纤维主辅桩修复喇叭口根管上颌中切牙的临床应用研究

发布时间：2018-05-16 10:52

本文选题：纤维桩 + 辅桩　；参考：《大连医科大学》2014年硕士论文

【摘要】：喇叭口状根管残根残冠临床较为常见,以前牙及前磨牙多发。其特点为根管开敞粗大，剩余牙体组织薄弱。目前,桩核冠是此类残根残冠保存最常采用的手段,但其固位形、抗力形差，桩核修复的远期效果不理想。目前的桩核修复系统因弹性模量、桩与根管壁的适合性、树脂材料的聚合收缩、临床操作的复杂性等各种因素存在桩核脱落、桩折、根折的现象，也是临床医生在残根残冠保存修复中一直面临的挑战和难题。天然牙根的存留有利于牙周膜本体感受器的保留，也减少了患者的失牙数和缺牙痛苦。因此，为更大限度的保留此类残根残冠，延长修复体的使用寿命，探寻一种更佳的喇叭口根管桩核修复方式是临床医生需要解决的问题。纤维主辅桩是近年来一种新型的桩核修复系统，具有弹性模量和牙本质接近，最大限度的适合根管壁的形态、减少树脂水门汀的用量，减少聚合收缩、临床操作简便等诸多优点而被推崇。目前，国内外对其研究主要集中在其抗折性能方面的基础研究，发现它可以增强牙根抗折性能，其临床应用方面鲜有报道。对于临床口腔医生修复残根残冠更注重的是其远期修复效果，主辅桩修复系统能否减少根折及脱桩的发生,获得长期的远期疗效,其应力传递的方式能否有利于降低应力集中？实际产生的微渗漏情况如何？临床修复的成功率又如何？这些问题需要相关研究进一步验证说明。本研究通过三维有限元法、染料渗透法、扫描电镜法等方法来探讨纤维主辅桩系统修复喇叭口根管牙本质的应力分布规律、冠向封闭性，同时结合临床实践，来追踪观察纤维主辅桩的临床应用效果，为主辅桩修复喇叭状根管残根残冠的临床推广应用提供一定的的生物力学支持、基础理论依据及临床参考。论文主要有三个部分构成，具体如下：第一部分纤维主辅桩修复喇叭口根管上颌中切牙的应力分析通过螺旋CT扫描一名健康男性上颌中切牙及牙槽骨，准确获取图像信息，运用Mimics、Geomagic等有限元软件，建立正常上颌中切牙及牙周组织三维有限元模型，采用Solidworks软件建立不同牙本质肩领高度喇叭口根管、纤维主桩、辅桩、金属桩、全冠、粘结剂等模型。按照牙本质肩领相同宽度0.5mm,不同肩领高度分为0mm、1mm、2mm组；按不同的桩核材料分为纤维主辅桩、单支纤维桩、金属桩组；按不同的咬合状态分为相同加载角度45°、不同加载力值（60N、80N、100N、120N、150N）和相同加载力值100N、不同加载角度（0°、30°、45°、60°、90°）两实验组，对喇叭口根管牙本质应力分布规律进行分析。结果如下：相比金属桩，主辅桩组可减少根尖部牙本质的应力集中，应力分布均匀，与单支纤维桩应力分布相近，无明显差异；随着牙本质肩领高度的升高，牙本质的应力峰值降低，应力分布范围减少。由0mm升至1mm高度时，这种变化最为明显，VonMises应力降低3.94%，最大拉应力降低4.18%；相同载荷角度45°，60N～150N合力范围内，相比单支纤维桩，纤维主辅桩组应力峰值略大，但无明显差异。两组应力峰值随合力值增大增加，牙本质Von Mises应力值最高达42.469MPa，均在牙本质承受的正常范围内；相同载荷力值100N，载荷角度0°～90°范围时，纤维主辅桩组应力峰值主辅桩组略大于单支纤维桩组，无明显差异。牙本质的应力分布范围和载荷角度变化密切相关，当加载角度为90°时，牙本质最大主应力值达54.153MPa，达到牙本质最大拉应力值。上述结果提示，相比金属桩，纤维主辅桩修复喇叭口根管可减少不可逆性根折的发生，与单支纤维桩的应力分布相近。喇叭口根管高度1mm，0.5mm厚度牙本质肩领的保留可以提供一定的箍效应，临床应尽量的保留剩余牙体组织。不同咬合状态下，咬合力及载荷角度的增大会增加牙颈部折裂的风险，临床应注意避免过大的合力及水平向分力。第二部分纤维主辅桩修复喇叭口根管上颌中切牙的微渗漏研究将52颗离体上颌中切牙经根管治疗后制备形成喇叭口状残根随机分为两组，单支预成纤维桩组，其中A1(n=20)，A2(n=6)；纤维主辅桩组，其中B1(n=20)，B2(n=6)。所有的样本经过水侵袭1月。将A1、B1置于印度墨水1周，，经染色、透明化处理，在体式显微镜下观察桩核与根管壁之间的微渗漏情况。将A2、B2分为根颈、根中、根尖横向三部分，每部分取四点，置于扫描电镜下颌向观察桩核-牙本质界面。采用等级计分记录观察结果，经非参数检验统计进行分析，结果发现,纤维主辅桩组修复方式引起的纤维桩冠向微渗漏值明显较单支纤维桩组小（P0.05）；纤维主辅桩组和单支纤维桩组均显示了不同程度的牙本质-粘结剂间隙，单支纤维桩组产生的粘接剂-牙本质界面不连续性较纤维主辅桩组明显，尤其在冠方（P0.05）实验结果提示，相比单支纤维桩，纤维主辅桩通过减少树脂水门汀的用量，可以减少微渗漏的发生，更有利于桩核修复的冠向封闭，降低脱落的风险,为纤维主辅桩的临床应用提供有力的理论依据。第三部分纤维主辅桩修复喇叭口根管临床应用疗效观察——附典型病例按照临床纳入标准，筛选28名患者37颗需修复的喇叭口单根管患牙经根管治疗后行纤维主辅桩+复合树脂核及全瓷冠修复，于修复完成后每半年进行临床复查，追踪26个月，参照美国加州牙科协会对修复体的评价标准的修改表对修复体完整性、边缘适合性、牙周及根尖周组织健康状况进行评价。37个修复体完整，成功率100%；冠边缘适合性好达91.89%，可接受8.11%；色泽匹配好达75.68%；牙龈状况好达83.79%；纤维桩及树脂核无松动、折裂、缝隙等；根尖未见异常，无根折发生。临床追踪结果说明纤维主辅桩系统是一种良好的喇叭口状残根残冠的桩核修复方式，可以在临床推广应用。综上所述，纤维主辅桩修复喇叭口状根管残根残冠具有一定的优势,体现在以下几个方面：1.相比金属桩，纤维主辅桩根尖部牙本质应力分布均匀，与单支纤维桩应力分布相似，可减少不可逆性根折的发生。喇叭口根管1mm高度、0.5mm厚度的牙本质肩领的保留可以提供一定的箍效应。2.纤维主辅桩组与单支纤维桩应力分布未见明显不同。咬合状态影响牙本质的应力分布，临床应尽量降低合力，减少桩核修复体所受水平分力。3.纤维主辅桩的应用可减少微渗漏的发生，有利于桩核冠向封闭性，降低桩核脱落的风险。4.纤维主辅桩系统临床修复喇叭口残根残冠取得良好的临床效果，可以作为保存此类残根残冠简便有效的桩核修复方式。
[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.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R783.3

【参考文献】