块状珊瑚羟基磷灰石成骨效能及重建下颌后牙区牙槽骨高度的研究

发布时间：2018-05-26 03:55

本文选题：块状珊瑚羟基磷灰石 + 成骨效能　；参考：《南方医科大学》2014年硕士论文

【摘要】：研究背景人们经济水平的提高和种植技术的发展,为种植体广泛应用于部分缺牙或无牙颌患者提供了更大的可能。种植区骨量是评估预测种植体能否长期行使功能的一个重要因素。然而,很多时候,患者因为外伤、牙周炎等情况,缺牙区牙槽嵴高度丧失,给种植义齿修复缺失牙及重建咬合功能带来了挑战,增加了外科手术的难度。下颌后牙区是临床上最主要的缺牙部位之一。由于下颌神经管的存在,很多垂直高度重度吸收的患者往往无法容纳种植体的植入。针对这个问题,临床上有多种术式可供选择,常见的处理方式有引导骨组织再生术、牵张成骨术、onlay植骨术、下牙槽神经游离术。onlay植骨,又名上置法植骨,是将移植材料固定于牙槽骨表面以增加高度的植骨方法。onlay植骨因其骨增量效果的肯定性,在临床上已经得到了广泛地应用。 onlay植骨术中,自体骨块因其特有的成骨活性、骨诱导性以及骨传导性,一直是该术式的金标准。自体骨块移植是由患者自身取新鲜骨组织来恢复受体区骨缺损的方法。自体骨块移植包括血管化自体骨块移植以及非血管化自体骨块移植两种。非血管化自体骨块移植因其操作简便、创伤较小,已经在onlay骨增量手术中得到了广泛地应用。自体骨块来源于患者本身,其主要优点是无排斥反应,移植存活率高。但自体骨块移植因其来源有限,需要开辟第二术区,给患者增加了额外的痛苦,并增加了患者一定的经济负担。针对自体骨块移植的不足,人们开始广泛关注同种异体骨块。同种异体骨块移植指患者骨缺损处获得的骨源来自骨捐赠者捐赠的相应骨组织,可以是即取即用,也可以是先通过骨库保存后,在合适的时间使用。同种异体骨移植物的来源相对自体骨块来说较为广泛。其形状可以是致密较脆的皮质骨、疏松多孔的松质骨,或者是两者的结合物。同种异体骨保存技术的发展,以及更加完善的骨库的建立,使同种异体骨移植在多个国家得到了应用。但是,同种异体骨移植存在着交叉感染、免疫排斥以及移植物愈合较为缓慢等情况,这些是临床医生及患者必须考虑的问题。异种骨块移植的主要来源是牛骨和猪骨。异种骨块移植的数量几乎不受限制,移植物可以根据需要预先制备成各种形状,来满足术中的要求。但异种骨的骨诱导活性跟其抗原性具有相同的物质基础,在消除其抗原性的同时,往往破坏了其骨诱导活性。两者之间存在一定的矛盾关系。另一方面,由于疯牛病的出现,日本以及欧洲的部分国家已经禁止使用牛骨来源的异种骨。由于常规骨移植物的不足,骨移植物的生物替代材料成为了另一个人们广泛关注的对象。珊瑚转化的羟基磷灰石是其中的一个重要代表。珊瑚羟基磷灰石(coralline hydroxyapatite, CHA)是近年较常用的一种多孔羟基磷灰石,其作为一种新型骨替代材料,具有良好的生物相容性、骨传导性、无免疫源性等独特的优势。制备珊瑚羟基磷灰石的天然材料主要来自石珊瑚中的滨珊瑚和角孔珊瑚,这两种珊瑚在太平洋及西印度洋分布较为广泛。滨珊瑚平均孔径为200um,角孔珊瑚为500um。前者类似人类皮质骨,后者与松质骨孔径接近,是理想的骨移植物替代材料。临床上使用的珊瑚羟基磷灰石主要有颗粒状和块状两种外形的产品。最近十几年来,随着大量文献报道了颗粒状的珊瑚羟基磷灰石在种植术中引导骨再生的良好表现以及块状珊瑚羟基磷灰石加工工艺的进步,块状珊瑚羟基磷灰石在下颌骨垂直onlay骨增量手术中的应用,国外开始有少量报道,并取得了良好的骨增量效果。但块状珊瑚羟基磷灰石因其质地较脆,很难用小钛钉固位,其固位问题一直是影响其广泛使用的一个原因,并且国内外很少文献报道块状珊瑚羟基磷灰石中心血供及成骨效能方面的情况,未能为块状珊瑚羟基磷灰石的应用提供组织学方面的支撑。目的 1.本课题通过研究珊瑚羟基磷灰石圆柱体植入兔子股骨远中干骺端后的血供情况、成骨效能,为块状珊瑚羟基磷灰石的临床应用提供组织学上的依据。 2.对比块状珊瑚羟基磷灰石与自体骨块采用onlay植骨术恢复下颌后牙区牙槽骨高度的临床效果,探讨块状珊瑚羟基磷灰石通过箱状洞形楔入力固位的临床操作可行性以及愈合情况。方法 1.动物实验部分：30只健康雄性新西兰大白兔随机分为实验组和空白对照组两组。实验组包含24只大白兔,在大白兔双侧股骨的远中干骺端,通过空心取骨钻制备圆柱形极限骨缺损,并植入相应大小的珊瑚羟基磷灰石圆柱体。观察时间点分别为4周、8周、12周。在上述每个时间点分别处死8只动物,共获得48个标本,定性观察珊瑚羟基磷灰石圆柱体在各个时间点的成骨、降解以及血供的情况。对照组含有6只大白兔,在其双侧股骨的远中干骺处,制备与实验组大小一致的圆柱形骨缺损,不植入任何骨替代物,12周后处死,观察该骨缺损的愈合情况。实验组不同时间段的新骨面积百分比,采用one way ANOVA进行检验,P0.05两者之间的差别具有统计学意义。 2.临床试验部分：选择2010-01至2014-06在广东省口腔医院种植中心接受牙种植的后牙缺失患者37人(男20人,女17人),由A、B两组组成。