二氧化锆全瓷冠修复效果的长期临床研究

二氧化锆全瓷冠修复效果的长期临床研究浙江省台州市立医院口腔科，318000 卢宇 杨枫，严齐会摘要 目的 研究大样本量的二氧化锆全瓷冠修复后3年的修复效果及成功率。方法 采集自2005年10月至2006年11月在我院口腔修复科行二氧化锆全瓷冠修复的患者的临床资料，共有161名患者的204颗二氧化锆全瓷冠义齿纳入研究。结果 多数全瓷冠位于后牙区（78%）。临床修复效果较好，未发生全瓷冠核破裂及继发龋32颗义齿出现并发症（16%），其中12颗（6%）发生严重并发症而修复失败。其中5颗基牙被拔除，丧失固位力而重做4颗，瓷面破裂2颗，持续疼痛1颗。结论 二氧化锆全瓷冠凭借其可靠的性能，可以应用于前磨牙及磨牙的全瓷冠修复。同时也应继续进行更长期的临床随访，以确定其长期修复效果。关键词：二氧化锆、全瓷冠、并发症、CAD/CAM技术Long Term Clinical Outcome of Zirconia Single CrownsYu LuDepartment of Stomatology, Taizhou Municipal Hospital ,Zhejiang Province.318000Abstract Objectives: The aim was to present the 3-year outcome of zirconia single crowns. Methods: All patients treated with porcelain-veneered zirconia single crowns during the period October 2005 to November 2006 were included. The patient records were scrutinized for data on the restorations and the supporting teeth. Information was available for 161 patients and 204 crowns. Results: Most crowns (78%) were placed on premolars and molars. The clinical outcome of the crowns was favourable. No zirconia core fractured and no caries was observed on the abutment teeth. Some types of complicationwere recorded for 32 (16%) crowns or abutment teeth. The most severe complications, in total 12 restorations (6%), were recorded as failures: abutment tooth was extracted (5), remake of crown due to lost retention (4), veneer fracture (2) and persistent pain (1). Conclusions: The results of the present 3-year study suggest that zirconia crowns are a promising prosthodontic alternative also in the premolar and molar regions. However, to evaluate the long-term success further studies are necessary.Key words：zirconia, all-ceramic crown, complications, CAD/CAM technology随着国人生活水平的提高，人们对美观的要求也越来越高，近十几年来金属烤瓷全冠已因其优良的修复效果和高成功率成为口腔修复的重要方法。全瓷修复体具有良好的牵物相容性和与天然牙相近的色泽，具有极佳的美观效果，被越来越多的患者所喜爱。氧化锆陶瓷由于具有高的断裂韧性、强度、硬度和耐磨性等优良性能，从陶瓷材料中脱颖而出，成为最有发展前景的新型结构材料。目前，氧化锆全冠已在临床上逐渐应用开来，但是对其长期疗效尚没有大样本系统的研究报道。在一篇关于3-5个单位氧化锆全瓷固定桥的研究中1，研究者发现只有1/57的桥体出现断裂，但是由于其他并发症，氧化锆全瓷固定桥的5年成功率仅有74%。有趣的是目前关于氧化锆全瓷冠的研究多集中于固定桥而对于单个全瓷冠报道较少。随着二氧化锆全瓷冠在口腔修复中应用的越来越广泛，目前需要更多的关于其长期修复效果及成功率的临床研究。本文的目的即为研究大样本量的二氧化锆全瓷冠修复后3年的修复效果及成功率。一、资料和方法自2005年10月至2006年11月共有169名患者在我院口腔修复科行216颗二氧化锆全瓷冠修复，2009年随访时有8名患者共12颗全瓷冠失访。因而共有161名患者的204颗全瓷冠纳入研究。161名患者中，56%为女性，患者平均年龄56岁（25-85岁）。修复方法 1、牙体预备：牙体预备要求预备后的牙体无倒凹，且各线角圆钝。二氧化锆采用cercon材料牙体预备切端磨除量1.502.00 mm。唇颊面磨除量1.50mm，邻面1.00mm，舌面1.00-1.50。2、颈缘预备：肩台宽度lmm；对于后牙，前牙的邻面及舌面，肩台位置采用龈上；对于上前牙唇侧肩台位置采用龈沟内。肩台基本形态为直角肩台或大的浅凹形。用Gingi-Pak排龈线排龈约5min，去除排龈线。颊舌侧近远中6。聚合角，合面与牙外形一致，不要锐角，否则易崩瓷，冠折。3、修复体制作：采用硅橡胶印模材料取模，灌制超硬石膏模型；VITAl6色比色板比色。采用德国进口材料cercon(泽康)德国进口设备CERECinlab系统和计算机辅助技术制作二氧化锆全瓷内冠支架，采用vita公司Vm9进行外部饰瓷。资料收集患者的性别、年龄、修复牙数、对合牙情况、修复前牙髓治疗情况、粘结材料、继发龋、以及失去固位力和折裂等并发症均进行记录。如修复后支持牙脱落、修复体出现不可修复的碎裂或重做、患者出现持续疼痛均认为修复失败。同时于复诊时检查并记录修复体活动情况，照美国加州牙科协会的全瓷修复诊临床标准：，对二氧化锆烤瓷牙修复结果进行检查评价：修复体保存完整：修复体没有脱落、折断、开裂和崩瓷；不完整：修复体出现脱落、折断、开裂或崩瓷。颜色匹配：修复体与邻牙在颜色和半透明度上一致；不匹配：修复体在颜色和半透明度上和邻牙不一致。边缘适合：修复体与牙紧密贴合，边缘没有可以钩住探针的缝隙；不适合：修复体与牙体之间有明显可以被钩住的缝隙，牙本质或基质暴露。牙龈反应有：牙龈健康完好，无充血及红肿；无：牙龈不同程度红肿充血，或有牙周袋形成。同时记录患者的主观满意度（采用视觉模拟评分法，0为非常不满意，100为非常满意）。二、结果在216颗二氧化锆全瓷冠中，切牙38颗，尖牙10颗，前磨牙71颗，磨牙97颗。大多数全瓷冠（n=168；78%）位于前磨牙或磨牙区。因8名患者失访，因而共有161名患者的204颗全瓷冠纳入随访研究。共有32颗全瓷冠或基牙出现并发症（15.5%）。排除早期易治疗的并发症，如粘固后暂时性疼痛，可通过重新粘固而治疗的修复体松脱等，较严重并发症的发生率为9%。其中5颗基牙被拔除（2%），1颗出现根折，4颗出现牙髓炎或牙周炎，所有被拔除的基牙均已于修复前行根管治疗；9颗基牙带冠后需行牙髓治疗（6%），均为后牙。12颗全瓷冠（7%）粘固后松脱，但其中8颗可重新粘固。未发现基牙继发龋。粘固后有3名患者出现牙齿敏感，2名患者于数月后恢复，1名患者重新制作修复体。共有10名患者的12颗全瓷冠（6%）修复失败：基牙拔除5颗，丧失固位力而重做4颗，瓷面破裂2颗，持续疼痛1颗。修复后2年内失败率较低，第三年失败率增加。3年总成功率为92.7%。复诊时修复体检查结果见表1。表1 二样化锆全瓷冠修复3年后修复效果/例全瓷冠数修复体完整度颜色匹配边缘适合性牙龈反应完整不完整匹配不匹配适合不适合有无2042022204020042004患者对于二氧化锆全瓷冠满意率平均为97，对于美观的满意率平均为90，对于舒适度的评分平均为93。三、讨论口腔陶瓷材料的特点是压缩强度，硬度及耐磨度均非常高。氧化锆陶瓷有较高的机械参数（抗弯强度超过900 MPa，断裂韧性约为7MPam1/2，是现在氧化铝陶瓷的2-3倍），极限负载能力强，三单位齿桥上的承受力约为2 000 N。同时氧化锆陶瓷不仅具有人体应用的生物安全基础，无细胞毒性而且能在口腔内能稳定存在，不释放有害杂质，并且不降解。