当代牙种植体设计进步与临床意义

doi:10.7518/hxkq.2017.01.003

摘要/Abstract

摘要：

牙种植体本身的研发设计进展深刻的影响了临床技术的进步,也深刻的影响了临床治疗效果,甚至给临床治疗理念或流程带来里程碑式的变革。当代牙种植体的设计与临床进步主要表现为：1）种植体根方设计影响了即刻种植的初期稳定性,即刻种植时植入超出牙槽窝上方约3~5 mm的种植体部分的外形结构决定了该种植体的初期稳定性,其外形结构主要体现在种植体根方轮廓设计、螺纹设计及自攻性方面。2）种植体的外形结构设计影响了即刻修复的可能性,即刻修复的基础在尚无骨结合时种植体通过其机械设计可以获得大于35 Ncm的初期稳定性。微锥度种植体外形,密集型深螺纹,含有良好的自攻刃设计均有利于机械锚定,即初期稳定性,这是即刻修复的物理学基础与机械可能性。3）种植体颈部设计影响美学效果,为了避免拔牙窝唇颊侧骨板吸收显露种植体颈部的金属暗影,均应避免使用颈部膨大设计的种植体,而应采用小直径种植体以利于美学修复美学区域进行种植修复,最好具有平台转移的设计,以获得良好的美学效果。4）种植体与基台的连接设计是骨内种植体设计的关键环节,功能上除了连接种植体与修复体,抗旋转外还需要抵抗或传导各个方向的咀嚼力,连接方式的稳定性会直接影响种植体颈部骨组织的长期稳定性,锥度连接和管套管连接方式都是有良好记录的种植体连接方式。5）平台转移设计影响到种植体颈部骨组织的稳定性,国际上大量临床研究结果及笔者所在科室应用均认为,具有平台转移设计的种植体有利于保存种植体颈部骨组织,无论是在单牙修复还是在多牙或无牙颌种植修复中都表现出良好的种植体颈部骨组织稳定性。6）数字化技术为种植临床技术提供了更为精确,更为高效的高科技方式。应用数字化印模技术结合计算机辅助设计/计算机辅助制作软件及专用设备进行修复体的设计、制作将成为未来种植修复的发展趋势。种植体及其配件的持续研发为临床数字化技术提供了可能性,新一代椅旁数字化系统口内扫描前无需喷粉,免除了即刻种植后伤口由喷粉致感染的潜在风险,解决了即刻种植术后即刻扫描的技术难题。7）种植体基台的特殊设计以满足临床新技术创新发展的需求,推进了临床流程的显著变革。All-on-four即刻修复技术和Weldone口内焊接即刻修复技术的问世都是新型特殊修复基台研发突破进而推动了临床新技术的创新。

关键词: 牙种植体, 牙种植体-基台设计, 即刻负重, 计算机辅助设计

Abstract:

The development of clinical implant dentistry was intensively affected by dental implant design improvement and innovation, which brought about new concept, even milestone-like changes of clinical protocol. The current improve-ments of dental implant design and their clinical importance could be highlighted as followings: 1) The implant apical design influences the implant preliminary stability in immediate implant. The apical 3-5 mm design of implant makes implant stable in immediate implant, because this part would be screwed into alveolar bone through fresh socket, the other part of implant could not be tightly screwed in the socket because of smaller implant diameter. Implant apical form, screw design, self-taping of apical part would be essential for immediate implant. 2) The enough preliminary stability of implant makes immediate prosthesis possible. When osseointegration does not occur, the implant stability comes from a mechanical anchorage, which depends on implant form, screw thread and self-taping design. 3) Implant neck design may have influence for soft tissue recession in esthetic zone. The implant with large shoulder would not be selected for the esthetic area. The platform design may be more favorable in the area. 4) The connection design between implant and abutment is thought a very impor-tant structure in implant long-term stability. Moose taper and “tube in tube” were well documented structure design in 20-year clinical practice in Peking University. 5) In last 15 years, the plenty studies showed the platform design of implant had positive influence in implant marginal bone level. Whatever in single implant restoration or multi-implant prosthesis. 6) The digital technology makes clinical work more precise and high-tech. This would be a trend in implant dentistry. New generation of chair-side digital computer-aided design/computer-aided manufacturing makes immediate prosthesis without conventional impression possible. 7) New abutment design have changed clinical protocol greatly. The All-on-four concept and Weldone concept benefit both from the abutment innovation, which were large angulated abutment and special welding abutment materials.

