口腔种植成骨材料的研究现状及进展

随着口腔种植技术的快速发展，种植修复已逐渐成为牙列缺损和牙列缺失患者的首选治疗方案。种植区牙槽骨骨量充足是种植修复成功的前提条件及关键因素。然而，临床上种植区牙槽骨骨量不足十分常见，影响种植修复体的功能发挥、美学效果及远期疗效。口腔植骨材料配合骨增量手术是目前临床常用重建缺失骨组织，使其骨量满足种植要求的方法之一。口腔植骨材料的自身特性如生物相容性、骨传导、骨诱导及骨生成等性能对植骨成功率具有至关重要的影响。该文从植骨材料的性能、分类及临床运用三个方面重点介绍口腔种植成骨材料的研究现状及最新进展，以期为成骨材料的临床选择及种植修复成功率的提高提供理论指导。     

骨移植同期种植体植入和二期种植体植入的比较研究

牙槽骨严重萎缩或外伤后的颌骨缺损往往在种植治疗时存在骨量不足,需要重建牙槽骨的生理形态.为达到良好的美学效果和功能恢复,在种植术时需要在垂直向和唇舌向恢复牙槽骨形态.临床上有不同的种植体周围软、硬组织处理方法和在软硬组织条件不佳的种植和重建.常用的方法有游离骨块移植、自体松质骨移植、自体或异体的骨生物材料移植增量技术、带血管的大块骨移植、骨劈开、骨牵引技术等等.     

上前牙智齿冠周骨Onlay植骨种植修复1例

<正>种植义齿是近年来修复缺失牙的首选方法,其功能和美观与天然牙最接近。对于前牙美学区,唇侧骨板较薄,牙缺失容易导致水平向骨量不足,将会影响种植体植入位置、初期稳定性、美学效果等关键因素^[1],因此牙槽骨缺损的再生及重建修复是口腔种植的关键点^[2],目前有多种方法进行水平骨增量,包括自体骨块状移植(onlay植骨)^[3],骨劈开,水平牙槽骨牵张术,异种骨移植,单独或与移植材料组合的引导骨再生,但目前对美学区的理想水平骨增量方法尚未达成共识^[4]。     

GBR技术应用于上前牙种植骨缺损的临床研究

目的：评估引导骨再生技术（GBR）在上前牙不同类型骨缺损种植修复中的效果。方法：对35例上前牙牙槽骨缺损种植的患者采用GBR技术进行骨增量,其中29例种植体周围骨缺损患者仅采用GBR技术,在植体植入骨床后,同期植入Bio～oss人工骨粉,表面盖Bio～gide可吸收性胶原膜;6例牙槽骨缺损患者采用移植自体块状骨联合Bio～oss人工骨粉,盖Bio～gide可吸收性胶原膜,5～6个月后行Ⅱ期种植体植入术。结果：所有患者在植体植入术后6～12个月临床观察种植体与骨结合良好,软组织形态与周围组织一致,行冠或桥修复,修复后12个月随诊复查无种植体失败。结论：引导骨再生技术皆能有效地对上前牙不同类型骨缺损进行骨增量,符合美学种植要求。     

帐篷钉技术在牙槽骨修复与再生中的临床应用及操作规范

牙槽骨是牙医学的基础,牙槽骨缺损的修复与再生和口腔种植、口腔正畸、牙周及口腔修复等亚专业学科关系密切。因此,对牙槽骨进行有效的修复与重建具有重要的临床意义和社会效益。随着引导骨再生（guide bone regeneration,GBR）技术的发展,基于以“稳定为核心”的牙槽骨修复与再生理念,一种全新的骨增量技术快速发展,且在临床上获得了有效验证,即基于帐篷钉技术的骨增量方案。该技术具有技术敏感性低、操作简单、手术时间短及费用低等特点。另外,可以单纯应用生物医用材料,在不需要自体骨参与的情况下完成牙槽骨严重缺损的修复与再生。因此,该项技术获得了越来越多医师和患者的青睐。但目前广大医师对如何正确将其有效用于临床仍面临诸多困难,如正规手术操作流程、帐篷钉放置的位置及方向、放置可吸收生物膜与放帐篷钉的顺序以及安放配钉的位点等。鉴于此,本项目组基于临床手术操作流程,撰写了帐篷钉技术在牙槽骨修复与再生中临床应用操作规范,旨在为广大口腔医师在应用该项技术时提供一定的参考和依据,并对其临床推广应用起到积极作用。     

