本文選題：種植體周圍炎 + 過度負荷�。� 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：研究背景 種植體周圍炎(Peri-implantitis)是指伴有(或不伴有)軟組織炎癥的種植體周圍骨組織的進行性吸收,其發(fā)病率為28-56%。種植體周圍炎是導(dǎo)致臨床種植體失敗的主要原因。種植體周圍炎具有其臨床表現(xiàn)特點,一開始表現(xiàn)為為附著喪失,探診深度增加,早期骨吸收僅累及牙槽嵴頂,根方仍保持骨結(jié)合狀態(tài),種植體可以不松動,后期隨著周圍支持骨的逐漸喪失,牙槽骨高度減低,或可探及較深的種植體周袋,發(fā)生種植體松動,從而導(dǎo)致骨結(jié)合的失敗。后期放射線檢查可觀察到種植體周圍骨組織有透射吸收影,骨吸收的類型可以分類為蝶形、漏斗型或裂隙狀骨吸收。 種植體周圍炎最早由Levignac在1965年觀察并描述,后來由Mombelli等人定義為“在特定位點發(fā)生的,類似牙周疾病的感染”。這個定義后來發(fā)展并更換為“與種植體周圍支持骨喪失相關(guān)的炎癥反應(yīng)”。在2011年發(fā)表的一個共識報告里認為,細菌感染是引起種植體周圍骨喪失的始動因素。該報告還特別強調(diào)了與種植體周圍炎有關(guān)的臨床特點以及種植體周圍炎與牙周炎病因的相似性。然而有些學(xué)者卻認為,種植體和骨是直接結(jié)合的,與具有緩沖作用的牙齒和牙周膜連接方式大不相同,因此與臨床相關(guān)種植體周圍骨喪失的特定病因不一定也是菌斑積聚。所以有人提出了其它原因來支持不可預(yù)知的骨喪失,如過度的機械負荷。這些其它原因誘導(dǎo)已經(jīng)骨結(jié)合的界面發(fā)生反應(yīng)性變化,最終導(dǎo)致整個種植體失敗。 由于所提出的關(guān)于種植體周圍炎的致病原因研究最多的是菌斑生物膜積聚和過度咬合負載,所以以往動物研究專門關(guān)注在這些普遍認為的致病因素上。以往學(xué)者通過動物實驗和臨床檢查得出結(jié)論,認為在種植體周圍感染的過程中,菌斑生物膜的積聚是其原發(fā)病因。而對于過度負荷因素對種植體周圍骨吸收的影響一直未有定論。Isidor對猴的動物實驗研究發(fā)現(xiàn)過度負荷對種植體骨結(jié)合喪失的影響比菌斑積聚更大；Rosenberg等和Sanz等從臨床和微生物學(xué)的角度出發(fā),將種植體周圍骨吸收劃分為細菌性和非細菌性的；而Kozlovsky等通過對犬的研究結(jié)果得出,當(dāng)種植體周圍黏膜無炎癥狀態(tài)時,過度負荷增加了骨-種植體接觸,并且只是輕度降低了邊緣骨高度,而若存在種植體周圍炎癥時,過度負荷則加重了菌斑引起的骨吸收；Isidor認為過度負荷引起骨整合的喪失,而菌斑積聚引起的是骨組織的吸收而非骨整合的喪失。 誘導(dǎo)菌斑積聚多通過在種植體和基臺連接處周圍結(jié)扎絲線或正畸橡皮筋來建立動物模型；絲線結(jié)扎誘導(dǎo)法是通過破壞種植體-軟組織界面的上皮袖口的封閉作用,從而引起的菌斑堆積、微環(huán)境變化進而導(dǎo)致種植體周圍軟硬組織破壞。而過度負荷一般是由加高咬合或是在兩個種植體之間連接彈性裝置來實現(xiàn)。 目的 本實驗試圖在建立的種植體周圍炎動物模型的基礎(chǔ)上,通過臨床探診和組織學(xué)觀察來研究過度負荷對種植體周圍骨吸收的影響。 材料與方法 1.材料 健康成年雄性Beagle犬4只,犬齡16～18個月,體重12.5～14.5kg。購自高要市康達實驗動物科技有限公司,所選的實驗動物生化指標(biāo)均正常,神態(tài)正常,無急性炎癥,無傳染性疾病。所有犬牙列完整,無慢性牙周病及齲病,口腔黏膜正常,咬合關(guān)系正常。Beagle犬飼養(yǎng)和動物實驗手術(shù)均在南方醫(yī)科大學(xué)南方醫(yī)院動物實驗研究中心進行。實驗選用種植體為Dentium種植系統(tǒng)SuperLine系列型號FX4010SW種植體32顆,規(guī)格4.0mm×10mm,大顆粒噴砂及酸蝕(sandblasted, large-grit, acidetched, SLA)表面處理。