Key words: dental implants, dental implant-abutment design, immediate dental implant loading, computer-aided design

中图分类号:

R783.6

林野. 当代牙种植体设计进步与临床意义[J]. 华西口腔医学杂志, 2017, 35(1): 18-28.

Ye. Lin. Current dental implant design and its clinical importance[J]. West China Journal of Stomatology, 2017, 35(1): 18-28.

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参考文献 75

[1]	Vignoletti F, Sanz M.Immediate implants at fresh extraction sockets: from myth to reality[J]. Periodontol 2000, 2014, 66(1):132-152.
[2]	Al-Sabbagh M, Kutkut A.Immediate implant placement: surgical techniques for prevention and management of com-plications[J]. Dent Clin North Am, 2015, 59(1):73-95.
[3]	Horváth A, Mardas N, Mezzomo LA, et al.Alveolar ridge preservation. A systematic review[J]. Clin Oral Investig, 2013, 17(2):341-363.
[4]	Araújo MG, Sukekava F, Wennström JL, et al.Ridge altera-tions following implant placement in fresh extraction sockets: an experimental study in the dog[J]. J Clin Periodontol, 2005, 32(6):645-652.
[5]	Raes F, Cosyn J, Crommelinck E, et al.Immediate and con-ventional single implant treatment in the anterior maxilla: 1-year results of a case series on hard and soft tissue response and aesthetics[J]. J Clin Periodontol, 2011, 38(4):385-394.
[6]	Block MS, Mercante DE, Lirette D, et al.Prospective eva-luation of immediate and delayed provisional single tooth restorations[J]. J Oral Maxillofac Surg, 2009, 67(11 Suppl):89-107.
[7]	Xu D, Wang Z, Sun L, et al.Classification of the root posi-tion of the maxillary central incisors and its clinical signifi-cance in immediate implant placement[J]. Implant Dent, 2016, 25(4):520-524.
[8]	Sakoh J, Wahlmann U, Stender E, et al.Primary stability of a conical implant and a hybrid, cylindric screw-type im-plant in vitro[J]. Int J Oral Maxillofac Implants, 2006, 21(4):560-566.
[9]	Wu SW, Lee CC, Fu PY, et al.The effects of flute shape and thread profile on the insertion torque and primary stability of dental implants[J]. Med Eng Phys, 2012, 34(7):797-805.
[10]	Kan JY, Roe P, Rungcharassaeng K.Effects of implant mor-phology on rotational stability during immediate implant placement in the esthetic zone[J]. Int J Oral Maxillofac Im-plants, 2015, 30(3):667-670.
[11]	Steigenga JT, al-Shammari KF, Nociti FH, et al. Dental im-plant design and its relationship to long-term implant success[J]. Implant Dent, 2003, 12(4):306-317.
[12]	Marković A, Calvo-Guirado JL, Lazić Z, et al.Evaluation of primary stability of self-tapping and non-self-tapping dental implants. A 12-week clinical study[J]. Clin Implant Dent Relat Res, 2013, 15(3):341-349.
[13]	林野, 邱立新, 李健慧, 等. 即刻种植义齿的临床研究[J]. 中华口腔医学杂志, 2003, 38(2):100-102.
	Lin Y, Qiu LX, Li JH, et al.Clinical study of immediate implant[J]. Chin J Stomatol, 2003, 38(2):100-102.
[14]	Abuhussein H, Pagni G, Rebaudi A, et al.The effect of thread pattern upon implant osseointegration[J]. Clin Oral Implants Res, 2010, 21(2):129-136.
[15]	Chung SH, Heo SJ, Koak JY, et al.Effects of implant geo-metry and surface treatment on osseointegration after func-tional loading: a dog study[J]. J Oral Rehabil, 2008, 35(3):229-236.
[16]	Smeets R, Stadlinger B, Schwarz F, et al.Impact of dental implant surface modifications on osseointegration[J]. Bio-med Res Int, 2016, 2016:6285620.
[17]	Wennerberg A, Albrektsson T.Effects of titanium surface topography on bone integration: a systematic review[J]. Clin Oral Implants Res, 2009, 20(Suppl 4):172-184.
[18]	Le Guéhennec L, Soueidan A, Layrolle P, et al.Surface treat-ments of titanium dental implants for rapid osseointegration[J]. Dent Mater, 2007, 23(7):844-854.
[19]	Bonfante EA, Granato R, Marin C, et al.Biomechanical testing of microblasted, acid-etched/microblasted, anodized, and discrete crystalline deposition surfaces: an experimental study in beagle dogs[J]. Int J Oral Maxillofac Implants, 2013, 28(1):136-142.
