后牙咬合對前牙修復(fù)的影響

1、The Influence of Posterior Occlusion When Restoring Anterior Teeth后牙咬合對前牙修復(fù)的影響abstract When any type of esthetic restorative procedure is being considered or performed, a comprehensive diagnosis and treatment plan is required. Attention to the diagnostic signs of the loss of posterior support (LPS)

2、and their influence on the anterior dentition will guarantee a more predictable outcome. Historical solutions and their inadequacies are addressed. Patient presentations are utilized to demonstrate contemporary treatment of patients requiring esthetic rehabilitations who are lacking posterior suppor

3、t.摘要：當(dāng)任何一種美容修復(fù)計(jì)劃被制訂或是執(zhí)行的時(shí)候，一個全面的診斷和治療計(jì)劃是必須的。 在修復(fù)過程中，對后牙支持喪失的體征和其對前牙牙列產(chǎn)生的影響加以考慮，將確保產(chǎn)生一個可 以預(yù)見的結(jié)果。從前治療方法及其不足在這里被提出。這里我們利用的病例耐心地向大家展示了 對后牙支持喪失但需要美觀重建的患者進(jìn)行治療的最新的治療方法。there is a general consensus that tooth retention amongst the aging population pays credence to preventive dentistry and patient education.

4、 Appearance is a common concern for this group of patients. A comprehensive examination allows the clinician to diagnose risk factors that are responsible for the deterioration of oral health and function. These patients often request restorative treatment with indirect restorations to enhance their

5、 appearance(figure 1). During the diagnostic phase,critical elements of posterior occlusion are overlooked at the expense of longevity of the proposed treatment (figures 2 and 3). Health, function, and esthetics should be the ultimate aim of any medical or dental comprehensive treatment plan.在關(guān)注預(yù)防口腔

6、醫(yī)學(xué)和老年教育的老年人中對保留牙齒的態(tài)度是一致的。這些患者中對美觀都很 重視。全面的檢查將使臨床醫(yī)生能夠?qū)鹂谇唤】岛凸δ茉斐蓳p害的原因作出診斷。這些患 者常會要求用間接修復(fù)體進(jìn)行修復(fù)以加強(qiáng)他們的美觀。在診斷階段，后牙咬合關(guān)系的因素常會被 忽略將導(dǎo)致修復(fù)體不能被長期使用。健康，功能和美觀都應(yīng)是牙科綜合治療計(jì)劃的最終目的。figure 1. Maxillary anterior teeth restored with porcelain laminate veneers for patient with adequate posterior support and occlusal stab

7、ility.圖1.后牙有良好的支撐和咬合穩(wěn)定的患者通過瓷貼面修復(fù)的上頜前牙.figure 2a. Maxillary anterior teeth previously restored but failed due to posterior bite collapse.圖2a,因?yàn)楹笱酪Ш媳罎⑺律锨把佬迯?fù)失敗figure 2b. Posterior support needs to be established before anterior teeth are restored. 圖2b,在前牙修復(fù)之前，后牙咬合支持需要被建立.figure 2c. Cardinal signs for

8、LPS are present clinically圖2C，后牙支持喪失的主要臨床癥狀figure 2d. Cardinal signs for LPS are present radiographically.在放射檢查中顯示的后牙支持喪失的主要癥狀figure 3a. Patient presented with LPS.后牙支撐喪失的患者figure 3b. Mucosal-supported RPD failed to provide posterior support.粘膜支持的可摘局部義齒 不能提供足夠的后牙支持figure 3c. Cardinal signs of LPS ar

9、e present.后牙支撐喪失的主要體征Diagnosis 診斷Diagnosis and treatment planning cannot be based on esthetic desires alone. A number of factors need to be evaluated prior to decision making:診斷和治療計(jì)劃不能僅以美觀為基礎(chǔ)。在 作結(jié)論之前，許多因素都應(yīng)該被考慮。1.Occlusal stability 咬合的穩(wěn)定性2.Status of periodontal and dental disease 牙周和牙齒疾病的情況Anatomica

10、l limitations 解剖的限制4.Space management 空間的管理。Posterior support is an important factor to consider in order to achieve occlusal stability. The loss of posterior support is defined as the loss of occluding vertical dimension as a result of the loss or drifting of posterior teeth. Secondary occlusal tra

