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. 2020 Apr 18;52(2):339–345. [Article in Chinese] doi: 10.19723/j.issn.1671-167X.2020.02.023

牙龈退缩患牙的牙龈厚度评估

Gingival thickness assessment of gingival recession teeth

Zi-yuan CHEN 1,*, Jin-sheng ZHONG 2,*, Xiang-ying OUYANG 2,△, Shuang-ying ZHOU 2, Ying XIE 2, Xin-zhe LOU 2
PMCID: PMC7433469  PMID: 32306020

Abstract

Objective

To evaluate the gingival thickness and gingival biotype of gingival recession teeth of Chinese population.

Methods

A total of 112 non-molar teeth with gingival recession in 34 patients were included. Direct measurement, cone-beam computerized tomography (CBCT) measurement and periodontal probe method were used to evaluate gingival thickness and biotype. Gingival thickness was measured at 2 mm apical to the gingival margin. Direct measurement was performed with a caliper of 0.01 mm resolution and anesthesia needles attached to silicone disk stops. Gingival biotype was assessed by sulcus probing, if the periodontal probe was visible through the gingival tissue, the gingival biotype was thin; If not visible, the gingival biotype was thick. The differences of gingival thickness among different gingival biotype, tooth site and gingival recession type were analyzed respectively. Besides, the results of CBCT measurement was analyzed compared with the direct measurement.

Results

The average gingival thickness of non-molar recession teeth was (1.17±0.41) mm. The average gingival thickness of thick and thin biotype group were (1.38±0.4) mm and (0.97±0.30) mm, respectively, with statistically significant difference (P＜0.001).The median of gingival thickness was 1.1 mm. Using 1.1 mm as the cut-off value of thick and thin gingival thickness group, the results matched well with the gingival biotype classification results by periodontal probe method (P=1.000). The average gingival thickness of maxillary teeth was significantly thicker than that of the mandibular teeth. They were (1.39±3.44) mm and (1.01±0.31) mm, respectively (P＜0.001). The mean gingival thickness of MillerⅠ, Ⅱ and Ⅲ degree gingival recession teeth were (1.15±0.34) mm, (0.83±0.17) mm and (1.26±0.56) mm, respectively, without statistically significant difference (P=0.205). The gingival thickness measurement results between CBCT method and direct measurement were without statistically significant difference (P=0.206).

Conclusion

In the non-molar gingival recession teeth, the cut-off value of gingival thickness to classify thick and thin biotype of Chinese population was 1.1 mm. The average gingival thickness of the maxillary teeth was significantly thicker than that of the mandibular teeth. Besides, CBCT measurement was an accuracy method for evaluating facial gingival thickness.

Keywords: Gingival thickness, Gingival biotype, Gingival recession

牙龈退缩是一个常见的牙周问题,指的是牙龈缘位于釉牙骨质界的根方,或同时有牙间乳头的退缩,导致牙根暴露于口腔中[1,2].牙龈退缩的出现与许多因素相关,如不正确的刷牙习惯或牙线使用方法[3,4,5],牙周炎导致牙周支持组织的吸收和破坏[6,7,8],菲薄的牙龈生物型,正畸移动牙齿至牙弓唇侧或舌侧等,牙龈厚度是其中重要因素之一[9,10,11,12,13,14].了解牙龈退缩患牙的牙龈厚度及牙龈生物型,对牙龈退缩的治疗有一定临床意义.

目前,牙龈厚度的评估方法主要分为定性评估和定量测量两大类.定性评估指牙龈生物型的评判[13,15-18],临床上最常用的方法为牙周探针法,即将牙周探针插入龈沟内,观察牙周探针是否透过牙龈被看到,从而判断牙龈生物型,其优势在于方便,快捷,临床便于实施,缺点是无法获得牙龈厚度的具体数据.现在最常用的牙龈厚度定量测量的方法为直接测量法,即采用锐利器械直接穿透牙龈,然后用游标卡尺测量,但这种方法为有创且需要在局部麻醉下进行[10-11,19-23].近年来,在制定种植方案,复杂牙周牙体疾病诊断等都会应用到锥形束CT (cone-beam computerized tomography,CBCT), 在利用CBCT评估硬组织的同时,可评估软组织厚度[24,25,26].然而,目前尚未见临床研究比较CBCT法与直接测量法评估牙龈厚度的区别.

本研究旨在用直接测量法,CBCT法及牙周探针法分别评估牙龈退缩患牙的牙龈厚度及生物型,并比较不同牙龈生物型,不同牙位及不同牙龈退缩类型患牙牙龈厚度的区别,同时分析CBCT法与直接法测量牙龈厚度的差异.

