牙龈退缩的病因和临床治疗进展
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摘要
牙龈退缩是口腔临床常见症状之一。牙龈退缩引起的牙周软组织缺损及其带来的与美学、修复、正畸治疗有关的问题越来越受到重视。本文基于牙龈退缩的病因、分类和治疗三个方面作一综述,为牙龈退缩的诊治提供参考。牙齿的解剖特征差异、细菌病毒感染、创伤、刷牙方式不当等因素都有可能导致牙龈退缩。Miller分类为目前最常用的分类标准,根据牙龈退缩与膜龈联合的关系以及邻面牙槽骨或牙间乳头的丧失情况分为4类。现有的冠向复位瓣术、侧向转位瓣术及上皮下结缔组织移植术等膜龈手术对MillerⅠ类和Ⅱ类牙龈退缩已能获得较为满意的效果;对Ⅲ类牙龈退缩的术后疗效欠佳,只能达到部分根面覆盖;Ⅳ类牙龈退缩时手术治疗无法达到根面覆盖。对于重度牙周炎导致的MillerⅣ类牙龈退缩的患者,手术治疗效果差,亦可考虑义龈等修复方法。近年来,多种生物材料联合应用于牙龈退缩的膜龈手术治疗中,如牙釉质基质衍生物、同种异体移植脱细胞真皮基质、猪胶原基质和富血小板纤维蛋白等,这些生物材料的使用可提高根面覆盖率、或增加牙龈厚度及角化龈宽度,或避免了对腭区取瓣手术,降低了手术风险,增加了患者的依从性。
Gingival recession is one of the common oral symptoms. Periodontal soft tissue defects caused by gingival recession and problems related to aesthetics, prosthetics and orthodontic treatment have garnered increasing attention.This article reviews the etiology, classification and treatment of gingival recession to provide a reference for the diagnosis and treatment of gingival recession. Anatomical characteristics of teeth, bacterial and viral infection, Occlusion trauma, Improperbrushing methods and other daily behaviors and iatrogenic factors may lead to gingival recession. Miller classification is the most commonly used classification standard. It is divided into 4 degrees according to the relationship between gingival recession and the association between the gingival membrane and the loss of adjacent alveolar bone or interdental papilla. Gingival surgeries, such as coronally advanced flap, laterally positioned flap, subepithelial degrees and Ⅱ gingival recession retreat, obtain a more satisfactory success rate. Regarding the Ⅲ degree gingival recession, the postoperative curative effect is poor and can only cover part of the root. Regarding Ⅳ degrees gingival recession, surgery cannot reach the root surface coverage. For patients with Miller Ⅳgingival recession caused by severe periodontitis, the surgical treatment is poor, and repair methods, such as sputum, can also be considered. In recent years, a variety of biological materials have been jointly applied to gingival surgery, such as tooth enamel matrix derivative(EMD), allograft acellular dermal matrix(ADM), porcine collagen matrix(PCM) and plateletrich fibrin(PRF). The use of these biomaterials can improve root coverage, increase gingival thickness and keratinized gingival width, avoid the requirement of palatal flap removal, reduce the surgical risk and increase patient compliance.
Gingival recession is one of the common oral symptoms. Periodontal soft tissue defects caused by gingival recession and problems related to aesthetics, prosthetics and orthodontic treatment have garnered increasing attention.This article reviews the etiology, classification and treatment of gingival recession to provide a reference for the diagnosis and treatment of gingival recession. Anatomical characteristics of teeth, bacterial and viral infection, Occlusion trauma, Improperbrushing methods and other daily behaviors and iatrogenic factors may lead to gingival recession. Miller classification is the most commonly used classification standard. It is divided into 4 degrees according to the relationship between gingival recession and the association between the gingival membrane and the loss of adjacent alveolar bone or interdental papilla. Gingival surgeries, such as coronally advanced flap, laterally positioned flap, subepithelial degrees and Ⅱ gingival recession retreat, obtain a more satisfactory success rate. Regarding the Ⅲ degree gingival recession, the postoperative curative effect is poor and can only cover part of the root. Regarding Ⅳ degrees gingival recession, surgery cannot reach the root surface coverage. For patients with Miller Ⅳgingival recession caused by severe periodontitis, the surgical treatment is poor, and repair methods, such as sputum, can also be considered. In recent years, a variety of biological materials have been jointly applied to gingival surgery, such as tooth enamel matrix derivative(EMD), allograft acellular dermal matrix(ADM), porcine collagen matrix(PCM) and plateletrich fibrin(PRF). The use of these biomaterials can improve root coverage, increase gingival thickness and keratinized gingival width, avoid the requirement of palatal flap removal, reduce the surgical risk and increase patient compliance.