11、uma has been defined as the effects induced by occlusal force (normal or abnormal) acting on teeth with decreased periodontal support. Hence, it is possible for a patient with an almost intact dentition, but with a reduced periodontium to present with the signs of LPS (figure 4).為提高咬合的穩(wěn)定性，后牙的支持是一個必須

12、要考慮的重要因素。喪失的后牙支持一般定義為因 為后牙缺失或是移位而導(dǎo)致咬合垂直距離的喪失。其次，咬合創(chuàng)傷也被定義為因?yàn)橐Ш狭?正常 的或是不正常的)作用于牙周支持喪失的牙上引起的。因此對于擁有完整牙列的患者，但也會因 為不良的牙周情況而出現(xiàn)后牙支持喪失的癥狀figure 4. Radiographs of patient with almost intact dentition but with reduced periodontium with the signs of LPS.牙列較完整但牙周狀況較差的并帶有后牙支撐喪失的患者的放射影像Clinically, such a diagnosi

13、s is based upon five cardinal signs (figures 2 and 3):PDL wideningFremitusFractured restorationsDriftingExcessive wear臨床上，這種診斷主要是基于五個主要的體征。1。牙周韌帶增寬2。震顫3。修復(fù)或充填物斷裂4。漂移5。過度磨耗Treatment Solutions for the Loss of Posterior Support 對后牙支持喪失的治療方法Solutions for the treatment of patients presenting with the cli

14、nical signs of the loss of posterior support include:對伴后后牙支持喪失患者體征的患者進(jìn)行治療的方法主要有Removable partial dentures (RPD)可摘局部義齒Cross-arch splinting 跨弓夾板療法Implant-supported restorations 種植支持式修復(fù)體 Removable Partial Dentures 可摘局部義齒There remains a group of patients that for medical, psychological, and financial re

15、asons are poor candidates for fixed prosthodontics. These patients can be restored to function with the use of RPDs. Patient selection and the correct diagnosis are critical when deciding if treatment with removable prosthesis is appropriate. When treating a patient who exhibits the cardinal signs o

16、f LPS, a tooth or implant (supported and/or retained) RPD can provide additional support. With appropriate dia gnosis and case selection these types of RPDs can satisfy the patients functional needs.有一些患者因?yàn)獒t(yī)療，心理或是經(jīng)濟(jì)的原因不會選擇固定義齒修復(fù)。這些患者可以通過可摘局部 義齒來恢復(fù)其功能。當(dāng)確定是否使用可摘局部義齒修復(fù)時(shí)，耐心地選擇和正確地診斷很關(guān)鍵。當(dāng) 治療一個有后牙支持喪失體征的患

17、者時(shí)，基牙或是種植體(支持或是固位)的可摘局部義齒能提 供輔助的支持。經(jīng)過適當(dāng)?shù)脑\斷和病例選擇這種類型的可摘局部義齒能夠滿足患者的功能要求。 However, there remains a group of patients who do not have an adequate number of posterior teeth or implants for a tooth-/implant-supported, or retained RPD. For this group of patients, tooth replacement with a mucosal supported

18、RPD may not have any functional benef its and posterior support will not be re-established, leading to further demise of the dentition.然而，也有一些患者并不具備足夠數(shù)目的基牙或是種植體為可摘局部義齒提供基牙或種植支持或 固位。對于這些患者，用粘膜支持的可摘局部義齒來代替天然牙不可能為患者提供滿意的功能和 恢復(fù)后牙的支持。將導(dǎo)致牙列情況的進(jìn)一步變壞。Restoring posterior support with mucosal-supported RPDs i

19、s controversial from a mechanical and periodontal view point. Whilst under load, the mucosa moves millimeters while natural teeth only move a mere 25-50 microns. This is based on the concept of differential movement of the mucosal tissues (millimeters) and the teeth (25-50 microns). These biomechani

20、cal issues compounded with patient compliance (25 percent of denture wearers never use their dentures) make it harder for a mucosal-supported RPD to provide adequate posterior support5 (figure 3). Prospective controlled studies have also shown that the oral function of subjects with a shortened dent

