本文選題：纖維樁 + 輔樁　； 參考：《大連醫(yī)科大學》2014年碩士論文

【摘要】：喇叭口狀根管殘根殘冠臨床較為常見,以前牙及前磨牙多發(fā)。其特點為根管開敞粗大，剩余牙體組織薄弱。目前,樁核冠是此類殘根殘冠保存最常采用的手段,但其固位形、抗力形差，樁核修復的遠期效果不理想。目前的樁核修復系統(tǒng)因彈性模量、樁與根管壁的適合性、樹脂材料的聚合收縮、臨床操作的復雜性等各種因素存在樁核脫落、樁折、根折的現(xiàn)象，也是臨床醫(yī)生在殘根殘冠保存修復中一直面臨的挑戰(zhàn)和難題。天然牙根的存留有利于牙周膜本體感受器的保留，也減少了患者的失牙數(shù)和缺牙痛苦。因此，為更大限度的保留此類殘根殘冠，延長修復體的使用壽命，探尋一種更佳的喇叭口根管樁核修復方式是臨床醫(yī)生需要解決的問題。纖維主輔樁是近年來一種新型的樁核修復系統(tǒng)，具有彈性模量和牙本質接近，最大限度的適合根管壁的形態(tài)、減少樹脂水門汀的用量，減少聚合收縮、臨床操作簡便等諸多優(yōu)點而被推崇。目前，國內外對其研究主要集中在其抗折性能方面的基礎研究，發(fā)現(xiàn)它可以增強牙根抗折性能，其臨床應用方面鮮有報道。對于臨床口腔醫(yī)生修復殘根殘冠更注重的是其遠期修復效果，主輔樁修復系統(tǒng)能否減少根折及脫樁的發(fā)生,獲得長期的遠期療效,其應力傳遞的方式能否有利于降低應力集中？實際產生的微滲漏情況如何？臨床修復的成功率又如何？這些問題需要相關研究進一步驗證說明。 本研究通過三維有限元法、染料滲透法、掃描電鏡法等方法來探討纖維主輔樁系統(tǒng)修復喇叭口根管牙本質的應力分布規(guī)律、冠向封閉性，同時結合臨床實踐，來追蹤觀察纖維主輔樁的臨床應用效果，為主輔樁修復喇叭狀根管殘根殘冠的臨床推廣應用提供一定的的生物力學支持、基礎理論依據(jù)及臨床參考。論文主要有三個部分構成，具體如下： 第一部分纖維主輔樁修復喇叭口根管上頜中切牙的應力分析 通過螺旋CT掃描一名健康男性上頜中切牙及牙槽骨，準確獲取圖像信息，運用Mimics、Geomagic等有限元軟件，建立正常上頜中切牙及牙周組織三維有限元模型，采用Solidworks軟件建立不同牙本質肩領高度喇叭口根管、纖維主樁、輔樁、金屬樁、全冠、粘結劑等模型。按照牙本質肩領相同寬度0.5mm,不同肩領高度分為0mm、1mm、2mm組；按不同的樁核材料分為纖維主輔樁、單支纖維樁、金屬樁組；按不同的咬合狀態(tài)分為相同加載角度45°、不同加載力值（60N、80N、100N、120N、150N）和相同加載力值100N、不同加載角度（0°、30°、45°、60°、90°）兩實驗組，對喇叭口根管牙本質應力分布規(guī)律進行分析。結果如下：相比金屬樁，主輔樁組可減少根尖部牙本質的應力集中，應力分布均勻，與單支纖維樁應力分布相近，無明顯差異；隨著牙本質肩領高度的升高，牙本質的應力峰值降低，應力分布范圍減少。由0mm升至1mm高度時，這種變化最為明顯，VonMises應力降低3.94%，最大拉應力降低4.18%；相同載荷角度45°，60N～150N合力范圍內，相比單支纖維樁，纖維主輔樁組應力峰值略大，但無明顯差異。兩組應力峰值隨合力值增大增加，牙本質Von Mises應力值最高達42.469MPa，均在牙本質承受的正常范圍內；相同載荷力值100N，載荷角度0°～90°范圍時，纖維主輔樁組應力峰值主輔樁組略大于單支纖維樁組，無明顯差異。牙本質的應力分布范圍和載荷角度變化密切相關，當加載角度為90°時，牙本質最大主應力值達54.153MPa，達到牙本質最大拉應力值。 上述結果提示，相比金屬樁，纖維主輔樁修復喇叭口根管可減少不可逆性根折的發(fā)生，與單支纖維樁的應力分布相近。喇叭口根管高度1mm，0.5mm厚度牙本質肩領的保留可以提供一定的箍效應，臨床應盡量的保留剩余牙體組織。不同咬合狀態(tài)下，咬合力及載荷角度的增大會增加牙頸部折裂的風險，臨床應注意避免過大的合力及水平向分力。 第二部分纖維主輔樁修復喇叭口根管上頜中切牙的微滲漏研究 將52顆離體上頜中切牙經根管治療后制備形成喇叭口狀殘根隨機分為兩組，單支預成纖維樁組，其中A1(n=20)，A2(n=6)；纖維主輔樁組，其中B1(n=20)，B2(n=6)。所有的樣本經過水侵襲1月。將A1、B1置于印度墨水1周，，經染色、透明化處理，在體式顯微鏡下觀察樁核與根管壁之間的微滲漏情況。將A2、B2分為根頸、根中、根尖橫向三部分，每部分取四點，置于掃描電鏡下頜向觀察樁核-牙本質界面。采用等級計分記錄觀察結果，經非參數(shù)檢驗統(tǒng)計進行分析，結果發(fā)現(xiàn),纖維主輔樁組修復方式引起的纖維樁冠向微滲漏值明顯較單支纖維樁組小（P0.05）；纖維主輔樁組和單支纖維樁組均顯示了不同程度的牙本質-粘結劑間隙，單支纖維樁組產生的粘接劑-牙本質界面不連續(xù)性較纖維主輔樁組明顯，尤其在冠方（P0.05） 實驗結果提示，相比單支纖維樁，纖維主輔樁通過減少樹脂水門汀的用量，可以減少微滲漏的發(fā)生，更有利于樁核修復的冠向封閉，降低脫落的風險,為纖維主輔樁的臨床應用提供有力的理論依據(jù)。 第三部分纖維主輔樁修復喇叭口根管臨床應用療效觀察——附典型病例 按照臨床納入標準，篩選28名患者37顆需修復的喇叭口單根管患牙經根管治療后行纖維主輔樁+復合樹脂核及全瓷冠修復，于修復完成后每半年進行臨床復查，追蹤26個月，參照美國加州牙科協(xié)會對修復體的評價標準的修改表對修復體完整性、邊緣適合性、牙周及根尖周組織健康狀況進行評價。37個修復體完整，成功率100%；冠邊緣適合性好達91.89%，可接受8.11%；色澤匹配好達75.68%；牙齦狀況好達83.79%；纖維樁及樹脂核無松動、折裂、縫隙等；根尖未見異常，無根折發(fā)生。 臨床追蹤結果說明纖維主輔樁系統(tǒng)是一種良好的喇叭口狀殘根殘冠的樁核修復方式，可以在臨床推廣應用。 綜上所述，纖維主輔樁修復喇叭口狀根管殘根殘冠具有一定的優(yōu)勢,體現(xiàn)在以下幾個方面：1.相比金屬樁，纖維主輔樁根尖部牙本質應力分布均勻，與單支纖維樁應力分布相似，可減少不可逆性根折的發(fā)生。喇叭口根管1mm高度、0.5mm厚度的牙本質肩領的保留可以提供一定的箍效應。2.纖維主輔樁組與單支纖維樁應力分布未見明顯不同。咬合狀態(tài)影響牙本質的應力分布，臨床應盡量降低合力，減少樁核修復體所受水平分力。3.纖維主輔樁的應用可減少微滲漏的發(fā)生，有利于樁核冠向封閉性，降低樁核脫落的風險。4.纖維主輔樁系統(tǒng)臨床修復喇叭口殘根殘冠取得良好的臨床效果，可以作為保存此類殘根殘冠簡便有效的樁核修復方式。