自体块状骨移植重建牙槽骨骨量不足后种植修复的临床观察

目的探讨自体块状骨移植重建牙槽骨骨量不足后种植修复的临床效果。方法 2010年1月至2016年12月完成的自体块状骨移植结合引导骨再生技术(guided bone regeneration,GBR)重建牙槽骨骨量不足的病例共30例,植入种植体共81颗。按照自体块状骨的供区来源分为颌骨组(16例34颗)和髂骨组(14例47颗)两组,通过临床随访及影像学检查,分别计算并比较其种植体存留率。结果 30例自体块状骨移植结合GBR后骨增量明显且愈合良好,术后均无明显供区并发症。同期或延期种植体植入,经平均7.8个月(4~18个月)骨结合期后,除1例种植体因松动拔除,其余29例均完成永久修复。种植体植入后平均随访期为26个月(9~68个月),植入的81颗种植体在随访期内存留率为98.76%。其中颌骨组升支取骨失败1颗,种植体存留率为97.06%;髂骨组失败0颗,种植体存留率为100%,两者统计学上无显著性差异(P>0.05)。结论自体块状骨移植重建牙槽骨骨量不足后种植修复,其种植体存留率,较骨量正常情况下的种植修复无明显差异。颌骨与髂骨两种供区的块状自体骨,其移植重建牙槽骨骨量不足均可取得理想的种植修复临床效果。但颌骨内取骨因避免了第二术区、减少手术时间、术后并发症小等优点,临床上应予以优先选择。     

取骨方式对自体骨活性及在引导骨再生术中成骨效应的影响

临床牙槽骨缺损可以采用各类骨增量材料进行修复重建,但对于骨缺损大的区域,获取和加入一定比例的自体骨是获得良好成骨预后的一个重要环节.临床制取自体骨屑的方法有很多种,包括通过手持器械如骨凿、刮骨器取骨,采用机用旋转器械如取骨环钻、超声骨刀、骨吸引收集器等.文章总结了不同取骨方法所获得自体骨的活性及成骨效能,希望为临床引导...     

植骨材料在口腔种植中的应用概况及进展

近年来,多种传统和新型的植骨材料及手术方法在颌面部牙槽骨缺损的重建中得到广泛应用,有效解决了因炎症、外伤、肿瘤手术等原因导致的骨量不足问题,拓宽了口腔种植的适应证,提升了种植修复的临床效果。文章根据目前口腔种植领域中常用植骨材料的特点,分类讨论了自体骨、同种异体骨、异种骨及各种人工合成的骨替代材料在口腔种植中的应用现状,并简述了组织工程骨的研究现状和应用前景。     

自体骨移植与引导骨再生在外胚层发育不全综合征种植修复中的应用

目的:在自体骨移植、引导骨再生实现骨增量的基础上,通过种植方法对外胚层发育不全综合征导致的牙列缺损进行修复。方法:对1例牙槽骨重度萎缩的外胚层发育不全综合征患者,先后通过自体髂骨游离移植、引导骨再生技术,使患者牙槽骨实现宽度、高度上的增量和上下颌牙槽骨空间位置的改善,然后在上下颌骨牙槽骨分别植入5枚、4枚种植体,最后采用种植固定桥修复方法恢复患者牙列缺损。结果 :通过自体髂骨游离移植和引导骨再生技术,患者上下颌牙槽骨在高度和宽度的增量能满足种植体植入需要,同时唇舌向位置关系得到改善,种植体支持的上下颌固定桥修复体较理想地恢复了患者牙列的完整性,咬合关系良好。结论:对牙槽骨重度萎缩的外胚层发育不全综合征患者,综合应用自体骨移植、引导骨再生等技术,能解决患者种植修复过程中牙槽骨量严重不足的问题。     