21、al arch (S DA) did not differ compared to subjects who have a S DA and were wearing a RPD.6-8從機(jī)械和牙周的角度考慮，用粘膜支持的可摘局部義齒來恢復(fù)后牙的支持是有爭議的。當(dāng)經(jīng)受咬 合的時(shí)候，粘膜會變形幾毫米，而天然牙僅會移動25-50微米。這種爭議正是基于這種理論。 這種生物力學(xué)的原理加之患者的順應(yīng)性(有25%的患者不會使用他們的義齒)使這種義齒很難 提供足夠的后牙支持。前瞻性的對照研究表明短牙弓的受試者和缺牙弓但使用可摘局部義齒的受 試者相比口腔功能沒有顯著的差異。Therefore, a dista

22、l extension RPD did not appear to provide the patient with any additional posterior support or occlusal stability. Another survey of 77 patients with RPDs, reported social and oral function at levels compared to those with no dentures.9 There appears to be little need to replace lost posterior teeth

23、 with dentures until the person has fewer than three posterior functional units. The authors could not detect a lasting benefit from RPD wear .因此一個遠(yuǎn)中游離游離缺失的可摘局部義齒不會給患者提供足夠的后牙支撐和咬合穩(wěn)定。另一個 對77個使用可摘局部義齒的患者進(jìn)行的調(diào)查報(bào)告了和不使用義齒的患者相比他們的社交和口腔 功能的水平。結(jié)果表明除非患者少于三個后牙功能單位沒有必要對其進(jìn)行修復(fù)。這位作者不能從 使用可摘局部義齒的患者中找到使用義齒的好處。The fu

24、nctional benefits of RPDs remain controversial as definitive controlled clinical trials have yet to be performed. However, based on c urrent data and a logical approach to diagnosis and treatment planning, one should employ more caution when opting to restore a patient who exhibits LPS with a RPD.在作

25、最終的對照臨床實(shí)驗(yàn)完成之前，可摘局部義齒使用的好處仍是有爭議的。然而，基于目前的 數(shù)據(jù)和對診斷和治療計(jì)劃的理論推理，醫(yī)生在對后牙支持喪失的患者進(jìn)行可摘局部義齒修復(fù)時(shí)應(yīng) 謹(jǐn)慎一些。Effect of RPD on Periodontal Status可摘局部義齒對牙周狀況的影響Many studies have looked at the effect of RPDs on dental and periodontal structures.10,11 Some have concluded that with a high level of periodontal maintenance an

26、d oral hygiene RPDs do not result in periodontal disease.10 Howevei, there is evidence to the contrary. In one controlled in-vivo study of 99 patients, it was found that“There was a strong correlation between the presence of local pathological alterations accompanying the use of RPDs and poor oral h

27、ygiene.”11許多研究都關(guān)注于可摘局部義齒對牙齒和牙周狀況的影響。一些研究表明高水平的牙周維護(hù)和保 持口腔衛(wèi)生狀況的情況下，可摘局部義齒的使用不會引起牙周疾病。然而也有相反的證據(jù)。一例 對99個患者的體內(nèi)對照實(shí)驗(yàn)表明，在口內(nèi)病理變化和可摘局部義齒使用及較差的口腔衛(wèi)生狀況 間有很強(qiáng)的相關(guān)性。Eighteen to 25 percent of RPD abutments were “l(fā)oose” and periodontal inflammation was associated with 68 percent of all abutments. In another 10-year st

28、udy, survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces, it was found that survival of teeth adjacent to a single posterior edentulous space was negatively associated with RPD placement compared with no treatment.12 If the patient with a mucosal-supported R

29、PD is unable to maintain an adequate level of oral hygiene, further tooth loss is more likely. Losing more teeth will worsen the problem associated with LPS.約 18% 到 25% 的可摘局部義齒的基牙 會出現(xiàn)松動，并且牙周炎癥會見于68%的基牙。在另一個10年的，關(guān)于缺牙間隙兩側(cè)治療及未 治療的基牙的保存率的研究中，實(shí)驗(yàn)表明，與不用可摘局部義齒修復(fù)的患者相比，經(jīng)過可摘局部 義齒修復(fù)的鄰近后牙缺隙的基牙的保存率與可摘局部義齒的使用負(fù)相關(guān)。如

30、果一個患者使用一個 粘膜支持的可摘局部義齒，且不能保持一個良好的口腔衛(wèi)生狀況，進(jìn)一步的牙齒缺失是可能的。 缺失更多的牙齒將使與后牙支持喪失相關(guān)的問題加重。RPDs functional benefits remain controversial as definitive-controlled clinical trials have yet to be performed. The ability to draw consensus on the benefits and impacts based on currently available data may be premature.