[Abstract]:The residual root and residual crown of bell shaped root canal is more common in clinic. There are many common teeth and premolars. Its characteristic is that the root canal is open and large, and the residual tooth tissue is weak. At present, the pile core crown is the most commonly used means to preserve the residual crown and crown, but its retention shape, the resistance form is poor and the long-term effect of the pile core repair is not ideal. The current pile core repair system is due to the bomb. A variety of factors such as the sexual modulus, the suitability of the pile and the root canal wall, the polymerization shrinkage of the resin material, the complexity of the clinical operation, and other factors such as the peeling off of the pile core, the pile folding and the root fracture are the challenges and problems that the clinicians face in the preservation and repair of the residual root and residual crown. The retention of the natural root is beneficial to the retention of the periodontal membrane proprioceptor and the reduction of the natural tooth root. Therefore, in order to retain the residual root and crown, prolong the service life of the prosthesis, explore a better way to repair the bell root canal pile nuclear repair is a problem that the clinicians need to solve. Fiber main and auxiliary pile is a new type of pile core repair system in recent years, with elastic modulus and dentin. At present, the research on its flexural properties is mainly focused on the basic research on its flexural performance, and it is rarely reported in clinical application. For clinical dentists to repair the residual root and crown more attention is the long-term restoration effect. Can the main and auxiliary pile repair system reduce the occurrence of root fracture and pile removal, and obtain long-term long-term effect. Can the stress transfer method be beneficial to reduce the stress concentration? How is the actual leakage of leakage? And how is the success rate of clinical repair? Some questions need to be examined for further verification.
In this study, three dimensional finite element method, dye penetration method and scanning electron microscope method were used to investigate the stress distribution of the fiber main auxiliary pile system to repair the dentin of the bell mouthed root canal, and to follow the clinical practice, to track the clinical application effect of the main fiber auxiliary pile, and to repair the residual root and residual crown of the horn root canal. The clinical application provides some biomechanical support, basic theoretical basis and clinical reference. The paper consists of three parts, as follows:
