed high crestal bone stability around the conical tapered platform-switched implants. Disclosure The implants and prosthetic parts were kindly provided by MIS Implants (Israel) for 3 all centers. JN, JG and LS are ad-hoc consultants for the same Company. No other financial support was given to this follow-up study. REFERENCES 1. Holm-Pedersen P, Lang NP, Muller F. What are the longevities of teeth and oral implants? Clin Oral Implants Res 2007; 18 Suppl 3: 15-19. 2. Albrektsson T, Buser D, Sennerby L. On crestal/marginal bone loss around dental implants. Int J Oral Maxillofac Implants 2012; 27: 736-738. 3. Barros R, Novaes AJ, Papalexiou V. Buccal bone remodeling after immediate implantation with a flap or flapless approach: A pilot study in dogs. Titanium 2009; 1: 25-51. 4. Caneva M, Botticelli D, Rossi F, Cardoso LC, Pantani F, Lang NP. Influence of implants with different sizes and configurations installed immediately into extraction sockets on peri-implant hard and soft tissues: an experimental study in dogs. Clin Oral Implants Res 2012; 23: 396-401. 5. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996; 23: 971-973. 6. Dias EC, Bisognin ED, Harari ND, Machado SJ, da Silva CP, Soares GD, Vidigal GM, Jr. Evaluation of implant-abutment microgap and bacterial leakage in five external-hex implant systems: an in vitro study. Int J Oral Maxillofac Implants 2012; 27: 346-351. 7. Broggini N, McManus LM, Hermann JS, Medina RU, Oates TW, Schenk RK, Buser D, Mellonig JT, Cochran DL. Persistent acute inflammation at the implant-abutment interface. J Dent Res 2003; 82: 232-237. 8. Shin YK, Han CH, Heo SJ, Kim S, Chun HJ. Radiographic evaluation of marginal bone level around implants with different neck designs after 1 year. Int J Oral Maxillofac Implants 2006; 21: 789-794. 9. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of
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success. Int J Oral Maxillofac Implants 1986; 1: 11-25. 10. Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P,Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008; 17: 5-15. 11. Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO. Success criteria in implant dentistry: a systematic review. J Dent Res 2012; 91: 242-248. 12. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteenyear follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol 2006; 33: 290-295. 13. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol 2000; 71: 546-549. 14. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res 2005; 16: 440-446. 15. Qian J, Wennerberg A, Albrektsson T. Reasons for marginal bone loss around oral implants. Clin Implant Dent Relat Res 2012; 14: 792-807. 16. Canullo L, Fedele GR, Iannello G, Jepsen S. Platform switching and marginal bone-level alterations: the results of a randomized-controlled trial. Clin Oral Implants Res 2010; 21: 115-121. 17. Strietzel FP, Neumann K, Hertel M. Impact of platform switching on marginal peri-implant bone-level changes. A systematic review and meta-analysis. Clin Oral Implants Res 2014. 18. Hermann JS, Cochran DL, Nummikoski PV, Buser D. Crestal bone changes around titanium implants. A radiographic evaluation of unloaded nonsubmerged and submerged implants in the canine mandible. J Periodontol 1997; 68: 1117-1130. 19. Covani U, Marconcini S, Crespi R, Barone A. Bacterial plaque colonization around dental implant surfaces. Implant Dent 2006; 15: 298-304. 20. Cumbo C, Marigo L, Somma F, La Torre G, Minciacchi I, D’Addona A. Implant platform switching concept: a literature review. Eur Rev Med Pharmacol Sci 2013; 17: 392-397. 21. Mangano C, Iaculli F, Piattelli A, Mangano F. Fixed restorations supported by Morse-taper connection implants: a retrospective clinical study with 10-20 years of follow-up. Clin Oral Implants Res 2015; 26: 1229-1236. 22. Yamanishi Y, Yamaguchi S, Imazato S, Nakano T, Yatani H. Influences of implant neck design and implant-abutment joint type on peri-implant bone stress and abutment micromovement: three-dimensional finite element analysis. Dent Mater 2012; 28: 1126-1133. 23. Pessoa RS, Muraru L, Junior EM, Vaz LG, Sloten JV, Duyck J, Jaecques SV. Influence of implant connection type on the biomechanical environment of immediately placed implants - CT-based nonlinear, three-dimensional finite element analysis. Clin Implant Dent Relat Res 2010; 12: 219-234. 24. Sannino G, Barlattani A. Mechanical evaluation of an implant-abutment self-locking taper connection: finite element analysis and experimental tests. Int J Oral Maxillofac Implants 2013; 28: e17-26. 25. Hansson S. Implant-abutment interface: biomechanical study of flat top versus conical. Clin Implant Dent Relat Res 2000;
SCIENTIFIC UPDATE
Author
J. EKSTEIN1, M.TANDELICH1, J. NART2, J.L. CALVO GUIRADO3, L. SHAPIRA4 1 以色列耶路撒冷希
伯来大学口腔医学系 牙周病科 2 西班牙巴塞罗那加 泰罗尼亚国际大学牙 周病科 3 西班牙穆尔西亚大 学医学牙科学系一般 牙科和种植科 4 以色列耶路撒冷希 伯来大学哈达撒牙科 学系特聘教授
具有平台转换装置的锥形种植体周围的边缘骨水平：一个随访了14个月的多诊所合作回顾性研究
具有平台转换装置的锥形 种植体周围的边缘骨水 平：一个随访了14个月的 多诊所合作回顾性研究 文章引自 Ekstein J, Tandelich M, Nart J, Calvo Guirado Jl, Shapira L Marginal Bone Level Around Conical Connection Tapered Implants With Platform Switching: A Multicenter Retrospective Study At 14 Months Follow-Up. J Osseointegr 2016;8(1):3-7.
摘要 目的牙科种植体要获得长期的成功，主要取决于种植体周围边缘骨的稳定性，义齿基台相对 种植体平台（平台转换）缩窄和/或加紧种植体和基台的连接，似乎对减小牙槽骨的吸收有潜 在的作用。本次研究的目的在于分析平台转换和锥形链接设计对最新设计的种植体周围边缘 骨流失情况的影响。 材料和方法在三个不同的牙科诊所里接受了种植治疗的研究对象被纳入本次回顾性研究。患 者们接受了植入锥形平台转换连接装置的种植体。在接受治疗后对边缘骨水平的变化进行评 估，在植入种植体的当天（测量基线） 和种植后14个月时用X线片估量了近中和远端骨的高度。 结果112个锥形平台转换连接种植体被植入三个中心的37个患者口腔内，患者平均年龄 为53岁。平均随访14个月后，种植体的成活率为100%。在第1年中边缘骨的流失量为 0.67±0.45mm。 三个不同中心的受试者记录之间没有明显的统计学差异。 结论根据本回顾性研究，经过14个月的随访，我们观察到了有限的边缘骨流失和100%的成活 率。结果表明，最新设计的具有平台转换装置的锥形种植体周围的牙槽骨有很好的稳定性。 引言 在临床牙科治疗中，成功地用骨整合种植体来 替补丢失的自然牙是一个很大的进步，植入疗 法在成活率方面取得了显著的改进。如今，牙 齿种植体的报道成活率都很高：一般来讲，只 有2.5%的种植体在义齿加载之前丢失，假牙修 复后，每年的平均失败率在0.5-1.3%之间（1）。 因此，今天的牙科界主要专注于种植体的成活 率和结果的稳定性上。骨内种植能否取得长久 的成功主要取决于支持骨的保存情况。事实 上，保持边缘骨水平的骨整合和稳定性对种植 成功是必不可少的。 种植体周围骨边缘损失会受到很多因素和现象 的影响（2), 这些可能包括外科手术（3), 植入 物的定位（4), 牙周组织的厚度（5), 在种植体 基台的连接处有很小的间隙（6), 种植体的设计 （8) 等等等。所有这些都有可能影响边缘骨嵴 的稳定性。
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定义种植牙成功的标准还有待讨论，但取得并 维护良好的骨整合是被公认的关键因素，因此 边缘骨的流失是一个很关键的因素。 功能加载后的一年内，种植体颈部周围的牙 槽骨不可避免的流失在小于2mm的牙槽骨的 情况，在牙科界被认为是可以接受的；在一些 个别的共识声明中甚至认为是一个圆满的结 果（9，10)。但是牙龈组织的预见稳定性应该 维持到放入种植体一年以后，并且如果每年 流失的量要是超过0.2mm的话，算是不乐观的 情况（9)。但是，也有一些作者声称第一年的 边缘骨流失量在1.5mm(11),1.8mm(12),或者1.52mm(13)可以算作是个满意的结果。尽管不同 系统的植入物之间的线程有一定的可变性，小 于3个线程的变化也被认为是个成功的标准。 以减少牙槽骨损失为设计理念而设计的种植体 已经被研发出来，并融合在种植体的结构之 中。义齿基台相对种植体平台（转换平台）缩 窄和/或加紧种植体和基台的连接，似乎对减
小牙槽骨的吸收有潜在的作用。平台转换连接 装置种植体的使用显示出更少的牙槽骨损失， 提高了牙槽骨的保存，并导致控制生物空间的 吸收和稳定的审美结果（16)。最近的一项汇总 分析显示，与标准的种植体基台配置的种植体 设计相比，平台转换装置的种植体周围骨流失 量明显地减少（17)。 本次研究的目的在于分析平台转换和锥形链接 设计对最新设计的种植体周围边缘骨的流失情 况的影响。
材料和方法 数据的收集 本次回顾性观察研究中的患者所接受治疗的 中心：其中一个在以色列的耶路撒冷（由LS 担任研究主管), 另外一个在西班牙的巴塞罗 那（由JN担任研究主管), 还有一个在西班牙 的穆尔西亚（由JG担任研究主管)。所有受 试者的口腔均用锥形种植体，里边用锥形种 植体基台链接和一个平台转换装置（MISC锥 形链接系列种植体由以色列MIS公司提供)。 入选和排除标准 受试患者是根据以下几条标准筛选出来： 1. 拔牙后最少三个月以上才载入种植体 2. 无任何妨碍植入治疗的病史 3. 通过CT扫描和X线检查，残留骨应该允许 植入至少直径3.75mm和10mm长的种植体。 和次水平骨增量的潜能。 排除标准为： 1.全身性疾病患者，如糖尿病患者 2.孕期和哺乳期患者 3.有严重的夜磨牙和咬牙习惯者 4.在过去的12个月接受过头部放射治疗者 5.在过去的12个月内接受过双磷酸盐治疗者 6.每日吸烟超过10支的患者
们接受口腔卫生指导，并用0.2%的氯己定溶液 每天冲洗2次，从手术单天开始到缝合线拆除 为止。根据需要给患者术后止疼用药指示。手 术后7-10天后拆除缝合线。所有的种植体都通 过浸入式放置；在安装完种植体之后的2至4个 月时，通过翻起一小瓣牙周组织使其暴露并再 次安装。至少2周之后，种植体已被装载，根 据修复指南，装载之后，所有患者至少每6个 月就需要接受一个专业牙科医师的菌斑控制检 查。
X线检查和评估 所有种植体在植入后立即用X线片检查（时间 点1：T0 基线), 在种植后的平均时间为14个月 时又做了一次X线片检查(时间点1：T1)。通过 对胶片架或全景进行并行计算技术，我们获得 了包括口腔和根尖的X线片（美国产Gendex全 景X线摄影机); 使用了一个口内数字成像系统 （芬兰图苏拉的Soredex公司的Digora荧光板读 数器)。用”ImageJ”软件在电脑上采集了所有的 尺寸。只对种植体周围的垂直骨层次进行了评 估；这个尺寸是种植体的颈部至种植体圆底部 与骨接触点之间的垂直距离(图1)。
图1
种植体周围垂直骨水 平尺寸，是种植体 的颈部到种植体圆 底部与骨接触点之间 的距离
边缘骨水平在前后两个X线片上的测量值显示 出差异(T1-T0= ∆IBL)。边缘骨的流失量是通过 相乘实际种植体长度和复诊时的恒定点至种植 体基台链接处的距离 (∆IBL)，最后除以在X线片 上测量所得的种植体长度。 计算公式如下: 边缘骨流失量= 种植体实际长度X (∆IBL) X线片上测量出的种植体长度 X线片的测量由一个在口腔放射方面有丰富经 验且对本研究不知情的牙周病医师完成(MT)。
手术过程 所有手术均由三个医务人员执行：两个牙周 医师(LS和JN)和一个口腔外科医生（JG）。所 有手术均在局部麻醉状态下完成，并在术前 用2克的阿莫西灵抗生素（以色列Teva公司的 Moxypen, 西班牙Clariana公司的Actimoxi)。 手术结束后，使患者继续服用抗生素，一日3 次，每次500毫克，服用5天。在种植体颈部周 围骨遗失的病例中，用异种骨（意大利都灵 Tecnoss公司的Osteobiol® Gen-Os）和胶原膜 （意大利都灵Tecnoss公司的Osteobiol® Evolution）代替的方法进行了引导骨再生术，患者
Fig.1
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SCIENTIFIC UPDATE 具有平台转换装置的锥形种植体周围的边缘骨水平：一个随访了14个月的多诊所合作回顾性研究
表一
三个中心的∆IBL + SD（标准偏差）值没 有统计差异 LS,代表Lior Shapira; JN ,代表Jose Nart; JG 代表José Guirado. 图2
关于 ∆IBL，三个中 心的结果对比没有统 计差异LS,为人名 Lior Shapira的缩写; JN 为 Jose Nart的缩写; JG为 José Guirado的缩写; SE 代表标准误差; SD 代表标准偏差
表2
根据性别和吸烟情况 分组做出的∆IBL+SD（标准偏差）值没 有统计差异
统计方法 主要结果的变量是 ∆IBL，本次测试的假设命题 为，这些变量是否会低于那些已在一些文献中 被接受的变量。 在统计分析过程中使用了STATISTICA v7.0软 件（美国塔尔萨StatSoft 软件公司），用描述 性统计法来探索患者的统计数据，定义了双向 性患者和种植的描述性变量（如是否吸烟、受 诊诊所、后继的X线片等）。 用T检验法描述了每个被描述的小组之间出现 的MBL量。基于患者的平均MBL量和每个种植 体的MBL量来完成数据分析。 在所有的统计分析中，一个P值为<0.05表示统 计差异。
29根的长度为10mm，还有4根的长度为8mm. 从种植第一天起至六个月的时间里，所有的种 植体都有一个烤瓷冠。 在整个研究过程中，没有种植体出现种植失败 现象，一年后的结果是成活率为100%。 通过配对T检验和非参数T检验配对样品，显示 出近中的种植体近中和远端的表面MBL量没有 差异。 从基线到14个月时边缘骨的流失量为0.67±0.45 mm，三个中心所测量到的MBL值之间没有显 著性差异（表1，图2） 在男性患者和女性患者之间没有边缘骨流失量 的差异，吸烟者和非吸烟者之间的边缘骨流失 量也没有差异（表2）。
结果 一共在37个（20个男性和17个女性）研究对象 的口腔内植入了112根锥形平台转换链接装置 的种植体，患者平均年龄为53±13岁（从29岁 到79岁）；其中10个患者为吸烟患者（每日吸 烟量为少于10支），有30根种植体被LS植入18 个患者的口腔内，有36根种植体被LG植入7个 患者的口中，36根种植体被JN植入12个患者的 口中。其中49根种植体被种植在上颌骨中，其 他的63根种植体被种植在下颌骨中；有54根种 植体有常规直径为3.75mm，44根种植体的直径 为4.2mm,而其他的14根种植体被认为是属于宽 种植体（5mm的直径）。至于长度，其中有28 根的长度为13mm,有51根的长度为11.5mm，有
手术顺序和结果 图3至图10是一个由LS治疗的病例图片(以色列 耶路撒冷的牙科中心)。
CENTER
LS
JG
∆IBL
0.79±0.5
0.56±0.4
JN 0.67±0.2
AVERAGE 0.67±0.45
讨论 本次研究的结果表明，种植体装载一年之内 出现有限的骨水平变化。从临床意义上讲， 从种植体周围骨测量到的骨流失量明显地小 于2毫米的种植成功标准（9,10)。牙槽骨的吸 收经常与种植体和基台交接处存在微小间隙 有关，尤其是当这个微小间隙靠近周围骨时 (9,8)。这个小间隙促进了细菌的渗透并向接近 牙槽骨的地方扩张，引发牙槽骨炎症，最后
Fig.3
Fig.2
Fig.4
MALE/FEMALE ∆IBL
40
0.62±0.3/0.8±0.48
Doctor 牙医 by Infodent•2/2016
SMOKER/NON SMOKER 0.54±0.33/0.77±0.41
导致骨吸收（19）。因此，在种植体的交接处 预防细菌渗透是现代两阶段式种植体生产中的 主要挑战。保存种植体周围的骨，是保证种植 体支撑的修复牙愈后效果的主要因素，牙槽骨 的散失可能导致软组织的崩塌，并对种植体支 撑的修复牙产生不利的影响；较厚的剩余骨可 以大大地降低微小间隙的不利影响，是因为微 小间隙和牙槽骨之间的距离会因剩余骨的厚度 的增加而增加。锥形链接的种植体可以保持自 身的基台界面（又名平台转换或交换）与牙槽 骨的距离，因此促进改善生物学和美学效果。 平台转换装置的种植体显示出更小的牙槽骨损 失，提高牙槽骨的保存，并能够控制生物空间 的重新定位，所有这些特点促成了稳定的美学 效果（20）。并保证无并发症，存活率高，20年 之间可以用一个种植体来装载修复义齿（21)。 最近的一项汇总分析表明，于标准的基台配置 种植体相比，平台转换装置的种植体周围骨流
失量明显地减少（17）。人们认为内部为锥形 结构的种植体基台的链接从机械角度来讲更加 稳固，它比平面对平面和管中管式的链接更紧 密（22）。通过最小化交接处的微小移动减少 了牙槽骨平面骨的流失（23）。有锥形链接装 置的种植体的周围还有利于负载的分部，从而 能够更好地保留边缘骨（22，23，24，25）。 锥形链接设计简化维护，并确保所有临床情况 下的可靠性（26）。此次研究中所用的种植体 也都具备这些优点，所以导致了更好的骨保存 能力（22，24，26）。 来自一些种植体制造商的数据表明，用不同系 统的种植体产生不同的于骨水平变化结果，但 骨损失量总是少于2毫米，而2毫米的骨流失量 在种植史上被认为是可以接受的（27, 28, 29) 。 一个最近的汇总分析报告指出，经过5年的随 访，于义齿装载时的于骨水平相比，不同种 植体的骨损失量如下：（Astra tech dental im-
Fig.5
Fig.6
Fig.7
Fig.8
图 3 种植体代替了牙
齿的位置
图 4 用胶原膜引导骨 再生 图 5 翻起的组织瓣被 放回原处并被缝合 图 6 四个月后的第
二部手术进行种植体 暴露
图 7 种植体暴露时发 现有新骨形成
Fig.9
图 8 愈合基台并缝合
Fig.10
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SCIENTIFIC UPDATE 具有平台转换装置的锥形种植体周围的边缘骨水平：一个随访了14个月的多诊所合作回顾性研究
plant）种植体的平均边缘骨水平变化值为0.24毫米，(Branemark system)种植体的变化值为0.75毫米、(Stramann dentalimplant system)为0.48毫米（29）。从这些显著的稳定结果 来看，我们应该提出一个问题：如果试验中的种植可以提 供更好的结果的话，是否应该制定一个更加严格的关于种 植成功的标准。 通过本次回顾性研究，在14个月的随访后，观察到了有限 的边缘骨流失和100%的种植体成活率。这个结果显示了有 平台转换装置的锥形种植体周围牙槽骨有更好的稳定性。