另外，氧化锆陶瓷材料是目前能够最大限度再现自然牙形态，颜色和光泽(包括荧光和乳光)的人工材料。是一种极为优异的口腔修复材料。本研究表明，二氧化锆全瓷冠修复后三年，修复效果满意，患者主观满意度高。根据CDA标准，绝大多数修复体达到临床要求，无继发龋及严重的修复体周围软组织反应。但多数患者需加强口腔卫生保健。虽然多数修复体位于后牙区（78%），但是仅有4颗全瓷冠出现瓷层破裂。结合之前的报道2,3，二氧化锆全瓷冠完全可以承担后牙区正常的咬合功能。一项关于非二氧化锆全瓷冠的的回顾性研究发现4，修复后并发症的的平均发生率为8%，瓷层破裂是最主要的失败原因。这提示修复体所处的位置与其成功率密切相关。切牙，前磨牙，及磨牙全瓷冠的破裂率分别为3%，7%和21%。与本研究的结果对比可以发现，二氧化锆全瓷冠的综合性能以获得明显提高，原来认为的全瓷冠应尽量避免用于后牙的看法并不适用于二氧化锆全瓷冠。二氧化锆全瓷冠修复的其他并发症的发生率并不高，如牙髓炎，根折，继发龋等的发生率与金瓷冠相比均较低。这可能是由于目前全瓷冠瓷层只要0.5mm厚，因而牙体制备时切削牙体较少所致。但是修复体脱位的发生率相对较高，本研究显示3年全瓷冠保存率为93%，另一研究5发现后牙区全瓷冠与金瓷冠五年保存率分别为93%和96%，这可能与粘结材料等的不同有关。但是多数脱落全瓷冠均可容易的重新粘固。另有有关金瓷冠的报道显示6，基牙根充失败的发生率的较高，本研究在全瓷冠也发现相同问题。这可能是由于磨牙预备时磨除量相对较大造成的。本研究为一项基于临床的研究，可能由于患者的依从性，随访缺失等原因造成结果出现一定的偏差。但是本研究样本量较大，研究者采用了国际上通用的复诊及记录标准，研究结果应当是可信的。四、结论二氧化锆全瓷冠凭借其可靠的性能，可以应用于前磨牙及磨牙的全瓷冠修复。同时也应继续进行更长期的临床随访，以确定其长期修复效果。参考文献1 Sailer I, Fehe r A, Filser F, Gauckler LJ, Lu thy H, Hammerle CH. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. International Journal of Prosthodontics 2007; 20: 383388.2 Cehreli MC, Ko kat AM, Akca K. CAD/CAM Zirconia vs. slipcast glass-infiltrated Alumina/Zirconia all-ceramic crowns: 2-year results of a randomized controlled clinical trial. Journal of Applied Oral Science 2009; 17: 4955.3 Encke BS, Heydecke G, Wolkewitz M, Strub JR. Results of a prospective randomized controlled trial of posterior ZrSiO(4)-ceramic crowns. Journal of Oral Rehabilitation 2009; 36: 226235.4 Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. Journal of Prosthetic Dentistry 2003; 90: 3141.5 Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of the survival and complication rates of all-ceramic and metalceramic reconstructions after an observation period of at least 3 years. Part I. Single crowns. Clinical Oral Implants Research 2007; 18: 7385.6 Burke FJT, Lucarotti PSK. Ten-year outcome of crowns placed within the General Dental Services in England and Wales. Journal of Dentistry 2009; 37: 1224.（英文版 ） Two regulations promulgated for implementation is in the party in power for a long time and the rule of law conditions, the implementation of comprehensive strictly strategic plan, implementation in accordance with the rules and discipline to manage the party, strengthen inner-party supervision of major initiatives. The two regulations supporting each other, the adhere to a positive advocate, focusing on morality is of Party members and Party leading cadres can see, enough to get a high standard; around the party discipline, disciplinary ruler requirements, listed as negative list, focusing on vertical gauge, draw the party organizations and Party members do not touch the bottom line . Here, the main from four square face two party rules of interpretation: the first part introduces two party Revised regulations the necessity and the revision process; the second part is the interpretation of the two fundamental principles of the revision of laws and regulations in the party; the third part introduces two party regulations modified the main changes and needs to grasp several key problems; the fourth part on how to grasp the implementation of the two regulations of the party. and revised the necessity and revised history of the CPC Central Committee the amendment to the Chinese Communist Party members and leading cadres honest politics several guidelines and column 1 by 2015 to strengthen party laws and regulations focus. Two party regulations revision work lasted a Years, pooling the wisdom of the whole party, ideological consensus, draw historical experience, respect for the wisdom of our predecessors, which reflects the unity of inheritance and innovation; follow the correct direction, grasp the limited goals, adhere to the