![美学修复牙体预备](https://wfqqreader-1252317822.image.myqcloud.com/cover/683/36534683/b_36534683.jpg)
上QQ阅读APP看书,第一时间看更新
(四)形态
将预备体边缘设计为龈下,还可以满足很多形态设计上的需要。
牙龈形态是天然牙或修复体临床冠部形态的重要组成部分(图2-27)。修复体的穿龈部分形态会影响到牙龈的形态,与此同时,牙龈形态又会影响修复体的临床冠部形态。这个理念就是“穿龈轮廓”的理念。
所谓穿龈轮廓,就是修复体自龈沟以上、至穿出牙龈部分的形态和凸度,它会对牙龈形态、临床冠形态产生明显影响。需要注意的是,穿龈轮廓与生物学宽度是完全不同的两个概念,在规范的操作的前提下,对穿龈轮廓的调整、控制是不会影响到生物学宽度的(图2-28)。
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-27_921.jpg?sign=1738992931-DmTejsRHK1EkI1X4nEIvKnesVtDV1rd9-0-8273a07a2137dd4a36650150c7652168)
图2-27 牙龈形态影响修复体的形态
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-28_924.jpg?sign=1738992931-j2ZdUKmsuw1x4xtlj5zPid8Cq7PMFx4e-0-1679d3a527e812b4668f95ea54109b47)
图2-28 穿龈轮廓与生物学宽度(引自伊籐雄策《暂时性修复体》)
当需要对牙龈形态进行调整时,有不同的选择。如果需要大面积、大范围调整牙龈曲线,或者说重新创造、塑造一条新的牙龈曲线时,牙周手术是一个非常必要且有效的治疗手段;如果需要在龈沟深度以内进行形态、轮廓的改善,则通过临时冠的穿龈轮廓进行调整则是一个非常适宜的、更精确、更微创的治疗方法(图2-29~2-34)。
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-29_928.jpg?sign=1738992931-Hi0cGlRXtnGswGm6OHdXbTcavFHiq6Z6-0-0a138a4d7249a554198b0918197f0128)
图2-29 修复前,患牙临床冠短于同名牙
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-30_931.jpg?sign=1738992931-BnS6xSAmWcywCN2hrnsotN9lTl8bIGaw-0-5de243c132d9fefa6617805228423d04)
图2-30 牙体预备,将边缘设计为龈下
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-31_935.jpg?sign=1738992931-MoChpAE7y8cSixzmxVtv8NEKgei8HhSe-0-5a240b9e58c820dd23f539742b1097bd)
图2-31 调整临时修复体的穿龈部分凸度
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-32_938.jpg?sign=1738992931-Z8aXG6g9unKrsoewZYMxr3bztDe70L6S-0-0aeace1bb1d86b918329420508a10286)
图2-32 调整后的临时修复体戴入,牙龈形态随着穿龈轮廓的调整而变化,修复体形态获得改善
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-33_941.jpg?sign=1738992931-Qq4oEONN0UyTXUuuCjcN3Z1QFkuZnn86-0-15252b2973240932f386a2ed9072dbae)
图2-33 按照新的牙龈曲线完成的修复体,外形轮廓与同名牙一致性明显增强,获得比较满意的修复效果
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-34_944.jpg?sign=1738992931-khRivbebbvQPfP6a854gDl8yzkNfEG2E-0-8ec36336f899a43cf7f99468b568eaa9)
图2-34 修复前后的对比,可以看到修复后牙龈曲线整体向根方移动,并且牙龈曲线最高点( Z点)也按照同名牙的特点向远中位置移动。这一类非常精确的形态调整通过临时冠的穿龈轮廓改变来调整,较通过其他治疗手段更易获得精确的效果
利用控制穿龈轮廓的方法,可以使一些疑难病例获得满意的治疗效果。牙周手术和穿龈轮廓的调整两种治疗手段,有时需要结合应用,有时需要认真思考、选择应用(图2-35~2-55)。
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-35_949.jpg?sign=1738992931-BvRqfFresu9qotCHGiHtFHLfBP7flJ5h-0-043f27b8a998a4f32652588fa8ae2c15)
图2-35 治疗前,前牙缺损,露龈微笑
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-36_952.jpg?sign=1738992931-PLsI2HmjSGdyClXv5JqmoHcHzuK6iYfw-0-b1275d430845e7486f23326f084439e6)
图2-36 左侧切牙缺失,前牙深覆
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/BZ_40_1647_1071_1690_1113.png?sign=1738992931-oB3Hx1xPFW4xx0AwWTO5TCEAjKgCG5ez-0-07f5acaeba400d8c39b7e264c59dc60b)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-37_956.jpg?sign=1738992931-tg0Fucfvu7Ra4q5eXDcEKeMZUI222e47-0-2bf4bf5bd4295d8b69fbae54fadf42ec)
图2-37 上前牙牙龈曲线不良
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-38_959.jpg?sign=1738992931-oq7oizFGZGX6LBeEaxOMcV8SSElA3qkx-0-c56f27881f5e467b20e39983095633e6)
图2-38 上前牙整体偏腭侧
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-39_962.jpg?sign=1738992931-aqfFzpe3VfBXUR6uvVsx2ujSO5Xxosvj-0-ba8228d5d4561ada8914bab33303a7c5)
图2-39 研究模型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-40_965.jpg?sign=1738992931-Yy9lUVWAqFJDwLopAEKZSQ8RbP0i83dQ-0-79af46c2cde32bf2b09237b221a3c119)
图2-40 设计合理的牙龈曲线
