【作者】 张玲；

【导师】 邓丽；

【作者基本信息】 南昌大学 ， 口腔医学（专业学位）， 2021， 硕士

【摘要】 研究背景:随着口腔种植技术的普及,学者们在关注骨结合的同时,对种植体周围软组织不足的处理也成为种植治疗的研究热点^[1]。种植位点足够宽度的附着龈对植体的健康和稳定有着非常重要的作用^[2]。当植体周围角化龈不足2mm时,黏膜到嵴顶形成三角形系带,种植位点易出现菌斑积聚及局部食物嵌塞,增加了骨丧失的风险^[3]。如何保证足够的附着龈宽度成为当下种植的研究热点。目前,国内外对于附着龈宽度不足的增宽方法主要有:游离龈移植术、根向复位瓣术、带蒂瓣术（全厚瓣或部分厚瓣）等^[4]。这些方法能够在一定程度上增宽附着龈,解决附着龈宽度不足带来的问题,但手术难度较高,创伤较大,并不能够为绝大多数患者所接受。本研究旨在探索一种简单有效的手术方法,有效增宽附着龈,缩短种植修复疗程。目的:探讨一种改良的根向复位瓣术增宽附着龈的临床效果。对临床牙列缺损已行种植一期手术,二期手术前种植位点颊侧附着龈宽度不足2mm的患者,进行局部改良的附着龈增宽术,短期随访观察治疗效果,以寻求一种简单有效且更能被大众接受的附着龈增宽方式,为临床种植体周围附着龈宽度不足患者的治疗提供新的思路。方法:病例资料来自南昌大学第三附属医院2018年9月至2020年1月就诊,且已行种植一期手术植入Superline植体,二期术前测量种植位点附着龈宽度不足2mm的患者10例（10颗种植体）,为研究组;2018年9月前满足相同标准的患者10例（10颗种植体）,为对照组。所有种植位点均在上颌后牙区,一期手术均为潜入式愈合方式,且已达到二期手术标准。20例患者二期术前检查种植位点颊侧的牙龈附着情况,使用电子游标卡尺分三次测量并记录附着龈宽度,取平均值。对口内外进行消毒,注射利多卡因局部麻醉,实验组在种植位点设计偏腭侧水平切口,颊侧做近远中向的垂直切口,形成梯形切口,沿设计切口切开,注意不涉及龈乳头,不切透骨膜。锐性分离半厚瓣,保留骨面上的骨膜及部分结缔组织,剥离部分肌纤维组织,将半厚瓣推向颊侧根方,根向缝合至膜龈联合以下的移行沟处,使颊侧软组织瓣带一宽度≥2mm的角化牙龈。此处注意根向复位需要超过5mm,因软组织在愈合后会出现30%-50%的收缩。暴露封闭螺钉,置换旋入愈合基台。对照组常规进行二期手术上愈合基台。术后24小时内冰敷,生理盐水含漱,口服抗生素3-5天预防感染,术后2周拆线,一个月后进行取模冠修复。结果:1、术后1个月实验组附着龈宽度（5.72±0.86）mm高于对照组（1.23±0.55）mm,差异有统计学意义（P<0.05）,实验组较术前平均增宽4.81 mm。2、术后6个月实验组附着龈宽度（5.65±0.85）mm高于对照组（1.16±0.53）mm,组间对比差异有统计学意义（P<0.05）。3、2周拆线时,研究组1个种植位点因缝线脱落造成黏膜愈合不佳,依然存在炎症反应,其余位点黏膜均愈合较好,2组比较差异有统计学意义（P<0.05）。4、2组术后6个月改良菌斑指数比较差异有统计学意义（P<0.05）。结论:1、本研究设计偏腭侧的切口,将腭侧附着龈向颊侧根方复位缝合固定,研究数据显示术后1个月实验组附着龈宽度（5.72±0.86）mm高于对照组（1.23±0.55）mm,术后6个月实验组附着龈宽度（5.65±0.85）mm高于对照组（1.16±0.53）mm,组间对比差异有统计学意义（P<0.05）,说明改良根向复位瓣术增宽附着龈效果较理想。尽管实验组附着龈在6个月时较1个月时有少量收缩,但差异无统计学意义（P>0.05）,说明此种附着龈增宽术效果比较稳定,短期内不会发生明显的吸收。2、对2组患者术后2周创口的愈合情况进行比较发现,除研究组因1个位点缝线脱落造成愈合不良外,其余均愈合较好,研究组和对照组牙龈均能达到较理想的愈合。3、组术后6个月进行术区口腔健康状况的比较发现,实验组术区口腔卫生状况明显优于对照组,表现为菌斑积聚较少,P<0.05,差异具有统计学意义。4、此方法能有效增宽附着龈,在种植二期手术同时进行,缩短种植修复疗程;无需开辟第二术区,创伤较小;能够改善口腔卫生,为临床种植体周围附着龈宽度不足的治疗提供新的思路。更多还原