partys leadership, to solve the masses of the people reflect a focus on the problem. The new revision of the and , reflects the partys 18 and the eighth session of the third, the spirit of the fourth plenary session, reflecting the experience of studying and implementing the General Secretary Xi Jinping series of important speech, reflects the partys eighteen years comprehensive strictly practice. (a) revised two regulations of the party need of in based on revised, the promulgation and implementation of January 2010, to strengthen the construction of the contingent of leading cadres play an important role. But with the party to manage the party strictly administering the deepening, has not been able to fully meet the actual needs. Content is too complicated, eight prohibition, 52 are not allowed to hard to remember, and also difficult to put into practice; the second is concisely positive advocated by the lack of prohibited provisions excessive, no autonomy requirements; the third is banned terms and discipline law, both with the party discipline, disciplinary regulations repeat and Criminal law and other laws and regulations repeat; the fourth is to clean the theme is not prominent, not for the existing problems, and is narrow, only needle of county-level leading cadres above. is in 1997 based on revision, in December 2003 the promulgation and implementation, to strengthen the construction of the party play very important role. Along with the development of the situation, which many provisions have been unable to fully meet the comprehensive strictly administering the practice needs. One is Ji law, more than half of the provisions and criminal law and other countries laws and regulations Repetition; two is the political discipline regulations is not prominent, not specific, for violation of the party constitution, damage the authority of Party Constitution of misconduct lack necessary and serious responsibility to pursue; third is the main discipline for the leading cadres, does not cover all Party members. Based on the above situation, need to and the two is likely to be more relevant regulations first amendment. By revising, really put the authority of Party discipline, the seriousness in the party tree and call up the majority of Party members and cadres of the party constitution of party compasses party consciousness. (II) two party regulations revision process the Central Committee of the Communist Party of China attaches great importance to two regulations revision . Xi Jinping, general books recorded in the Fifth Plenary Session of the eighth session of the Central Commission for Discipline Inspection, on the revised regulations made clear instructions. According to the central deployment, the Central Commission for Discipline Inspection from 2014 under six months begin study two regulations revision. The Standing Committee of the Central Commission for Discipline Inspection 4 review revised. Comrade Wang Qishan 14 times held a special meeting to study two regulations revision, amendment clarifies the direction, major issues of principle, path and target, respectively held a forum will listen to part of the province (area) secretary of the Party committee, Secretary of the Discipline Inspection Commission, part of the central ministries and state organs Department The first party committee is mainly responsible for people, views of experts and scholars and grassroots party organizations and Party members. Approved by the Central Committee of the Communist Party of China, on 7 September 2015, the general office of the Central Committee of the Party issued a notice to solicit the provinces (autonomous regions, municipalities) Party, the