该患者的最佳治疗方案是先正畸治疗,改善上前牙排列、位置,再进行修复治疗。但患者年纪较大,不能接受正畸治疗,要求直接考虑修复治疗。由于患牙整体偏向腭侧,采用牙周手术不能获得满意的美学效果。经探测患牙均有3mm左右的龈沟深度,决定利用穿龈轮廓调整形态。
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-41_970.jpg?sign=1738992931-wXgaPHC6lS27kTfX2LbBGvKLLa8W0u8r-0-71ceb14622951b417a8227e162783c0e)
图2-41 模型设计
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-42_973.jpg?sign=1738992931-e6eSa311IcZcFhg2l8A1p8y74vG0lrgw-0-6cb413fb3b52ea3d88f2ee3230fbb49d)
图2-42 诊断蜡型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-43_976.jpg?sign=1738992931-5dYrJmIBLIRC4FDibyRQc3V9CLCFe8Ai-0-4a89844228460bfd15ef6ebb219fb55e)
图2-43 研究模型
面观
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/BZ_41_626_1302_665_1346.png?sign=1738992931-ndzwjhBvafonaFc54OtIihl8uRn6C462-0-872fd07b22b66e78ee3f9df2fa5202a4)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-44_980.jpg?sign=1738992931-kaOcsQf6zZNoika2zjWh3qWfXrsKE8DJ-0-084b709d4ebb14588ed9338b273e80c8)
图2-44 模型设计
面观
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/BZ_41_1113_1300_1153_1340.png?sign=1738992931-fOBLaEiSrIMmoccMU2vBOJ46wxR740ut-0-4cb9159dab6beca753c61e056732a0d9)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-45_984.jpg?sign=1738992931-RYecC3AIX31g6vvtPz4CTBmawXXzUzge-0-38e9688c8cee0f9e74f7be48b9e41119)
图2-45 诊断蜡型
面观
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/BZ_41_1616_1303_1653_1344.png?sign=1738992931-5FkO6GLF71SGxldLbbQBMZNcptLsb9d9-0-cab0eb2dd5f38750c8ff7c3fa6df3b1d)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-46_988.jpg?sign=1738992931-Zme4APuqxykaev1qFkGDMdCQt8PytidP-0-3325faa51194412356ea1d6d30a9173e)
图2-46 导板指示下进行桩核牙体预备
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-47_991.jpg?sign=1738992931-lFM8OcyJZdh1Dx3kjTA6P7bMDQ2Bjarh-0-cdfd062b7c0b9c634cd06f91768c6994)
图2-47 导板指示下进行桩核牙体预备
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-48_994.jpg?sign=1738992931-dC6BWDw3IVwrijvUhQpL8A7JXhcp3Cyi-0-796421691c3961b9dec236a7386bd74f)
图2-48 铸造桩核改善牙体长轴方向
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-49_997.jpg?sign=1738992931-yoZVlqrTfjeq57GgAQeKFTUNPryPiuZP-0-31a6ba6457d6c22f35560adefce37e62)
图2-49 利用诊断蜡型在口内复制临时修复体,唇侧为“背猴”形式
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-50_1000.jpg?sign=1738992931-aX1jVXqRISjfL7TM3lxBSbo8lL1gKZXD-0-0ae77379976065201092b2d1806d6d6c)
图2-50 利用对临时修复体穿龈轮廓的不断调整,修复体成为从龈下穿出的形式
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-51_1004.jpg?sign=1738992931-KnZQFMjb1wbtNvHIu3EP4JyhVPfcqFhj-0-449d89bf2a127c0d29b9689941288419)
图2-51 去除临时修复体后可见的牙龈形态,牙龈曲线明显向根方移动,保存典型牙龈乳头形态
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-52_1007.jpg?sign=1738992931-vjPgulIds4ylbeyu4arALTNB4vnz0ZZj-0-ec178cdf79bc3f8761e426c7b4ce4641)
图2-52
面观,预备体周围形成明显的“牙龈袖口”形态,为永久修复的形态效果做好了准备。牙龈保持非常健康的状态
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/BZ_42_1216_913_1256_953.png?sign=1738992931-xfuLfBzY1VDx32q1k4t24CS7RxrWpHtd-0-e24034ded414a73899bfb852ea177b57)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-53_1011.jpg?sign=1738992931-MPicj0jMIynzp1p8pB8bDJLk6t3mU3m1-0-37687d66f2aa20dacc8f292479ad13b4)
图2-53 永久修复体需要形成和临时修复体一致的穿龈形态
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-54_1014.jpg?sign=1738992931-wRdV6eEDcQggfcVxBLOpnAkLsrevDZMk-0-c8e39cdf86e78d0d0d9b99c433a1ea6e)
图2-54 修复后,牙龈曲线获得明显改善
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-55_1017.jpg?sign=1738992931-YmxejBb3qodyGvOsAi9lkBkw9oEZqd7N-0-62fc8b7e974a1c7a850f57c022c627b9)
图2-55 修复后非常健康的牙龈状态