申明 承蒙以色列的MIS Implants公司提供了3个中心中所用的种 植体和义齿，JN 、JG和LS都是以上公司的特聘顾问。 在本次研究中没有得到来自其它方面和其他形式的经济支 持。 参考文献 1. Holm-Pedersen P, Lang NP, Muller F. What are the longevities of teeth and oral implants? Clin Oral Implants Res 2007; 18 Suppl 3: 15-19. 2. Albrektsson T, Buser D, Sennerby L. On crestal/marginal bone loss around dental implants. Int J Oral Maxillofac Implants 2012; 27: 736-738. 3. Barros R, Novaes AJ, Papalexiou V. Buccal bone remodeling after immediate implantation with a flap or flapless approach: A pilot study in dogs. Titanium 2009; 1: 25-51. 4. Caneva M, Botticelli D, Rossi F, Cardoso LC, Pantani F, Lang NP. Influence of implants with different sizes and configurations installed immediately into extraction sockets on peri-implant hard and soft tissues: an experimental study in dogs. Clin Oral Implants Res 2012; 23: 396-401. 5. Berglundh T, Lindhe J. Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol 1996; 23: 971-973. 6. Dias EC, Bisognin ED, Harari ND, Machado SJ, da Silva CP, Soares GD, Vidigal GM, Jr. Evaluation of implant-abutment microgap and bacterial leakage in five external-hex implant systems: an in vitro study. Int J Oral Maxillofac Implants 2012; 27: 346-351. 7. Broggini N, McManus LM, Hermann JS, Medina RU, Oates TW, Schenk RK, Buser D, Mellonig JT, Cochran DL. Persistent acute inflammation at the implant-abutment interface. J Dent Res 2003; 82: 232-237. 8. Shin YK, Han CH, Heo SJ, Kim S, Chun HJ. Radiographic evaluation of marginal bone level around implants with different neck designs after 1 year. Int J Oral Maxillofac Implants 2006; 21: 789-794. 9. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants 1986; 1: 11-25. 10. Misch CE, Perel ML, Wang HL, Sammartino G, Galindo-Moreno P,Trisi P, Steigmann M, Rebaudi A, Palti A, Pikos MA, Schwartz-Arad D, Choukroun J, Gutierrez-Perez JL, Marenzi G, Valavanis DK. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008; 17: 5-15. 11. Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO. Success criteria in implant dentistry: a systematic review. J Dent Res 2012; 91: 242-248. 12. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteenyear follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol 2006; 33: 290-295. 13. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol 2000; 71: 546-549. 14. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects
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with progressive bone loss at implants. Clin Oral Implants Res 2005; 16: 440-446. 15. Qian J, Wennerberg A, Albrektsson T. Reasons for marginal bone loss around oral implants. Clin Implant Dent Relat Res 2012; 14: 792-807. 16. Canullo L, Fedele GR, Iannello G, Jepsen S. Platform switching and marginal bone-level alterations: the results of a randomized-controlled trial. Clin Oral Implants Res 2010; 21: 115-121. 17. Strietzel FP, Neumann K, Hertel M. Impact of platform switching on marginal peri-implant bone-level changes. A systematic review and meta-analysis. Clin Oral Implants Res 2014. 18. Hermann JS, Cochran DL, Nummikoski PV, Buser D. Crestal bone changes around titanium implants. A radiographic evaluation of unloaded nonsubmerged and submerged implants in the canine mandible. J Periodontol 1997; 68: 1117-1130. 19. Covani U, Marconcini S, Crespi R, Barone A. Bacterial plaque colonization around dental implant surfaces. Implant Dent 2006; 15: 298-304. 20. Cumbo C, Marigo L, Somma F, La Torre G, Minciacchi I, D’Addona A. Implant platform switching concept: a literature review. Eur Rev Med Pharmacol Sci 2013; 17: 392-397. 21. Mangano C, Iaculli F, Piattelli A, Mangano F. Fixed restorations supported by Morse-taper connection implants: a retrospective clinical study with 10-20 years of follow-up. Clin Oral Implants Res 2015; 26: 1229-1236. 22. Yamanishi Y, Yamaguchi S, Imazato S, Nakano T, Yatani H. Influences of implant neck design and implant-abutment joint type on peri-implant bone stress and abutment micromovement: three-dimensional finite element analysis. Dent Mater 2012; 28: 1126-1133. 23. Pessoa RS, Muraru L, Junior EM, Vaz LG, Sloten JV, Duyck J, Jaecques SV. Influence of implant connection type on the biomechanical environment of immediately placed implants - CT-based nonlinear, three-dimensional finite element analysis. Clin Implant Dent Relat Res 2010; 12: 219-234. 24. Sannino G, Barlattani A. Mechanical evaluation of an implant-abutment self-locking taper connection: finite element analysis and experimental tests. Int J Oral Maxillofac Implants 2013; 28: e17-26. 25. Hansson S. Implant-abutment interface: biomechanical study of flat top versus conical. Clin Implant Dent Relat Res 2000; 2: 33-41. 26. do Nascimento C, Miani PK, Pedrazzi V, Goncalves RB, Ribeiro RF, Faria AC, Macedo AP, de Albuquerque RF, Jr. Leakage of saliva through the implant-abutment interface: in vitro evaluation of three different implant connections under unloaded and loaded conditions. Int J Oral Maxillofac Implants 2012; 27: 551-560. 27. Berglundh T, Abrahamsson I, Lindhe J. Bone reactions to longstanding functional load at implants: an experimental study in dogs. J Clin Periodontol 2005; 32: 925-932. 28. Engquist B, Astrand P, Dahlgren S, Engquist E, Feldmann H, Grondahl K. Marginal bone reaction to oral implants: a prospective comparative study of Astra Tech and Branemark System implants. Clin Oral Implants Res 2002; 13: 30-37. 29. Laurell L, Lundgren D. Marginal bone level changes at dental implants after 5 years in function: a meta-analysis. Clin Implant Dent Relat Res 2011; 13: 19-28.
SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review
Immediate implants in extraction sockets with periapical lesions: an illustrated review TO CITE IN THIS ARTICLE: Novaes Jr. AB, Muglia VA, ramos, Ud, reino dM, Ayub lG. Immediate implants in extraction sockets with periapical lesions: an illustrated review. J osseointegr 2013;5(3):45-52.
Author Athur B. Novaes jr. 1, ValdIir A. MuglIa 3, Umberto d. Ramos 1, Danilo M. ReIno1, Lauro g. Ayub 2 1 department of Bucco-Maxillo-Facial surgery and Traumatology and Periodontology, school of dentistry of ribeirao Preto, University of sao Paulo, ribeirão Preto, SP, Brazil 2 department of clinical dentistry, school of dentistry, Pontifical catholic University of rio Grande do sul, Porto Alegre, rs, Brazil Rio Grande 3 department of Prosthetic dentistry, school of dentistry of ribeirao Preto, University of sao Paulo, ribeirão Preto, SP, Brazil KEY WORDS
Bone grafting; dental implants; Immediate implant loading; Periapical disease.
ABSTRACT
Aim: Immediate implantation has gained great attention since first proposed. Immediate implants in replacement of teeth with periapical lesion is, to date, an issue of discussion. The aim of this study is to perform an illustrated literature review of immediate implants in sockets exhibiting previous periapical lesions. Materials and methods: A search on medline/eMBAse database was done for the literature review which is presented together with two case reports illustrating the state of the art of immediate implants on sockets with periapical lesions. Both cases are presented in areas with great aesthetic demands and a periapical lesion of considerable size. The two cases were conducted following strict granulation tissue removal and careful rinsing and pre-operative antibiotics, followed by good primary stability of the dental implant. Results and conclusion: Both cases represented successes in aesthetics and function, describing a successful protocol for immediate implant installation in areas exhibiting periapical lesions. INTRODUCTION Since the publication of the first papers describing the phenomenon of osseointegration and the very first clinical trials (1, 2), the interest on osseointegrated implant rehabilitation has grown exponentially. At first, for the treatment of totally edentulous patients, posteriorly for partially edentulous and single unit implants. The classic protocol for the treatment with osseointegrated implants recommended 6 to 8 month between tooth extraction and implantation. This long waiting period is associated with an unavoidable bone loss that occurs after tooth extraction, which may lead to difficulties such as insufficient bone at the time of implantation. The insufficient bone leads to the use of angulated implants or the need of bone grafting procedures, increasing the morbidity, the treatment chair time and costs. At first, the main concern was with bone quality, and with the length and width of the site of implantation. With the advances on guided bone regeneration and grafting procedures, most of the problems related to the amount of bone has been solved or mostly solved, now the focus is mainly on aesthetics and amount of soft tissue increase or stability (3, 4). Immediate implantation has gained attention
Fig.1 44
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Fig.2
in order to avoid the problems related to the time lag between extraction and implant placement. The difference between crestal bone level and success rate has been evaluated by a number of authors (6,7). The success of immediate implants has been reported as similar to delayed implantation, as suggested by the original protocol (7, 8, 9), becoming an attractive treatment protocol to reduce treatment time and the lag between implantations and the prosthesis. Most of the reasons for tooth extraction include infected areas as a result of microbial and inflammatory diseases, such as periodontal disease, or periapical lesions from endodontic infections. Thus, an increasing interest has been shown on how immediate implantation would perform in infected sites. This illustrated review has the objective of reviewing current literature and to propose a predictable clinical protocol for immediate implantation on infected sites, presenting two clinical cases with 12 months of follow up. Literature on immediate implant placement in AlveolI with periapical lesions Periapical lesions are known as areas of inflammatory reaction due to the presence of pathologic agents on
an infected root canal. On histologic examination it is possible to notice the presence of granulation tissue and inflammation with a dense neutrophil infiltrate near the apical foramen delimiting the bacteria on the apical part of the root canal.Thus, a number of authors consider the presence of periapical lesions a risk to the predictability of immediate implant success, contraindicating this treatment protocol (10-13). On the other hand, some authors showed, on histological studies, that immediate implantation in sockets with periapical lesions presented similar results to non-infected sites (14). The first report of success on immediate implantation in sockets with periapical lesions was described by Novaes Jr and Novaes in 1995 (15). The protocol suggested by the authors included careful extraction and debridation of the socket (removing a thin layer of bone from hte periapical lesion area with chisels and curettes to remove any infected bone and to induce bleeding, thus favoring cell population of the graft) followed by copious irrigation with saline solution, by guided bone regeneration, primary closure and a systemic antibiotic regimen, starting 24 hours before implantation. A prospective randomized study comparing the placement of immediate implants in sites with previous periapical lesions with delayed implantation was published in 2006. The investigation included clinical and radiographic parameters, microbiological culture from samples collected from periapical lesions and Resonance Frequency Analysis (RFA) measuring
implant stability. The authors reported a success rate of 92% for immediate implants and 100 % for delayed implant placement. Although there was a numerical difference, there was no significant statistical difference (16). A study with 34 subjects compared the clinical results achieved by implant placement in periapical lesion sites and healthy sites. One year after the implant placement, there was no difference between the treatment protocols. This study showed that immediate implant placement in periapically compromised teeth is not contraindicated (17).