[20]	Wennerberg A, Hallgren C, Johansson C, et al.A histomor-phometric evaluation of screw-shaped implants each prepared with two surface roughnesses[J]. Clin Oral Implants Res, 1998, 9(1):11-19.
[21]	Fouda MFA, Nemat A, Gawish A, et al.Does the coating of titanium implants by hydroxyapatite affect the elaboration of free radicals. An experimental study[J]. Aust J Basic Appl Sci, 2009, 3(2):1122-1129.
[22]	Weingart D, Steinemann S, Schilli W, et al.Titanium depo-sition in regional lymph nodes after insertion of titanium screw implants in maxillofacial region[J]. Int J Oral Maxillo-fac Surg, 1994, 23(6Pt 2):450-452.
[23]	Røkkum M, Reigstad A, Johansson CB.HA particles can be released from well-fixed HA-coated stems: histopathology of biopsies from 20 hips 2-8 years after implantation[J]. Acta Orthop Scand, 2002, 73(3):298-306.
[24]	Yeo IS, Kim HY, Lim KS, et al.Implant surface factors and bacterial adhesion: a review of the literature[J]. Int J Artif Organs, 2012, 35(10):762-772.
[25]	Bornstein MM, Lussi A, Schmid B, et al.Early loading of nonsubmerged titanium implants with a sandblasted and acid-etched (SLA) surface: 3-year results of a prospective study in partially edentulous patients[J]. Int J Oral Maxillo-fac Implants, 2003, 18(5):659-666.
[26]	Di P, Lin Y, Li JH, et al.The All-on-Four implant therapy protocol in the management of edentulous Chinese patients[J]. Int J Prosthodont, 2013, 26(6):509-516.
[27]	Choquet V, Hermans M, Adriaenssens P, et al.Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region[J]. J Periodontol, 2001, 72(10):1364-1371.
[28]	Tarnow DP, Cho SC, Wallace SS.The effect of inter-implant distance on the height of inter-implant bone crest[J]. J Perio-dontol, 2000, 71(4):546-549.
[29]	Teughels W, Merheb J, Quirynen M.Critical horizontal di-mensions of interproximal and buccal bone around implants for optimal aesthetic outcomes: a systematic review[J]. Clin Oral Implants Res, 2009, 20(Suppl 4):134-145.
[30]	Chen ST, Buser D.Clinical and esthetic outcomes of im-plants placed in postextraction sites[J]. Int J Oral Maxillofac Implants, 2009, 24(Suppl):186-217.
[31]	Hämmerle CH, Araújo MG, Simion M, et al.Evidence-based knowledge on the biology and treatment of extraction sockets[J]. Clin Oral Implants Res, 2012, 23(Suppl 5):80-82.
[32]	Chen ST, Darby IB, Reynolds EC.A prospective clinical study of non-submerged immediate implants: clinical out-comes and esthetic results[J]. Clin Oral Implants Res, 2007, 18(5):552-562.
[33]	Hürzeler MB, Fickl S, Zuhr O, et al.Clinical failures and shortfalls of immediate implant procedures[J]. Eur J Esthet Dent, 2006, 1(2):128-140.
[34]	Canullo L, Caneva M, Tallarico M.Ten-year hard and soft tissue results of a pilot double-blinded randomized controlled trial on immediately loaded post-extractive implants using platform-switching concept[J]. Clin Oral Implants Res, 2016. doi: 10.1111/clr.12940.
[35]	Herekar M, Sethi M, Mulani S, et al.Influence of platform switching on periimplant bone loss: a systematic review and meta-analysis[J]. Implant Dent, 2014, 23(4):439-450.
[36]	Strietzel FP, Neumann K, Hertel M.Impact of platform switching on marginal peri-implant bone-level changes. A systematic review and meta-analysis[J]. Clin Oral Implants Res, 2015, 26(3):342-358.
[37]	Broggini N, McManus LM, Hermann JS, et al. Persistent acute inflammation at the implant-abutment interface[J]. J Dent Res, 2003, 82(3):232-237.
[38]	Gracis S, Michalakis K, Vigolo P, et al.Internal vs. external connections for abutments/reconstructions: a systematic review[J]. Clin Oral Implants Res, 2012, 23(Suppl 6):202-216.