Dentium種植系統(tǒng)愈合基臺32顆,型號HAB402035L。Dentium種植系統(tǒng)分體式六角基臺(含基臺螺絲)32顆,型號DAB4510HL。 2.實驗分組情況 擬在種植體植入術(shù)后10w安裝修復(fù)基臺,按種植體是否過度負荷和種植體頸部是否結(jié)扎絲線這2個處理因素,將每只Beagle犬口內(nèi)的8顆種植體分為四組,分組具體情況如下：下頜每側(cè)近中2顆種植體安裝修復(fù)基臺后為不加負載,遠中2顆種植體利用加高對應(yīng)上頜咬合獲得過度負荷,然后隨機選取其中一側(cè)4顆種植體通過在基臺頸部纏繞4-0絲線獲得感染,另一側(cè)4顆種植體則為非感染側(cè)。這樣,每只Beagle犬口內(nèi)共有4組種植體,每組各2顆,分組為UU(unloaded and uninflamed)、LU (loaded and uninflamed)、UI (unloaded and inflamed)、LI (loaded and inflamed)。 3.動物模型的建立 4只Beagle犬術(shù)前禁食24h,禁水4h,按30mg/kg的劑量在靜脈注射3%戊巴比妥鈉進行全身麻醉后,利用牙挺和牙鉗拔除犬雙側(cè)下頜共8顆前磨牙。術(shù)后使用抗生素進行預(yù)防性感染。8w拔牙創(chuàng)愈合后,自牙槽嵴頂切開牙齦,分離粘骨膜瓣。無菌生理鹽水冷卻下,逐級預(yù)備種植窩,在每只Beagle犬的下頜前磨牙區(qū)每側(cè)各植入4顆種植體,種植體完全就位后確保種植體頸部頂端與牙槽嵴頂在同一骨水平,安放愈合基臺。種植體植入術(shù)后10w取下愈合基臺,安放修復(fù)基臺,隨機選取一側(cè)的種植體基臺頸部結(jié)扎4-0絲線,另一側(cè)則不結(jié)扎絲線。充填樹脂加高遠中2顆種植體的對應(yīng)上頜牙齒的咬合,使上下第一磨牙咬合時可通過厚約1mm的10層滲透性咬合紙,進而使遠中2顆種植體獲得過度的咬合力。安放修復(fù)基臺后使用0.05%醋酸洗必泰溶液和兒童軟毛刷清潔對照側(cè)未結(jié)扎絲線側(cè)的牙列,每周進行1次。加載2個月后心內(nèi)空氣栓塞法處死實驗動物。 4.臨床指標(biāo)測量 種植體植入后愈合10w,觀察種植術(shù)區(qū)愈合情況。種植體周圍無感染,無松動脫落,愈合基臺完好。在安放修復(fù)基臺后2w、4w、6w、8w的時間點對4只beagle犬進行叩診、松動度檢查和種植體周的探診。選用塑料探針來探查種植體周,使用時垂直進入牙周袋底,力度約為0.2N,檢查牙齦指數(shù)(GI, gingival index)、改良齦溝出血指數(shù)(mSBI, modified Sulcus Bleeding Index)以及牙周探診深度(PD,probing depth). 5. X-ray觀察 4只beagle犬處死后分離出下頜骨,通過放射檢查定位,制取獨立標(biāo)本后置于10%福爾馬林液中浸泡72h完成初固定。之后將帶種植體的獨立樣本分別用保鮮膜包裹好,采用平行投照的原理,利用數(shù)碼牙片機觀察種植體周圍骨組織的情況。 6.制作不脫鈣組織切片及組織學(xué)觀察 將完成初固定的標(biāo)本利用EXAKT300CP組織切割系統(tǒng)修整后完成終固定,梯度酒精逐級脫水,光固化樹脂滲透,光照包埋聚合后,利用EXAKT400CS/AW打磨系統(tǒng)和EXAKT300CP組織切割系統(tǒng)切片,電子測量控制系統(tǒng)下磨片,甲苯胺藍染色,封片,移至光學(xué)顯微鏡下觀察并測量興趣區(qū)骨組織-種植體接觸率(BIC%, bone-implant contact as percent of the total implant osseous length). 7.統(tǒng)計學(xué)分析 應(yīng)用SPSS13.0統(tǒng)計軟件對實驗獲取的各類檢測指標(biāo)的數(shù)據(jù)進行歸類、整合及分析,進行統(tǒng)計學(xué)分析。