【Abstract】 Background:With the popularization of oral implant technology,while scholars are paying attention to osseointegration,the treatment of insufficient soft tissue around the implant has also become a research hotspot in implant treatment^[1].Adhesive gums with sufficient width at the implant site play a very important role in the health and stability of the implant^[2].When the keratinized gingival around the implant is less than 2mm,the mucosa to the crest forms a triangular frenulum,and the implant site is prone to plaque accumulation and local food impaction,which increases the risk of bone loss^[3].How to ensure sufficient attached gingival width has become a research hotspot in current planting.At present,the main methods for widening the insufficient width of attached gums at home and abroad are:free gingival transplantation,root reduction flap surgery,pedicled flap surgery（full or partial thick flap）,etc.^[4].These methods can widen the attached gingiva to a certain extent and solve the problems caused by insufficient attached gingival width.However,the operation is more difficult and traumatic,and it is not acceptable to most patients.This study aims to explore a simple and effective surgical method that effectively widens the attached gums and shortens the course of implant restoration.Objective:To explore the clinical effect of an improved appically repositioned flap surgery to widen the attached gingiva.For patients with clinical dentition defects who have undergone implantation surgery in the first stage,and the buccal attachment gingival width of the implant site before the second stage surgery is less than 2mm,the local modified attachment gingival widening surgery will be performed,and the short-term follow-up will observe the treatment effect to find a simple An effective and more acceptable way of widening attached gingiva provides new ideas for the treatment of patients with insufficient gingival width around clinical implants.Methods:The Department of Stomatology of the Third Affiliated Hospital of Nanchang University has performed the first-stage operation to implant Superline implants,and20 patients（20 implants）with the implant site attached to the gingival width less than 2mm were measured before the second-stage operation.All implant sites are in the posterior maxillary area.The first-stage operation adopts the submerged healing method,and it has reached the second-stage operation standard.Twenty patients were randomly divided into experimental group and control group with 10 cases each.Before the second stage of operation,20 patients were checked for gingival attachment on the buccal side of the implant site.The width of the attached gingiva was measured three times using an electronic vernier caliper and the average value was taken.Disinfect the inside and outside of the mouth,and inject lidocaine for local anesthesia.The experimental group designed a partial palatal horizontal incision at the implant site,and a mesiodistal vertical incision on the buccal side to form a trapezoidal incision.Make an incision along the designed incision.Note that the gums are not involved.The nipple does not cut through the periosteum.Separate the semi-thick flap sharply,preserving the periosteum and part of the connective tissue on the bone surface,peeling off part of the muscle fiber tissue,pushing the semi-thick flap toward the root of the buccal side,and suture the root to the transition groove below the membranous gingival joint to make the buccal soft tissue The flap is a keratinized gingival with a width≥2mm.Note that the root reduction needs to exceed 5mm,because the soft tissue will shrink by 30%-50%after healing.The sealing screw is exposed and the replacement screwed into the healing abutment.The control group routinely performed second-stage surgery on the healing abutment.Within 24 hours after operation,apply ice,gargle with normal saline,take antibiotics for 3-5 days to prevent infection,remove stitches 2 weeks after operation,and perform crown restoration one month later.Results:1.The width of attached gingiva（5.72±0.86）mm in the experimental group was higher than that in the control group（1.23±0.55）mm at 1 month after operation.The width of the experimental group was 4.81 mm wider than the preoperative average,P<0.05.2.The width of attached gingiva（5.65±0.85）mm in the experimental group was higher than that in the control group（1.16±0.53）mm at 6 months after surgery,and the difference between the groups was statistically significant（P<0.05）.3.When the sutures were removed at 2 weeks,the mucosa in the two groups healed well,and the comparison of the attachment point reconstruction was P<0.05,the difference was statistically significant.4.There was a statistically significant difference in the modified plaque index between the two groups at 6 months after the operation.Conclusion:1.In this study,a partial palatal incision was designed,and the palatal attached gingiva was restored and sutured to the buccal root.The research data showed that the width of the attached gingiva（5.72±0.86）mm in the experimental group was higher than that in the control group（1.23±0.55）mm,the width of attached gingiva（5.65±0.85）mm in the experimental group was higher than that in the control group（1.16±0.53）mm at 6 months after operation.The difference between the groups was statistically significant（P<0.05）,indicating the improved root reduction.The effect of flap surgery to widen the attached gingiva is ideal.Although the attached gingiva of the experimental group contracted slightly at 6 months compared with that at 1month,the difference was not statistically significant（P>0.05）,indicating that the effect of this type of attached gingival widening surgery is relatively stable,and there will be no obvious short-term absorb.2.Comparing the wound healing of the two groups of patients 2 weeks after operation,it is found that P>0.05,the difference is not statistically significant,indicating that the experimental group and the control group can achieve ideal healing of the gums.3.The oral health status of the operation area of the group was compared 6months after the operation.It was found that the oral health status of the experimental group was significantly better than that of the control group,which showed less plaque accumulation,P<0.05,the difference was statistically significant.4.This method can effectively widen the attached gingiva,which can be performed at the same time during the second stage of implantation surgery,shortening the course of implant restoration;there is no need to open a second operation area,and the trauma is small;it can improve oral hygiene,and is for the clinical implants with insufficient gingival width.Treatment provides new ideas.更多还原