1. 资料与方法

1.1. 病例资料

选择2015年2月至2016年12月就诊于北京大学口腔医院牙周科的牙龈退缩患者共34例,其中男性9例,女性25例,年龄为25~53岁,总共纳入112颗非磨牙牙龈退缩患牙.所有患者因牙龈退缩接受了根面覆盖手术治疗.患者因种植治疗,根折根裂诊断,复杂阻生牙拔除等需拍摄CBCT.本研究开始前已通过北京大学口腔医院生物医学伦理委员会审查批准(PKUSSIRB-201519007), 所有受试者均签署知情同意书.

1.1.1 纳入标准 (1)Miller Ⅰ度,Ⅱ度及Ⅲ度非磨牙连续多牙或单牙牙龈退缩[1];(2)唇颊侧中央牙龈退缩≥1 mm;(3)牙龈退缩患牙的探诊深度≤3 mm且无探诊出血;(4)牙龈退缩患牙无明显的扭转及拥挤.

1.1.2 排除标准 (1)妊娠或哺乳期,或者在研究期间计划妊娠者;(2)全身情况不宜进行牙周手术者;(3)正在服用影响牙周组织的药物者;(4)局部瘢痕影响手术者;(5)吸烟者.

1.2. 临床检查

所有临床检查均由同一名主治医生完成.临床检查内容包括:(1)牙龈退缩深度 (recession depth, Rec): 颊侧中央位置CEJ至龈缘的垂直距离;(2)角化龈宽度 (width of keratinized tissue, WKT): 颊侧中央位点龈缘至膜龈联合的垂直距离;(3)探诊深度 (probing depth,PD):颊侧中央位点龈缘至龈沟底的垂直距离;(4)牙龈生物型 (gingival biotype, GB): 采用Kan等[15]于2003年提出的牙龈生物型检查及分类方法,即牙周探针法来判断,分为薄生物型和厚生物型,以上4项检查工具均为William牙周探针;(5)直接测量牙龈厚度 (gingival thickness measured by direct measurement, GTDM): 在根面覆盖手术前局部麻醉后进行测量,测量位置为患牙颊侧中央距离龈缘2 mm处,首先,利用带止动片的必兰局麻针头垂直穿透牙龈直至牙根表面;然后将止动片拨动至与牙龈表面轻轻接触;最后取出针头,用精确度为0.01 mm的游标卡尺测量针尖至止动片的距离,即为牙龈厚度.整个测量过程由同一校准过的检查者重复两次,取平均值作为直接测量的牙龈厚度[20].

1.3. CBCT法测量牙龈厚度

1.3.1 CBCT拍摄方法 拍摄CBCT时患者佩戴塑料开口器[24,25],以避免唇颊侧软组织与牙龈的接触(图1).使用NewTom VGi (QR s.r.l, 意大利)在8 cm×8 cm高清模式下进行CBCT拍摄并获得原始数据,使用NNT(4.00版)软件进行数据分析及牙龈厚度测量,重建层厚为0.15 mm.

1.

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佩戴塑料开口器拍摄CBCT

CBCT scan with a plastic lip retractor

1.3.2 CBCT牙龈厚度测量 用NNT (4.00版) 软件对CBCT图像进行调整,使得图像矢状面 (Y平面) 与目标患牙牙长轴平行,水平面 (Z平面) 与咬合面平行.之后在矢状面上进行牙龈厚度测量,测量位点为牙龈缘根方2 mm.CBCT测量所得的牙龈厚度(gingival thickness measured by CBCT,GTCBCT) 即为垂直于软组织表面,从牙龈表面至牙根表面的直线距离(图2和图3).测量数据精确到0.1 mm.所有患牙的牙龈厚度测量均由同一检查者重复测量2次,取平均值作为CBCT测量的牙龈厚度.CBCT测量法可重复性检测:由2名不同临床经验的医师进行CBCT牙龈厚度测量.每位医师均重复测量 2次,两次测量的间隔时间为1周.

2.

CBCT图像上清晰的牙龈边界

Clear gingival margin on the CBCT image

B, bottom; T, top, T: 0.15 mm, the images were reconstructed with the voxel of 0.15 mm.

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3.

CBCT矢状面图像上进行牙龈厚度测量

Measurement of the buccal gingival thickness in the sagittal view

Yellow line: 2 mm from the gingival margin; red line: the distance from the gingival surface to the root surface is 1.3 mm. B, bottom; T, top, T: 0.15 mm, the images were reconstructed with the voxel of 0.15 mm.

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1.4. 统计学分析

采用SPSS24.0软件,计量资料以均数±标准差表示,不同牙龈生物型,牙位及牙龈退缩类型牙龈厚度的比较中两组计量资料的比较:(1)如果数据服从正态分布且具备方差齐性,采用独立样本t检验进行比较;(2)如果数据服从正态分布但不具备方差齐性,则采用校正独立样本t检验进行分析;(3)如果数据不服从正态分布,则采用非参数检验Mann-Whitney U检验进行分析.不同牙龈生物型,牙位及牙龈退缩类型牙龈厚度的比较中多组计量资料的比较:(1)如数据服从正态分布且具备方差齐性,采用单因素方差分析进行比较;(2)如果数据不服从正态分布或者不具备方差齐性,则采用非参数检验Kruskal-Wallis 检验进行分析.计数资料的比较采用非参数检验Mann-Whitney U检验.CBCT法测量牙龈厚度的可重复性通过配对t检验及组内相关系数(intra-class correlation coefficient,ICC)进行分析.直接测量法与CBCT测量法测得牙龈厚度结果差异采用配对t检验.P<0.05时认为差异有统计学意义,ICC值大于0.75时表示信度良好.