central ministries and commissions, state ministries and commissions of the Party (party), the General Political Department of the military, every 3 people organization of Party of two regulations revision opinion. Central Commission for Discipline Inspection of extensive solicitation of opinions, careful study, attracting, formed a revised sent reviewers. In October 8 and October 12, Central Committee Political Bureau Standing Committee and the Political Bureau of the Central Committee After consideration of the two regulations revised draft. On October 18, the Central Committee of the Communist Party of China formally issued two regulations. Can say, two laws amendment concentrated the wisdom of the whole party, embodies the party. Second, and revision of the basic principles of two party regulations revision work and implement the partys eighteen, ten eight plenary, the spirit of the Fourth Plenary Session of the Eleventh Central Committee and General Secretary Xi Jinping important instructions on the revised and , highlighting the ruling party characteristics, serious discipline, the discipline quite in front of the law, based on the current, a long-term, advance as a whole, with Bu Xiuding independent and . Main principle is: first, adhere to the party constitution to follow. The constitution about discipline and self-discipline required specific, awaken the party constitution of party compasses party consciousness, maintaining the authority of the constitution. General Secretary Xi Jinping pointed out that no rules, no side round. Party constitution is the fundamental law, the party must follow the general rules. In early 2015 held the eighth session of the Central Commission for Discipline Inspection Fifth Plenary Session of the 16th Central Committee, Xi Jinping again pointed out that constitution is the party must follow the general rules, but also the general rules. the revision of the and is Method in adhere to the regulations established for the purpose of combining rule of virtue is to adhere to the party constitution as a fundamental to follow, the constitution authority set up, wake up the party constitution and party rules the sense of discipline, the party constitution about discipline and self-discipline specific requirements. 4 second is to adhere to in accordance with the regulations governing the party and the party. The Party of rule of virtue de, mainly refers to the partys ideals and beliefs, excellent traditional style. The revised the closely linked to the self-discipline, insisting on the positive initiative, for all members, highlight the vital few, emphasized self-discipline, focusing on the morality, and the majority of Party members and the ideological and moral standards. The revised Ji method separately, Ji, Ji Yan to Method, as a negative list, emphasizing the heteronomy, focusing on vertical gauge. Is this one high and one low, a positive reaction, the strict party discipline and practice results transformation for the integration of the whole party to observe moral and discipline requirements, for the majority of Party members and cadres provides benchmarking and ruler. Third, insist on to. In view of the problems existing in the party at the present stage, the main problems of Party members and cadres in the aspect of self-discipline and abide by the discipline to make clearly defined, especially the partys eighteen years strict political discipline and political rules, organization and discipline and to implement the central eight provisions of the spirit against the four winds and other requirements into Disciplinary provisions. Not one pace reachs the designated position, focusing