31、The majority of evidence is from correlational, poorly controlled studies with biased or select samples. However, current data should not be disregarded as it does provide some useful information in relation to clinical outcomes and trends.在最終的對照臨床實(shí)驗(yàn)結(jié)果作出前，可摘局部義齒的優(yōu)點(diǎn)目前仍有爭議?；谀壳暗臄?shù)據(jù)得出關(guān) 于好處和影響的達(dá)成一致是不成熟的。

32、大多數(shù)基于對病例對照實(shí)驗(yàn)得出的相關(guān)性結(jié)果都存在偏倚 或是選擇樣本誤差。但目前的數(shù)據(jù)也不能不考慮，因?yàn)樗吘篂榕R床的工作提供了一些有用的信 息和臨床的結(jié)果的趨勢。Cross-arch Splinting 跨弓夾板Cross-arch splinting has also been used to treat patients diagnosed with LPS. Adequate oral hygiene, and sufficient number of abutment teeth are essential to the success of such treatment modalit

33、ies13 (figure 5). The patient in figure 5 received a periodontal prosthesis more than 20 years ago. This should be considered a successful restoration.How ever, had failure occurred a short period after delivery of the definitive restorations, the consequences may have been catastrophic. As every to

34、oth is joined together in a single prosthesis, a localized problem may deem the restoration or a large part of it nonfunctional, requiring replacement. The risk-to-benefit ratio for these restorations is unfavorable.14 It has been said that “for every advantage splinting has to offer there is at lea

35、st one disadvantage that must be accepted.” 跨弓夾板也曾被用于治療診斷為后牙支持喪失的患者。在這種治療中，充分的口腔衛(wèi)生控制和足 夠數(shù)目的基牙是必須的。圖5中的患者接受牙周修復(fù)超過了 20年，這例被認(rèn)為是一例成功的治 療。然而如果應(yīng)用最終修復(fù)體后失敗發(fā)生，那么結(jié)局應(yīng)是災(zāi)難性的。因?yàn)槊總€牙齒都被連成一個 整體，一個局部的問題將會引起整個修復(fù)體功能喪失，以致于需要替換。這種修復(fù)體的風(fēng)險(xiǎn)和好 處的比例也是不利的。據(jù)說：每一項(xiàng)夾板的優(yōu)點(diǎn)都會有一個相應(yīng)的缺點(diǎn)與之對應(yīng)。figure 6 demonstrates how the failed prosthesis

36、 in figure 5 was remade with the use of dental implants for support. “New sophisticated techniques are available, but the concept of a correctdiagnosis, identifying the etiological factors, formulating a treatment plan and developing a logical sequence of therapy hold true today as they did five dec

37、ades ago.”16圖6提示了圖5中失敗的病例如何通過口腔種植來獲得支持?！靶碌某墒斓募夹g(shù)可以被獲得，然 而和50年以前一樣，正確的診斷，準(zhǔn)確地判斷病因，制定治療計(jì)劃，并確定合理的治療順序依 然十分重要。figure 5a. Radiographs of maxillary reconstruction with cross-arch stabilization at 20 years.利用跨弓夾板進(jìn)行上頜修復(fù)重建20年的患者的放射影像figure 5b. Occlusal view of maxillary reconstruction with chipped ceramics, de

38、ntal caries, and fractured connector necessitating replacement of prosthesis at 20 years 上頜利用瓷貼面進(jìn)行的 修復(fù)重建咬合面觀.經(jīng)過20年后發(fā)生的齲壞及連接體斷裂迫使必須重新修復(fù).6a. Radiographs of patient in Figure 5 after maxillary reconstruction with dental implant supported restorations圖5中的患者利用口腔種植體進(jìn)行重新修復(fù)后的放射影像figure 6b. Right lateral vie

39、w of maxillary implant-supported restorations. 右側(cè)觀figure 6c. Left lateral view of maxillary implantsupported restorations .左側(cè)觀Implant-supported Restorations 種植支持式修復(fù)體The use of osseointegrated dental implants have defied many of the empirical guidelines previously accepted.The survival of cantilevere