引文
[1]Mythri S,Arunkumar SM,Hegde S,et al.Etiology and occurrence of gingival recession-an epidemiological study[J].J Indian Soc Periodontol,2015,19(6):671-675.
[2]Liu F,Pelekos G,Jin LJ.The gingival biotype in a cohort of Chinese subjects with and without history of periodontal disease[J].JPeriodontal Res,2017,52(6):1004-1010.
[3]Chalabi M,Rezaie F,Moghim S,et al.Periodontopathic bacteria and herpes viruses in chronic periodontitis[J].Mol Oral Microbiol,2010,25(3):236-240.
[4]Hennequin-Hoenderdos NL,Slot DE,Van der weijden GA.Incorrect application of epidemiologic concepts in the incidence of complications associated with lip?and/or tongue piercings:a systematic review[J].Int J Dent Hyg,2016,14(1):62-73.
[5]Rasperini G,Acunzo R,Cannalire P,et al.Influence of periodontal biotype on root surface exposure during orthodontic treatment:a preliminary study[J].Int J Periodontics Restorative Dent,2015,35(5):665-675.
[6]Sharma K,Mangat S,Kichorchandra MS,et al.Correlation of orthodontic treatment by fixed or myofunctional appliances and periodontitis:a retrospective study[J].J Contemp Dent Pract,2017,8(4):322-325.
[7]Jati AS,Furquim LZ,Consolaro A.Gingival recession:its causes and types,and the importance of orthodontic treatment[J].Dental Press J Orthod,2016,21(3):18-29.
[8]Miller PD.A classification of marginal tissue recession[J].Int JPeriodontics Restorative Dent,1985,5(2):8-13.
[9]Nordland WP,Tarnow DP.A classification system for loss of papillary height[J].J Periodontol,1998,69(10):1124-1126.
[10]Kumar A,Masamatti SS.A new classification system for gingival and palatal recession[J].J Indian Soc Periodontol,2013,17(2):175-181.
[11]Cairo F,Pagliaro U,Nieri M.Treatment of gingival recession with coronally advanced flap procedures:a systematic review[J].J Clin Periodontol,2008,35(8):136-162.
[12]Yilmaz E,Ozcelik O,Comert M,et al.Laser-assisted laterally positioned flap operation:a randomized controlled clinical trial[J].Photomed Laser Surg,2014,32(2):67-74.
[13]Ozcelik O,Seydaoglu G,Haytac MC.An explorative study to develop a predictive model based on avascular exposed root surface area for root coverage after a laterally positioned flap[J].J Periodontol,2015,86(3):356-366.
[14]叶晓毅,刘南佑,黄雁红,等.冠向复位瓣联合结缔组织瓣治疗下前牙牙龈退缩[J].口腔疾病防治,2018,26(11):722-726.
[15]Tonetti MS,Jepsen S.Clinical efficacy of periodontal plastic surgery procedures:consensus report of group 2 of the 10th European workshop on periodontology[J].J Clin Periodontol,2014,41(Suppl15):36-43.
[16]Sanz M,Simion M.Surgical techniques on periodontal plastic surgery and soft tissue regeneration:consensus report of group 3 of the 10th European workshop on periodontology[J].J Clin Periodontol,2014,41(Suppl15):92-97.
[17]Pini-Prato GP,Cairo F,Nieri M,et al.Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions:a split-mouth study with a 5-year follow-up[J].J Clin Periodontol,2010,37(7):644-650.
[18]Bouchard P,Malet J,Borghetti A.Decision-making in aesthetics:root coverage revisited[J].Periodontol 2000,2001,27(1):97-120.
[19]林智恺,束蓉,钱洁蕾,等.改良侧向转位冠向复位瓣联合结缔组织移植治疗单牙重度牙龈退缩的临床效果[J].上海交通大学学报(医学版),2017,37(5):656-660.