上置法（Onlay）植骨术中块状骨应用的研究进展

植入区有足够的牙槽骨量是保证牙种植成功的一个前提条件,但临床上经常遇到由于多种原因导致的植入区骨量不足,给种植修复带来困难,需要进行骨增量手术。     

Particulated bone grafts--effectiveness of bone cell supply

OBJECTIVE: The objective of this study was to measure the amount of viable bone cells present in different types of bone graft. MATERIAL AND METHODS: Bone chips were harvested from the trabecular or cortical bone of the mandible or the iliac crest and either milled or not. The average size of unmilled bone particles was 5 x 5 x 5 mm and that of milled was 2 x 2 x 2 mm. Drill sludge was obtained using either a ball reamer, a diamond ball or an implant drill (the latter from mandibular bone and of average dimension 1 x 1 x 1 mm). A measure of 0.5 g of each category was cultured in Dulbecco's modified Eagle's medium with additives for four weeks. Cell counts were performed. An analysis of the osteocalcin synthesis, the alkaline phosphatase (ALP) activity, the collagen types and the concentration of bone-specific collagen cross-links in medium supernatants was performed. RESULTS: Cells stained positively for osteocalcin and ALP in all groups. Bone-specific collagen cross-links could be quantified and collagen of types I and V was present with no difference in all groups. Unmilled spongy bone chips revealed greater cell counts than milled (P<0.05). Spongy bone chips revealed greater cell counts than cortical bone chips (P<0.05). Drill sludge obtained by hard alloy ball reamer showed the least amount of viable cells (P<0.05). CONCLUSIONS: Bone milling reduces the quantity of osteoblasts. Bone obtained by the ball reamer supplies a smaller number of cells than bone obtained by other methods. Unmilled spongy bone chips appear to offer the greatest amount of viable osteoblasts.     

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目的评价前牙区牙槽骨水平宽度不足的患者联合应用骨劈开、骨挤压和骨引导再生术行同期种植体植入的临床效果。方法 2004—2009年福州市第一医院口腔科就诊的前牙区牙缺失伴前牙区牙槽骨水平宽度不足的种植患者28例,联合应用骨劈开、骨挤压,填入骨粉,行骨引导再生术后同期植入40颗种植体,术后4～6个月内完成上部修复。术后1年,通过临床检查、全景片等观察效果。结果术前、后牙槽骨平均宽度分别为(3.2±0.89)mm、(6.5±0.75)mm,平均增加了(3.3±0.34)mm。术后牙槽骨宽度与术前相比,差异有统计意义(t=2.47,P<0.05)。术后无明显并发症发生,种植体行使功能良好,仅1例患者的1颗牙种植失败,种植近期成功率达97.5%。结论对前牙区牙槽骨水平宽度不足的患者,联合应用骨劈开、骨挤压和骨引导再生术行同期种植体植入,可增加骨量,获得种植体的同期植入,减少患者痛苦,改善种植修复的临床效果。     

Differential effects of bone graft substitutes on regeneration of bone marrow

Background: This study used a rat tibial marrow ablation model to test the hypothesis that bone remodeling within the medullary canal varies with bone graft materials of different chemical compositions and structural properties, impacting marrow cavity restoration. Bone graft materials were selected based on their relative resorption or degradation in vivo and their osteogenic properties. Methods: Following ablation of the right tibial marrow in male Sabra‐strain rats, materials were implanted in the proximal marrow cavity: poly‐d,l ‐lactide‐co‐glycolide 75 : 25 (PLGA); coralline‐hydroxyapatite (HA), calcium‐sulfate (CaSO4), collagen–HA–tricalcium phosphate granules, anorganic bovine bone mineral, demineralized bone matrix (DBM), 45S5 Bioglass (BG), PLGA with BG 50 : 50, PLGA : BG 80 : 20, and PLGA and PLGA:BG 50 : 50 plus bone marrow (BM). Control tibias were ablated but received no implants. At 2 (endosteal bone healing), 4 (marrow cavity remodeling) and 8 weeks (marrow restoration), six to eight animals per group were euthanized and tibias processed for histomorphometry of proximal and distal medullary canals. Results: Control tibias showed primary bone in proximal and distal medullary canals at 2 weeks, with trabeculae surrounded by cellular marrow. At 4 and 8 weeks, control trabeculae were thinned and marrow had more fat cells. In the treated tibias, trabecular bone volume (TBV) varied with time and was material specific. Most implants supported comparable TBV at 2 weeks. Sites with CaSO4 or DBM exhibited decreased TBV with time whereas trabecular bone was retained in proximal tibias containing other materials, closely juxtaposed to the implants. TBV did not always correlate directly with implant volume, but changes in BM volume were correlated inversely with TBV. Addition of BM increased marrow restoration in sites containing PLGA; however, BM reduced restoration of marrow when added to PLGA : BG. Although the presence of implants in the proximal tibia resulted in retention of trabecular bone, there was a time‐dependent reduction in TBV in distal canals; the rate and extent of the distal TBV reduction were implant dependent. Conclusions: Thus, although many materials can support bone formation in the marrow cavity, bone quality, quantity, and physical relationship to the implant, and its rate of resorption differ in a material‐dependent manner, resulting in differences in the restoration of marrow. Clinical relevance: Bone graft materials should be selected not only for their ability to support new bone formation but also for their impact on the remodeling phase of bone healing.     