A组19人,块状珊瑚羟基磷灰石通过箱状洞形楔入力固定；B组18人,自体骨块通过钛钉常规固位。植骨6个月后行相应种植手术。 (1)在植骨前、骨块植入后、种植体植入时、修复完成即刻、修复完成后的每12个月复诊,拍摄全景片并比较A、B两组对应时间段垂直骨高度的吸收值,采用Mann-Whitney检验,P0.05两者之间的差别具有统计学意义。 (2)以种植术后即刻种植体边缘骨水平L2为基线,分别计算A、B两组修复完成即刻(T3)、修复完成后12月(T4)、修复完成后24月(T5)的种植体边缘骨水平与基线的边缘骨水平之差,分别记录为种植体周缘骨吸收量L3-L2、L4-L2、L5-L2。采用Mann-Whitney检验,P0.05两者之间的差别具有统计学意义。结果 1.动物实验部分 (1)手术共植入48块珊瑚羟基磷灰石圆柱体,均固位良好,未见松动及脱出,松动率为0%。所有兔子在实验中均未出现创口感染化脓等情况。 (2)大体标本观察：实验组切开大白兔的股骨干骺端皮肤,可见之前切开的骨膜已经紧密覆盖植入的圆柱状珊瑚羟基磷灰石,圆柱状骨块与受体区嵌合良好,稳固无松动。4周时,实验组珊瑚羟基磷灰石圆柱体与周围自体骨结合良好,生物相容性佳,无明显炎症反应及肉眼可见缝隙。植入物与周围自体骨边界尚清楚。8周时,实验组珊瑚羟基磷灰石圆柱体与周围自体骨结合良好,周围骨质长入珊瑚羟基磷灰石圆柱体四周,两者之间的边界模糊。12周时,实验组珊瑚羟基磷灰石圆柱体与周围骨质边界基本消失,周围骨质长入圆柱体中,其横切面白色圆形区域缩小；空白对照组创面缩小,有部分软组织长入。 (3)组织学观察：实验组珊瑚羟基磷灰石圆柱体的标本在脱钙后行石蜡组织学切片以及HE染色,圆柱体的边缘可看见明显的骨组织长入其中,并伴有珊瑚羟基磷灰石的降解。珊瑚羟基磷灰石区域被染成深蓝色,新长入的骨组织被染成颜色较深的红色物质,间充质成近似浅蓝色物质。 4周时的实验组骨组织切片均可见红色新生骨沿着圆柱体的边缘生长,骨细胞被生长快速的新生骨基质包绕其中。边缘的珊瑚羟基磷灰石有少量降解。新生骨与周围的宿主骨紧密结合,形成骨性连接,无明显纤维组织介入。这个阶段的新生骨主要由含较多骨细胞的编织骨组成。 8周时,柱状珊瑚羟基磷灰石的边缘结构进一步溶解,新生骨组织明显增多,骨小梁变粗并发生融合。周围的宿主骨与新生骨形成骨性紧密结合,无明显纤维组织介入。圆柱体中央有少量血管长入,并有少量新骨形成。这个阶段的新生骨主要由较为细小的编织骨构成。 12周时,圆柱体植入区边缘珊瑚羟基磷灰石降解明显,圆柱体边缘新生骨量进一步增多,板状骨有相当规模的量形成,少量骨髓腔分化形成。圆柱体与周围的宿主骨形成紧密结合的骨性连接,无纤维组织介入。圆柱体中央有较多血管长入,骨小梁增粗融合。12周时,对照组圆柱形骨缺损的边缘仅有少量新骨生成,缺损主要由炎症细胞以及成纤维细胞构成,缺损中心为空白区域,没有明显骨组织长入。 (4)实验组新生骨计量学统计分析：实验组4周、8周、12周的新生骨面积百分比采用One-Way ANOVA,对各时间段间进行两两比较,4周与8周时比较,4周时明显小于8周,差异具有统计学意义(P=0.02)；4周与12周时比较,4周时明显小于12周,差异具有统计学意义(P=0.001)；8周时明显小于12周(P=0.03)。 2.临床试验部分 (1)A、B两组植骨成功率以及统计学分析：A组19个患者植入39块珊瑚羟基磷灰石,两个患者中的4块珊瑚羟基磷灰石骨高度增量失败,一例植骨区血供不佳,例患者植骨区骨质疏松,块状CHA固位不良。A组珊瑚羟基磷灰石的植骨成功率为90%。B组18个患者,其中一名患者切口裂开,植骨失败,B组的植骨成功率为94%。A、B组移植成功率进行四格表资料的卡方检验,两组间差异无统计学意义(P0.05)。 (2)A、B两组通过垂直onlay植骨,植骨后到6个月后种植体植入这一阶段,垂直骨高度的吸收值(H1-H2),A组B组,差异具有显著性(P0.01)；骨块植入后到上部结构完成这一阶段,垂直骨高度的吸收值(H1-H3),A组B组,差异具有显著性(P0.01)；骨块植入后到上部结构完成后12个月,A组的垂直骨高度吸收值(H1-H4)显著小于B组(P0.01)；骨块植入后到上部结构完成后24个月,垂直骨高度的吸收值(H1-H5),A组B组,差异具有统计学意义(P0.01)。A、B组内四个阶段的骨高度吸收值差异具有统计学意义,植骨6个月内吸收值最小,完成修复后24个月骨高度吸收值最大。 (3)A、B两组中种植体周缘骨吸收量,以种植术后种植体边缘骨水平L2为基线,修复完成时的周缘骨吸收值(L3-L2),A组B组,差异具有统计学意义(P=0.028)；修复完成后12个月的周缘骨吸收值(L4-L2),A组B组,差异具有统计学意义(P=0.025)：修复完成后24个月的种植体周缘骨吸收量(L5-L2),A组显著小于B组(P=0.013)。A、B组内三个阶段的种植体周缘骨吸收量差异具有统计学意义,植骨6个月内种植体周缘骨吸收量最小,完成修复后24个月种植体周缘骨吸收量最大。结论 1.珊瑚羟基磷灰石圆柱体在大白兔股骨干骺端标准骨缺损模型中愈合良好。2.珊瑚羟基磷灰石圆柱体具有良好的骨传导活性,标准骨缺损大小的圆柱状珊瑚羟基磷灰石在植入8周后可以获得较好的中心血供以及成骨效能。 3.块状珊瑚羟基磷灰石在低平的下颌后部缺牙区通过箱状洞形楔入固位具有良好的可操作性,临床固位效果可靠。 4.块状珊瑚羟基磷灰石与自体骨块两种材料均能有效地恢复下颌后牙区垂直高度,两者成功率无统计学差异。块状珊瑚羟基磷灰石增加的骨高度表现出良好的稳定性。