加載后2w、4w、6w、8w,4組探診的GI、mSBI比較采用多個獨立樣本非參數(shù)檢驗(K Independent Samples Test)中的多組等級/頻數(shù)表資料的比較進行統(tǒng)計；加載后2w、4w、6w、8w,4組探診深度的變化比較采用單個重復(fù)測量因素的方差分析；8周后4組骨組織-種植體接觸率的比較采用單向方差分析(One-Way ANOVA)。檢驗水準(zhǔn)為α=0.05,當(dāng)P0.05時,差異被認為無統(tǒng)計學(xué)意義；當(dāng)P0.05時,差異被認為具有統(tǒng)計學(xué)意義。 結(jié)果 1.大體觀察 所有Beagle犬均于全麻后3～5小時內(nèi)清醒,清醒后30min內(nèi)可站立行走,自行進食飲水。拔牙術(shù)和種植術(shù)后10d內(nèi)飼喂流食,第10d拆除縫線后恢復(fù)飼喂Beagle犬專用飼料,進食飲水無障礙,精神良好,活動正常,體重變化不大,全部存活。種植體植入術(shù)后種植體未出現(xiàn)排斥反應(yīng),愈合基臺均存留。 2.探診指標(biāo)測量 加載后2w的GI,UU組和LU組之間無顯著性差異,UI組和LI組之間無顯著性差異,LU組和LI組之間存在顯著性差異。加載后2w的mSBI,UU組和LU組之間無顯著性差異,UI組和LI組之間存在顯著性差異,LU組和LI組之間存在顯著性差異。 加載后4w的GI和mSBI, UU組和LU組之間存在顯著性差異,UI組和LI組之間無顯著性差異,LU組和LI組之間存在顯著性差異。 加載后6w的GI, UU組和LU組之間存在顯著性差異,UI組和LI組之間無顯著性差異,LU組和LI組之間存在顯著性差異。加載后6w的mSBI, UU組和LU組之間存在顯著性差異,UI組和LI組之間存在顯著性差異,LU組和LI組之間存在顯著性差異。 加載后8w的GI, UU組和LU組之間存在顯著性差異,UI組和LI組之間無顯著性差異,LU組和LI組之間存在顯著性差異。加載后8w的mSBI,UU組和LU組之間存在顯著性差異,UI組和LI組之間存在顯著性差異,LU組和LI組之間存在顯著性差異。 加載后2-8w的PD值通過分析發(fā)現(xiàn),隨著加載時間推移,不同處理組的PD值具有顯著性差異。通過多重比較方法得出,在2w、4w、6w、8w時,UU組和LU組之間均無顯著性差異,UI組和LI組之間均無顯著性差異,LU組和LI組之間均具有顯著性差異。 3. X-ray檢查 加載后8w,UU組和LU組的種植體近遠中牙槽骨幾近與種植體頸部頂端平齊,未見明顯吸收,UI組種植體頸部近遠中牙槽骨則出現(xiàn)裂隙狀透射影,說明種植體頸部已經(jīng)開始出現(xiàn)骨吸收,LI組跟UI組相比較種植體頸部的透射影呈角形,說明牙槽嵴頂部骨吸收活動更加嚴重。 4.組織學(xué)比較 利用顯微鏡自帶圖像分析軟件觀察分析,加載后8w的UU組、LU組、UI組、LI組的平均BIC%為：(83.15±2.47)%,(87.71±1.77)%,(83.58±2.52)%,(86.76±2.06)%,通過分析后比較得出4組之間的差異具有統(tǒng)計學(xué)意義,進一步比較后發(fā)現(xiàn)UU組和LU組之間存在顯著性差異,UI組和LI組之間存在顯著性差異,LU組和LI組之間無顯著性差異。 鏡下可觀察到：(1)UU組和UI組：骨組織與種植體表面緊密接觸,周圍可見平行排列的板層骨,同心圓狀哈弗氏管散在分布于其中；(2)LU組和LI組：骨組織與種植體表面結(jié)合緊密,周圍呈致密板層骨結(jié)構(gòu),骨細胞有規(guī)律地分布在板層結(jié)構(gòu)中,哈弗氏管大量形成呈緊密排列狀。 結(jié)論 1. Beagle犬性情溫順,容易飼養(yǎng),易于操作,體格強健,疾病抵抗能力強,其牙槽骨較寬,骨質(zhì)致密,與人的牙槽骨較為接近,對于拔牙后延期植入種植體達到骨整合有較為成熟的實驗流程,可以成功應(yīng)用于建立種植體周圍炎動物模型的研究。 2.絲線結(jié)扎誘導(dǎo)菌斑積聚能導(dǎo)致種植體周圍軟組織炎癥,并增加種植體周圍的探診深度。 3.當(dāng)種植體周圍軟組織存在炎癥時,種植體頸部骨組織吸收明顯。 4.過度負荷會增加骨-種植體接觸率,軟組織炎癥并不影響骨-種植體接觸率。
[Abstract]:Background of the study