2. 结果

共纳入112颗非磨牙牙龈退缩患牙,其中包括61颗前牙及51颗前磨牙,48颗上颌牙及64颗下颌牙.直接测量法得到的平均牙龈厚度为(1.17±0.41) mm (0.36~2.64 mm).平均牙龈退缩深度,探诊深度及角化龈宽度分别为(2.45±1.00) mm (1.0~6.0 mm),(1.59±0.55) mm (1~3 mm) 及 (2.89±1.58) mm(0~7 mm).

2.1. 不同牙龈生物型的牙龈厚度

牙周探针法评估生物型的检查结果中,有55颗牙齿为厚龈生物型,平均牙龈厚度为(1.38±0.42) mm (0.53~2.64 mm);薄龈生物型牙齿有57颗,平均牙龈厚度为(0.97±0.30) mm (0.36~1.89 mm).厚龈生物型的牙龈厚度显著厚于薄龈生物型(P<0.001).厚,薄牙龈生物型的平均牙龈退缩深度,探诊深度及角化龈宽度间的差异无统计学意义(P>0.05,表1).

1.

不同牙龈生物型的牙龈厚度(x±s)

Gingival thickness of different gingival biotypex±s/mm

Gingival
biotype		 n Rec PD WKT GTDM
Rec, recession depth; PD, probing depth; WKT, width of keratinized tissue; GTDM, gingival thickness of direct measurement. a, results of independent-samples t test; b, results of Mann-Whitney U test; c, calibration of independent sample t test.
Thick 55 2.46±1.00 1.60±0.56 3.11±1.66 1.38±0.42
Thin 57 2.44±0.99 1.58±0.53 2.69±1.50 0.97±0.30
P 0.895a 0.839a 0.233b <0.001c
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112颗患牙的牙龈厚度中位数值为1.1 mm.若以1.1 mm为牙龈厚度分界值,将患牙人工划分为厚龈,薄龈两组,与牙周探针法结果比较差异无统计学意义(P=1.000,真阳性率76.4%,真阴性率73.1%).若以1.0 mm为牙龈厚度分界值,与牙周探针法结果比较差异也无统计学意义(P=0.163,真阳性率78.2%,真阴性率63.2%,表2).

2.

牙龈生物型评估(频率分布)

Gingival biotype assessment (frequency distribution)

Gingival biotype
probe method		 Cut-off 1.0 mm Cut-off 1.1 mm
Thick
(>1.0 mm)		 Thin
(≤1.0 mm)		 Thick
(>1.1 mm)		 Thin
(≤1.1 mm)
* P<0.05, represents statistically significant difference, results of Mann-Whitney U test.
Thick (55) 43 12 41 14
Thin (57) 21 36 15 42
Predictive value 43/55
(78.20%)		 36/57
(63.20%)		 42/55
(76.40%)		 42/57
(73.70%)
P 0.164 1.000
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2.2. 不同牙位的牙龈厚度

根据直接法测量牙龈厚度的结果,上颌牙的平均牙龈厚度明显厚于下颌牙,分别为(1.39±3.44) mm及(1.01±0.31) mm,差异有统计学意义(P<0.001).不同上颌牙位之间的牙龈厚度也不相同,单因素方差分析结果显示上颌不同牙位之间的牙龈厚度差异有统计学意义(P=0.025).上颌前磨牙(1.57±0.46) mm的牙龈厚于上颌切牙(1.27±0.44) mm及上颌尖牙 (1.18±0.28) mm.但是,单因素方差分析结果显示下颌不同牙位之间的牙龈厚度差异无统计学意义(P=0.356,表3).

3.

