![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=1739595306-SpGvMiaSwbB6zd2FOrKILnUDDtzur1PL-0-5f7b6f9eabb96c43ec5e5c5578be4af6)
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=1739595306-2tTzDcLWUtBZK2TY7DEYI0nlbv7Rine4-0-7131c134af2c24b9e70e6ef660f8554c)
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=1739595306-NbyYAIWem69gz5RwvpyAvZGNI8ax065s-0-640d2db34aed4226eabda2a1f8fd7aca)
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=1739595306-8Cls6HCFCzpcQ3mBh7fklzsYKWLfrmCh-0-776401d3d0fc56b27101da46527eeb39)
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=1739595306-U4aoGqahEJGak1BMNNvhiuPYKcg8yjvA-0-9ad84a906148a03070d57101c015f19d)
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=1739595306-fhlNH0GA8qBK7ywtVpmRnjxInmh6eYvj-0-06f6d17b8137e0a255b3fdc48927b0eb)
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=1739595306-B9nXS4oGIJcbofmtnuxxi2xU5RQaMXtC-0-3929bec1bd5b33afc68229180c0b7ce4)
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=1739595306-McQ8Mdp56vtSjLoJ40cOIpVdAfWR9Nx7-0-a6a06de829703659a404db25150079fc)
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=1739595306-zN1Nnr78Q7WgTxaWvIXbw2oKH8yFWHep-0-490be228c9569dd15729279305701501)
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=1739595306-4DFKIy8psbU7sm97viV4BfaSsF5lJBr5-0-83d61c5a1e4c0ca7ee2d398e750323a3)
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=1739595306-UDbLd581mTpoVk4W2cPin50HsPBU0jrE-0-86a594ed82f2b9ae710ae25821d8f28f)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-37_956.jpg?sign=1739595306-oi10zhnlTIqKVt3OsBpxwRmY1LXxjO3a-0-cfd7b3c9705743144369a7833ec7833d)
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=1739595306-pSdj20YE5xZP6HVMXad5DCza5q1GUmJI-0-7bf8dbbaccbe29c2c90c6871b0f68242)
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=1739595306-8Mg8fRZr7YqsVvXbO6YIE3W1vTHjMyFB-0-b5d910c9dc81485e7e4b5c59f7933636)
图2-39 研究模型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-40_965.jpg?sign=1739595306-y6wJkOMiHooZGkUdQRiitunWxAULbKIz-0-cbec80b3390cfec7b05dd532358eade4)
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=1739595306-M4sdLSmgXcMWC2V3siUQvDiOGsSJ3j8R-0-c2fef4f1e1ecdf9b726fe2cd6b8167f2)
图2-41 模型设计
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-42_973.jpg?sign=1739595306-DfhMZsa6M2SOPU88fH3SRppQEWjALu9E-0-ff0d748f006e13717035c5f9404cd27f)
图2-42 诊断蜡型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-43_976.jpg?sign=1739595306-UCWA9AHIiri6AllXxZquDFnpJg0FOGSK-0-6c18c3ea8cbfc2ee229f63b94eee5a4d)
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=1739595306-RSOpXJ9ZEI28GfVCgaxSmdRJA2IFEy7J-0-598284eff976d0e7c7fa529ed72d73ee)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-44_980.jpg?sign=1739595306-BtJt6yHZfeQDM59E88ereWfX7OO761ZC-0-cf313ba7cf2c8ccb3f85e240629bf03c)
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=1739595306-prGoIKdj1ekRjphhJ3vzUQ8S9bDDAysL-0-89b7b38c2bab8fdc75f04e0e45031111)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-45_984.jpg?sign=1739595306-lup0n8T56au1iDBysADmlrGrs8ziNwUo-0-d44b860cdbe1a08d09a54604080b99ee)
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=1739595306-WUidJ9P4a11XQ2Hn0pNXILAySrQ7JHUn-0-ed5ace7f9aa1d87c3304630096729f59)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-46_988.jpg?sign=1739595306-QNTaLT4cOXeKLdaOv3u3tVcSw50hCPUI-0-e522846ddc8e3cf522c3bb0ffa7c8cbb)
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=1739595306-W3pWAKd57sEYf8laUsvTzuD9D9O9jx4k-0-24b264a9f800f014bab0d0196f758284)
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=1739595306-oGX95jXEXHMBFidyNYhKklYOuInOT08F-0-0375d89662ca271e1c8cabc2dea5a986)
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=1739595306-ZkbgksrJo4Q8yWr9IsCNKY6kXEdAvRuH-0-bae7982e14b11695e1c0a555ca072eb5)
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=1739595306-6fMZQQqjfxzkJtkbpfTdBs1JahqOyelr-0-8880a6a2503f89cec7b8ad122b24f9ba)
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=1739595306-jdWYZQY7m962e9SxMBGh0QJRmkXN7RUi-0-1fdb93f4c4b84c64b1b2dd66f1db6a0b)
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=1739595306-bWrfRe9mCNhw1i3t8orjfcAuilTrrabO-0-7167373962511f9891cc7e48099674c1)
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=1739595306-AikXs3oLe6coSbgppqiqFP3hKSsJfNCY-0-d1b321750af642095ff0e30cee948597)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-53_1011.jpg?sign=1739595306-9xw2G0m4H2rLQgsy14y08aruQcP0QB1p-0-452496b9a75783e6c06aa1bac5989383)
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=1739595306-O77mMG5xeZttNfTMqkde6HNtpciwwWWv-0-3a7e6b0c228b38d79a8314338dab9b14)
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=1739595306-gYiHxNNnXvVXqGihyj5cQ4K7TeKX0shU-0-e0f9727d987f13ca002416b22de3a628)
图2-55 修复后非常健康的牙龈状态