40、d restorations supported by four to five short dental implants in the symphisis of the mandible is well documented.18,19 These complete mandibular prostheses, which replace 12 to 14 teeth, with up to 10-15 mm posterior cantilevers clearly defy the empirical rules that have been religiously followed

41、in clinical dentistry (figure 7). A new era in clinical dentistry has arrived. Two patients are selected to demonstrate the contemporary treatment of the loss of posterior support.骨性結(jié)合的口腔種植體的使用已經(jīng)以許多從前的治療原則提出挑戰(zhàn)。用4到5個種植體作為支 撐的懸臂梁式的下頜修復(fù)體的存活率很高。這些下頜修復(fù)體可以代替12到14個天然牙，長達(dá) 10到15mm的后牙懸臂梁對從前口腔臨床工作中獲得的經(jīng)驗(yàn)提出挑戰(zhàn)。臨床

42、牙科的新時(shí)期已經(jīng) 來臨。有二例患者已經(jīng)被選中用現(xiàn)代的治療方法進(jìn)行后牙支持喪失的治療。The patient in figures 4 and 8 presented with the cardinal signs for LPS. In order to establish posterior support the treatment plan for this patient consisted of:圖4到圖8中的患者帶有后牙支持喪失的主要體征。為了使患者恢復(fù)后牙支持主要的治療方法 有：The removal of the teeth with poor or nonmaintainab

43、le prognosis14;Bilateral sinus lifts20; andReplacement of missing teeth with implant-supported restorations.1。去除那些預(yù)后不良或沒有保留價(jià)值的牙齒。2。雙側(cè)上頜竇提升3。利用種植支持式義齒代替缺失的牙齒。After removal of the maxillary teeth and prior to dental implant placement, an immediately loaded provisional prosthesis was delivered to resto

44、re the dentition and establish posterior support. Three transitional dental implants were used as abutments for the immediately loaded prosthesis in order to establish posterior support (figure 9). The patient was stabilized in terms of disease control, occlusion, function, phonetics, and esthetics.

45、 The immediately loaded transitional dental implants were removed once the definitive dental implants were osseointegrated and loaded. The additional step of providing the patient with a transitional implant-supported provisional restoration ensured patient comfort during the osseointegration period

46、 while minimizing the risk of uncontrolled loading and micromotion of the definitive dental implants.21在拔除上頜牙齒之后，和進(jìn)行種植修復(fù)之前，一個即刻的義齒被制作以為患 者恢復(fù)牙列的功能及獲得后牙支撐。三個過渡性的口腔種植體被用來作為這個即刻修復(fù)體的基牙 以建立后牙的支撐?；颊咴诳谇患膊?，咬合，功能，發(fā)音和美觀等方面都比較穩(wěn)定。當(dāng)最終的口 腔種植體達(dá)到骨性愈合和穩(wěn)定后，即刻的義齒可以被去除。這種種植支持的過渡性義齒的應(yīng)用使 患者在種植體骨性愈合階斷能夠獲得足夠的舒適，并減少了不可控制的負(fù)荷，

47、和最終種植體的微 運(yùn)動。figure 7a. Photo of mandibular hybrid prosthesis supported by five short dental implants and cantilevered.五個短的口腔種植體支持的下頜單臂梁式修復(fù)體圖片figures 7b. Radiograph of mandibular hybrid prosthesis.放射影像figure 8. Preoperative photo of pa tient. Cardinal signs of LPS are present with an almost intact de

48、ntition. Generalized periodontal attachment loss is the cause of LPS. 患者的術(shù)前照片.雖然沒 有牙列缺損，但牙周病變是引起后牙支撐喪失的原因.figure 9a. Three transitional dental implants are used to provide posterior support and function.三個過渡性口腔種植體被使用figure 9b. Intaglio surface of maxillary immediately loaded provisional restoration.