Part one stress analysis of fiber main and auxiliary piles to repair the maxillary central incisors of bell shaped root canal
Through spiral CT scanning a healthy male maxillary incisor and alveolar bone, accurately obtaining image information, using Mimics, Geomagic and other finite element software, the three-dimensional finite element model of normal maxillary incisor and periodontium was established, and Solidworks software was used to establish the root canal of different dentin shoulder collar, fiber main pile, auxiliary pile and metal pile. According to the same width 0.5mm, the height of the shoulder collar is divided into 0mm, 1mm, 2mm group according to the same width of the dentin shoulder collar, and the different pile core materials are divided into fiber main and auxiliary piles, single fiber pile and metal pile group; the different loading conditions are divided into 45 degrees of the same loading angle, and the different loading force values (60N, 80N, 100N, 120N, 150N) and the same loading force value 100 N, different loading angles (0, 30, 45, 60, 90) two experimental group, the stress distribution of the root canal dentin is analyzed. The results are as follows: compared with the metal pile, the main and auxiliary pile group can reduce the stress concentration of the dentin in the root tip, the stress distribution is uniform, and the stress distribution of the single fiber pile is similar, there is no obvious difference; with the dentin shoulder collar The peak stress peak value decreases and the stress distribution range decreases with the height increase. From 0mm to 1mm height, this change is most obvious, VonMises stress is reduced by 3.94%, maximum tensile stress is reduced by 4.18%; the same load angle 45 degrees, 60N to 150N joint force range, compared with single fiber pile, the peak stress of the main fiber pile group is slightly larger, but it is not obvious. Differences. The peak stress value of two groups increases with the resultant force value, the stress value of dentin Von Mises is up to 42.469MPa, all in the normal range of dentin. When the same load load is 100N, the load angle is from 0 to 90 degrees, the peak stress of the main and auxiliary pile group is slightly larger than that of the single fiber pile group, and there is no obvious difference between the dentin stress and the stress. The distribution range and load angle change are closely related. When the loading angle is 90 degrees, the maximum principal stress value of dentin reaches 54.153MPa, reaching the maximum tensile stress value of dentin.