[Abstract]:Research background
The improvement of people's economic level and the development of implant technology provide a greater possibility for the widespread use of dental implants for partial or dental implants. Bone mass is an important factor in assessing the long-term function of the implant. However, the patient has many cases, such as trauma, periodontitis, and the high alveolar ridge in the odontic area. The loss of degree has brought challenges to implant denture restoration and reconstruction of occlusal function, which has increased the difficulty of surgical operation.
The posterior mandibular region is one of the most important parts of the clinical teeth. Because of the existence of the mandibular canal, many patients with severe vertical height and severe absorption are often unable to accommodate implant implantation. There are many surgical options for this problem. The common treatment methods include guided bone tissue regeneration, distraction osteogenesis, and onlay bone grafting. Surgery, inferior alveolar nerve free operation.Onlay bone graft, also known as the upper method of bone graft, is the implant material fixed to the surface of the alveolar bone to increase the height of bone graft method.Onlay bone graft because of its positive bone increment effect, has been widely used in clinical.
In onlay bone graft, autogenous bone mass is the gold standard of this type because of its unique osteogenic activity, bone inducibility and bone conductivity. Autogenous bone graft is a method for restoring bone defect in the recipient region by the patient's own fresh bone tissue. Autogenous bone graft includes vascularized self bone graft and non vascularized autogenous bone graft. The two. Non vascularized autologous bone graft has been widely used in onlay bone increment surgery because of its simple operation and less trauma. Autologous bone mass originates from the patient itself, its main advantage is no rejection reaction and high survival rate. However, autogenous bone graft needs to open up the second operation area and increase the amount of the patient because of its limited source. External pain and increase the patient's financial burden.