不同牙位的牙龈厚度x±s

Gingival thickness of different tooth site and tooth type x±s/mm

Tooth site n Rec PD WKT GTDM
Rec, recession depth; PD, probing depth; WKT, width of keratinized tissue; GTDM, gingival thickness of direct measurement. a, results of independent-samples t test between maxillary and mandibular teeth; b, results of calibration of independent sample t test between maxillary and mandibular teeth.
Maxillary 48 2.34±0.96 1.71±0.54 3.42±1.66 1.39±0.44
Incisors 15 1.57±0.60 1.87±0.64 4.67±1.14 1.27±0.44
Canines 11 2.64±0.78 1.55±0.52 3.27±1.21 1.18±0.28
Premolars 22 2.73±0.96 1.68±0.48 2.64±1.68 1.57±0.46
Mandibular 64 2.53±1.02 1.50±0.54 2.44±1.38 1.01±0.31
Incisors 22 2.52±0.98 1.41±0.50 3.43±1.49 0.93±0.31
Canines 13 2.04±0.72 1.46±0.52 2.23±0.88 1.04±0.25
Premolars 29 2.76±1.11 1.59±0.57 1.74±0.97 1.06±0.33
P 0.326a 0.045a 0.001a <0.001b
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2.3. 不同牙龈退缩类型的牙龈厚度

纳入Miller Ⅰ度牙龈退缩患牙77颗,Miller Ⅱ度及Ⅲ度患牙分别为3颗及32颗.Miller Ⅰ 度,Ⅱ度,Ⅲ度牙龈退缩患牙的平均牙龈厚度分别为(1.15±0.34) mm,(0.83±0.17) mm及(1.26±0.56) mm(表4).虽然Miller Ⅱ度牙龈退缩患牙的平均牙龈厚度最薄,与Miller Ⅰ度及Ⅲ度牙龈厚度的平均差异分别为0.32 mm与0.43 mm,但组间差异无统计学意义.

4.

不同牙龈退缩类型的牙龈厚度x±s

Gingival thickness of different gingival recession type x±s/mm

Gingival
recession		 n Rec PD WKT GTDM
Rec, recession depth; PD, probing depth; WKT, width of keratinized tissue; GTDM, gingival thickness of direct measurement. a, results of one-way ANOVA test among all gingival recession type; b, results of Kruskal-Wallis test among all gingival recession type.
Miller Ⅰ 77 2.35±0.92 1.56±0.55 2.88±1.29 1.15±0.34
Miller Ⅱ 3 2.83±1.04 2.00±0.00 0 0.83±0.17
Miller Ⅲ 32 2.66±1.15 1.63±0.55 3.19±1.96 1.26±0.56
Total 112 2.45±1.00 1.59±0.55 2.89±1.58 1.17±0.41
P 0.189a 0.305b 0.012b 0.205b
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2.4. CBCT测量牙龈厚度

2.4.1 可重复性检查 CBCT牙龈厚度测量自身一致性检验结果显示,检查者间隔1周的测量结果之间的平均差异为0.01 mm, 差异无统计学意义(检查者1:P=0.280;检查者2:P=0.351),ICC值分别为0.970 (检查者1)和0.990 (检查者2).取两位检查者两次CBCT牙龈厚度测量结果的平均值,进行不同检查者之间的一致性结果比较,结果显示两位检查者之间的平均差异值为0.01 mm, 差异无统计学意义(P=0.188), ICC值为0.989.

2.4.2 与直接测量法结果比较 CBCT测量法及直接法得到的牙龈厚度的平均值分别为(1.20±0.33) mm与 (1.17±0.42) mm,平均差值均为0.03 mm, 差异无统计学意义(P=0.206).

3. 讨论

本研究采用直接测量法与CBCT测量法评估了34名患者112颗牙龈退缩患牙的颊侧牙龈厚度,分析了不同牙龈生物型,不同牙位及不同牙龈退缩类型牙龈厚度的差异,并且比较了直接测量法与CBCT法两种方法评估牙龈厚度的差异,人群牙龈厚度的中位数值为1.1 mm,以1.1 mm为牙龈厚度的厚,薄分界值,能良好地与牙周探针法评估的厚,薄牙龈生物型结果相匹配.本研究发现在非磨牙牙龈退缩患牙中,区分中国人群厚,薄牙龈生物型的牙龈厚度分界值为1.1 mm;上颌牙的平均牙龈厚度显著厚于下颌牙,另外,用CBCT-开口器的方法评估颊侧牙龈厚度具有良好的准确性.

本研究得到的非磨牙牙龈退缩患牙的平均牙龈厚度为(1.17 ± 0.41) mm.与大部分文献报告的牙龈退缩患牙牙龈厚度相比,本研究得到的结果偏厚,Cairo等[27]用直接测量法在龈缘下1.5 mm测量上颌非磨牙牙龈退缩患牙的牙龈厚度,平均值为0.73~0.76 mm.Andrade等[20]用直接测量法,测量膜龈联合冠方1 mm的牙龈退缩患牙牙龈厚度,平均厚度为0.80~1.01 mm.也有研究测量龈缘下3 mm或龈缘至膜龈联合中点的牙龈厚度[28,29],其平均厚度为0.76~0.82 mm.但是,也有文献报告牙龈退缩患牙的平均牙龈厚度为1.40[30]或1.60 mm[31].Rajendran等[31]测量上颌牙龈退缩患牙的牙龈厚度,测量位点为龈缘至膜龈联合的中点,得到的平均厚度为1.57~1.60 mm.不同文献报告的牙龈退缩患牙平均牙龈厚度差异较大,这可能与不同研究采用的测量位点及方法不同有关,也可能与受试人种不同相关.