Fig. 1 Periapical rx showing extensive periapical lesion on the upper right central incisor. Fig. 2 A cT scan was used as a diagnostic tool to plan the immediate implant..
A retrospective study with 922 implants (285 placed in periapical infected sites and 637 in healthy sites) compared the success rate on both treatment protocols: success was defined as successful osseointegration, restoration and absence of periimplantitis. Success rates were 97.5% for the test group (periapical infection group) and 98.7% for the control group (healthy group). Therefore, the authors considered the placement of immediate implants in periapically infected sites a safe and a viable treatment protocol (18).
Fig. 3 cT can with the sagittal view showing the hypodensity (green arrow) and the bone height available for implant anchorage.
Another retrospective study comparing implant placement into infected sockets and on pristine sites with a mean time of function of 64 months reported a similar success rate (98.1% for infected sites and 98.2% for pristine sites) for both treatment protocols (19).
Fig. 4 Three dimensional model fabricated from the cT scan and the surgical and prosthetic planning Fig.5 clinical aspect of the tooth before extraction.
Fig.5
Fig.6 The pre-existent metalloceramic crown was removed before extraction. Frontal view.
Fig.3
Fig.4
Fig.6
Fig.8
Fig.7 occlusal view of the tooth without the prosthesis, before extraction. Fig.8 Tooth extraction with the periotome, minimally invasive approach. Fig.9 Tooth extracted with the periapical lesion attached.
Fig.7
Fig.10 occlusal aspect of the socket after tooth extraction. There was minimal surgical damage to adjacent soft tissue
Fig.9
Fig.10 Doctor ç&#x2030;&#x2122;ĺ&#x152;ť by Infodentâ&#x20AC;˘2/2016
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SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review
Fig. 11 occlusal view from the 3d model and the tridimensional position of the implant carefully planned. Fig. 12 occlusal view of the surgical guide showing the optimal prosthetic position for the implant. Fig. 13 occlusal view of the implant after insertion. Fig. 14 The full flap preserving corona The full flap preserving coronal attached gingiva, soft tissues and aesthetics. Thick buccal bone on the apical aspect required a graft to avoid fenestration. Fig.15 Graft (bioactive glass) in position.
CASE REPORT Case 1 The upper right central incisor was indicated for extraction due to an extensive periapical lesion diagnosed from periapical radiographs (Fig. 1). Due to favorable clinical characteristics, tooth replacement with an immediate implant-supported crown, flapless surgery and immediate provisionalization was planned. On the first visit all compromised sites were recorded and a scaling and root planning was performed. Oral hygiene instructions were given in order to perform excellent plaque control. The gingival marginal position and apico-coronal crown dimensions were established with a diagnostic waxing, considering gingival thickness and architecture. A Cone Beam CT scan was performed in order to obtain a tridimensional model (Fig. 2, 3). Thus, it was possible to fabricate a surgical guide and a precise reverse treatment planning. A surgical simulation (Fig. 4) on the 3D model to choose and individualize the prosthetic component and the
confection of a provisional crown before the surgical phase was made. The surgical phase was performed with local anesthesia and the prescription of Amoxicillin 875 mg for 10 days, starting 24 hours before the surgical procedure. Flapless tooth extraction, with the least amount of trauma as possible, was performed and the socket was carefully debrided as suggested by Novaes Jr and Novaes (15) (Fig. 5-10). After irrigation with saline solution the socket walls were inspected and the vestibular wall and socket morphology were considered suitable for immediate implant insertion. The surgical guide was placed (Fig. 11, 12) and the protocol for socket preparation was performed, in accordance to the manufacturer’s instruction, for a 4.5 mm diameter and 15 mm length implant (XiVe S Plus, Dentsply Implants, Mannheim, Germany). The implant was placed 1 to 1.5 mm from
Fig.11
Fig.12
Fig.13
Fig.14
Fig.15
Fig.16
Fig.17
Fig.18
Fig.16 Primary closure achieved and provisional crown in position. Fig.17 Final aspect of the provisional crown after surgery.
Fig.19
Fig.20 Fig.22
Fig.18 Periapical radiograph on the immediate post-operative period. Fig.19 Periapical radiograph taken 1 month after surgery. Fig.20 Periapical radiograph taken 3 months after surgery with the zirconia abutment.
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Fig.21
Fig.23
Fig.24
the buccal bone wall and anchored on the nasal cavity floor to obtain primary stability (Fig. 13). Although the coronal alveolar wall was in good condiditon, the apical portion was too thin, due to the periapical lesion, and a grafting material (Biogran, Biomet 3i, Palm Beach, FL- USA) was placed with an apical access (Fig. 14, 15). A provisional crown was placed after the implant and grafting procedures. A zirconia abutment (Cercon, Dentsply Implants, Mannheim, Germany) was connected to the implant and a metal-free ceramic crown was cemented (Fig. 16-18). At 1 and 3 months post-operatively, a periapical radiograph was performed (Fig. 19, 20), and clinical photos were taken (Fig. 21, 22). During this period the left central incisor was lost due to trauma. After 6 and 12 months a CT scan was made to ensure treatment success and resolution of the periapical lesion (Fig. 23-25).
Case 2 The upper right incisor was indicated for extraction due to an endo-perio lesion diagnosed by periapical radiographs (Fig. 26). Based on defect configuration, analyzed by a CT scan examination (Fig. 27), an immediate implant with an immediate provisional crown was planned. The tooth was extracted with a previous antibiotic prescription (Amoxicillin 875 mg-Potassium Clavulanate 125 mg combination, twice daily, for ten days, starting one day before the procedure). After tooth extraction a 5.5 mm diameter and 13 mm length implant (XiVe S Plus, Dentsply Friadent, Mannheim, Germany) was inserted 1 mm apically to palatal bone wall (Fig. 28-30). On the same day, a 4.5 mm diameter prosthetic component was installed and a provisional crown was placed, performing a platform switching strategy (Fig. 31). After 9 months, a metalloceramic
Fig.25
Fig. 21 Periapical rx showing clinical buccal aspect of the zirconia abutment. Fig. 22 clinical occlusal aspect of the zirconia abutment. Fig. 23 Final aspect of the prosthetic crown 6 months after prosthesis installation. Fig. 24 cT scan 12 months after surgery. Fig.25 Periapical radiograph 12 months after surgery.
Fig.26 Fig.27
Fig.28
Fig.29
Fig.26 Periapical radiograph showing extensive periapical lesion on the upper right incisor. Fig.27 cT scan showing buccal bone wall fenestration on apical aspect of the tooth. Fig.28 clinical aspect of the tooth before extraction.
Fig.30
Fig.31
Fig.29 A full flap was reflected. Implant was positioned subcrestaly to the bone crest. Fig.30 clinical aspect of the surgical area after flap closure.
Fig.32
Fig.33
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SCIENTIFIC UPDATE Immediate implants in extraction sockets with periapical lesions: an illustrated review crown was placed (Fig. 32). At 12 months, a control periapical radiograph and CT scan was requested (Fig. 33), confirming the treatment success. Fig. 31 Provisional crown in place. Fig. 32 Final clinical aspect after the metalloceramic crown was cemented. Fig. 33 Periapical radiograph and cT scan of the area 1 year after prosthesization
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DISCUSSION In order to maintain aesthetic and functional conditions with implant therapy, it is important to preserve alveolar bone dimensions, gingival margin position, gingival thickness and keratinized gingival tissue. Thus, aiming to reduce alveolar process resorption and treatment time, immediate implant placement in fresh extraction sockets has been largely proposed (7, 8, 9,2 0). However, most of the reasons for tooth extraction include infected areas caused by tooth fracture, periodontitis or endodontic infection. It is still controversial and there is no scientific or clinical consensus about the immediate implant indication in areas of chronic periapical infected sites, in addition, few clinical data are available. Some clinical reports have suggested that history of endodontic or periodontal infections is a predictive risk marker for future implant infection and failure (21, 22, 23). This hypothesis may be justified by the possibility of soft and hard tissue contamination located near the implant surgical bed. This led most clinicians to avoid immediate placement of dental implants at infected sites and to consider periapical infection a contraindication for immediate implantation (25). On the other hand, placement of immediate implant in chronically infected sites may have successful outcomes and is not a contraindication in all cases. A prospective controlled clinical study comparing immediate implants in sites with or without periapical lesions failed to achieve differences between the two protocols. The failure index did not increase in the presence of periapical lesions when the implant achieved primary stability (14, 15, 17). More recent data of a retrospective study (418 implants placed in sockets with periapical lesions) with a minimum of 2 years follow up showed a survival rate (98.1%) similar to implants placed on pristine sites (98.2%) (27). A protocol option to achieve a successful outcome was proposed by Novaes Jr and Novaes in 1995 (15) ,consisting in the elimination of the etiological factors and to create favorable conditions for tissue healing. In the first step the patient must receive oral hygiene instructions and scaling and root planing in order to perform good plaque control. After one week, a reduction of soft tissue inflammation can be noted and the surgery in association with the use of antibiotics (for 10 days, every 8 hours, starting 24 hours before surgical procedure) (15) can be performed. Atraumatic flapless tooth extraction is encouraged, and the socket must have 4 intact walls and in sequence should be carefully debrided (14, 15). The contaminated soft and hard tissues removal by meticulous debridement (15, 25), combined with pre- and postoperative antibiotics will establish a favorable basis for bone healing and osseointegration (15). Some other factors must be considered: the extent of bone resorption and the angle of the implant for a satisfactory aesthetic re-
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storation (15). The implant should be placed in the optimal aesthetic position, if not, the procedure should be delayed and a GBR should be considered in order to avoid future aesthetic complications. In case of compromised buccal bone walls, in order to preserve horizontal alveolar bone dimensions, association of Guided Bone Regeneration procedures can create adequate aesthetic conditions avoiding visualization of a gray band, from the implant, due to buccal wall fenestration. However, it is possible to perform a flapless approach in cases in wich the buccal bone fenestration is expected. Planning a GBR procedure with an apical approach, as shown in this paper, is only possible with a CT scan as a diagnostic tool before tooth extraction. The preservation of the coronal buccal wall crest will permit stability of the gingival position, avoiding black spaces and gingival recession or implant abutment exposure, giving an optimal aesthetic result. According to a recent systematic review, immediate implant placement into sockets with previous periapical pathology is not contraindicated when a protocol of systematic debridement and cleaning is performed. The same publication reported that the use of bone graft and the use of systemic antibiotics, although controversial, is encouraged to avoid possible post- operative complications at the regenerated site (28). More recently, a controlled clinical trial with aesthetic and radiographical outcomes after 5 years was published (29). This study compared immediate implants placed in sockets exhibiting previous periapical lesions (n=11) with sockets without this condition (n=15), both groups received GBR concomitant to implant installation and received 5 days of systemic antibiotics (Amoxicillin 750 mg) and were instructed to rinse with chlorhexidine 0.2% (period not informed). The implants were loaded 3 months after installation. The results achieved did not demonstrate differences between both groups on the parameters evaluated. None of the immediate implants installed in sites with previous periapical lesions exhibited retrograde periimplantitis during the 5 years of follow up (29). This protocol cannot be used in cases where an acute infection persists even when the pre-surgical antibiotic is used, the immediate implant placement should be postponed, the tooth removed and the acute infection treated (25). It is indicated for experienced surgeons since the correct debridement of the granulation tissue, avoiding violation of noble tissues, accurate guided bone regeneration procedures, correct 3D implant positioning and primary stability are important factors for treatment success. CONCLUSION The proposed protocol used in the two cases reported, presented a successful outcome, achieving elimination of the infection and immediate dental implant placement with good functional and aesthetic outcomes. This is possible thanks to a meticulous execution of the proposed treatment protocol..