In view of the shortage of autologous bone graft, people begin to pay wide attention to allograft bone blocks. The bone source obtained from allograft bone graft recipients is derived from the corresponding bone tissue donated by bone donors. It can be used as an immediate use, and can be used first through the bone bank and at a suitable time. The source of allograft allograft. Compared with the autogenous bone mass, the shape can be a compact, crisp cortical bone, loose porous cancellous bone, or a combination of the two. The development of the allograft bone preservation technology and the establishment of a more perfect bone bank make allograft bone graft in many countries. However, allograft bone graft exists. Cross infection, immune rejection and slow healing of graft are the problems that clinicians and patients must consider.
The main source of xenograft bone graft is bovine bone and pig bone. The number of xenograft bones is almost unrestricted, and the grafts can be prepared in various shapes to meet the requirements. However, the bone induction activity of the xenobone has the same material basis as its antigenicity, and is often destroyed while eliminating its antigenicity. There is a certain contradiction between the bone induced activity. On the other hand, because of the emergence of BSE, some countries in Japan and Europe have banned the use of xenogeneic bones from bovine bone origin.
Coralline hydroxyapatite (CHA) is one of the most commonly used hydroxyapatite (CHA) as a new type of porous hydroxyapatite as a new type of bone in recent years. The two corals are widely distributed in the Pacific and Western India oceans. The average pore size of the corals is 200um, and the angle Kong Shanhu is 500um.. The former is similar to human cortical bone, and the latter is close to the cancellous bone. It is an ideal substitute for bone graft.