49、臨時(shí)義齒的組織面figure 9c. Occlusal view showing copings on transitional dental implants indexed to maxillary provisional restoration with acrylic resin.從咬合面觀看臨時(shí)種植體上的根帽被用樹脂粘在了過渡性義齒上figure 9d. Satisfactory esthetics achieved with the implant-supported and immediately loadedprovisional restoration.過渡義齒的外觀較滿意p

50、rovisionalOnce osseointegration of definitive dental implants had been established, indirect restorations were fabricated to maintain posterior support. The provisional restorations (figure 10) allowed objective evaluation of occlusal stability, phonetics, and esthetics prior to the fabrication of t

51、he definitive restorations22 (figure 11). Comparison of the photos in figures 10 and 11 demonstrates how the treatment objectives that were established and tested with the provisional restorations were duplicated in the definitive restorations. Posterior support had been established with the aid of

52、implant-supported restorations.一旦最終口腔種植樹體的骨性愈合完成，間接的過渡性修復(fù)體被制作以保持后牙的支持。這種過 渡性修復(fù)體使我們在最終修復(fù)體完成之前能夠?qū)σШ戏€(wěn)定性，發(fā)音，和美觀作出評估。比較圖10和圖11提示治療目的是如何實(shí)現(xiàn)的，及如何在最終修復(fù)體制作中復(fù)制過渡性修復(fù)體。后牙支 撐通過種植支持式修復(fù)體得以恢復(fù)。figure 10a. Right lateral view of definitive implant-supported provisional restorations.最終修復(fù)體的右面觀figure 10b. Left lateral vie

53、w of definitive implant-supported provisional restorations.左面觀The patient in f igure 12 presented with pathological loss of tooth structure, which resulted in posterior bite collapse and loss of vertical dimension of occlusion.3,23-25 Radiographs clearly show the extent of damage to the dentition (f

54、igure 12). Many teeth had also been affected by pathological tooth surface loss associated with attrition and erosion.23 Signs of both diurnal and nocturnal bruxism were clearly visible on presentation. The proximity of the chin to nose distance and the presence of angular folds and angular cheiliti

55、s confirmed the diagnosis of the loss of vertical dimension of occlusion (figure 13).圖12中的患者是因?yàn)椴±硇缘匮荔w結(jié)構(gòu)喪失， 導(dǎo)致后牙咬合崩潰，以致于垂直距離降低。放射檢查提示了牙列的廣泛的損壞。許多牙齒也因?yàn)?牙齒表面的磨損及腐蝕而病理性缺損。白天或是晚上的磨牙癥的癥狀也可以看到。下頜前點(diǎn)到鼻 的距離降低及口角皺紋及口角炎的發(fā)生都提示了垂直距離的降低。figure 12a. Radiographs of a patient with a severely compromised dentition on

56、presentation. 嚴(yán)重牙列缺損的患者的放射影像figure 12b. Intraoral photograph of patient in Figure 12a.圖12中患者的口內(nèi)像DXY.GJMfigure 13. Patient presented with persistent angular folds and cheilitis relating to loss of vertical dimension of occlusion.患者呈現(xiàn)垂直距離降低的癥狀，口角炎.和口角皺紋加深figure 14. Provisional restorations. The mandib

57、ular arch with immediately loaded prosthesis at two weeks.臨時(shí)修復(fù)體.種植后2星期用過渡性義齒修復(fù)In order to re-establish posterior support for this patient, it was decided to restore the maxillaryteeth with tooth-supported cast restorations, and the mandibular teeth with implantsupported restorations. The provisional

58、 restorations allowed objective evaluation of occlusal stability, phonetics, and esthetics prior to the fabrication of the definitive restorations.22 The decision to immediately load the mandibular arch for this patient was based on a combination of factors (figure 14).為了重建患者后牙的支撐，決定在患者上頜用天然牙支持的鑄造修復(fù)

59、體來修復(fù)。而在下頜采用種 植體支持的修復(fù)體。過渡性的修復(fù)體使在最終修復(fù)體完成之前可以客觀地對患者咬合穩(wěn)定性，發(fā) 音和美觀等方面進(jìn)行評估。這種即刻加載的方法是基于對患者多方面因素的考慮。Firstly, success with immediate loading of the mandible is well documented.26,27Secondly, patients wearing complete mandibular dentures opposing a fixed prosthesis in the maxilla tend to have poor acceptance

60、of treatment.Thirdly, the provision of a fixed prosthesis in the mandible for this patient will immediately overcome the two major diagnostic findings for this patient. Posterior support and vertical dimension were both re-established with immediate effect. The osseointegration period may coincide w