REFERENCES 1. Branemark PI, Adell r, Breine U, hansson Bo, lindström J, ohlsson A. Intra- osseous anchorage of dental prostheses. I.experimental studies. scand J Plast recons surg 1969;3:81-100. 2. Branemark PI, hansson Bo, Adell r, Breine U, lindström J, hallén o, ohlsson A. osseointegrated implants in the treatment of the edentulous jaw. experience from a 10 year old period. scand J Plast recons surg 1977; 16 (suppl) 3. Tarnow d, elian N, Fletcher P, Froum s, Magner A, cho sc, salama M, salama h, Garber dA.Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74:1785-8. 4. degidi M, Novaes AB Jr, Nardi d, Piattelli A. outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Periodontol 2008;79:1056-61. 5. schulte w, heimke G.The Tubinger immediate implant. Berlin Quintessenz 1976;27:17–23. 6. degidi M, Nardi d, Piatelli A. Peri-implant Tissue and radiographic Bone levels in the Immediately restored single-Tooth Implant: A retrospective Analysis. J Periodontol 2008;79:252-9. 7. Block Ms, Mercante de, lirette d, Mohamed w, ryser M, castellon P. Prospective evaluation of Immediate and delayed Provisional single Tooth restauration. J oral Maxillofac surg 2009;67(suppl 3):89-107. 8. schwartz-Arad d, Gulayev N, chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923- 8. 9. cornelini r, cangini F, covani U, wilson TG Jr. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. Int J Periodontics restorative dent 2005;25:439-47. 10. schwartz-Arad d, chaushu G.The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915–23. 11. Becker w, Becker Be. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports. Int J Periodontics restorative dent 1990;10:377–91. 12. Tolman de, Keller ee. endosseous implant placement immediately following dental extraction and alveoloplasty: Preliminary report with 6-year follow- up. Int J oral Maxillofac Implants 1991;6:24–8. 13. Barzilay I. Immediate implants: Their current status. Int J Prosthodont 1993;6:169–75. 14. Novaes AB Jr, Vidigal GM Jr, Novaes AB, Grisi MFM, Polloni s, rosa A. Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J oral Maxillofac Implants 1998;13:422–72 15. Novaes AB Jr, Novaes AB. Immediate implants
placed into infected sites: a clinical report. Int J oral Maxillofac Implants 1995;10:609-13. 16. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod 2006;6:705-10. 17. siegenthaler dw, Jung re, holderegger c, roos M, hämmerle chF. replacement of teeth exhibiting periapical pathology by immediate implants. A prospective controlled clinical trial. clin oral Impl res 2007;18:72737. 18. Bell cl, diehl d, Bell BM, Bell re. The immediate placement of dental implant into extraction sites with periapical lesions: A retrospective chart review. J oral Maxillofac surg 2011;69:1623-7. 19. Fugazzotto PA, A retrospective Analysis of Implants Immediately Placed in sites with and without Periapical Pathology in 64 Patients. J Periodontol 2011 [ahead of print]. 20. lazzara rJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics restorative dent 1989;9:332-43. 21. Ayangco l, sheridan PJ. development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: a series of reports. Int J oral Maxillofac Implants 2001;16:412-7. 22. oh TJ, yoon J, wang hl. Management of the implant periapical lesion: a case report. Implant dent 2003;12:41-6. 23. Karoussis IK, salvi Ge, heitz-Mayfield lJ, Brägger U, hämmerle ch, lang NP. long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI dental Implant system. clin oral Implants res 2003;14:329-39. 24. Polizzi G, Grunder U, Goené r, hatano N, henry P, Jackson wJ, et al.. Immediate and delayed implant placement into extraction sockets: a 5-year report. clin Implant dent relat res 2000;2:93- 9. 25. casap N, Zeltser c, wexler A,Tarazi e, Zeltser r. Immediate placement of dental implants into debrided infected dentoalveolar sockets. J oral Maxillofac surg 2007;65:384-92. 26. Fugazotto P. A retrospective analysis of Immediately Placed Implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J oral Maxillofacial Impl 2012; 27:194-202. 27. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod. 2006;101:705-10. 28. waasdorp JA, evian cI, Mandracchia M. Immediate Placement of Implants into Infected sites: A systematic review. J Periodontol 2010;81:801-8.
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SCIENTIFIC UPDATE
牙窝根尖周变病的即刻种植:一篇有插图说明的述评
牙窝根尖周变病的即刻种植: 一篇有插图说明的述评 引用了本述评: Novaes Jr. AB, Muglia VA, ramos, Ud, reino dM, Ayub lG. Immediate implants in extraction sockets with periapical lesions: an illustrated review. J osseointegr 2013;5(3):45-52.
Author Athur B. Novaes jr. 1, ValdIir A. MuglIa 3, Umberto d. Ramos 1, Danilo M. ReIno1, Lauro g. Ayub 2 1 巴西圣保罗大学里贝 兰普雷图牙科学院， 口腔与颜面外科学 系、外伤学系和牙周 病学系。 2 巴西RIO GRANDE 天主教大学阿雷格里 港牙科学院临床牙科 学系。 3 巴西圣保罗大学里贝 朗普雷图牙科学院牙 科修复学系l 关键词 骨移植，牙的种植， 即刻种植载入， 尖周病。
摘要 从第一次被提出至今，即刻种植已获得了极大的关注，即刻种植牙替换根尖病变的牙齿是到 今天为止一直被讨论的话题。这次研究的目的是，提供一个配有插图说明的根尖病变牙窝即 刻种植的述评。 材料和方法 我们对MEDLINE/ EMBA的文摘数据库进行了搜索，和文献中介绍的两个配有拔牙窝根尖病 变的即刻种植技术步骤插图的案例。两个案列中的手术部位都有极高的审美要求而且存在相 当规模的牙窝根尖周病变现象。对这两个案例都实施了严格的肉芽组织切除、仔细冲洗拔牙 窝和配合术前康生素的治疗。其次是保证种植牙良好的初期稳定性。 结果和结论 这两个案列的结果都呈现了满意的功能与美学效果。为根尖周病变区进行即刻种植描述了一 个成功的治疗方案。 前言 从发表第一篇关于骨结合这一技术与其第一个 临床试验 (1、2 ) 至今，人们对对骨结合式种植 修复的兴趣已经增长了好多倍。从当初对完全 无牙颌患者的治疗，到后来对部分无牙颌患者 的治疗，再到对单颗牙齿的修复。 传统的骨结合式种植，对拔牙和种植手术时间 的间隔要求是6到8个月。在拔牙后这段长时间 的等待中会发生不可避免的骨遗失，这样的话 植入时就会有骨量不足的问题。骨量不足导致 了需要使用角形植入物或骨移植的办法来解 决。这就导致增加了发病率、疗程的延长和成 本的增加。在种植过程中首先需着重考虑的是 与骨质量和种植部位的深度和宽度，随着诱导 骨再生和骨移植技术的进步，骨量不足所带来 的大部分问题已经解决或大部分已得到解决。 现在主要关注美学效果和软组织增加与稳定性 ( 3、4) 。 因为可以避免拔牙和种植手术间隔时间长所带 来的问题，即刻种植已经得到了人们的重视。 这一技术最早在1976年被提出 (5) ， 此后一直
Fig.1
50
Doctor 牙医 by Infodent•2/2016
成为业界科学讨论的主题。 已经有很多的学者对牙槽嵴水平和成功率之间 的差异做出了评估 ( 6、7) .关于即刻种植术的 成功，人们像报道治疗方案本身时一样的报道 它，并和其他传统方案一样被推荐 ( 7、8、9) , 由于缩短了治疗时间和植入物与假体之间滞后 的问题，即刻种植成了一个很吸引人的治疗方 案。 大多数拔牙原因包括感染区的微生物和炎症引 起的疾病，如牙周炎，或因牙髓感染的根尖 病变。因此，一个越来越感兴趣的问题被提了 出来，如何在一个受感染的区域内进行即刻种 植。这篇配有插图的综述的目标是，查阅现有 的文献资料，并给如何在受感染区域进行即刻 种植提出一个可预测的临床方案，介绍两个经 过12个月跟踪治疗的临床病例。 牙窝根尖周病变即刻种植的文献 所谓的根尖周病变就是由于被感染根管上有病 源菌而引起炎症反应的区域，在组织学检查中 可以发现肉芽组织增生和有密集的嗜中性粒细 胞的炎症渗入到根尖孔的周围，把细菌界定在 Fig.2
根管的根尖部。因此，一些学者认为根尖周病 变对即刻种植的成功存在可预见性的风险，与 这种治疗方案是相悖的 (10至13) 。另一方面， 一些研究者在组织学研究中发现对根尖周病变 牙槽进行即刻种植时呈现出类似非感染区域的 症状 (14) 。
有显著的统计学差异 (16) 。 通过对34个受试者由种植体植入根尖病变部位 和健康部位所取得的临床效果进行对比。种植 体植入1年后结果是，两种治疗方案的结果之 间没有差异。这个研究表明即刻种植体与根尖 周损害牙齿并不相悖 (17)。
首例牙槽根尖周病变即刻种植成功的报告于 1995年发表在Novaes Jr and Novaes上 (15)。 该方案作者提出的建议包括小心的提取和种植 窝的准备(在根尖周病变区用骨凿和刮匙薄薄 的去除所有被感染骨，并诱导出血从而有利于 移植中细胞的增生)之后用丰富的生理盐水溶 液冲洗，到引导骨再生和初次缝合，在离种 植还有24小时时需要做系统性的抗生素治疗方 案。
一项对922列种植手术的回顾性研究( 285个种 植在根尖周感染部位，和637个在健康部位，) 相比两种治疗方案的成功率，结果是成功的定 义为：成功的骨结合修复，没有不被吸收的植 入物。成功率分别为试验组(根尖周感染组)为 97.5%，和对照组(健康组)为98.7%。所以作者 认为在根尖周感染的部位即刻种植是一个安全 可行的治疗方法 (18)。
通过对比在根尖周病变区即刻种植法和延期种 植法。一个前瞻性的随机对照研究报告在2006 年发表了。该调查包括临床和影像指标对从根 尖周病变中提取的样品进行微生物培养和谐振 频率分析的办法来测量种植体的稳定性。作者 的报告显示，即刻种植成功率为92%，延期种 植为100%。两种方案，虽然有个数值差，但没
另一个回顾性研究是对种植物植入感染部位和 植入健康部位后64个月内进行功能测试。最后 对两种治疗方案都报道了类似的成功率，(感 染部位种植的成功率为98.1%,健康部位的种植 成功率为98.2%)(19)。
图1
尖周RX显示右上角 中门牙有严重的根尖 周病变 图2
图2用CT扫描作为诊 断工具进行规划即刻 种植 图3
矢状的CT扫描图显示 低密度绿箭头所指处 和骨长度适合种植棒 的固定。 图4
利用CT扫描制造了三 维模型以用于手术规 划和义齿的制造 图5
拔牙前牙齿临床外观 图6
Fig.5
图6之前的金属瓷冠 在术前被摘除，正面 观。 图7
Fig.3
拔牙前旧义齿被取下 后的咬合视图
Fig.4
图8
Fig.6
Fig.8
用微创拔牙法拔掉患 牙。 图9
有根尖病变的牙齿被 提取出来。 图 10
提取手术后拔牙窝的 咬合视图，手术对临 近软组织的伤害减到 了最小化
Fig.7
Fig.9
Fig.10 Doctor 牙医 by Infodent•2/2016
51
SCIENTIFIC UPDATE
牙窝根尖周变病的即刻种植:一篇有插图说明的述评
病例报告 图 11
取自三维模型的咬合 视图和通过精心设置 的种植棒三维位置 图 12
手术指南视图显示最 佳美学效果的种植棒 位置 图13
植入种植棒后的视图 图 14
保留完整的冠瓣附着 牙龈和软组，这有助 于得到满意的美学效 果。为避免开窗，需 要在厚颊骨顶端进行 移植。
病例1 上门牙右边中间的一颗被指出需要拔除，因为 根据根尖X光片(图1)的显示确诊为严重的根尖 周病变。根据临床特征的需要，我们决定用 即刻种植体支撑种植牙来替代原牙、无翻瓣手 术和即刻临时修复。初诊中所有受损部位都被 记录了下来，并对受损部位进行了刮治和根面 整平，为了得到良好的菌斑控制效果，对口腔 进行了卫生处理。考虑到牙龈的厚度和结构， 用诊断涂蜡法给龈缘位置和APICO冕冠建立 了尺寸。为获得一个三维模型还做了一个锥束 CT扫描(图2和3)。 这时，制定一个手术指南和精确的反向治疗计
划已经有了可能。在制定手术步骤之前，我们 通过对一个三维模型进行外科仿真(图4)来选择 和个性化义体部件并制出一个合适的临时冠。 手术是在局部麻醉状太下进行的，另外，开了 10天用的875毫克阿莫西林处方 ，患者应该在 手术前24小时开始服用。 根据Novaes Jr and Novaes【15】的建议做了无 翻瓣拔牙，拔牙时尽量把创伤减小到最低,拔出 牙齿后仔细清理了拔牙窝创口(图5至10)。用生 理盐水冲洗结束，检查拔牙窝壁，确定前庭壁 合牙窝组织结构适合植入即刻种植棒时，手术 指南就被列出来了(图11和12)。 种植窝的准备已经完成，根据种植棒生产商给 出的指示为一个4.5毫米直径，15毫米长标准的 XiVe S Plus种植体准备了种植窝（XiVe S Plus 种植棒由德国曼海姆Dentsply Implants公司生
图 15
移植物生物活性玻璃 已经放置 图 16
初步缝合已经完成， 临时冠固定完毕
Fig.11
Fig.12
Fig.13
Fig.14
Fig.15
Fig.16
Fig.17
Fig.18
图 17 术后临时冠最终效 果图 图 18
即时手术后的根尖X 光片 图 19 手术1个月后的根尖 X光片
Fig.19
Fig.20 Fig.22
图 20
氧化锆基台种植3个 月后的根尖X光片
Fig.21
Fig.23
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Doctor 牙医 by Infodent•2/2016
Fig.24
