![美学修复牙体预备](https://wfqqreader-1252317822.image.myqcloud.com/cover/683/36534683/b_36534683.jpg)
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(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=1739148306-PlEjWKeBFPl4Yn1LAuggZJpGt5VaOvAT-0-d28af37352b8b4a46b691e2558f57c21)
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=1739148306-Nq2ZbYKDMosJPnOMKkAzL7kcilxWGZZR-0-b0df38606288107274658b5f01c60b47)
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=1739148306-yi0F5GTzr8ye9SqGwt4xT6vzYQ87g77e-0-5366ffa19773439df81854dc43811e15)
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=1739148306-ANum21OxpsLSCZdCEQ5SPglHK7LjuLhH-0-078b6bec080f6dc5d97f1024a4255d84)
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=1739148306-TiTWax5jzJiB346lqSiPVKcrjbDNij8P-0-ace73ba96d2981cf37f4ef7ab33f9493)
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=1739148306-kuTxQ7btKC85hSqftSeb51YqQgQG8LAe-0-0393ad87217062b6df91d2e571698923)
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=1739148306-RE7JLVcWebIYyxuHLPGhYqiqxjrbGY22-0-6f3947c35113caefc21ec3e91853ecee)
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=1739148306-ysAx7LqbWd6ETdtKaLOf0cGolg76f1YM-0-22aa89139e711a9de66ac554f7ccf03e)
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=1739148306-Cy1KjLrY2otiw9ze9yoahtjS8Cx737ZC-0-dcc81746aed57d78df5feaf411cef0cf)
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=1739148306-UOiPMlUBjhyl94LajrNrwXQ4shYWrxUG-0-3221614b658c54a9ccc552f488fb1321)
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=1739148306-pNURMcGVo7wsu6F1QQBlk4msTrqAwBvf-0-d2adb97a584afabec03b52a18617a9c3)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-37_956.jpg?sign=1739148306-5HutNl5SkIcGlIpUCITsyLvKpMxzWZIQ-0-53c4617b068a60b836b032c858b3d745)
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=1739148306-SdySJg6t1JvywOttz2nQQBo0klwsdovK-0-d41c71294cf42a9a1229d09190205292)
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=1739148306-KFuxGuEU6nbh2DkfJXQwW97LVzWp5nlF-0-29dfd1af9d8bc94e7342eb1eaf1701cd)
图2-39 研究模型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-40_965.jpg?sign=1739148306-sZN6EZ91bE6Ve9OZvTQ82rSgky6y1a0c-0-3502717928c373c2b8141227696f2c13)
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=1739148306-f5kyKbH0D0zp5IG71DLs9wYp7HlG9BIX-0-a4293ca9f0caac12fb2ecc2a63bff2e3)
图2-41 模型设计
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-42_973.jpg?sign=1739148306-VQfASZZgqXviN5yx248fX9FIMluJCH9Z-0-8b2b49dd2af51de1def7f2a1f15ee06e)
图2-42 诊断蜡型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-43_976.jpg?sign=1739148306-hG5381UK0UUFNEjrcFMRs0PLW6J4e3Ks-0-0c7e714831102f4b9a555a4a983a8c7c)
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=1739148306-hqMjc9DBPQwzFBrgpUxOR69N8IJ0ODXp-0-a2d49b806f2289daa18179ca28aa57e9)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-44_980.jpg?sign=1739148306-lG6QdE90r7EbR2guPoihD7ZVAnbjAECY-0-efd28c354612c28170e704902fc62494)
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=1739148306-wbxgSv4FA4GWluuK1xamDwtaeLvb6LgS-0-e625ff50192db6970d7ae5cd2190146b)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-45_984.jpg?sign=1739148306-OhmxQYS3nYYrmzxRNUpXXylUP3fdnjZb-0-989afc6306a19636f6061b14986ad7aa)
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=1739148306-lhDn34OfRBmEb93QB7J1LfkinPat54m8-0-ec2294f31d390ff18915529374eccbff)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-46_988.jpg?sign=1739148306-pSUJ9npnkchdbDq7VptmAQFIO7M0lh0b-0-d3789b23fa306986d4ca2baee9d0fe07)
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=1739148306-iBAGEL8COCyP3VtzKsEZ0sngtLdxzGIm-0-e19ac092dd9ad65076307a151ee2d558)
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=1739148306-tlXECDcq4Jcxa3lnrkdWswfHymGFCuJ8-0-9a2ca59bf803dfff85e095c8a29df3a3)
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=1739148306-heXVC5pw12PedJCWJkksqEnanogzCmCA-0-3f90e1ed4c336488de0533b7d57d980a)
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=1739148306-IzrTOTrl0KT68nI6CtQalpBwsE960Zcm-0-99ef3e4a190204e03c307aba73abb636)
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=1739148306-973XQJNBIDjrVI1pQTJNKXljVhF3ufpx-0-b533f7b9df1577c60cc369c93d7e85a5)
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=1739148306-BzKCVJV5HqjMRvZ73oMVQDmcVpKwRprA-0-6d7f1b620c84cf98cbddde58ff4d8be9)
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=1739148306-HJsMETazIBPqjQhLZwGiX8VCKmCPBGZE-0-fc04df36506b51cbf3ce1a6dcb2b3922)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-53_1011.jpg?sign=1739148306-WkOJ5aDCk2zqoJrcGsyQYzmoXeaaFxaw-0-bf1345af4c88bfdc5b3e01ea89d898d4)
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=1739148306-NbYTX3qF5ipy0F89WLGCNCIeXyxZfDDZ-0-4513da39101c91ba81ba5547c1c2a526)
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=1739148306-RgLj8MMCpMJwxcDmP45GWv1D1Dv3Tcfo-0-ef3da43b8537c266bd28801b258d1fc5)
图2-55 修复后非常健康的牙龈状态