[39]	Steinebrunner L, Wolfart S, Ludwig K, et al.Implant-abutment interface design affects fatigue and fracture strength of im-plants[J]. Clin Oral Implants Res, 2008, 19(12):1276-1284.
[40]	Steinebrunner L, Wolfart S, Bössmann K, et al.In vitro eva-luation of bacterial leakage along the implant-abutment in-terface of different implant systems[J]. Int J Oral Maxillofac Implants, 2005, 20(6):875-881.
[41]	Al-Nawas B, Kammerer PW, Morbach T, et al.Retrospec-tive clinical evaluation of an internal tube-in-tube dental implant after 4 years, with special emphasis on peri-implant bone resorption[J]. Int J Oral Maxillofac Implants, 2011, 26(6):1309-1316.
[42]	Sutter F, Weber HP, Sorensen J, et al.The new restorative concept of the ITI dental implant system: design and engi-neering[J]. Int J Periodontics Restorative Dent, 1993, 13(5):408-431.
[43]	do Nascimento C, Miani PK, Pedrazzi V, et al. Leakage of saliva through the implant-abutment interface: in vitro eva-luation of three different implant connections under unloaded and loaded conditions[J]. Int J Oral Maxillofac Implants, 2012, 27(3):551-560.
[44]	Merz BR, Hunenbart S, Belser UC.Mechanics of the implant-abutment connection: an 8-degree taper compared to a butt joint connection[J]. Int J Oral Maxillofac Implants, 2000, 15(4):519-526.
[45]	Tesmer M, Wallet S, Koutouzis T, et al.Bacterial coloniza-tion of the dental implant fixture-abutment interface: an in vitro study[J]. J Periodontol, 2009, 80(12):1991-1997.
[46]	Weng D, Nagata MJ, Bosco AF, et al.Influence of microgap location and configuration on radiographic bone loss around submerged implants: an experimental study in dogs[J]. Int J Oral Maxillofac Implants, 2011, 26(5):941-946.
[47]	Pieri F, Aldini NN, Marchetti C, et al.Influence of implant-abutment interface design on bone and soft tissue levels around immediately placed and restored single-tooth implants: a randomized controlled clinical trial[J]. Int J Oral Maxillofac Implants, 2011, 26(1):169-178.
[48]	Hansson S.A conical implant-abutment interface at the level of the marginal bone improves the distribution of stresses in the supporting bone. An axisymmetric finite element ana-lysis[J]. Clin Oral Implants Res, 2003, 14(3):286-293.
[49]	Mangano C, Mangano F, Piattelli A, et al.Prospective cli-nical evaluation of 1 920 Morse taper connection implants: results after 4 years of functional loading[J]. Clin Oral Im-plants Res, 2009, 20(3):254-261.
[50]	Schmitt CM, Nogueira-Filho G, Tenenbaum HC, et al.Per-formance of conical abutment (Morse Taper) connection implants: a systematic review[J]. J Biomed Mater Res A, 2014, 102(2):552-574.
[51]	Yao KT, Kao HC, Cheng CK, et al.The potential risk of conical implant-abutment connections: the antirotational ability of cowell implant system[J]. Clin Implant Dent Relat Res, 2015, 17(6):1208-1216.
[52]	Fauroux MA, Levallois B, Yachouh J, et al.Assessment of leakage at the implant-abutment connection using a new gas flow method[J]. Int J Oral Maxillofac Implants, 2012, 27(6):1409-1412.
[53]	Lazzara RJ, Porter SS.Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels[J]. Int J Periodontics Restorative Dent, 2006, 26(1):9-17.
[54]	Hermann JS, Buser D, Schenk RK, et al.Biologic width around titanium implants. A physiologically formed and stable dimension over time[J]. Clin Oral Implants Res, 2000, 11(1):1-11.
[55]	Cumbo C, Marigo L, Somma F, et al.Implant platform swit-ching concept: a literature review[J]. Eur Rev Med Phar-macol Sci, 2013, 17(3):392-397.
[56]	Canullo L, Fedele GR, Iannello G, et al.Platform switching and marginal bone-level alterations: the results of a rando-mized-controlled trial[J]. Clin Oral Implants Res, 2010, 21(1):115-121.
[57]	Gardner DM.Platform switching as a means to achieving implant esthetics[J]. N Y State Dent J, 2005, 71(3):34-37.