病例2 通过根尖X光片诊断，右侧上切牙由于牙周内 侧病变而需要被拔除（图26）。CT扫描片（图 27）的检查分析显示有结构缺陷的存在，基于 此因，决定对其进行即刻种植和使用临时冠。 在提前服用了一天的康生素后（阿莫西林875 毫克，克拉维酸钾125毫克的组合，每日两 次，连续服用10天，在手术开始前一天开始服 用）拔除了牙齿，提取牙齿后一颗5.5毫米直径 13毫米长的种植棒被固定在离颊骨壁1毫米处 （图28至30）。在同一天，一个4.5毫米直径的 义齿部件被安装好了，然后用旋转基台的办法 放置了临时冠（图31）。9个月后用金属瓷冠 替代了临时冠(图32），12个月后，为了确认治 疗的成功，做了根尖X光片和CT扫描（图33）。
图 21
氧化锆基台的临床颊 侧面 图 22
氧化锆基临床咬合面 图 23
义齿安装6个月后义 齿冠最终外观效果 图 24
手术12个月后的CT扫 描图 图 25
Fig.25
手术12个月后的根尖 X光片 图 26
根尖X光片显示，右 上切牙有严重的根尖 病变
Fig.26 Fig.27
Fig.28
Fig.29
图 27 扫描显示颊骨壁位于 牙根尖部位穿孔 图 28
除之前的牙齿临床 外观 图 29
一片完整的冠瓣被反 褶起，把种植棒定位 在骨嵴顶端正中。 图 30
Fig.30
Fig.31
Fig.32
瓣关闭后手术区临床 外观
Fig.33
Doctor 牙医 by Infodent•2/2016
53
SCIENTIFIC UPDATE
牙窝根尖周变病的即刻种植:一篇有插图说明的述评
讨论
图 31
临时冠入位 图 32
胶固金属瓷冠后的最 终临床效果图 图 33
义齿安装1年后根尖X 光片和CT扫描图
在种植疗法中，为了确保种植的美学和功能效 果，保留牙槽骨的尺寸、牙龈缘位置、牙龈厚 度和牙龈角化组织是非常重要的。因此，为了 减少牙槽突的吸收和减短治疗时间，在新鲜的 拔牙窝内即刻植入种植体被广泛推荐 (7、8、 9、20)。然而，大多数需要拔牙的原因，由牙 齿折裂、牙周炎或牙髓感染引起的。对慢性根 尖周炎感染的区域的即刻种植，并没有达成一 个科学或临床上的共识，它仍然是个有争议的 话题。此外，也没有很多的临床资料可用来参 考。一些临床报告表明，牙髓或牙周发炎史是 一个对导致种植后发炎和种植失败的预测性风 险指标 (21、22、23) 。可以通过靠近种植手术 床附近的软硬组织受到污染来证明这个假说。 这导致了大多数临床医生避免在受感染区域即 刻种植，并认为根尖周感染对即刻种植来说是 一个禁忌 (25)。 另一方面，在慢性感染部位即刻植入种植体有 可能获得成功的结果，而且并不是对所有情形 的禁忌。一个乐观的临床对照研究，比较根尖 病变即刻种植和无根尖病变即刻种植两种治疗 方案的失败率，当手术取得初期稳定时，发 现手术失败指数并没有因为有根尖病变的存 在而增加 (14、15、17)。一个最新的回顾性研 究数据显示，通过对481例根尖周病变的即刻 种植，经过不少于2年的跟踪观察后，发现其 存活率为98.1％，接近于无尖周病变即刻种植 98.2％的存活率 (27)。 Novaes Jr 和 Novaes在1995年提出了一个可以 获得满意结果的治疗方案 (15)，就是通过消除 致病因素和创造有利于组织愈合的条件。为了 得到一个良好的菌斑控制效果，首先，需要对 病人实施口腔卫生措施和刮治与跟面平整。一 个星期后，可以注意到软组织炎症已经减少， 这时在使用抗生素的同时可以进行手术了。抗 生素用法：从手术前24小时时服用第一次，之 后每8个小时一次，连续服用10天 (15)。提倡 用无创无翻瓣拔牙法，拔牙窝必需有4个完整 的壁，接下来还要对其进行清创处理 (14、15) 。要用细致的清创手术去除受污染的软、硬组 织 (15、25)，结合术前与术后的抗生素服用将 为骨愈合及骨结合创造一个有利的条件 (15)。 其他一些必需考虑的因素：骨吸收程度和令人 满意的美学修复效果的种植体角度 (15)。重要 的是，植入物应该放置在最佳审美位置，如果 没有得到这个效果，为了避免将来的审美并发 症，应该考虑诱导骨再生（GBR）。 如果遇到受损害的颊骨壁，为了保证牙槽骨尺 寸的水平，使用诱导性骨再生程序可以建立足 够的审美条件，因为这样可以在种植手术中避 免由于颊壁穿孔而出现灰色区域。然而，在有 可能出现颊骨开窗的情况下可以进行无翻瓣手
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术。要设计一个像本篇所示的根尖诱导骨再生 程序的话，拔牙前一定要 用CT扫描来作为诊 断工具。冠状颊侧壁嵴的保存，有利于牙龈位 置的稳定，可避免出现黑色空间和牙龈萎缩或 种植体基台的暴露；可以带来最佳的美学效 果。根据一个最近的系统性述评，在治疗过程 中进行清创和清洁处理的情况下，曾有根尖病 变的拔牙槽对即刻种植来说并不是一个禁忌。 同一个出版物也报道，虽然对骨移植和系统性 的抗生素应用还有争议，但提倡避免骨再生部 位有可能的术后并发症 (28)。 最近，发表了一个针对美学和影响学结果而 进行了5年的临床对照试验报告 (29)。这项研 究比较了有根尖病变牙窝和无根尖病变牙窝 的即刻种植，两组均接受了诱导性骨再生方案 （GBR）和接受5天的系统性服用康生素（阿 莫西林750毫克）并嘱咐用0.2％的洗必泰冲洗 （没有指出具体的期限）。种植体在安装3个 月后载入。两组所取得的结果并没有评估参数 上的差异。在5年的跟踪研究中，根尖病变牙 窝患者的种植体周围并没有发现任何逆向情况 (29)。 对有持续性急性感染部位是不可以用此治疗方 案的，即时在手术前使用抗生素的情况下，这 种情况下，应该推迟即刻种植计划，直到完成 拔牙，急性感染被得到处理和控制 (25)。对一 个有经验的外科医生而言的，除了对肉芽组织 进行正确清创、避免伤到高贵组织、精确的诱 导骨再生程序、正确的3D植入定位和初期的稳 定性都是影响手术成功的重要因素。
结论 提供的两个病例中所用的治疗方案呈现了一个 圆满的结果，既消除了感染又兼顾了即刻种植 结果良好的功能和美学效果。这可能要归功于 所提出的治疗方案得到了认真细致的执行。
参考文献 1. Branemark PI, Adell r, Breine U, hansson Bo, lindström J, ohlsson A. Intra- osseous anchorage of dental prostheses. I.experimental studies. scand J Plast recons surg 1969;3:81-100. 2. Branemark PI, hansson Bo, Adell r, Breine U, lindström J, hallén o, ohlsson A. osseointegrated implants in the treatment of the edentulous jaw. experience from a 10 year old period. scand J Plast recons surg 1977; 16 (suppl) 3. Tarnow d, elian N, Fletcher P, Froum s, Magner A, cho sc, salama M, salama h, Garber dA.Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Periodontol 2003;74:1785-8. 4. degidi M, Novaes AB Jr, Nardi d, Piattelli A. outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Periodontol 2008;79:1056-61. 5. schulte w, heimke G.The Tubinger immediate implant. Berlin Quintessenz 1976;27:17–23. 6. degidi M, Nardi d, Piatelli A. Peri-implant Tissue and radiographic Bone levels in the Immediately restored single-Tooth Implant: A retrospective Analysis. J Periodontol 2008;79:252-9. 7. Block Ms, Mercante de, lirette d, Mohamed w, ryser M, castellon P. Prospective evaluation of Immediate and delayed Provisional single Tooth restauration. J oral Maxillofac surg 2009;67(suppl 3):89-107. 8. schwartz-Arad d, Gulayev N, chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923- 8. 9. cornelini r, cangini F, covani U, wilson TG Jr. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. Int J Periodontics restorative dent 2005;25:439-47. 10. schwartz-Arad d, chaushu G.The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915–23. 11. Becker w, Becker Be. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case reports. Int J Periodontics restorative dent 1990;10:377–91. 12. Tolman de, Keller ee. endosseous implant placement immediately following dental extraction and alveoloplasty: Preliminary report with 6-year follow- up. Int J oral Maxillofac Implants 1991;6:24–8. 13. Barzilay I. Immediate implants: Their current status. Int J Prosthodont 1993;6:169–75.
15. Novaes AB Jr, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J oral Maxillofac Implants 1995;10:609-13. 16. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod 2006;6:705-10. 17. siegenthaler dw, Jung re, holderegger c, roos M, hämmerle chF. replacement of teeth exhibiting periapical pathology by immediate implants. A prospective controlled clinical trial. clin oral Impl res 2007;18:72737. 18. Bell cl, diehl d, Bell BM, Bell re. The immediate placement of dental implant into extraction sites with periapical lesions: A retrospective chart review. J oral Maxillofac surg 2011;69:1623-7. 19. Fugazzotto PA, A retrospective Analysis of Implants Immediately Placed in sites with and without Periapical Pathology in 64 Patients. J Periodontol 2011 [ahead of print]. 20. lazzara rJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics restorative dent 1989;9:332-43. 21. Ayangco l, sheridan PJ. development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: a series of reports. Int J oral Maxillofac Implants 2001;16:412-7. 22. oh TJ, yoon J, wang hl. Management of the implant periapical lesion: a case report. Implant dent 2003;12:41-6. 23. Karoussis IK, salvi Ge, heitz-Mayfield lJ, Brägger U, hämmerle ch, lang NP. long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI dental Implant system. clin oral Implants res 2003;14:329-39. 24. Polizzi G, Grunder U, Goené r, hatano N, henry P, Jackson wJ, et al.. Immediate and delayed implant placement into extraction sockets: a 5-year report. clin Implant dent relat res 2000;2:93- 9. 25. casap N, Zeltser c, wexler A,Tarazi e, Zeltser r. Immediate placement of dental implants into debrided infected dentoalveolar sockets. J oral Maxillofac surg 2007;65:384-92. 26. Fugazotto P. A retrospective analysis of Immediately Placed Implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J oral Maxillofacial Impl 2012; 27:194-202. 27. lindeboom JA, Tjiook y, Kroon Fh. Immediate placement of implants in periapical infected sites: a prospective randomized study in 50 patients. oral surg oral Med oral Pathol oral radiol endod. 2006;101:705-10. 28. waasdorp JA, evian cI, Mandracchia M. Immediate Placement of Implants into Infected sites: A systematic review. J Periodontol 2010;81:801-8.
14. Novaes AB Jr, Vidigal GM Jr, Novaes AB, Grisi MFM, Polloni s, rosa A. Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J oral Maxillofac Implants 1998;13:422–72
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INDUSTRY NEWS Asa Dental
种植术前准备 口腔种植手术是一个简单的外科手术，它的要求与一般外 科手术一样，要做好手术室环境、病人、器械及医护人员 等的各项准备，保证种植手术的无菌原则。针对以上环 节，简述其相应要求：
一、手术室环境 手术室必须至少准备一个单间，手术尽量安排在上午，术 前一天做好手术室的清洁卫生，关好门窗，进行紫外灯消 毒，保证手术室无菌。若在门诊手术，环境消毒和手术人 员的无菌衣物一定要到位。手术当天患者戴好帽子，穿好 脚套进入手术室。若有多台手术，要保证手术室的消毒时 间和无菌环境。
二、患者手术术前准备要求 1、排除禁忌症，女性避开月经期 2、患者需拍好X片检查，取好模型 3、术前做好口腔准备：拔除龋齿、残根，治疗好口腔疾 病，口腔清洗； 4、验血常规、肝功、血糖、出凝血时间。糖尿病患者术前 2周控制糖化血红蛋白≤7%，术后10周内仍保证糖化血红 蛋白≤7% 5、术前一天吃抗菌素（常规抗菌药） 6、术前测血压、脉搏、体温；对于高度紧张的患者术中监 测指标 7、术前口内口外消毒
三、器械及敷料准备 1、敷料： 方巾（双层, 5块, 80cm*80cm或以上), 用于包裹病人头颈部 洞巾（双层, 1块, 长度能从头遮盖到膝关节, 宽度要超过双 肩） 布套（双层，3个，1.5米/个，直径7cm左右，套种植机马 达和吸唾管），若无布套可用一次性医用无菌保护套。若 吸唾管是一次性无菌的，则可省去一个布套。
手术工具盒包布（双层，2块，根据诊所实际盛装手术器械 的弯盘尺寸而定） 种植器械盒包布（双层，2块，80cm*80cm，） 手术人员口罩、帽子、洗手衣、洗手裤及无菌手术衣（一 台手术2-3套）、无菌手套 无菌生理盐水（1颗牙1-2瓶，视牙而定，夏季最好术前 24-48小时放入冰箱冷却） 小推车*2（放种植器械盒和手术工具盒用，视手术室整体 配置而定） 2、口外手术工具盒： 口镜*1~2、 拉钩*1（可用口镜代替） 持针器*1个、 镊子*1、 大小刮匙各*1、 止血钳*2（弯\直） 牙龈分离器*1 骨膜分离器*1 刀柄*1 尖刀片或小圆刀片*1 缝针5*12规格 缝线0＃或1＃ 巾钳3-4个、 眼科剪*1 纱布、棉球若干 吸引头*1（最好是硬质的，同时起到牵拉作用） 50ml注射器(含针头)加无菌盛物小碗*1或输液皮条加血压袖 带（外冷却用） 另：（针对个别病例准备）骨凿，骨锉，小锤子，咬骨 钳，盛物小碗，骨粉，骨膜 以上工具可集中在一起打包消毒 3、种植手术器械：种植机 手术工具盒 4、其他：吸唾用强吸；洗手液，碘伏，酒精四、医护人员 医生向患者讲解 手术术中及术后 注意事项，签手 术同意书； 医生、医助洗手 穿衣，准备手 术；巡回护士做 好巡回工作。
刘双斌医生 全科资深医生，意大利安萨器械（ASA Dental）培训讲师。有十余年丰富的临床工作经验。毕业于天津医科大学， 口腔医学硕士学位（牙周病及种植方面）。在牙体治疗、根管治疗、美学修复、以及复杂拔牙手术,种植牙等多学科 具有相当丰富的临床经验。曾多年在涉外高端齿科诊所任职，工作中非常注重无痛治疗及微创治疗。擅长种植牙的 修复治疗以及CAD/CAM微创修复、现代精细根管治疗并注重多学科的综合序列治疗。曾应邀参加首届全球华人口 腔大会及多届国际口腔种植会议，赴多地交流学习，多次参加全国比赛并获得奖项.