本研究发现,以1.1 mm为牙龈厚度的分界值划分牙龈厚,薄生物型,比较符合本研究人群牙周探针法的检查结果.目前国际共识认为,牙周探针法测得厚牙龈生物型的平均牙龈厚度大于1 mm,薄龈型的平均牙龈厚度小于等于1 mm[32],这可能与不同研究人群牙龈厚度及牙龈透光性不同有关.有组织学研究表明,牙周探针法评估的厚薄牙龈生物型,组织学差异主要表现为结缔组织厚度不同.厚龈生物型牙龈的结缔组织厚度显著厚于薄龈生物型,但是上皮组织的厚度二者没有显著差异[33].牙周探针插入龈沟内可视与否,除了与牙龈厚度相关,还可能与牙龈的透光性相关.有可能牙龈胶原纤维含量高,不容易透光,胶原纤维含量少,易透光,但这仍需进一步实验证实.

本研究牙龈退缩人群上颌牙的牙龈厚度显著厚于下颌牙,与其他研究中国牙周健康人群牙龈厚度的数据基本相符[33,34,35,36,37],牙周健康人群上颌中切牙的平均牙龈厚度为 1.19~1.43 mm,上颌侧切牙为0.98~1.11 mm,上颌尖牙为0.87~1.12 mm,下颌前牙的牙龈厚度为0.96~1.18 mm.本研究牙龈退缩人群的牙龈厚度与这些健康人群相比,稍偏薄,这可能与牙龈较薄患牙易出现牙龈退缩有关[9].另外,本研究牙龈退缩患者的角化龈宽度低于牙周健康人群[35,38].有研究显示,中国汉族牙周健康人群上,下颌牙的平均角化龈宽度分别为3.7~5.6 mm,2.9~4.5 mm[38].本研究上,下颌牙齿的平均角化龈宽度分别为3.42 mm及2.44 mm, 明显低于上述牙周健康人群.

牙龈厚度对于选择根面覆盖的手术方式有重要意义,目前治疗牙龈退缩的常见手术方式有冠向复位瓣术,结缔组织移植术等.当牙龈较薄时,选择结缔组织移植术能实现更佳的根面覆盖结果.有研究结果表明,当牙龈厚度≤0.8 mm时,冠向复位瓣术联合结缔组织移植术比单独使用冠向复位瓣术能实现更佳的术后结果[27].当牙龈较厚,单独使用冠向复位瓣术也能实现良好的根面覆盖结果.治疗MillerⅠ度及Ⅱ度连续多牙牙龈退缩时,在角化龈宽度大于1 mm且牙龈厚度大于1 mm的位点单独使用冠向复位瓣术,只有当角化龈宽度小于1 mm或者角化龈宽度在1~2 mm,但牙龈厚度小于1 mm时才联合结缔组织移植术,术后1年及3年的完全根面覆盖率分别达到了98.5%及94.7%,术后1年及3年单纯使用冠向复位瓣术患牙,与联合结缔组织移植术患牙的完全根面覆盖率差异均无统计学意义[39].本研究人群牙龈厚,薄生物型的分界值为1.1 mm,这提示临床医师,当牙龈厚度小于1.1 mm时,联合使用结缔组织移植术治疗牙龈退缩可能实现更稳定可靠的术后结果,当牙龈厚度大于1.1 mm且角化龈宽度大于1 mm,腭侧供区结缔组织又有限时,单独使用冠向复位瓣术也可实现良好的术后结果.

牙龈厚度对于根面覆盖手术的术后结果也有重要影响.有研究曾经报告利用冠向复位瓣技术联合釉基质衍生物治疗MillerⅠ度或Ⅱ度单牙牙龈退缩时,术后12个月的完全根面覆盖率与牙龈厚度相关[19].另外有系列病例报告利用冠向复位瓣技术治疗19名患者的MillerⅠ度或Ⅱ度单牙牙龈退缩时发现,龈瓣厚度大于0.8 mm与术后3个月时的完全根面覆盖结果相关[11].此外,也有研究报告龈瓣厚度大于1.2 mm时,采用冠向复位瓣技术治疗Miller Ⅰ度单牙牙龈退缩术后6个月的完全根面覆盖率显著高于龈瓣厚度小于1.2 mm[40].这说明治疗牙龈退缩的根面覆盖结果与基线时的牙龈厚度相关,薄牙龈相较于厚牙龈更难实现完全的根面覆盖.有系统综述分析可能是因为较厚的牙龈比较薄的牙龈能提供更好的血液供应条件,同时也利于术者的操作[12],提示临床医生,当术前患者为薄龈生物型时,根面覆盖手术的难度及风险会增大,术前牙龈生物型的判断及牙龈厚度的测量有助于帮助预测患牙的根面覆盖结果.