Coralline hydroxyapatite is clinically used mainly for granular and massive two shaped products. In the last decade, with a large number of reports on the good performance of granular coral hydroxyapatite in implant guided bone regeneration and the progress of the massive coralline hydroxyapatite processing technology, massive coral hydroxyapatite has been reported. The application of vertical onlay bone increment in the mandible has been reported in a small amount, and good bone incremental effect has been achieved abroad. However, massive coral hydroxyapatite is difficult to use with small titanium nails because of its brittle texture. Its retention problem has been one of the reasons for its widespread use, and the massive coral hydroxyl groups are rarely reported at home and abroad. The blood supply and osteogenic efficiency of apatite core did not provide histological support for the application of coralline hydroxyapatite.
objective
1. this study provides a histological basis for the clinical application of the massive coral hydroxyapatite by studying the blood supply of the coralline hydroxyapatite cylinder implanted in the distal metaphysis of the femur of the rabbit.
2. the clinical effect of restoring the height of the alveolar bone in the mandibular posterior region by onlay bone grafting and massive coral hydroxyapatite was compared with the autogenous bone mass, and the clinical operation feasibility and healing condition of the massive coral hydroxyapatite through the Cape shaped wedge force fixation were discussed.
Method
1. animal experiment part: 30 healthy male New Zealand white rabbits were randomly divided into the experimental group and the blank control group (two groups). The experimental group included 24 white rabbits in the distal epiphysis of the bilateral femur of the white rabbit. The cylindrical ultimate bone defect was prepared through the hollow drill, and the corresponding large small coralline hydroxyapatite cylinder was implanted. 8 animals were killed at each time point at 4 weeks, 8 weeks and 12 weeks respectively. A total of 48 specimens were obtained. The osteogenesis, degradation and blood supply of the coralline hydroxyapatite cylinder at each time point were observed. The control group contained 6 large white rabbits in the distal epiphysis of the femur of both sides, to prepare the same cylindrical shape as the experimental group. Bone defect, no bone replacement, 12 weeks after death, to observe the healing of the bone defect. The percentage of the new bone area in the experimental group was tested by one way ANOVA at different time periods, and the difference between the two P0.05 was statistically significant.
2. clinical trial Part: 37 people (20 men and 17 women) were selected from 2010-01 to 2014-06 in Guangdong oral hospital planting center. 19 people in group.A were composed of A and B two groups, and massive coral hydroxyapatite was fixed by box shaped wedge force; 18 in group B, the autogenous bone was fixed by titanium nail for 6 months. The operation was performed accordingly.
(1) when the bone was implanted before the bone graft, the implant was implanted, the restoration was completed immediately, and the restoration was completed every 12 months. The panoramic film was taken and the absorption value of the vertical bone height in the corresponding time segments of the A, B two groups was compared, and the difference between the two of the P0.05 was statistically significant.
(2) the difference between the marginal bone level of the implants and the marginal bone level of the baseline after the completion of the repair completed in December (T4), and the difference in the marginal bone level of the baseline at 24 months (T5) after the completion of the repair was completed, with the baseline of the edge bone level L2 of the implants immediately after the implantation of the implant, respectively A, B two, and 24 months after the completion of the repair. The bone absorption of the implant margin L3-L2, L4-L2, and L5-L2. were detected by Mann-Whitney, respectively. The difference between P0.05 and the two has statistical significance.
Result
1. animal experiment part
(1) a total of 48 coralline hydroxyapatite cylinders were implanted in the operation, with good retention, no loosening and release, and the loosening rate of all rabbits in 0%. did not appear in the experiment.