[58]	Sahabi M, Adibrad M, Mirhashemi FS, et al.Biomechanical effects of platform switching in two different implant systems: a three-dimensional finite element analysis[J]. J Dent (Tehran), 2013, 10(4):338-350.
[59]	Pellizzer EP, Falcón-Antenucci RM, de Carvalho PS, et al. Photoelastic analysis of the influence of platform switching on stress distribution in implants[J]. J Oral Implantol, 2010, 36(6):419-424.
[60]	罗佳, 胡秀莲, 林野, 等. 下后牙区平台转移设计种植体植入深度对边缘骨水平影响的临床研究[J]. 北京大学学报(医学版), 2012, 44(1):65-69.
	Luo J, Hu XL, Lin Y, et al.Influence of the placing depth of implants with platform switching on the marginal bone level in the posterior mandible: a clinical study[J]. J Peking University(Health Sciences), 2012, 44(1):65-69.
[61]	李倩, 林野, 邱立新, 等. 平台转换技术用于上颌前牙种植修复的临床研究[J]. 中华口腔医学杂志, 2008, 43(9):537-541.
	Li Q, Lin Y, Qiu LX, et al.Clinical study of application of platform switching to dental implant treatment in esthetic zone[J]. Chin J Stomatol, 2008, 43(9):537-541.
[62]	李倩, 林野, 邱立新, 等. 平台转换连接种植体与对接连接种植体修复牙列缺损的前瞻性比较研究[J]. 中国口腔种植学杂志, 2009, 14(2):45-46.
	Li Q, Lin Y, Qiu LX, et al.Controlled prospective clinical study of dental implant restoration with platform-switched implants and butt-joint implants[J]. Chin J Oral Implant, 2009, 14(2):45-46.
[63]	van der Meer WJ, Andriessen FS, Wismeijer D, et al. App-lication of intra-oral dental scanners in the digital workflow of implantology[J]. PLoS ONE, 2012, 7(8):e43312.
[64]	Patel N.Integrating three-dimensional digital technologies for comprehensive implant dentistry[J]. J Am Dent Assoc, 2010, 141(Suppl 2):20S-24S.
[65]	Joda T, Brägger U.Patient-centered outcomes comparing digital and conventional implant impression procedures: a randomized crossover trial[J]. Clin Oral Implants Res, 2016, 27(12):e185-e189.
[66]	Patzelt SB, Spies BC, Kohal RJ.CAD/CAM-fabricated implant-supported restorations: a systematic review[J]. Clin Oral Implants Res, 2015, 26(Suppl 11):77-85.
[67]	Rauscher O.Impressionless implant-supported restorations with Cerec 4.2[J]. Int J Comput Dent, 2014, 17(2):159-168.
[68]	Degidi M, Nardi D, Piattelli A.One abutment at one time: non-removal of an immediate abutment and its effect on bone healing around subcrestal tapered implants[J]. Clin Oral Implants Res, 2011, 22(11):1303-1307.
[69]	Hartlev J, Kohberg P, Ahlmann S, et al.Immediate placement and provisionalization of single-tooth implants involving a definitive individual abutment: a clinical and radiographic retrospective study[J]. Clin Oral Implants Res, 2013, 24(6):652-658.
[70]	Maló P, Rangert B, Nobre M.“All-on-Four” immediate-function concept with Brånemark System implants for com-pletely edentulous mandibles: a retrospective clinical study[J]. Clin Implant Dent Relat Res, 2003, 5(Suppl 1):2-9.
[71]	Patzelt SB, Bahat O, Reynolds MA, et al.The all-on-four treatment concept: a systematic review[J]. Clin Implant Dent Relat Res, 2014, 16(6):836-855.
[72]	邸萍, 林野, 李健慧, 等. “All-on-4”种植即刻修复技术的临床应用研究[J]. 中华口腔医学杂志, 2010, 45(6):357-362.
	Di P, Lin Y, Li JH, et al.Clinical study of “All-on-4” im-plant immediate function in edentulous patients[J]. Chin J Stomatol, 2010, 45(6):357-362.
[73]	赵旭, 邸萍, 林野, 等. “All-on-4” 无牙颌种植即刻修复技术的初步临床观察[J]. 北京大学学报(医学版), 2014, 46(5):720-726.
	Zhao X, Di P, Lin Y, et al.Implanting the edentulous jaws with “All-on-4” immediate reconstruction: a preliminary clinical observation[J]. J Peking University(Health Sciences), 2014, 46(5):720-726.
[74]	Degidi M, Gehrke P, Spanel A, et al.Syncrystallization: a technique for temporization of immediately loaded implants with metal-reinforced acrylic resin restorations[J]. Clin Im-plant Dent Relat Res, 2006, 8(3):123-134.
[75]	Degidi M, Nardi D, Piattelli A.A six-year follow-up of full-arch immediate restorations fabricated with an intraoral welding technique[J]. Implant Dent, 2013, 22(3):224-231.