富血小板纤维蛋白在牙槽嵴位点保存应用中的临床研究

发布时间：2018-03-28 05:31

本文选题：富血小板纤维蛋白　切入点：GBR　出处：《泸州医学院》2014年硕士论文

【摘要】：目的：以拔牙后引导骨组织再生（Guided Bone Regeneration，GBR）位点保存术（骨替代材料+屏障膜）作为对照组，观察富血小板纤维蛋白（Platelet-Rich Fibrin，PRF）在拔牙位点保存应用中的临床效果，比较两者牙槽骨骨量保存效果和骨质再生情况，并研究PRF位点保存效果随时间变化趋势，通过对比观察临床效果，分析两种材料的应用特点和应用优势，为临床拔牙后位点保存术材料的选择提供新的参考依据。方法：选取2012年12月到2014年3月到成都军区口腔种植修复临床专科中心就诊的19位患者（男性11位，女性8位，年龄19到61岁，平均40.8岁），共20颗无法保留的单颗上颌前牙或上颌前磨牙患牙（切牙5颗，前磨牙15颗）。按随机数字化表分为3组：对照组（Bio-oss组）、实验组1（A组）、实验组2（B组），其中Bio-oss组8颗牙位，A组、B组分别6颗牙位。Bio-oss组拔牙后以Bio-oss骨替代材料+屏障膜行GBR位点保存术，术后6个月完成种植体植入术。A组、B组均使用自体PRF进行位点保存术，分别于术后3个月、6个月行种植体植入术。所有患者于种植体植入术术中取2.2×6.0mm新生骨组织标本，固定备用。同期植入种植体Bego RIφ4.1×10.0mm，记录种植体完全就位时的植入扭矩值，初步评价两种新生骨组织的生物力学性能。拔牙术前3天（T1）、种植术前10天(T2)分别拍摄锥形束CT（Cone-Beam Computed Tomography, CBCT），利用GALAXIS软件获得影像，测量每位患者T1、T2唇侧牙槽嵴顶下2mm、5mm、8mm三个位点牙槽骨宽度及近远中牙槽嵴顶骨高度，分析三个观察位点的骨宽度和近远中牙槽嵴顶骨高度吸收值，评价Bio-oss组、A组、B组的骨量保存效果。对种植术中取得的骨组织标本进行HE染色，Masson三色染色，骨钙素（Osteocalcin，OC）、细胞核因子受体活化因子配基（Receptor activator of nuclear factor κB，RANKL）、骨保护素（Osteoprotegerin，OPG）三指标的免疫组织化学分析，评价三组患者新生骨组织的组织学特点。结果： 1．影像学观察：根尖X线片：Bio-oss组术后当日拔牙位点影像呈高密度影，拔牙窝边界清楚，骨替代材料颗粒清晰可辨。种植术前该组患者拔牙窝边界模糊，但冠方和中心区仍表现为高密度影；A组、B组术后当日拔牙位点影像呈低密度影，拔牙窝空虚，边界清楚。A组种植术前X线片显示拔牙窝边界模糊，透射影与周围骨接近，冠方中心区骨密度低于周围骨； B组种植前拔牙位点骨密度与周围骨接近（组图1-2）。 CBCT（T2）影像： Bio-oss组位点保存区骨密度较周围骨高，尤其在冠方和中心区表现明显，越靠近牙槽窝骨壁，骨密度越接近周围骨； A组位点保存区骨密度明显低于周围骨，越往冠方骨密度越低；B组位点保存区骨密度与周围骨接近，但中心区骨密度略低，仍能通过CBCT影像辨别（组图1-3）。 2.术中翻开粘膜瓣，暴露牙槽嵴顶，均可见原拔牙窝内充满硬组织，Bio-oss组黏膜瓣与骨面粘连明显，牙槽嵴顶骨面可见残留骨替代材料颗粒，A、B组病例牙槽嵴顶骨面光滑，易翻开黏膜瓣（组图2-3)。 3. Bio-oss组、A组、B组各自平均植入扭矩值均大于32N.cm，属理想的临床初期固位力。分别比较Bio-oss组与B组，A组与B组植入扭矩值差异未见统计学意义（P＞0.05）。 4.对比分析位点保存术前和种植体植入术前的CBCT影像，Bio-oss组、A组、B组牙槽嵴顶下2mm、5mm、8mm三个位点均存在骨宽度吸收，表现为冠方骨宽度吸收较根方严重。比较Bio-oss组与B组，A组与B组，三个位点的骨宽度吸收值未见统计学差异（P0.05）。Bio-oss组、A组、B组近远中牙槽嵴均存在骨高度降低，Bio-oss组与B组比较，近远中骨高度吸收均有统计学差异（P0.05），A组与B组比较，近远中骨高度吸收无统计学差异（P0.05）。 6.HE染色：Bio-oss组新生骨组织紧贴Bio-oss骨替代材料表面，外周被纤维结缔组织包绕，根方骨小梁较冠方宽大，密集；A组根方骨小梁较冠方宽大，密集，纤维结缔组织致密。冠方骨小梁稀疏，连接中断点多，间距宽，纤维结缔组织大量增生；B组骨小梁排列密集，由纤维结缔组织分隔形成网状结构；三组均可见骨血管化。Masson三色染色：三组均呈现红-蓝相间，Bio-ss组和B组新生骨百分比存在统计学差异（P0.05），A组和B组新生骨百分比无统计学差异（P0.05）。免疫组织化学分析：OC、RANKL、OPG三项指标免疫组织化学平均光密度分析结果显示Bio-ss组与B组，A组与B组均无统计学差异（P0.05）。结论： 1.应用PRF和Bio-oss骨替代材料+屏障膜进行拔牙后位点保存，拔牙窝内均有新生骨组织生成，表现为向心性成骨。 2.植入扭矩值能初步判定新生骨组织的骨质量，PRF位点保存3个月时骨量和骨质均能达到种植手术标准，，满足种植体植入条件。 3. PRF和Bio-oss骨替代材料均能一定程度保存拔牙位点的骨宽度，但不能完全阻断骨宽度的丢失，这种骨吸收主要发生在拔牙窝冠方，越往根方丢失量越小；PRF对骨高度保存的作用不如Bio-oss骨替代材料；应用PRF进行拔牙后位点保存术，术后3个月与6个月相比，骨高度和骨宽度的丢失差别不明显，已趋于稳定。 4. Bio-oss骨替代材料和PRF均能促进硬组织形成，组织学表现为新骨形成伴血管化活跃。Bio-oss骨替代材料会延迟拔牙窝骨组织愈合，临床使用时，成骨时间等待6个月以上为宜；PRF进行拔牙位点保存3个月时已能获得较好的骨质，但随着时间延长，新生骨质量会更好。
[Abstract]:Objective : To observe the clinical effect of platelet - rich fibrin ( PRF ) in the preservation of tooth extraction site by guiding bone tissue regeneration after tooth extraction ( bone substitute material + barrier film ) as the control group , compare the effect of bone mass storage and bone regeneration on the alveolar bone , and study the clinical effect of PRF locus . The clinical effect of the two materials was analyzed . The application characteristics and application advantages of the two materials were analyzed , and the new reference basis was provided for the selection of the material for post - extraction site preservation .