The above results suggest that the repair of the bell mouthed root canal can reduce the irreversible root fracture, and the stress distribution of the single fiber pile is close to that of the single fiber pile. The retention of the root canal height of 1mm, 0.5mm thickness of the dentinal shoulder collar can provide a certain hoop effect, and the residual tooth tissue should be retained as far as possible. In addition, the increase of bite force and angle of load will increase the risk of neck fracture.
The second part is to study the microleakage of maxillary central incisors restored with fiber main and auxiliary piles.
52 isolated upper maxillary incisors were divided into two groups, single branch prefabricated fiber pile group, A1 (n=20), A2 (n=6), and fiber main pile group, including B1 (n=20), B2 (n=6). All the samples were attacked by water for January. A1, B1 was placed in India ink for 1 weeks, dyed, transparent and in body microscope. The microleakage between the pile core and the root canal wall was observed. A2, B2 was divided into root neck, root, and three parts of root tip, each part was divided into four points, and the mandible was placed in the scanning electron microscope to observe the dentin dentin interface. The results were observed by the grade score record, and the results were analyzed by non parametric test statistics. The results showed that the repair method of the main fiber auxiliary pile group was introduced. The microleakage value of the fiber pile crown was significantly smaller than that of the single fiber pile group (P0.05). The fiber main and auxiliary pile groups and the single fiber pile groups showed different degrees of dentin bond gap, and the discontinuity of the adhesive dentin interface produced by the single fiber pile group was more obvious than that of the fiber main pile group, especially in the crown square (P0.05).
The experimental results show that, compared with single fiber pile, fiber main and auxiliary piles can reduce the occurrence of microleakage by reducing the amount of resin cement, which is more conducive to the closure of post and core restoration, reduce the risk of falling off, and provide a powerful theoretical basis for the clinical application of fiber main and auxiliary piles.
The third part of the clinical application of fiber main and auxiliary piles to repair bell shaped root canals: typical cases
According to the clinical inclusion criteria, 37 dental flared single root canal affected teeth of 28 patients were repaired after root canal treatment. After the repair, the clinical reexamination was carried out half a year after the repair was completed and followed for 26 months. The revised form of the evaluation standard of the California Dental Association on the restoration body was completed. Integrity, marginal fitness, periodontal and periapical tissue health evaluation of.37 repair body integrity, the success rate of 100%; crown edge of 91.89%, acceptable 8.11%; color match up to 75.68%; gingival condition up to 83.79%; fiber pile and resin core no loosening, fracture, gap and so on; no abnormal root apex, no root fracture occurred.
The clinical follow-up results show that the fiber main and auxiliary pile system is a good post and core restoration method with trumpet shaped residual roots and crowns. It can be widely applied in clinical practice.
To sum up, fiber main and auxiliary piles have some advantages to repair the residual root and residual crown of bell shaped root canal, which is reflected in the following aspects: 1. compared with metal pile, the stress distribution of the root tip of the main fiber auxiliary pile is uniform and similar to the stress distribution of single fiber pile, which can reduce the occurrence of irreversible root fracture. The 1mm height of the bell mouthed root canal and the thickness of 0.5mm The retention of the dentin shoulder collar can provide a certain hoop effect. The stress distribution of the.2. fiber main pile group and the single fiber pile is not obviously different. The occlusion state affects the stress distribution of the dentin, the clinical should reduce the resultant force as far as possible, and the application of the horizontal force.3. fiber main and auxiliary pile can reduce the occurrence of microleakage, and is beneficial to the reduction of the microleakage. The.4. fiber main auxiliary pile system has good clinical effect on repairing the residual root and residual crown of the bell mouth. It can be used as a simple and effective method to repair the residual root and crown of this kind of residual root and core.

【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R783.3

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