本研究除了采用直接测量法评估颊侧牙龈厚度,也利用CBCT法评估牙龈厚度,发现CBCT是一种可重复性高且准确性好的评价唇颊侧软组织厚度的方法.尽管两位检查者临床经验不同,但是他们的CBCT测量结果的平均差异为0.01 mm,差异没有统计学意义,而且两位检查者间隔1周的测量结果间的差异均无统计学意义.此外,CBCT法评估颊侧牙龈厚度还显示了良好的准确性.CBCT法与直接测量法得到的牙龈厚度的平均差异值仅为0.03 mm,差异没有统计学意义.这与尸骨研究得到的结果相似,文献报告新鲜尸骨上两种方法测量颊侧牙龈厚度的差异值仅为0.01 mm[17],两种方法测量干尸骨上模拟牙龈组织厚度的差异值仅为0.07 mm[18],差异均无统计学意义.这些研究表明无论在尸骨上还是运用于临床,CBCT都是一种准确性高的评估牙龈厚度的方法.

清晰可分辨的牙龈边缘是保证CBCT牙龈厚度测量法高度可重复性及良好准确性的基础,如果在没有任何辅助装置的情况下直接拍摄CBCT,唇颊侧软组织会与颊侧牙龈发生接触,这会导致CBCT图像上牙龈边缘难以分辨.为了避免唇颊侧软组织与牙龈发生接触,本研究在患者拍摄CBCT时让其佩戴塑料的开口器[24,25],以达到在CBCT图像上获得清晰牙龈边缘的目的.这种佩戴开口器的方法相较于Cao等[41]提出的阻射印模材料的方法更为简单,而且易于在临床上推广运用.

目前,CBCT对于辅助种植治疗,重度牙周炎患者的诊治,疑难根管,复杂牙拔除已不可或缺,且软组织形态,厚度对于种植治疗及牙周手术都有重要影响.当患者因治疗需要需拍摄CBCT,可在拍摄时让其佩戴塑料的开口器,同时获取清晰的软硬组织三维图像,便于牙周及种植手术确定最佳手术方案.若单独利用CBCT评价软组织情况,需要综合考虑其放射剂量与额外费用,以及是否可用其他方法替代.

本研究结果发现,厚,薄牙龈生物型组平均牙龈退缩深度的差异无统计学意义,这可能与本研究为横断面观察,纳入的受试者为牙龈退缩已经发生的患者有关.通常文献认为的薄龈型更容易发生牙龈退缩是指,如果进行纵向观察,薄龈生物型患者在同等的不当刷牙方法,咬合创伤等牙龈退缩致病因素影响下,发生牙龈退缩的速度更快,程度更重[9].如果对本研究受试者不加干预,继续观察,有可能出现薄龈生物型组牙龈退缩的变化量大于厚龈生物型组的情况.

综上所述,在非磨牙牙龈退缩患牙中,区分中国人群厚,薄牙龈生物型的牙龈厚度分界值为1.1 mm;上颌牙的平均牙龈厚度显著厚于下颌牙.用CBCT-开口器的方法评估颊侧牙龈厚度具有良好的准确性.