The peri - implant inflammation is the progressive absorption of peri - implant bone tissue with ( or without ) soft tissue inflammation , the incidence of which is 28 - 56 % . The peri - implant inflammation is the main cause of failure of clinical implant .

This definition was later developed and replaced by " inflammation reactions associated with bone loss associated with peri - implant bone loss " . The report also highlights the clinical features associated with peri - implant bone loss and the similarities between peri - implant and periodontitis . However , some scholars believe that implants and bone are directly bound and are not necessarily associated with bone loss associated with peri - implant bone loss . Other reasons are therefore proposed to support unpredictable bone loss , such as excessive mechanical loads . These other causes induce reactive changes in the interfaces that have been bone - bound , which ultimately lead to failure of the entire implant .

The study of animal experiments and clinical studies concluded that the accumulation of plaque biofilm was the primary cause of infection in peri - implant .
Rosenberg et al . and Sanz et al . , from the perspective of clinical and microbiology , divide the bone resorption around the implant into bacterial and non - bacterial ;
The results from the study of dogs showed that excessive loading increased the bone - implant contact when there was no inflammation in the mucosa around the implant , and only slightly reduced the marginal bone height , whereas in the presence of inflammation around the implant , excessive load increased bone resorption caused by plaque ;
Isidor is of the opinion that excessive loads cause loss of bone integration , and plaque accumulation results in the loss of bone tissue absorption rather than bone integration .

inducing plaque accumulation to build an animal model by ligation of a wire or orthodontic band around the implant and abutment junctions ;
The wire ligation induction method is achieved by destroying the sealing action of the epithelial cuffs of the implant - soft tissue interface , resulting in plaque build up , micro - environmental changes which in turn lead to the destruction of soft and hard tissue around the implant , and the excessive load is generally achieved by a high bite or by connecting an elastic device between the two implants .

Purpose

This study attempted to investigate the effect of excessive load on bone resorption around implants based on the establishment of an animal model of peri - implant inflammation .

Materials and Methods

1 . Materials

Healthy adult male Beagle dogs 4 , dog age 16 - 18 months , body weight 12.5 ~ 14.5kg . The selected experimental animal biochemistry index is normal , normal , no acute inflammation , no infectious disease . All canine teeth are complete , no chronic periodontitis and caries , oral mucosa is normal , bite relation is normal . Beagle dog breeding and animal experiment operation are treated on the surface of Southern Medical University Animal Experimental Research Center .

2 . Experimental grouping

There were four implants in each Beagle dog oral cavity . The four implants in each group were infected by higher jaw occlusion and four implants on the other side were non - infected .

3 . Establishment of animal model

The results showed that there were 8 anterior teeth on the anterior teeth of the dog . After the operation , four implants were removed from the top of the alveolar bone . After the implant was fully seated , four implants were implanted from the top of the alveolar bone . After the implant was fully seated , the top of the implant neck and the alveolar ridge were placed on the same bone level .

4 . Measurement of clinical indicators

The healing of implant was observed after implant implantation . There was no infection in the peri - implant region , no loose shedding , and good healing abutment . At 2w , 4w , 6w and 8w after the implantation of the prosthetic group , four dogs were examined for percussion , loosening and implant weeks . The implant was examined by plastic probe . The force was about 0.2N , the gingival index ( GI ) , the improved gingival sulcus bleeding index ( mSBI , modified Sulcus Index ) , and the periodontal diagnostic depth ( PD ) were improved .

5 . X - ray observations

After 4 dogs were sacrificed , the mandible was separated , and the specimens were placed in 10 % formalin for 72 h to complete initial fixation . Then , the independent samples with implant were wrapped with preservative film , and the bone tissue around the implant was observed by digital dental machine .

6 . Preparation and histological observation of calcium - free tissue

After finishing the initial fixed specimen with EXAKT300CP tissue cutting system , complete the final fixation , gradient alcohol step - by - step dehydration , photo - curing resin infiltration , illumination - embedding polymerization , using EXAKT400CS / AW polishing system and EXAKT300CP tissue cutting system slice , electronic measurement control system to stain and seal , and move to optical microscope to observe and measure the bone tissue - implant contact rate of interest area ( BIC % , bone - implant contact as percent of the total implant contact length ) .