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Doctor 牙医 by Infodent•2/2016
科室开展种植的前期准备工作 1. 种植手术室 相对独立的20㎡左右的手术室即可 2. 种植设备 • 必备设备：全景机 • 种植机 • 选配设备：CT 、超声骨刀等 3. 种植工具盒和手术器械 见附录 • 种植系统工具盒 • 种植手术专用手术器械 4. 种植手术服 包含手术衣，洞巾，包布，帽子 （奥齿泰有手术衣套装：3个手术衣，1个 洞巾，8个包 布，3个帽子） 4. 种植消耗品 无菌手套，口罩，无菌毛巾，12号及15号 无菌刀片，一次性注射器，纱布，锡纸，洗手液，氯方己 定含漱液，麻醉剂，金属注射器，碘伏棉球，缝合线，冰 袋，生理盐水 种植外科基本步骤（一） 一、一期手术（种植体植入）
1. 患者术前准备 （1）术前用药 – 抗生素、消炎药、抗焦虑药，氯己定
– 苯二氮类抗焦虑药：术前1小时服用 – 抗生素：术前3～7天 （2）消毒液冲洗（氯己定、聚烯吡酮磺） – 氯己定漱口：术前1分钟
2.外科手术器械和设备 • 种植机、种植外科工具盒 • 冷却盐水 • 缝线、缝针 • 骨移植材料 • 屏障膜 • 上颌窦提升工具 • 常规外科器械 (推荐明细件附录) 3. 手术原则 • 切口 – 第一切口必须明确到位 – 牵引骨膜时避免更大创伤（不要撕扯骨膜） – 充分但不必过度暴露 • 翻瓣 – 全层粘骨膜瓣翻开 – 翻瓣 – 去除骨面上的软组织 4. 种植窝制备 5. 缝合
Doctor 牙医 by Infodent•2/2016
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INDUSTRY NEWS Asa Dental
种植手术常规器械 - ASA Dental安萨 器械名称
安萨产品编号
备注
0480-3 0481-7 麻醉剂注射器
0481-8
麻醉
0483-3 牙探针 金属吸唾管 刀柄
0702L-15 0703L-1 0902-M 2904-6
吸唾
0350-7
刀柄
0350-5
角刀
0351-12
小圆刀
0351-15C
拉钩
牙周探诊
2602-1 2604
切开
口角牵开
2616-1 牙龈分离器 双面口镜头
MV1851-2 MV1850-9A
翻瓣
2230-5 2231-5CS
口镜柄
ML2101 LV1807-02 前牙 LV1807-04 前牙
格雷西刮治器 （准备几支即可）
LV1807-06 前牙 LV1807-08 后牙颊舌面
刮治
LV1807-10 后牙近中面 LV1807-12 后牙远中面 LV1807-14 0307-1 线剪，牙龈剪
0304-2TC 0309-2TC
缝合镊
0625-1
止血钳
0500-2
持针器
0415-15TC
骨刮匙
58
2000-1 2000-3
巾钳
0550-3
骨盛放碗
1030-4
骨锉
1812-04S
组织镊
0621-1
Doctor 牙医 by Infodent•2/2016
缝合
女士优雅系列
AsaLady
18 cm
♂ VS ♀ 15 cm
专注优雅女士的定制器械 。 这是一个事实：女人的手与男人的手不同。从事牙科专业的女士需要使用特定的器械。 截止目前，这些器械都以男人为出发点，他们的手掌较大，有着更长的手指和更强劲的握持力量。 Asa Dental 认为是时候改变这种情形了。 安萨公司要为牙科专业的女性员工提供更适于她们使用的手持器械。 所以本公司创造了Asa优雅女士系列。根据女性手部结构和尺寸， 量身设计了更适合女性使用的牙科器械。 它具有更舒适的手柄和更轻盈的重量。 出发点 从10 到12 % 更精巧的手。 从10 到12 % 更柔软的手指。 差异 适合的手柄。 根据女性手掌尺寸重新设计的握持点。 精巧以及更轻盈的把手。 结果 更简洁自然的操作性。 更准确更安全的工作方式。 肌腱和肌肉更舒适。
安萨单人股份有限公司. Asa Dental S.p.A. uninominale Via Valenzana di Sopra, 60 - Bozzano - 邮编 55054 Massarosa (Lu) - 意大利 Italy 电话 Tel +39 0584 938305 - 传真 Fax +39 0584 937167 - asadental@asadental.it www.asadental.it - www.asadental.com
SCIENTIFIC UPDATE B&B Dental
通过计算机导航骨浓缩后，聚合了 PEEK（聚醚醚酮）的临时义齿的即时 作者: Alfredo Natali学士（牙科医生，自由职业者） 在治疗过程中，我们总是试图找到最好的诊断概念；在这 个阶段，从制定治疗计划到实际治疗操作中，通过运用各 种学科的实际帮助，可以使用很多种不同的方法。
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每个手术都是为了解决一种实际的需求，需要仔细规划来 更好的达到手术目的。尽可能完整的康复、正常的口颌功 能、最小的创伤、最短的的时间、最少的成本和最小的困 扰，是牙科领域中一直以来在追求的理想目标。 在过去的十几年中，由于技术的进步和数字化工作流程的 演变，使从诊断到治疗康复的无缝工作流程的制定和执行 变成了可能，其适应症和可能性变得越来越大。 在牙种植中，我们看到了计算机导航种植的发展。由B&B DENTAL牙科新推出的计算机导航外科导板在数字光纤上 提供了更多的简化处理，这一步接一步地帮助了诊所在全 面学习过程中一些不可避免的弯路。 此过程可以整合里面的各个阶段，从概念上来讲是属于不 同场的，但是通过相关的顺序建立，在规划过程中，不同 区域之间的不断回归，使你能够正确地管理和规划接下来 的步骤。 一般来讲，规划过程可以分为三个宏观阶段： 1. 诊断阶段 2. 手术阶段 3. 修复阶段 接下来展示一个临床案例，里边介绍了主要的手术步骤：
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1.诊断阶段 我们可以看到第一个诊断区域，在这里我们收集了患者的 所有信息和客观数据，包括X射线和锥束CT（图片1）。 为了诊断预计种植区域骨的必要条件，和是否有足够宽度 和厚度的牙龈组织；以便于确认是否可以进行实施无翻瓣 手术。此外，患者还需要具备一个良好的开口状态，以便 于容易地放入专用的刀具和种植体。 在进行CT锥束扫描之前，应该进行初步的研究，从中得出 一个全景不透射性面膜(图片2)。 通过光学扫描或双放射性扫描获取面膜，可以获得经过数 字定位的解剖学参考（图片3）。 这些解剖学数据可以使牙医为患者做出一个预期的牙齿解 剖，并具有大量关于数量、位置、倾斜度、所有固定件和 有可能需要的基台的类型的信息（图片4）。 这些是规划过程中基本和必要的参数，但不止这些，事实 上还需要考虑手术因素和修复因素的相互影响。
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2 .手术阶段 即时负载要想获得一个好的康复，种植体需要具有一个 较好的初期稳定性（插入扭矩≥ 35 Ncm）；对于上颚来 说，即使进行了种植部位的准备并且种植体的形状也有助 于保证必要的初期稳定性，具有合适的骨可能会变得非 常困难，这是个此行业中的典型特征。为了克服这个难 题，B&B DENTAL牙科公司的Duravit 系统提供了手术导航 系统和传统的手术用具，有一系列的骨填充器。进行局部 扩大可以提高骨的局部密度并提高初期稳定性。 这种技术的优点也应用在了由B&B牙科公司所提供的3D指 导下的手术中(图片5). 把EV种植体的位置从理论转移到实 际操作中还需要一个面膜来指导（图片6）。比起手术导航 这个过程更为人所知，但我们必须考虑到影响手术计划的 具体措施要求。 比如，由B&B Dental牙科设计的特别型导筒具有特别的六 角形状，并具有高精确度，所以有一个给定的体积，在几 个种植体邻近的情况下可能会有干扰。此外，还需要考虑 到导航还有不可还原性的垂直影响，这有可能使种植体沉 入超过一定的限度。软件由3diemme创建，通过对干扰信号 的适当控制和套用来执行。
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3.修复阶段 多亏了第一个得到CE认证的3diemme的规划软件，可以在 手术前就得到临时伪影，因此不需要等待义齿的制造结 束，因为我们已经知道种植体的位置。 显然，由于可能存在于材料和黏膜中的弹性，在种植体定 位过程中会有一定的偏差。 这个方法的另一个优势表现在型导筒的六角形状，它突出 了连接种植体的位置(图片6)。如果把键盘的六角放置在导 航指示的位置中可以预见非旋转基态假牙的位置，例如多 用途六角形（MUA）骨填充器(图片7)。还可以进行规划减 少钛制零时插管的咬合面，并用一个专门制造的树脂来帮 助定位（图片7）。
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3diemme的规划软件和B&B牙科快速成型实验室的3D CAD/ CAM的结合给临时义齿的制造提供了无限的可能和选择。 有必要让计划符合于实际的生产可能性和每个临川情况下 可采用材料的特性。在制作了PEEK框架涂有丙烯酸类树脂 的临床试验中，这种规划可以认为是完整的并可以过度到 实际操作流程上。 图 10
手术操作阶段 通过血管收缩(阿提卡因 1:100.000)的局部麻醉后，在用倒置 的别针把面膜固定在前面板上之前，先进行黏膜切除，这 样更易于去除唇状纤维和黏膜厚度的评估（图片9）。 B&B DENTAL牙科提供一整套便于临床工作的特别手术套 装。B&B 3D试验室的面膜的固定，是个不容易的操作，需 要极为谨慎的进行（图片10）。然后，用钻枪在所需位置
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图 12 Doctor 牙医 by Infodent•2/2016
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INDUSTRY NEWS B&B Dental
创建第一截骨（图片11）。在这个阶段，最易于测试骨的 一致性，因此根据骨的一致性可以适当地调整外科手术方 案来增加获得初期稳定性的可能。
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为了增强面膜的稳定性，可以先植入两边最远端的种植 体。位置准备补充分并且骨头没有随着钻头被取出，而是 被压实，这多亏了骨填充器（图12）。在有更多的骨显露 不一致时，这个过程就显得更有必要，而上颌的远端部位 经常具有这些特点。 B&B DENTAL牙科生产的Duravit EV系列种植体，是固定 在种植体架上的，他有显著的提高整体稳定性的功能（图 13）。用间接视野来检查确定套筒的六边形与固定架的六 角是否完全对齐是很有用的（图14）。 骨填充和不充分准备的过程被运用于所有被计划种植的部 位，并取得了令人满意的稳定性。具体而言，在大部分的 操作中是用直键来代替装载架(图15)。在手术结束时去除了 面膜(图16)。
安装义齿阶段
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决定不给第13号牙的位置安装义齿，因为只具有刚好足够 的稳定性和小直径的夹具。在该种植体上放置了用PEEK做 的无菌黏膜愈合帽，它被包装在在B&B Dental牙科的所有 种植器械里边。在其他种植体上安装了MUA桩和Il MUA斜 桩，为了正确安装在种植体上，可能会使用到磨骨棒（图 17）。 结束安装MUA时，决定做了一个位置印记，以便于促进骨 梁的自行适应（图18）。 这个阶段在口内也很容易操作，但要给患者留下几个小时 来休息。
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经过休息后，先从近中的两根,直接把义齿下调到口腔内， 并固定位置（图19）。之后继续填满剩余的缝隙，拧紧义 齿固定位置注入丙烯酸类树脂并完成锁定。 义齿在实验室里完成加工并经过抛光（图21）。 最后到义齿的临床应用，调整咬合面并进行审美抛光（图 22）。 术后持续大约24小时中等程度的疼痛，出现了轻微的水 肿，无出血症状，患者对治疗有高满意度。 为了调整咬合，在7到14天的时候对临时义齿进行了检查， 在1到2个月和3个月时（图23）。没有出现任何并发症。对 临时义齿保持了长时间的维护，并等待换上最终的义齿。
alfredonatali@gmail.com For more information: commerciale@bebdental.it
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图 23
INDUSTRY NEWS Castellini
Touch the future with Castellini 与Castellini一起触摸未来 Eighty years of experience, innovation and clinical expertise concentrated into a high-class unit: Skema 6. Skema 6 by Castellini, with its high-tech instruments, touchscreen controls and integrated systems, offers dental professionals the ideal tool for high-performance treatment including conservative dentistry, endodontics and implantology. The advanced hygiene devices, fully certified by leading Italian universities, together with a design which ensures functionally ergonomic solutions, enables the dentist to work comfortably, enjoying total peace of mind. High-performance instruments Skema 6 is equipped with Implantor LED, an extremely lightweight induction micromotor with electronic torque control up to 5.3 Ncm and fully autoclavable. When equipped with a peristaltic pump integrated on the dentist’s module and a cutting-edge control panel, Skema 6 is ideal for surgical applications. Further handpieces can be fitted including Silent Power turbines, ultrasound handpieces (also for surgical applications) and an exclusive electronic apex locator offering maximum efficiency and clinical safety in endodontic treatments. The file position inside the root canal is shown on the touchscreen display fitted to the dentist’s module. When the apex distance threshold programmed by the operator is reached, the LAEC will emit a warning tone. Innovative touchscreen controls Equipped with one of two possible touchscreen control panels, Skema 6 provides dentists with the ultimate technologies to monitor and manage unit system parameters or instrument settings, allowing for multiple personalisation when more than one dental surgeon is able to work on the unit. Smart Touch, which combines a touch-sensitive screen with traditional keypad for control of patient chair movement, is provided as standard; Full Touch, available as an optional, features a tempered glass display and 5.7” touchscreen interface. Whatever the treatment being carried out, from conservative dentistry to oral surgery, both touchscreen control panels allow the working parameters of each individual instrument to be set and saved at the touch of a finger. Everything, from spray mode to turbine speed and micromotor torque, can be controlled via the touch-screen, as can the duration of disinfection cycles and selection of certified contra-angles, the parameters of which are immediately recognised by the dental unit. Dentists can also save the most frequently used settings. Full Touch also features a USB port, which can be used by dentists to load X-ray images and view them in full-screen mode. Another advantage of the USB port is that it lets dentists store their personalised settings on a memory stick. Certified hygiene systems for maximum protection Skema 6 can be completed with a selection of the most advanced devices on the market. In particular the fully automatic Autosteril system using Peroxy Ag+ or hydrogen peroxide, provides automatic high-le-
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vel disinfection of the spray water circuits, ensuring a mycobactericide, bactericide and anti-Legionella action, certified by the Sapienza University of Rome. Perfect for end-of-day hygienisation, dentists can also program the device for shorter cycles between patients ensuring excellent hygiene standards at all times. Other optional devices include the continuous disinfection system coupled to an air gap separation from mains water device (M.W.B.); independent water supply via a 1.8 litre tank (S.S.S.); an anti-retraction system as a standard feature preventing contaminant suction during the instrument stopping phase and minimising cross-contamination risks (A.C.A.); suction system hygienisation procedure using a special liquid from a dedicated tank (S.H.D.) and for surgical applications, as well as the peristaltic pump, a pneumatic supply protection device with an autoclavabile filter element (H.P.A.). Skema 6 brings dentistry a step closer to the future, with a host of innovative solutions enabling excellent hygiene, total control and enviable comfort, both for patients and medical staff. www.castellini.com
Skema 6是一款整合了八十年经验的新型临床专业高端设备。
Castellini的Skema 6是一款高科技工具，是牙科专业人员在 保守牙科、根管治疗和种植牙领域内进行高效能治疗的理 想工具。此先进设备得到了意大利领先大学的高度认可， 其设计在功能上符合人体工程学方案，这使得牙医能够舒 适愉快的工作。
高性能仪器 Skema 6配置有离子注入机LED屏幕，和极轻量级感应微电 机，电子扭矩控制可以高达5.3 Ncm，且可高温高压消毒。 配备有按牙医模块设计的蠕动泵和先进的控制面板，适合 在外科手术中应用。 可以外接静音动力涡轮机，手持式超声波（同样适合手术 应用)，和一个独立的根尖电子定位仪，在牙髓手术操作中 保证最大效率和手术安全。触控屏会会按牙科模块显示根 管位置，当达到由手术者设定的根尖距离临界值时，LAEC 会发出警告音。 创新型触摸屏控制器 由于配备了两个可用触屏控制面板之一，Skema 6给牙医提 供了无限的技术来监视和管理设备中的系统参数，或当有 多个牙医可以在本机上工作时允许对仪器进行多个个性化 的设置。 智能触控通过把一个触摸敏感屏幕结合在传统面板上，来 监控病人座椅的动向，本功能作为标准配置提供;全触控， 可作为可选，配有钢化玻璃显示屏和5.7“触摸屏界面。 从传统牙科到口腔外科，无论实施了何种治疗，两个屏幕
触摸控制面板都可以通过一根手指的触摸来进行设置和保 存。 从喷雾模式到涡轮机速度和微电机扭矩，一切都可以通过 触摸屏来控制，也可以制定消毒周期的持续时间和认证反 角的选择，这些参数会立即被该牙科仪器识别出来。牙医 也可以进行保存最常使用的设置。 全触摸还设有一个USB端口，可以让牙医加载X射线图像并 在全屏模式下观看。 USB端口的另一个优点是，它可以让 牙医把自己的个性化设置存储在一根存储棒上。
已通过认证的提供最大保护限度的卫生体系 可以通过选择市场上最先进的设备来完善SKEMA6。尤其 是全自动Autosteril系统，它通过使用过氧银离子或过氧化 氢来提供一个自动高水平消毒的喷水回路，来起到杀细菌 剂，杀菌剂和抗军团菌的作用，此系统由罗马Sapienza大学 认证。这对一天结束时的卫生工作是个完美的选择，牙医