References

  • 1.Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8–13. [PubMed] [Google Scholar]
  • 2.Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000. 2015;68(1):333–368. doi: 10.1111/prd.12059. [DOI] [PubMed] [Google Scholar]
  • 3.Addy M, Griffiths G, Dummer P, et al. The distribution of plaque and gingivitis and the influence of toothbrushing hand in a group of South Wales 11-12 year-old children. J Clin Periodontol. 1987;14(10):564–572. doi: 10.1111/j.1600-051x.1987.tb01517.x. [DOI] [PubMed] [Google Scholar]
  • 4.Gillette WB, Van House RL. Ill effects of improper oral hygeine procedure. J Am Dent Assoc. 1980;101(3):476–480. doi: 10.14219/jada.archive.1980.0295. [DOI] [PubMed] [Google Scholar]
  • 5.Abrams H, Kopczyk RA. Gingival sequela from a retained piece of dental floss. J Am Dent Assoc. 1983;106(1):57–58. doi: 10.14219/jada.archive.1983.0030. [DOI] [PubMed] [Google Scholar]
  • 6.Loe H, Anerud A, Boysen H. The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession. J Periodontol. 1992;63(6):489–495. doi: 10.1902/jop.1992.63.6.489. [DOI] [PubMed] [Google Scholar]
  • 7.van Palenstein Helderman WH, Lembariti BS, van der Weijden GA, et al. Gingival recession and its association with calculus in subjects deprived of prophylactic dental care. J Clin Periodontol. 1998;25(2):106–111. doi: 10.1111/j.1600-051x.1998.tb02416.x. [DOI] [PubMed] [Google Scholar]
  • 8.Tugnait A, Clerehugh V. Gingival recession-its significance and management. J Dent. 2001;29(6):381–394. doi: 10.1016/s0300-5712(01)00035-5. [DOI] [PubMed] [Google Scholar]
  • 9.Merijohn GK. Management and prevention of gingival recession. Periodontol 2000. 2016;71(1):228–242. doi: 10.1111/prd.12115. [DOI] [PubMed] [Google Scholar]
  • 10.Anderegg CR, Metzler DG, Nicoll BK. Gingiva thickness in guided tissue regeneration and associated recession at facial furcation defects. J Periodontol. 1995;66(5):397–402. doi: 10.1902/jop.1995.66.5.397. [DOI] [PubMed] [Google Scholar]
  • 11.Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol. 1999;70(9):1077–1084. doi: 10.1902/jop.1999.70.9.1077. [DOI] [PubMed] [Google Scholar]
  • 12.Hwang D, Wang HL. Flap thickness as a predictor of root coverage: a systematic review. J Periodontol. 2006;77(10):1625–1634. doi: 10.1902/jop.2006.060107. [DOI] [PubMed] [Google Scholar]
  • 13.Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: a systematic review from the AAP regeneration workshop. J Periodontol. 2015;86(Suppl 2):S56–S72. doi: 10.1902/jop.2015.130684. [DOI] [PubMed] [Google Scholar]
  • 14.Scheyer ET, Sanz M, Dibart S, et al. Periodontal soft tissue non-root coverage procedures: a consensus report from the AAP Regeneration Workshop. J Periodontol. 2015;86(Suppl 2):S73–S76. doi: 10.1902/jop.2015.140377. [DOI] [PubMed] [Google Scholar]
  • 15.Kan JY, Rungcharassaeng K, Umezu K, et al. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol. 2003;74(4):557–562. doi: 10.1902/jop.2003.74.4.557. [DOI] [PubMed] [Google Scholar]
  • 16.De Rouck T, Eghbali R, Collys K, et al. The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol. 2009;36(5):428–433. doi: 10.1111/j.1600-051X.2009.01398.x. [DOI] [PubMed] [Google Scholar]
  • 17.Eghbali A, De Rouck T, De Bruyn H, et al. The gingival biotype assessed by experienced and inexperienced clinicians. J Clin Periodontol. 2009;36(11):958–963. doi: 10.1111/j.1600-051X.2009.01479.x. [DOI] [PubMed] [Google Scholar]
  • 18.Kan JY, Morimoto T, Rungcharassaeng K, et al. Gingival biotype assessment in the esthetic zone: visual versus direct measurement. Int J Periodontics Restorative Dent. 2010;30(3):237–243. [PubMed] [Google Scholar]
  • 19.Berlucchi I, Francetti L, Del Fabbro M, et al. The influence of anatomical features on the outcome of gingival recessions treated with coronally advanced flap and enamel matrix derivative: a 1-year prospective study. J Periodontol. 2005;76(6):899–907. doi: 10.1902/jop.2005.76.6.899. [DOI] [PubMed] [Google Scholar]
  • 20.Andrade PF, Grisi MF, Marcaccini AM, et al. Comparison between micro- and macrosurgical techniques for the treatment of localized gingival recessions using coronally positioned flaps and enamel matrix derivative. J Periodontol. 2010;81(11):1572–1579. doi: 10.1902/jop.2010.100155. [DOI] [PubMed] [Google Scholar]
  • 21.Bittencourt S, Del Peloso Ribeiro E, Sallum EA, et al. Surgical microscope may enhance root coverage with subepithelial connective tissue graft: a randomized-controlled clinical trial. J Periodontol. 2012;83(6):721–730. doi: 10.1902/jop.2011.110202. [DOI] [PubMed] [Google Scholar]