7 . Statistical Analysis

SPSS 13.0 was applied to classify , integrate and analyze the data of various kinds of test indexes acquired by the experiment . The GI and mSBI of 2w , 4w , 6w , 8w , and 4 groups after loading were compared .
After loading 2w , 4w , 6w , 8w and 4 , the variance of probing depth was compared with that of single repeat measurement .
One - way ANOVA was used for the comparison of bone tissue - implant contact rates at 4 groups after 8 weeks . The level of test was 偽 = 0.05 , when P0.05 , the difference was considered to be of no statistical significance ;
When P0.05 , the difference was considered statistically significant .

Results

1 . General observations

All Beagle dogs were conscious in 3 to 5 hours after general anesthesia , and were able to stand and walk within 30 minutes after waking . After extraction and 10 days after implantation , the animals were fed with a diet . After 10 days of extraction , the animals were fed with special feed . After 10 days of removal of the suture , the animals were fed with special feed for Beagle dogs . No obstacle to feeding drinking water , good mental health , normal activity and low body weight , all survived . After implant implantation , no graft rejection occurred and the healing abutment remained .

2 . Measurement of diagnostic index

There was no significant difference in the GI , UU and LU groups of 2w after loading . There was no significant difference between the UI group and the LI group . There was no significant difference between the LU group and the LI group . There was a significant difference between the group of mSBI , UU and LU after loading . There was a significant difference between the UI group and the LI group . There was a significant difference between the LU group and the LI group .

There was a significant difference between the GI and mSBI , UU and LU groups of 4w after loading , there was no significant difference between the UI group and the LI group , and there was a significant difference between the LU group and the LI group .

There was a significant difference between the two groups , namely the GI , UU and LU groups of 6w after loading . There was a significant difference between the LU group and the LI group . There was a significant difference between the LU group and the LI group . There was a significant difference between the UI group and the LI group , and there was a significant difference between the LU group and the LI group .

There was a significant difference between the two groups : the GI , UU and LU groups of 8w after loading . There was a significant difference between the LU group and the LI group . There was a significant difference between the LU group and the LI group . There was a significant difference between the group of mSBI , UU and LU after loading . There was a significant difference between the UI group and the LI group .

The PD values of 2 - 8w after loading were analyzed and found that the PD values of different treatment groups were significantly different with the time of loading . Through multiple comparison methods , there was no significant difference between the UU group and LU group at 2w , 4w , 6w , 8w , there was no significant difference between the UI group and the LI group , and there was significant difference between the LU group and LI group .

3 . X - ray inspection

The alveolar bone near the implant neck was almost flush with the top of the implant neck after loading 8w , UU and LU , but no obvious absorption was observed . The alveolar bone in the proximal part of the implant neck in the UI group appeared to have a fissure - like projection , indicating that the implant neck had begun to have bone resorption , and the LI group had an angle with the UI group to compare the penetration of the implant neck .

4 . Histological Comparison

The mean BIC % of the UU group , the LU group , the UI group and the LI group was ( 83.15 鹵 2.47 ) % , ( 87.71 鹵 2.52 ) % , ( 86.76 鹵 2.06 ) % , ( 86.76 鹵 2.06 ) % , and there was a significant difference between the two groups . There was no significant difference between the LU group and the LI group .

The results showed that : ( 1 ) UU group and UI group : the bone tissue was in close contact with the surface of implant body , the peripheral visible parallel lamellar bone , concentric circle Haversian canal scattered among them ;
( 2 ) LU and LI groups : the bone tissue is tightly combined with the surface of the implant body , the surrounding is a compact lamellar bone structure , the osteocytes are regularly distributed in the plate layer structure , and the Haversian canal is formed in a large number of closely aligned shapes .

Conclusion

1 . Beagle dog has the advantages of mild temperament , easy feeding , easy operation , strong physique , strong disease resistance , wide alveolar bone , compact bone , and relatively mature alveolar bone , and can be successfully applied to the research of establishing an animal model around the implant .

2 . wire ligation induces plaque accumulation which can lead to soft tissue inflammation around the implant and increase the depth of probing around the implant .

3 . When there is inflammation in the soft tissues around the implant , the bone tissue of the implant neck is obviously absorbed .

4 . Over - load increases the bone - implant contact rate , and soft tissue inflammation does not affect the bone - implant contact rate .
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R783.6

【參考文獻】

相關(guān)期刊論文 前5條

1 王東勝;;帶種植體骨磨片制作方法的改進[J];口腔頜面修復(fù)學(xué)雜志;2006年03期

2 劉雯;胡峗;鄧鋒;宋錦t，

本文編號：2106527