on in line with reality, pragmatic and effective. After the revision of major changes, major changes in the and modified and needs to grasp several key problems (a) adhere to according to regulations governing the party and party with morals in combination, for at the present stage, the leadership of the party members and cadres and Party members in existing main problems of self-discipline, put forward principles, requirements and specifications, showing Communists noble moral pursuit, reflected at all times and in all over the world ethics from high from low 5 common requirements. One is closely linked to the self-discipline, removal and no direct relation to the provisions of . the second is adhere to a positive advocate, eight prohibition 52 are not allowed to about the content of the negative list moved into synchronization amendment . Three is for all the party members, will apply object from the leadership of the party members and cadres to expand to all Party members, fully embodies the comprehensive strictly required. The fourth is prominent key minority, seize the leadership of the party members and cadres is the key, and put forward higher requirements than the ordinary Party members. Five is to simplify, and strive to achieve concise, easy to understand, easy to remember. The revised is the ruling Party since the first insists on a positive advocate forAll Party members and the self-discipline norms, moral declaration issued to all members of the party and the National Peoples solemn commitment. criterion of a clean and honest administration consists of 4 parts, 18, more than 3600 words. After the revision of the , a total of eight, 281 words, including lead, specification and Party member cadre clean fingered self-discipline norms, etc. Part 3 members low-cost clean and self-discipline, the main contents can be summarized as four must eight code. Lead part, reiterated on ideal and faith, fundamental purpose, the fine traditions and work style, noble sentiments, such as four must the principle of requirements, strong tone of self-discipline, The higher request for 6 and supervised tenet, the foothold in permanent Bao the partys advanced nature and purity, to reflect the revised standards requirements. Members of self-discipline norms around the party members how to correctly treat and deal with the public and private, cheap and rot thrifty and extravagance bitter music, put forward the four norms. Party leader cadre clean fingered self-discipline norms for the leadership of the party members and cadres of the vital few, around the clean politics, from civil servant of the color, the exercise of power, moral integrity, a good family tradition and other aspects of the leadership of the party members and cadres of the four norms to fully adapt to the strictly requirements, reflects the according to the regulations governing the law of recognition of deepening, the realization of the discipline construction and Jin Ju. is party a ruler, members of the basic line and follow. And the majority of Party members and cadres of Party organizations at all levels should adhere to the bottom line of thinking, fear discipline, hold the bottom line, as a preventive measure, to keep the partys advanced nature and purity. 1, respect for the constitution, refinement and discipline. Revised from comprehensive comb physical constitution began, the party constitution and other regulations of the Party of Party organizations and Party discipline requirements refinement, clearly defined in violation of the party constitution will be in accordance with regulations to give the corresponding disciplinary action. The original 10 categories o