也可以在不同的患者之间给设备设定更短的周期，以此来 确保在任何时候都有出色的卫生标准 。 其他可选设备包括可持续消毒的连接了一个空气间隙来分 离自来水的设备 (M.W.B.), 该设备用一个1.8升的罐体来实现 独立供水 (S.S.S.); 反收放系统作为标准配置，在仪器停用期 间防止污染物抽吸，并尽量减少交叉污染的风险 (A.C.A.); 抽吸系统的消毒程序运用一种来自一个专用罐体的特殊 液体 (S.H.D.), 这种液体还用于外科手术，以及蠕动泵，具 有一个可高温高压消毒的过滤元件的充气供给保护装置 (H.P.A.)。 SKEMA6使牙科离未来更近了一步，它用新颖的解决方 案，给病人和医务人员都提供了优秀的卫生质量和可以完 全被控制和令人羡慕的舒适性。 我们的网址：www.castellini.com
Doctor 牙医 by Infodent•2/2016
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INDUSTRY NEWS Silfradent
CGF Concentrated Growth Factors: Protocol and characterization The CGF is an autologous platelet concentrate, developed by Sacco, in 2006 and obtained from blood samples through a simple and standardized separation protocol, by means of a specific centrifuge (MEDIFUGE 200, Silfradent srl, Forli, Italy), without the addition of exogenous substances. The main feature of the CGF resides in its consistency: it is an organic matrix rich in fibrin, able to “trap” platelets, leukocytes and growth factors; elements that play an important role in the regenerative processes. CGF-(Concentrated Growth Factors) Salient features of the CGF: • Simple, safe and economic • Natural - 100% autologous • Thick Fibrin Matrix • Leukocytes, Platelets and Growth factors • Variable kinetics release • Matrix for Bone Graft Material The CGF may be a valuable aid in the field of regenerative medicine, to speed up the process of regeneration. In fact this growth factor concentrate, showed great regenerative properties and versatility (Sohn et al. 2009). Its use has been proposed in various situations ranging from filling of extraction sockets (Tadić et al., 2014) to the filling of the cavity after cystectomy (Mirković et al., 2015), or in the sinus lift procedure (Kim et al., 2014; Del Fabbro et al., 2013; Sohn et al., 2011). Moreover, it can be used alone or with autologous bone particles or biomaterials (Gheno et al., 2014). Some authors suggest wet the surface of the implants with CGF in order to accelerate the bone-integration (Siebrecht et al., 2002). • Scanning Electron Microscopy (SEM) studies, have shown that the CGF presents a fibrin network formed by thin and thick fibrillar elements (Rodella et al., 2014). • Histo-morphological studies (Borsani, Bonazza et al., 2015 submitted) have allowed to see the fibrin network structure and the distribution of blood cells (leukocytes, erythrocytes and platelets) in the CGF. • Finally, in vitro studies using different human cell lines (Borsani, Bonazza et al., 2015 submitted), have shown that the addition of the CGF to the culture medium, stimulated cell proliferation (Borsani, Bonazza et al., 2015, submitted).
CGF - MATERIALS BLOOD COLLECTION 1. Antiseptic swab 2. Complete butterfly 3. Tourniquet 4. Gauzes 5. Patches 6. Vacuette Test Tubes (Greiner Bio-One GmbH, Kremsmunster, Austria) 7. Tube rack
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CGF is obtained using polyethylene tubes (Vacuette Test Tubes), coated with silica micro particles and without the addition of exogenous substances. After collection, the blood samples are immediately centrifuged using a special centrifuge device (Medifuge, Silfradent, Italy).
CGF MEDIFUGE (Silfradent) Characteristics • Benchtop centrifuge dedicated to the CGF production, equipped with an appropriate rotor with alternate and controlled speed and with an acceleration always below 300 RCF. • The medical device MEDIFUGE allows for the use of up to 8 test tubes for the creation of CGF (fibrin); • A microprocessor control system allows for the maintaining of a constant speed; • The exception rotor system with self-ventilation protects the blood sample from heat exposure; •The rotor-holding compartment, the closing door and the test tube-holding jackets guarantee biological safety in terms of bio-containment, in the event of test tube breakage; •The test tube-holding jackets and rotor are built from thermal, antistatic material that is easy to clean, extract and sterilize in an autoclave at 135°; •MEDIFUGE is equipped with a decontamination cycle with UVC reflected light; •Cycle duration 5 minutes at 1,000 revs; •The electronic control engine and its internal parts require no maintenance; •Noise levels fall below the standards required and do not exceed 57 dBa. CGF centrifugation protocol (One step protocol) 30’’ acceleration 2’ 2,700 rpm/ 735 g 4’ 2,400 rpm/ 580 g 4’ 2,700 rpm/ 735 g 3’ 3,000 rpm/ 905 g 33’’ deceleration and stop At the end of the process, three blood fractions were identified: (1) the upper layer, representing the liquid phase of plasma named platelet poor plasma (PPP); (2) the lower layer, representing red blood cells (RBC) because of mainly contains erythrocytes; (3) the middle layer, representing the solid CGF consisting in three parts: the upper white part, the downer red part (about 0,5 cm from RBC) and the middle “buffy coat*” part (interface between white and red part) (Figure 1 A,B,C).
CGF- Morphological characterization FIBRIN NETWORK The use of electron microscopy (SEM), allowed to observe that the CGF fibrin network of the is constituted by thin and thick fibrillar elements (Figure 2A).
Fig.2A: SEM analysis of CGF, fibrin network Hematoxylin-eosin staining, allowed to observe the architecture of the CGF fibrin network (Figure 3). The images showed that the fibrin network and architecture changed moving from the buffy coat* to the white part. In particular, near the buffy coat* the fibrin network was strictly compact (Figure 3A) while far from the buffy coat* became with a larger mesh (Figure 3B).
Fig.3: Architecture of the fibrin network: A) near the buffy coat; B) far from the buffy coat; BLOOD CELLS The May Grunwald Giemsa histological staining (Figure 4A) and Hematoxylin-eosin (Figure 4B), allowed to localize blood cells present in the CGF. White blood cells are mainly located in the buffy coat* and dispersed in it, especially in the red part of the CGF; the red blood cells are present only in the red part of the CGF.
Figure 4: A) May Grunwald Giemsa; B) Hematoxylin-Eosin Fig.1A,B,C: phases of CGF
Doctor 牙医 by Infodent•2/2016
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INDUSTRY NEWS Silfradent
CGF浓缩生长因子：学术方案和性质特征 CGF是自体血小板浓缩液，由Sacco在2006年研发, 他借助一个离心机装置（该装置是由意大利 Forli的Silfradent 有限公司生产的MEDIFUGE200离心机）用一个标准化的简易分离法，在没有任何 外源附加物质的情况下, 将它从血液样本中分离出来。该CGF的主要特点在于它的一致性: 是 一个富含纤维蛋白的有机基体, 它可以“捕捉” 血小板、白血球和生长因子, 在再生过程中, 这些 元素都起着很重要的作用。 CGF-（浓缩生长因子） CGF的突出特点： •操作简单, 安全, 经济 •天然- 100％的自体 •粗纤维蛋白基质 •白细胞、血小板和生长因子 •可变的释放动能 •用于骨移植材料矩阵结构中 CGF可以给再生医学领域的操作提供有价值的帮助, 以 加快再生的过程。其实这种生长因子浓缩显示出极大的 可再生性和通用性（Sohn等人, 于2009年）。它的用途 已经被使用于各种不同的情况下和范围内, 从填充拔牙窝 （Tadić等人, 于2014年）, 到填充膀胱切除后的空腔（Mirković等人, 于2015年）, 或用于上颌窦的抬高手术中（Kim 等人 , 于2014年, Del Fabbro等人, 于2013; Sohn等人, 于2011年）。此外, 它还可以单独使用, 或与自体骨粒子或生物材料一起使用（Gheno等人, 于2014 年）。一些学者建议与CGF一起弄湿植入物的表面, 来加速 骨整合（Siebrecht等人，于2002年）。 •用扫描电子显微镜（SEM）研究表明, CGF是一个由薄纤 维状元素和厚纤维状元素够成的纤维蛋白网（Rodella等人, 在2014年提出）。 •组织形态学的研究（由BORSANI, Bonazza等人在 2015年提出）已经使人们能够看到CGF网状纤维蛋白的结 构和CGF中血细胞（白细胞、红细胞和血小板）的分布。 •最后, 对不同的人类细胞系进行体外实验（由 BORSANI, Bonazza等人在2015年提出）的结果证明, 在培养基中加入CGF, 可以起到刺激细胞增殖的作用 （由BORSANI, Bonazza等人, 在2015年提出）。
CGF- 材料 血样采集
1.防腐拭子 2.全套蝴蝶针 3.止血带 4.纱布 5.补丁 6.Vacuette血液收集管（由奥地利克雷姆斯明斯特的Greiner Bio-One国际有限公司生产） 7.试管架
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CGF是在不添加任何外源性物质的情况下, 在涂有二氧化 硅微粒的聚乙烯试管中（Vacuette试管）制造出来的。采 血后, 立即使用一种特殊的离心机（MEDIFUGE200离心机, 由意大利Forli的Silfradent 有限公司生产）将血液样品进行 离心而得。
CGF MEDIFUGE离心机（Silfradent有限公司生产） 特点 •台式离心机为了专门用于CGF的制备, 该机配备了一个可 以替换可稳速的转子, 并且在加速时始终低于300 RCF。 •MEDIFUGE离心机可以一次放置多达8个用于制造 CGF（纤维蛋白）的试管; •由一个微处理器控制系统来维持恒定的速度; •外加一个具有自通风功能的转子系统, 该系统避免了血液 样品暴露在热源之中; •在试管破裂的情况下, 转子仓、关闭的门和试管夹套子, 都 可以在生物防护方面提供可靠的生物安全性; •试管夹套子和转子都是由易散热、抗静电的材料制成, 因 此, 易于清洗和提取, 置于135℃高压灭菌器内消毒即可; •MEDIFUGE离心机还配备了一个利用UVC反射光的净化 循环系统; •净化时间为在转速1000下持续5分钟; •电子控制发动机及其内部部件无需维护; •噪音水平低于所要求的标准, 不超过57分贝。 CGF离心方法（一次离心法） 30’’加速 2’2700转/735克 4’2400转/580克 4’2700转/735克 3’3000转/905克 33’减速和停车 离心过程结束时, 血液被分成了三个层次:（1）上层, 有被叫做贫血小板血浆的液态血浆（PPP）; （2）红色的下 层, 是由于包含了大部分的红细胞所至（RBC）; （3）中间层, 由三个部分组成的固体CGF: 上部白色, 下边红色部分（至红细胞的距离约0.5厘米）和中间的 “血沉棕黄层*”部分（就是连接白色部分和红色部分的那一 段）（图1 A，B，C）。
CGF-形态特征
网状纤维蛋白 利用电子显微镜（SEM）, 可以观察到网状的纤维蛋白CGF 由薄纤维状元素和厚纤维状元素（图2A）构成。 图2A: 电子显微镜下看到的CGF网状纤维蛋白
苏木精 - 伊红染色体, 使我们能够观察到CGF网状纤维蛋白 的结构（图3）。图像显示, 网状纤维蛋白的结构在血沉棕 黄层和白色层中是不一样的。邻近血沉棕黄层的网状纤维 蛋白的网格显得特别严密紧凑（图3A）, 而远离棕黄层的网 状纤维蛋白的网格则比较粗大（图3B）。
网状纤维蛋白的结构 A）邻近血沉棕黄层；B) 远离棕黄层
血细胞 用迈格林华染色液（图4A）和苏木精 - 伊红（图4B）, 可以 定位到CGF中存在的血细胞。白细胞主要分部在血沉棕黄 层中, 并零散分散在CGF中的其它部分; 尤其是 在CGF的红色部分中; 而红细胞则只存在于CGF的红色部分 内。
图1ＡＢＣ：CGF的分层示意图
图4：A）迈格林华染色液 B）苏木精-曙红
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INFODENT INTERNATIONAL
Infodent.com: since 1994 the fastest way to experience the dental industry. Infodent.com: 体验牙科行业的最快方法自 1994年以来。 Visit now Infodent.com and subscribe for free to a world of services designed for dental distributors and dentists: 现在访问Infodent.com网页, 立刻免费订阅为了得到: • The worldwide trade-show calendar 全球贸易展览的日历 • Company highlights, discover the latest products 公司介绍, 为了发现最新产品 • Infodent international magazines free archive Infodent International杂志的免费存档 • Doctor by Infodent magazines free archive “牙医byInfodent” 杂志的免费存档 • iNews magazines free archive iNews杂志的免费存档 • Hundreds of scientific articles about dentistry 关于牙科的亿万文章
Questions are welcome: prc@infodent.com Infodent.com 请随时与我们联系吧: prc@infodent.com Infodent.com
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How to find distributors worldwide: 怎么找到全球的代理商:
ME 1 – Cut on dotted line. 削减虚线。 2 – Rotate 180 degrees. 旋转180度。 3 – Let’s write together the story of your success. 让我们一起写您的成功的故事吧。 Everytime you are looking for distributors. 每当您寻找代理商。
For your advertising in international newspapers, special FDI and IDS issue, co-exhibitions, web and digital services write to infodent@infodent.com 以在国际报纸做广告, FDI及IDS特刊, 联合展览, 数字化服务都请跟 infodent@infodent.com联系吧。
www.infodent.com Connecting distributors with manufacturers worldwide since 1994. 自1994年以来我们连接全球的代理商与制造商。
DENTECH CHINA EXHIBITION
Shanghai, 26 – 29 October 2016 上海, 2016.10.26-29 Infodent International for DenTech China: the living magazine project Infodent International 为DenTech China开展互动杂志项目 During DenTech China 2016, Infodent International is proud to introduce a great experience for all visitors: the living magazine. Every year thousands of manufacturers and dealers are used to read Infodent International looking for connections and contents to improve their business. Next October, for the first time, they can “live the pages”. 在“第二十届中国国际口腔器材展览会暨学术研讨会”(DenTech China 2016)召开期间， Infodent International将向所有观众推出一份互动杂志，将绝佳的体验带给大家。 每年有成千上万的生产商和经销商都习惯通过阅读Infodent International杂志， 寻找有助于拓展其业务的内容和商机。 今年10月，他们将在展会现场体验杂志互动项目。
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Doctor 牙医 by Infodent•2/2016
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DENTECH CHINA EXHIBITION
Contents:
How many times, after reading an article, you would like to ask something to its author? In DenTech China, finally, you can. Three conferences will entertain the audience about the two main Infodent International topics: developing business and scientific subjects.