异种骨移植对牙周骨缺损的作用及研究进展

异种骨移植作为骨缺损修复的常见方法,受到与骨相关学科工作者的关注,由于异种骨移植材料来源丰富,能满足日益增多的病人需求。本文就异种骨的免疫原性、处理方法和在牙周骨缺损修复中的应用及其进展加以综述,为异种骨移植物的基础和临床研究提供依据。     

Effects of cortical bone perforation on experimental guided bone regeneration

This study was designed to evaluate the effects of cortical bone perforation histologically and histomorphometrically on guided bone regeneration (GBR) in rabbits. After elimination of the periosteum, cortical bone defects of two sizes were made in the external cortical plate of the frontal bone (Group A: 1 x 15 mm; Group B: 3 x 15 mm). A non-resorbable membrane filled with autogenous blood was placed in the experimental area and secured with titanium pins. After 1 and 2 weeks, vascularized connective tissue and new bone were generated in the space surrounding the defects in both the groups. The amount of vascularized connective tissue generated in Group B was greater than that in Group A at 1 week. Alkaline phosphatase (ALP) was expressed on the bone surrounding the perforation. The expression of ALP was more extensive in Group B than in Group A and was proportional to the breadth of perforation. At 2 weeks, the perforated region was almost covered with new bone in Group A. ALP was expressed at the periphery of newly formed bone. The expression of ALP was proportional to the breadth and height of perforation. At 6 weeks, semicircular outgrowth of bone towards the periphery of the perforated region was observed in both the groups. Newly formed bone volume and ALP expression in Group B were more extensive than those in Group A. At 12 weeks, the space was filled with bone and connective tissue in both the groups. There was no difference in ALP expression between Groups A and B. Histomorphometric analysis showed significant differences between both the groups (two-way ANOVA, P<0.01). We conclude that a larger perforation is associated with prompter bone formation in the secluded space during GBR.     

实验犬磨牙根分叉骨缺损应用组织工程骨修复的效果分析

目的观察以组织工程方法修复大面积根分叉骨缺损的效果。方法以成骨条件培养液培养实验犬骨髓基质细胞(BMSCs)至第3代并以1×106/cm2的密度与猪的脱矿冻干骨(fdDBM)复合培养后回植于犬磨牙根分叉骨缺损区(2.0cm×1.0cm×0.8cm)。术后3个月与6个月取实验开窗区骨制作组织切片或2mm厚的骨磨片,观察新生骨组织形态及骨钙素与Ⅰ型胶原表达情况并作骨磨片的骨密度分析。所得数据用SAS6.12软件作t检验。结果6个月及3个月实验侧骨缺损完全修复。骨切片显示实验侧开窗区新生骨与正常骨无明显区别且Ⅰ型胶原和骨钙素表达亦同正常。X线骨密度数据显示回植后6个月实验组的骨密度高于对照组及回植3个月者。结论以组织工程骨修复大面积根分叉骨缺损是可行的。     

Long-term stability of autogenous bone grafts following combined application with guided bone regeneration

The aim of the study was to compare the long-term stability of membranous and endochondral autogenous bone grafts with or without combined application of guided bone regeneration (GBR). Twenty-five, male, 6-month old, albino rats were used in the study. The animals were divided into four groups (A5, A11, B5 and B11). Group A5 (control): The inferior border of the mandible was exposed in both sides. At one side of the jaw, a calvarial bone graft (baseline -3 x 4 x 0.64 mm) was placed at the inferior border of the mandible and was fixed with a standardized screw-type titanium microimplant. At the contralateral side, an ischiac bone graft (baseline -3 x 4 x 0.87) was transplanted. The healing period was 5 months. Group A11 (control): The animals were treated in the same manner as in Group A5 with the difference that the healing period was 11 months. Group B5 (test): The animals were treated in the same manner as in Group A5 with the difference that an e-PTFE membrane was adapted over the bone graft on each side of the jaw. Group B11 (test): The animals were treated in the same manner as in Group B5 with the difference that 5 months following transplantation the animals were subjected to a second operation and the membranes were removed. The healing period was 11 months. The animals were killed at 5 (Groups A5 and B5) or at 11 months (Groups A11 and B11) following mandibular augmentation and the jaws were defleshed. The width, the length and the thickness/height of the bone graft were evaluated by means of a stereomicroscope. At 5 months, both types of the membrane-treated bone grafts presented increase in all dimensions compared with baseline. However at 11 months, both types of the membrane-treated bone grafts exhibited a decrease in their dimensions which were similar to the baseline measurements. In the control groups, both types of bone graft presented significant resorption both at 5 and at 11 months with the ischiac bone grafts presenting more resorption in width and length than the calvarial bone grafts. It can be concluded that the long-term volume stability of autogenous endochondral and membranous onlay bone grafts combined with GBR is superior to that of autogenous endochondral and membranous onlay bone grafts alone.