![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=1738835354-u4y6vagqMg58YeRZMPkei8oeFVbqfPeC-0-0d71be5315020aa11860d69e323ebfc3)
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=1738835354-dayIItm4jIvEnDIGsaqmFM7fHfBtJ9aM-0-17bb2501fa4dec0fbc749edcf4cb9913)
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=1738835354-j6VdbBShHa2DrVldTQmMnbQW9h4rghqM-0-39401a9a4244d394ec5da7e252f380be)
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=1738835354-MDWC8IHMYV1JKLxn0s7QQVEZHxhcihwS-0-40100a4e52952bfb416fc881d7048058)
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=1738835354-pEv93LEDSagH5FfEhDCBoET26QoRTlue-0-1c63ec9583e2131481380e664feb074a)
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=1738835354-CYih6mSKOkIdN7bLWdgHRNZY7w4sSnen-0-86014a5ceeeb5c0a3f3b2cf568a50943)
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=1738835354-CB83we0ufmO8OYwU4gqKLELN767XCTpl-0-75b1bfccfb5434f90a00670efe914bfd)
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=1738835354-oEWEoyPcSjJw23nTngjrdZXMXrsID6L0-0-2ca32088a5504ffbefc826bad199373d)
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=1738835354-Np8XRPGN6fHLvb9f5V57XJpedZlXqhvG-0-9908eba530c0e3badd418b7c60c40cdf)
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=1738835354-tKMTPgQKRvOOYicSr9ycgGvITUtAq7Z4-0-3b0f644de8ba9a12d56391ce40bfac83)
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=1738835354-0ki2UTHnvRkAVjEv735d2DEMZzpQb7EC-0-93ae2aaa8e16dc1a856111f0789f8614)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-37_956.jpg?sign=1738835354-Hef6XAeCnLbpiQVODkjovMjGVHTxwDaw-0-bb7798a04511170d393b73778e0ba9a5)
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=1738835354-LtzViD8i0ugHUFN2l51X2ktpHHO8YKa2-0-7c37754a4f807dfbe4a23bf0696b8bee)
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=1738835354-dfDAJ5NR8QToFyCtktuIsJbgzVwJ3QIK-0-907c563d842efdf273ffc9b22a93c2d5)
图2-39 研究模型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-40_965.jpg?sign=1738835354-mRBS4RWsFkUggOPxcXoOtJ3NMTETIR0l-0-ca9bb3d66cb7b6253213dbf3b0c72654)
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=1738835354-ONIHruYPebSDE23UtbvYSnle0fK6XYxI-0-8505a767f7149b6ab2e24831d4fdc468)
图2-41 模型设计
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-42_973.jpg?sign=1738835354-TmPz0hbMcj4rB590Gp0qM0QiVg9fP2G0-0-7f12485ffe277ed23c442cd7df68b403)
图2-42 诊断蜡型
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-43_976.jpg?sign=1738835354-5u3XD7bfA83DX1bM01QezxCSS8ZiaDMN-0-52169980b616692ddce5e948fdc94fb6)
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=1738835354-SNcrM9mZm7Qxp6XtILVSDIQHzd3qWDOi-0-4c1dd5ee14756383bc5cb907cc40fa31)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-44_980.jpg?sign=1738835354-Zw81hxPm0Ns8pBs9XP3Ee0lNE1nDLWTW-0-485698b8c2ec71ee098420391c26e5b8)
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=1738835354-hw9xq6Yv5LKMhGdaZBTSb0j7gvTIVWYT-0-927e94f14ad38ec7e3429c9958b6c3c8)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-45_984.jpg?sign=1738835354-W27kr0t7NwXZA3C3eXiDiAn7bCgihE8M-0-3bf55de2b58838a887c4a76f3971def3)
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=1738835354-5L4SmnpyMFkrz6d1jvmVmJ4fBQdiL7w4-0-3064eb5acfabeb75b59a2ff149e7d566)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-46_988.jpg?sign=1738835354-BHWTW8Jv42cBLwLZuR1Oqwe3kno6Oafv-0-b3c279c1f764e85b884f8ebf7672d7de)
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=1738835354-R3WTgCwjgpFJT6cKZTMlIToUQ1aZAkgx-0-503ae11a5ca21ea9ef1633781f337375)
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=1738835354-GnvFr7ZFn7QI5dfvT99StoMT6fU9XMLr-0-67f6690bf5198c33a85b98851292bd48)
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=1738835354-ySp4lZSHrQFsHHvrVjqAp5jAHyfFZKFo-0-0e78afa05ef52bf46630e508db7ff0a4)
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=1738835354-54qgl0cY9N6IQzNVFfMhcCiK0dS6BHep-0-0c6c2a05b72bb843f84bd4237caec7a5)
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=1738835354-rIjh6yzjR0aDrtObylruZFrjRDNsKMIg-0-6004c7964f0f676a48d61a2e9bb58c65)
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=1738835354-YQVfcsjIXAyXdPkWSXtW7hN9q8AzwpPC-0-f052fb6ec9fd734f841497e32b6efbf9)
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=1738835354-mwhFy6RkpMRaW0qvDG06pijy2rrM5QCk-0-18680dc52606069f95be4c065e9a1ef8)
![](https://epubservercos.yuewen.com/8C08F5/19400080508687406/epubprivate/OEBPS/Images/P2-53_1011.jpg?sign=1738835354-60ZcmT240sRVWP1fRfAW0kyK8vBG7S0W-0-a03e0df7321eca062f7fb658c1186188)
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=1738835354-loWgsgfFUMuXtLniTCW6u81fpvRdYZBR-0-5f0fb92b76e887fb5a1f918401e7636f)
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=1738835354-Aq2CZDNUfLI4RKGifHX4U90www2t1Sav-0-42ac61c9aa42df63795d0a4f47b95b79)
图2-55 修复后非常健康的牙龈状态