[20]倪靖,束蓉.改良隧道技术结合上皮下结缔组织移植治疗多牙位牙龈退缩[J].上海交通大学学报(医学版),2015,35(12):1937-1940.
[21]赵静,李新月,释栋.上皮下结缔组织替代材料治疗牙龈退缩的临床应用[J].口腔疾病防治,2016,24(9):554-557.
[22]张玉峰.诱导性生物材料与牙周组织再生[J].中华口腔医学杂志,2017,52(10):615-619.
[23]Alkan EA,Parlar A.Enamel matrix derivative(emdogain)or subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions:a pilot study[J].Int J Periodontics Restor Dent,2013,33(5):619-625.
[24]Cheng GL,Fu E,Tu YK,et al.Root coverage by coronally advanced flap with connective tissue graft and/or enamel matrix derivative:a meta-analysis[J].J Periodontal Res,2015,50(2):220-230.
[25]Wei G,Liao HQ,Li G,et al.Root coverage using a coronally advanced flap with or without acellular dermal matrix:a meta-analysis[J].J Periodontal Implant Sci,2016,46(1):22-34.
[26]Willershausen I,Barbeck M,Boehm N.Non-cross-linked collagen type I/III materials enhance cell proliferation:in vitro and in vivo evidence[J].J Appl Oral Sci,2014,22(1):29-37.
[27]Mensi M,Scotti E,Salgarello S,et al.One-stage treatment of multiple recessions in the esthetic area with the bilaminar technique:clinical procedures and 24-month follow-up[J].Int J Esthet Dent,2016,11(4):494-504.
[28]Kumar A,Bains VK,Jhingran R,et al.Patient-centered microsurgical management of gingival recession using coronally advanced flap with either platelet-rich fibrin or connective tissue graft:a comparative analysis[J].Contemp Clin Dent,2017,8(2):293-304.
[29]Keceli HG,Kamak G,Erdemir EO,et al.The adjunctive effect of platelet-rich fibrin to connective tissue graft in the treatment of buccal recession defects:results of a randomized,parallel-group controlled trial[J].J Periodontol,2015,86(11):1221-1230.
[30]Paryag A,Lowe J,Rafeek R.Colored gingiva composite used for the rehabilitation of gingiva recessions and non-carious cervical lesions[J].Dent J(Basel),2017,5(4):1-7.
[31]李振财.正畸治疗对牙周病患者牙龈退缩的影响分析与研究[J].中国继续医学教育,2016,29(8):78-79.
[2]Liu F,Pelekos G,Jin LJ.The gingival biotype in a cohort of Chinese subjects with and without history of periodontal disease[J].JPeriodontal Res,2017,52(6):1004-1010.
[3]Chalabi M,Rezaie F,Moghim S,et al.Periodontopathic bacteria and herpes viruses in chronic periodontitis[J].Mol Oral Microbiol,2010,25(3):236-240.
[4]Hennequin-Hoenderdos NL,Slot DE,Van der weijden GA.Incorrect application of epidemiologic concepts in the incidence of complications associated with lip?and/or tongue piercings:a systematic review[J].Int J Dent Hyg,2016,14(1):62-73.
[5]Rasperini G,Acunzo R,Cannalire P,et al.Influence of periodontal biotype on root surface exposure during orthodontic treatment:a preliminary study[J].Int J Periodontics Restorative Dent,2015,35(5):665-675.
[6]Sharma K,Mangat S,Kichorchandra MS,et al.Correlation of orthodontic treatment by fixed or myofunctional appliances and periodontitis:a retrospective study[J].J Contemp Dent Pract,2017,8(4):322-325.
[7]Jati AS,Furquim LZ,Consolaro A.Gingival recession:its causes and types,and the importance of orthodontic treatment[J].Dental Press J Orthod,2016,21(3):18-29.
[8]Miller PD.A classification of marginal tissue recession[J].Int JPeriodontics Restorative Dent,1985,5(2):8-13.
[9]Nordland WP,Tarnow DP.A classification system for loss of papillary height[J].J Periodontol,1998,69(10):1124-1126.
[10]Kumar A,Masamatti SS.A new classification system for gingival and palatal recession[J].J Indian Soc Periodontol,2013,17(2):175-181.