Methods : 19 patients ( 11 male , 8 female , 19 to 61 years old , mean 40.8 years old ) were selected from December 2012 to March 2014 in the department of oral implantation and repair in Chengdu Military Region . All patients received 2.2 脳 6.0mm new bone tissue specimens from implant implantation . All patients received 2.2 脳 6.0mm new bone tissue samples . All patients received 2.2 脳 6.0mm new bone tissue samples .

Results :

1 . Imaging observation :

X - ray of root tip : The image of tooth extraction site of Bio - oss group was high density shadow , the border of tooth extraction and fossa was clear , bone substitute material particles were clearly identifiable . Before operation , the boundary of tooth extraction pit was blurred , but the crown and central area were still high density shadow ;
In group A and group B , the image of the tooth extraction site was low density shadow , and the tooth extraction cavity was empty and the border was clear . The X - ray film showed the blurring of the boundary of the tooth - extraction fossa before the operation of the group A , and the bone mineral density in the central region of the crown was lower than that of the surrounding bone ;
Bone mineral density was close to the surrounding bone in group B ( group 1 - 2 ) .

CBCT ( T2 ) image : the bone mineral density of the site preservation area of the Bio - oss group was higher than that in the surrounding bone , especially in the coronal and central areas , the closer the bone density approached the alveolar bone wall , the closer the bone density approached the surrounding bone ;
The bone mineral density of site A was significantly lower than that of the surrounding bone , and the lower the bone mineral density was .
Bone mineral density was close to the surrounding bone in Group B site , but the bone mineral density was slightly lower in the central region and could still be distinguished by CBCT image ( group 1 - 3 ) .

2 . During the operation , the mucoid flap was opened and the alveolar ridge was exposed . It was found that the original tooth cavity was filled with hard tissue , and the mucosal flap of the Bio - oss group had obvious adhesion with the bone surface . The residual bone substitute material particles were visible in the alveolar bone surface .

3 . The average implanted torque values of Bio - oss group , group A and group B were more than 32 N 路 cm , which were the ideal initial fixation force . The difference of implant torque values between Bio - oss group and group B , group A and group B was not statistically significant ( P > 0.05 ) .

4 . There was significant difference in bone width between the two groups ( P0.05 ) . Compared with group B , group A and group B , there were significant differences in bone height ( P0.05 ) . There was no significant difference in bone height absorption between Bio - oss group and group A , group A and group B ( P0.05 ) .

6 . HE staining : Bio - oss new bone tissue is closely attached to the surface of Bio - oss bone substitute material , and the periphery is surrounded by fibrous connective tissue .
In group A , the trabecular bone of the root of the root was wider , dense , and the connective tissue of the fiber was dense . The crown block was sparse , the connection was broken , the spacing was wide , and the connective tissue of the fibrous connective tissue was proliferated .
B , the trabecular structure is densely arranged , which is separated by fibrous connective tissue to form a net structure ;
The results showed that there was no statistical difference between the three groups : OC , RANKL and OPG . The results showed that there was no statistical difference between the three groups : OC , RANKL and OPG . The results showed that there was no statistical difference between the group A and group B ( P0.05 ) .

Conclusion :

1.Using PRF and Bio - oss bone substitute material + barrier film for post - extraction site preservation , new bone tissue was formed in the tooth extraction cavity .

2 . The implantation torque value can preliminarily determine the bone quality of the new bone tissue , and the bone mass and bone mass can reach the planting operation standard at the time of 3 months after the PRF site is preserved , so as to meet the implant condition of the implant .

3 . Both PRF and Bio - oss bone substitute can preserve the bone width of tooth extraction site to some extent , but the loss of bone width can not be completely blocked .
The effect of PRF on bone height preservation is inferior to that of Bio - oss bone substitute material .
There was no significant difference in bone height and bone width between 3 months and 6 months after extraction with PRF .

4 . Bio - oss bone substitute material and PRF can promote the formation of hard tissue , and the histological manifestation is that the new bone formation accompanied by vascularization is active . Bio - oss bone substitute material can delay the healing of bone tissue in the extraction socket , and the bone formation time waits for more than 6 months for clinical use ;
The quality of the new bone will be better with the extension of the time .

【学位授予单位】：泸州医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R782.11

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