  • 22.Ahmedbeyli C, Ipci SD, Cakar G, et al. Clinical evaluation of coronally advanced flap with or without acellular dermal matrix graft on complete defect coverage for the treatment of multiple gingival recessions with thin tissue biotype. J Clin Periodontol. 2014;41(3):303–310. doi: 10.1111/jcpe.12211. [DOI] [PubMed] [Google Scholar]
  • 23.Dogan SB, Dede FO, Balli U, et al. Concentrated growth factor in the treatment of adjacent multiple gingival recessions: a split-mouth randomized clinical trial. J Clin Periodontol. 2015;42(9):868–875. doi: 10.1111/jcpe.12444. [DOI] [PubMed] [Google Scholar]
  • 24.Januario AL, Barriviera M, Duarte WR. Soft tissue cone-beam computed tomography: a novel method for the measurement of gingival tissue and the dimensions of the dentogingival unit. J Esthet Restor Dent. 2008;20(6):366–374. doi: 10.1111/j.1708-8240.2008.00210.x. [DOI] [PubMed] [Google Scholar]
  • 25.Barriviera M, Duarte WR, Januario AL, et al. A new method to assess and measure palatal masticatory mucosa by cone-beam computerized tomography. J Clin Periodontol. 2009;36(7):564–568. doi: 10.1111/j.1600-051X.2009.01422.x. [DOI] [PubMed] [Google Scholar]
  • 26.Fu JH, Yeh CY, Chan HL, et al. Tissue biotype and its relation to the underlying bone morphology. J Periodontol. 2010;81(4):569–574. doi: 10.1902/jop.2009.090591. [DOI] [PubMed] [Google Scholar]
  • 27.Cairo F, Cortellini P, Pilloni A, et al. Clinical efficacy of coronally advanced flap with or without connective tissue graft for the treatment of multiple adjacent gingival recessions in the aesthetic area: a randomized controlled clinical trial. J Clin Periodontol. 2016;43(10):849–856. doi: 10.1111/jcpe.12590. [DOI] [PubMed] [Google Scholar]
  • 28.Aroca S, Molnar B, Windisch P, et al. Treatment of multiple adjacent Miller class I and Ⅱ gingival recessions with a modified coronally advanced tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol. 2013;40(7):713–720. doi: 10.1111/jcpe.12112. [DOI] [PubMed] [Google Scholar]
  • 29.Ozenci I, Ipci SD, Cakar G, et al. Tunnel technique versus coronally advanced flap with acellular dermal matrix graft in the treatment of multiple gingival recessions. J Clin Periodontol. 2015;42(12):1135–1142. doi: 10.1111/jcpe.12477. [DOI] [PubMed] [Google Scholar]
  • 30.Maroso FB, Gaio EJ, Rosing CK, et al. Correlation between gingival thickness and gingival recession in humans. Acta Odontol Latinoam. 2015;28(2):162–166. doi: 10.1590/S1852-48342015000200011. [DOI] [PubMed] [Google Scholar]
  • 31.Rajendran V, Uppoor A, Kadakampally D, et al. Comparison of minimally invasive coronally advanced flap and modified coronally advanced flap for the management of multiple adjacent gingival recession defects: A split mouth randomized control trial. J Esthet Restor Dent. 2018;30(6):509–515. doi: 10.1111/jerd.12418. [DOI] [PubMed] [Google Scholar]
  • 32.Jepsen S, Caton JG, Albandar JM, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: consensus report of workgroup 3 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Clin Periodontol. 2018;45(Suppl 20):S219–S229. doi: 10.1111/jcpe.12951. [DOI] [PubMed] [Google Scholar]
  • 33.Goncalves Motta SH, Ferreira Camacho MP, Quintela DC, et al. Relationship between clinical and histologic periodontal biotypes in humans. Int J Periodontics Restorative Dent. 2017;37(5):737–741. doi: 10.11607/prd.2501. [DOI] [PubMed] [Google Scholar]
  • 34.龚 寅, 谢 玉峰, 束 蓉. 上海汉族青年牙龈生物型的 CBCT 检测. 上海交通大学学报(医学版) 2017;37(8):1111–1115. [Google Scholar]
  • 35.祖 青, 杨 川, 陈 文君. 上前牙区角化龈宽度和牙龈厚度之间的相关性分析. 中国美容医学. 2017;26(11):98–100. [Google Scholar]
  • 36.林 璐, 何 平华, 苏 莎, et al. 牙龈厚度与上前牙唇侧骨板厚度的相关性研究. 实用口腔医学杂志. 2016;32(4):569–572. [Google Scholar]
  • 37.张 瑞, 束 蓉. 采用锥形束CT测量汉族年轻人群前牙唇侧健康牙龈厚度. 临床和试验医学杂志. 2018;17(2):214–218. [Google Scholar]
  • 38.孟 焕新, 张 胡. 120名汉族青年前段牙弓唇侧角化龈宽度的测量. 中华口腔医学杂志. 2010;45(8):477–481. [PubMed] [Google Scholar]
  • 39.Stefanini M, Zucchelli G, Marzadori M, et al. Coronally advanced flap with site-specific application of connective tissue graft for the treatment of multiple adjacent gingival recessions: a 3-year follow-up case series. Int J Periodontics Restorative Dent. 2018;38(1):25–33. doi: 10.11607/prd.3438. [DOI] [PubMed] [Google Scholar]
  • 40.Huang LH, Neiva RE, Wang HL. Factors affecting the outcomes of coronally advanced flap root coverage procedure. J Periodontol. 2005;76(10):1729–1734. doi: 10.1902/jop.2005.76.10.1729. [DOI] [PubMed] [Google Scholar]
  • 41.Cao J, Hu WJ, Zhang H, et al. A novel technique for measurement of dentogingival tissue by cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(2):e82–87. doi: 10.1016/j.oooo.2014.10.022. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Peking University (Health Sciences) are provided here courtesy of Editorial Office of Beijing Da Xue Xue Bao Yi Xue Ban, Peking University Health Science Center

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