[11]Cairo F,Pagliaro U,Nieri M.Treatment of gingival recession with coronally advanced flap procedures:a systematic review[J].J Clin Periodontol,2008,35(8):136-162.
[12]Yilmaz E,Ozcelik O,Comert M,et al.Laser-assisted laterally positioned flap operation:a randomized controlled clinical trial[J].Photomed Laser Surg,2014,32(2):67-74.
[13]Ozcelik O,Seydaoglu G,Haytac MC.An explorative study to develop a predictive model based on avascular exposed root surface area for root coverage after a laterally positioned flap[J].J Periodontol,2015,86(3):356-366.
[14]叶晓毅,刘南佑,黄雁红,等.冠向复位瓣联合结缔组织瓣治疗下前牙牙龈退缩[J].口腔疾病防治,2018,26(11):722-726.
[15]Tonetti MS,Jepsen S.Clinical efficacy of periodontal plastic surgery procedures:consensus report of group 2 of the 10th European workshop on periodontology[J].J Clin Periodontol,2014,41(Suppl15):36-43.
[16]Sanz M,Simion M.Surgical techniques on periodontal plastic surgery and soft tissue regeneration:consensus report of group 3 of the 10th European workshop on periodontology[J].J Clin Periodontol,2014,41(Suppl15):92-97.
[17]Pini-Prato GP,Cairo F,Nieri M,et al.Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions:a split-mouth study with a 5-year follow-up[J].J Clin Periodontol,2010,37(7):644-650.
[18]Bouchard P,Malet J,Borghetti A.Decision-making in aesthetics:root coverage revisited[J].Periodontol 2000,2001,27(1):97-120.
[19]林智恺,束蓉,钱洁蕾,等.改良侧向转位冠向复位瓣联合结缔组织移植治疗单牙重度牙龈退缩的临床效果[J].上海交通大学学报(医学版),2017,37(5):656-660.
[20]倪靖,束蓉.改良隧道技术结合上皮下结缔组织移植治疗多牙位牙龈退缩[J].上海交通大学学报(医学版),2015,35(12):1937-1940.
[21]赵静,李新月,释栋.上皮下结缔组织替代材料治疗牙龈退缩的临床应用[J].口腔疾病防治,2016,24(9):554-557.
[22]张玉峰.诱导性生物材料与牙周组织再生[J].中华口腔医学杂志,2017,52(10):615-619.
[23]Alkan EA,Parlar A.Enamel matrix derivative(emdogain)or subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions:a pilot study[J].Int J Periodontics Restor Dent,2013,33(5):619-625.
[24]Cheng GL,Fu E,Tu YK,et al.Root coverage by coronally advanced flap with connective tissue graft and/or enamel matrix derivative:a meta-analysis[J].J Periodontal Res,2015,50(2):220-230.
[25]Wei G,Liao HQ,Li G,et al.Root coverage using a coronally advanced flap with or without acellular dermal matrix:a meta-analysis[J].J Periodontal Implant Sci,2016,46(1):22-34.
[26]Willershausen I,Barbeck M,Boehm N.Non-cross-linked collagen type I/III materials enhance cell proliferation:in vitro and in vivo evidence[J].J Appl Oral Sci,2014,22(1):29-37.
[27]Mensi M,Scotti E,Salgarello S,et al.One-stage treatment of multiple recessions in the esthetic area with the bilaminar technique:clinical procedures and 24-month follow-up[J].Int J Esthet Dent,2016,11(4):494-504.
[28]Kumar A,Bains VK,Jhingran R,et al.Patient-centered microsurgical management of gingival recession using coronally advanced flap with either platelet-rich fibrin or connective tissue graft:a comparative analysis[J].Contemp Clin Dent,2017,8(2):293-304.
[29]Keceli HG,Kamak G,Erdemir EO,et al.The adjunctive effect of platelet-rich fibrin to connective tissue graft in the treatment of buccal recession defects:results of a randomized,parallel-group controlled trial[J].J Periodontol,2015,86(11):1221-1230.
[30]Paryag A,Lowe J,Rafeek R.Colored gingiva composite used for the rehabilitation of gingiva recessions and non-carious cervical lesions[J].Dent J(Basel),2017,5(4):1-7.
[31]李振财.正畸治疗对牙周病患者牙龈退缩的影响分析与研究[J].中国继续医学教育,2016,29(8):78-79.