(2) gross specimen observation: in the experimental group, the femoral metaphysis skin of the experimental rabbits was cut, and the periosteum of the anterior incision had been closely covered with the implanted cylindrical coral hydroxyapatite. The cylindrical bone mass was in good chimerism with the receptor area. The experimental group of coralline hydroxyapatite was well combined with the surrounding autologous bone when it was stable without loosening for.4 weeks. Good compatibility, no obvious inflammatory reaction and visible crevice in the naked eye. The boundary of the implant and the surrounding autogenous bone is clear for.8 weeks. The experimental group of coralline hydroxyapatite cylinder is well combined with the surrounding autologous bone and the surrounding bone grows into the coralline hydroxyapatite cylinder around it. The experimental group of coral hydroxyapatite when the boundary between the two is fuzzy for.12 weeks. The boundary of the cylinder and the surrounding bone disappeared basically, the surrounding bone grew into the cylinder, and the white circular area of the transverse section narrowed, and the wound in the blank control group narrowed and some soft tissue grew.
(3) histological observation: the specimens of the coralline hydroxyapatite cylinder in the experimental group were stained with paraffin tissue and stained with HE after decalcification. The edge of the cylinder could be seen to grow into the bone tissue, and the coral hydroxyapatite was degraded. The coral hydroxyapatite area was dyed deep blue, and the newly formed bone tissue was dyed into pigments. A dark red substance with a substance similar to a light blue substance.
The bone tissue section of the experimental group at 4 weeks shows that the red new bone grows along the edge of the cylinder, and the bone cells are wrapped around the new bone matrix with rapid growth. The coral hydroxyapatite on the edge has a little degradation. The new bone is closely combined with the surrounding host bone to form a bone connection without obvious fibrous tissue involvement. This stage is new. The bones are mainly composed of woven bone containing more bone cells.
At the 8 week, the marginal structure of the columnar coralline hydroxyapatite was further dissolved, the new bone tissue increased obviously, and the bone small Liang Bian was thicker and fused. The surrounding host bone formed bone closely with the new bone, without obvious fibrous tissue involvement. A small amount of blood vessels in the center of the cylinder and a small amount of new bone formed. It is made up of smaller knitted bones.
At the 12 week, the coralline hydroxyapatite was degraded obviously on the edge of the cylinder, and the newborn bone mass was further increased at the edge of the cylinder. The plate shaped bone was formed in a considerable scale, and a small amount of bone marrow cavity formed. The cylinder was closely connected with the surrounding host bone, and no fibrous tissue intervened. There were more blood vessels in the center of the cylinder. At the.12 week of small Liang Zengcu fusion, only a small number of new bone formation on the edge of the cylindrical bone defect in the control group was formed. The defect was mainly composed of inflammatory cells and fibroblasts, the defect center was a blank area, and no obvious bone tissue was found.
(4) statistical analysis of new bone metrology in the experimental group: the percentage of new bone area in the experimental group was 4 weeks, 8 weeks and 12 weeks, the percentage of new bone area was One-Way ANOVA, and 22 compared between each time period. The 4 and 8 weeks were compared, and 4 weeks were obviously less than 8 weeks. The difference was statistically significant (P=0.02); 4 weeks and 12 weeks were significantly less than 12 weeks, the difference has unification. Academic significance (P=0.001); 8 weeks was significantly less than 12 weeks (P=0.03).
2. clinical trial section
(1) the success rate and statistical analysis of bone graft in group A and B: 19 patients in group A were implanted with 39 coralline hydroxyapatite, 4 of two patients failed to increase the height of bone hydroxyapatite, one case of bone grafting area was poor, bone graft area was loose, and the success rate of coral hydroxyapatite in group CHA ungood.A group was 90%.B group success rate 18 patients, one of the patients were split open, bone graft failure, B group bone graft success rate was 94%.A, group B transplantation success rate of four lattice data of the chi square test, the difference between the two groups was not statistically significant (P0.05).
(2) A, B two groups through the vertical onlay bone graft, after bone graft after 6 months implant implantation at this stage, the absorption value of the vertical bone height (H1-H2), A group B group, the difference is significant (P0.01); after the bone mass implantation to the superstructure completion of this stage, the vertical bone height absorption value (H1-H3), A group B group, the difference is significant (P0.01); bone mass implantation In the 12 months after the completion of the upper structure, the vertical bone height absorption (H1-H4) in group A was significantly less than that in group B (P0.01).
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R783.6

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