您有多少次在阅读完一篇文章后，希望作者能解答您的一些疑问？ 在DenTech China 展会上，你就能实现这个愿望。 我们将召开三场研讨会，会议围绕Infodent International的两个主要议题：业务拓展及新技术推介。
Distributors wall:
The distributors wall is a must-read for all companies worldwide, a paper meeting point where to find dealers and new job opportunities. In DenTech China this wall will be real: a space continuously updated at the Infodent International booth to connect business and give our customers what they expect from their favourite magazine since 1994: the chance to improve. Distributors Wall 是全球所有业内企业必读的一份刊物，该刊物告诉大家到哪里寻找经销商,并提供新的工作机会。 在DenTech China展会上，我们将设立一面墙：在Infodent International主办方展台的空间里展示最新信息，帮助大家建立业 务联系，并让我们的客户从这份于1994年创办的读者喜闻乐见的杂志中得到想要的：改进的机会。
Company highlights: Infodent International提供信息
Infodent International booth will offer to all distributors visiting DenTech China the best selection of opportunities they are used to find in highlights pages. Why do distributors visit a trade-show? For the same reason they read Infodent International: to discover the right companies in order to expand their business. The selection of companies considered eligible involved in this project will contribute to the satisfaction both of our readers and of all DenTech China visitors. Infodent International展台将向到访DenTech China展会的所有分销商提供一份最佳商机信息汇编；以往，我们在展会杂志的 重点页面提供这些信息。为什么分销商会参加展会？是为了拓展自己的业务。他们阅读Infodent International杂志, 也是出于
同样的原因。
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DENTECH CHINA EXHIBITION The Conferences Program
The conferences program: 会议的内容:
MyRay is a worldwide name in image-assisted diagnostics, a brand that has earned the trust of dental professionals and radiologists all over the world, offering a complete range of imaging products dedicated to digital dentistry. Innovative solutions designed to improve the surgery work flow by providing quality, reliability and user-friendliness.
MyRay - 会议的官方合作伙伴 MyRay是图像辅助诊断的全球名称, 已经赢得了全球的牙科
专家及放射科医生的信任, 提供影像产品门类齐全的专用于 数字牙科。创新的解决方案，以提高通过提供高质量，高 可靠性和易用性手术的工作流程。
Scientific topic 新技术推介主题演讲
Speaker: Bingzhen Huang M.D.& Ph.D 演讲人： Bingzhen Huang 医生/博士 Title: CGF&AFG: Basic principle and clinical application 题目：CGF与AFG：基础原理及临床应用 Abstract: CGF (Concentrated Growth Factors) 、AFG（Autologous Fibrinogen Glue）are autologous fibrin and fibrinogen without any additive (anticoagulant and activator). In this presentation, I will show you how to make autologous fibrin, fibrinogen, thrombin easily and discuss with you the basic difference of autologous blood production (PRP, PRGF, PRF, CGF, AFG) and how and why these productions work. 内容提要： CGF (Concentrated Growth Factors) 和 AFG（Autologous Fibrinogen Glue）是不加入任何其他成分（抗凝剂或促凝剂）情况
wide range of information and procedures of reconstructive surgery. Limits, errors and possible complications will be analyzed supported by extensive clinical cases. 内容提要：
本课程的目的，是依据科学证据和临床经验，从美观和结 构的角度对牙龈重建和种植体进行一个简要分析。本课程 的将广泛介绍重建手术领域的各种信息和程序。我们将通 过丰富的临床案例，对相关的局限、失误和可能的并发症 进行分析。
Business topic 业务拓展主题演讲 Speaker: Emanuele Elo Usai 演讲人： Emanuele Elo Usai Title: 32 Dental marketing ideas for successful dentists 题目： 32个牙科营销思路，让您的牙科
职业生涯更成功 Abstract: Is being a good dentist enough to attract patients into your practice? The answer is no.This course aims to provide dentists some starting points needed to prepare and develop a marketing and communication strategy to improve their dental practice. A journey in 32 points across case histories and creative ideas, starting with the importance of identifying the business goals and continuing with traditional, non-conventional and digital ideas to increase the revenue. 内容提要：
牙医拥有精良的技术，就足以吸引患者前来自己诊所吗？ 答案是，这还不够。本课程旨在向牙医提供一些制定营销 和沟通策略所需的基本知识，以帮助他们发展自己的诊 所。我们将通过案例介绍32个创意思路。首先我们将从最 重要的一点入手：找出自己的业务目标；持续地通过常规 的、非常规思路，并使用数字化手段来增加收入。
下的自体纤维蛋白和纤维蛋白原。在这个演讲中，我将向 大家展示如何轻松制作自体纤维蛋白、纤维蛋白原、凝血 酶，并介绍各种自体血液制剂 (PRP, PRGF, PRF, CGF, AFG)基本 区别，以及这些制剂的作用机制。 Speaker: Dr. Liu Shuangbin 演讲人： Dr. Liu Shuangbin医生 Title: Treatment of aesthetic and structural alterations of the Mucogingival Junction (MGJ) 题目：牙龈黏膜交界( MGJ)的美观性和结
构性改变治疗 Abstract: The purpose of this course is to provide a brief analysis of the gingival reconstruction of teeth and implant from an aesthetic and a structural point of view, according to scientific evidence and through the clinical experience of the operator. The course will provide a
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Date and time: 27th of October, 2016 13.00 - 17.00 时间: 2016 年 10月 27日, 13.00 - 17.00 Free entry, write to prc@infodent.com to book your seat and your coffee break pass. 免费入场, 免费 coffee break。 联系邮箱prc@infodent.com For more, please visit www.infodent.com 如需了解更多信息，请访问 www.infodent.com
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â&#x20AC;˘ Inews The Infodent international special edition for the main dental trade-shows, distributed for free to all the exhibitors and visitors to reach the best audience ever and a lot of dentists. The next issues are for FDI Poznan and IDS 2017. Infodent Internationalç&#x2030;šĺ&#x2C6;&#x160;为ć&#x153;&#x20AC;é&#x2021;?čŚ ç&#x161;&#x201E;ç&#x2030;&#x2122;ç§&#x2018;č´¸ć&#x2DC;&#x201C;ĺą&#x2022;, ĺ&#x153;¨ĺą&#x2022;äź&#x161;ä¸ĺ&#x2026;?č´šĺ?&#x2018;ć&#x201D;žă&#x20AC;&#x201A; ä¸&#x2039;ä¸&#x20AC;个ĺ?&#x2018;襨: FDI Poznan ĺ?&#x160; IDS 2017ă&#x20AC;&#x201A; â&#x20AC;˘ Doctor by Infodent China is finally closer with this new B2C scientific magazine - in English and Chinese, of course - aimed to the most influential Chinese decision makers (hospitals directors, buyers, opinion leaders, trade and dentists) to connect the West with the East. čż&#x2122;ć&#x153;Źç§&#x2018;ĺŚçąťĺŁĺ&#x2C6;&#x160;ć?&#x201A;ĺż&#x2014;ďź&#x2C6;ĺ&#x2022;&#x2020;厜寚厢ć&#x2C6;ˇďź&#x2030;ç&#x161;&#x201E;ĺ&#x2021;şç&#x17D;°äź&#x161;寚ä¸ĺ&#x203A;˝ç&#x2030;&#x2122;ĺ&#x152;ťčĄ&#x152;ä¸&#x161;产ç&#x201D;&#x;é&#x2021;?čŚ ĺ˝ąĺ&#x201C;?ďź&#x152;ć&#x2014;¨ ĺ&#x153;¨ä¸şä¸ĺ&#x203A;˝ć&#x153;&#x20AC;ĺ&#x2026;ˇĺ˝ąĺ&#x201C;?ĺ&#x160;&#x203A;ç&#x161;&#x201E;éž&#x2122;ĺ¤´äź ä¸&#x161;ć&#x153;?ĺ&#x160;Ą ă&#x20AC;&#x201A;ć&#x2030;&#x20AC;ć&#x153;&#x2030;ć&#x2013;&#x2021;çŤ é&#x192;˝ć&#x2DC;Żä¸č&#x2039;ąĺ?&#x152;čŻă&#x20AC;&#x201A;ç&#x203A;Žć &#x2021;ć&#x2DC;Żä¸ĺ&#x203A;˝ç&#x2030;&#x2122;ĺ&#x152;ť čĄ&#x152;ä¸&#x161;ďź&#x152;ĺ&#x152;ťé&#x2122;˘é&#x2122;˘é&#x2022;żďź&#x152;䚰厜ďź&#x152;ć&#x201E;?č§ é˘&#x2020;č˘&#x2013;ďź&#x152;äź ä¸&#x161;éŤ&#x2DC;ĺą&#x201A;ĺ?&#x160;ç&#x2030;&#x2122;ĺ&#x152;ťä¸şäş&#x2020;ä¸&#x153;čż&#x17E;輿čż&#x203A;ă&#x20AC;&#x201A; â&#x20AC;˘ ImplantBook The first and only complete global guide about the implantology industry addressed to dentists and dealers, collecting in a single volume the widest offer never seen before.Book your free copy and get more info on implant-book.com 珏ä¸&#x20AC;ĺĽ&#x2014;ĺ&#x2026;łäş&#x17D;ç§?ć¤?ä¸&#x161;ç&#x161;&#x201E;ĺ&#x2026;¨é?˘ä¸&#x203A;䚌ďź&#x152; 为ç&#x2030;&#x2122;ĺ&#x152;ťĺ?&#x160;䝣ç?&#x2020;ĺ&#x2022;&#x2020;é&#x192;˝ă&#x20AC;&#x201A; çŤ&#x2039;ĺ&#x2C6;ťĺ&#x2026;?č´šé˘&#x201E;莢ć&#x201A;¨ç&#x161;&#x201E;ć?&#x201A;ĺż&#x2014;! ĺŚ&#x201A;é&#x153;&#x20AC;äş&#x2020;解ć&#x203A;´ĺ¤&#x161;äżĄć Żďź&#x152;诡é&#x2014;Žwww.implant-book.com â&#x20AC;˘ Infomedix International Since 2002 the B2B magazine targeting distributors worldwide: a landmark for the medical industry, generating every year thousands of connections. Each issue reaches more than 36.000 dealers, manufacturers, importers, exporters, wholesalers, agents and trade associations, circulating in the main exhibitions in 5 continents. Free on infomedixinternational.com. č&#x2021;Ş2002嚴䝼ć?Ľčż&#x2122;ć&#x153;Źç§&#x2018;ĺŚçąťć?&#x201A;ĺż&#x2014;ďź&#x2C6;ĺ&#x2026;ŹĺŻšĺ&#x2026;Źďź&#x2030;为ĺ&#x2026;¨ç?&#x192;ç&#x161;&#x201E;䝣ç?&#x2020;ĺ&#x2022;&#x2020;ă&#x20AC;&#x201A; ćŻ?ä¸&#x20AC;个ĺ?&#x2018;襨é&#x20AC; ĺ&#x2C6;°36.000ĺ¤&#x161;䝣ç?&#x2020;ĺ&#x2022;&#x2020;, ĺ&#x2C6;śé&#x20AC; ĺ&#x2022;&#x2020;, äš°ĺ?&#x2013;, ć&#x2030;šĺ?&#x2018;ĺ&#x2022;&#x2020;, 䝣ç?&#x2020;äşş, ĺą&#x2022;č§&#x2C6;äź&#x161;é&#x192;˝, ĺ&#x153;¨äş&#x201D;大洲 ç&#x161;&#x201E;ć&#x153;&#x20AC;é&#x2021;?čŚ ĺą&#x2022;äź&#x161;ĺ?&#x2018;ć&#x201D;žă&#x20AC;&#x201A;ĺ&#x2026;?č´šĺ&#x153;¨infomedixinternational.com Ask our staff for more info. We are happy to support you! 诡čˇ&#x;ć&#x2C6;&#x2018;䝏ç&#x161;&#x201E;äşşĺ&#x2018;&#x2DC;č &#x201D;çłťĺ?§, ć&#x2C6;&#x2018;䝏é&#x192;˝ĺž&#x2C6;éŤ&#x2DC;ĺ&#x2026;´ĺ¸Žĺ&#x160;Šć&#x201A;¨!
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2-2016
www.my-ray.com DenTech China ¡ 2016, 26-29 Octobrer ¡ Booth B05-06, B31-32 , Hall 1
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Retrospective radiographic study of marginal bone changes of 88 implants placed with split crest technique in the maxillary latero-posterior area
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27/09/16 12:30
Immediate implants in extraction sockets with periapical lesions: an illustrated review
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Marginal bone level around conical connection tapered implants with platform switching: A multicenter retrospective study at 14 months follow-up
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Doctor ç&#x2030;&#x2122;ĺ&#x152;ť by Infodentâ&#x20AC;˘2/2016
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The Chapters: Dental implants, Osteointegration & biomaterials, 3D printers, Rotary instruments, Equipment & supplies for implants, Radiology, Piezosurgery, Software, Micromotors.
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