中華民國牙體復形學會雜誌 - taod.org.t · #24, 25, 26 ﬁnal impressions, ﬁnal cementation #43x45 final impression, final ... partial denture (RPD) is an economic choice

中華民國牙體復形學會雜誌

目錄

Journal of the A cademy of Operative DentistryVolume IV ● Number I

PUBLISHER：Ker-Kong Chen

EDITORIAL OFFICE：The Academy of

Operative Dentistry

ADDRESS：3F, Dept. of Dentistry, National

Taiwan Uni. Hospital, No.1, Changede St.,

Jhongjheng Dist, 100, Taipei, Taiwan

TEL：(02)2382-6145

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EDITOR-IN-CHIER：Fa-Jen Wang

EDITORIAL BOARD：Bor-Shiunn Lee,

Pei-Chen Li, Kuang-Hsun Lin, Tai-Cheng

Lin, Yu-Chih Chiang, Wen-Chiech Kuo,

Jiang-Yun Chen, Yi-Jyun Chen, Yen-Hsiang

Chang, Shu-Fen Chuang, Wen-Yi Tseng,

Wen-Jyh Rou

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發行人：陳克恭

出版者：中華民國牙體復形學會

地　址： 100台北巿中正區常德街1號

　　　　台大醫院牙科部3樓

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編輯委員：李伯訓、呂佩真、林光勳、

林泰政、姜昱至、郭文傑、

陳江雲、陳易駿、張晏祥、

莊淑芬、曾琬瑜、羅文智

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100台北巿中正區常德街1號台大醫院

牙科部3樓

中華民國一○三年九月

第卷

September 20144 第期1

● Restorative treatment of a patient previously treated with concurrent chemoradiotherapy (CCRT)

接受合併化學及放射線治療患者之復形病例治療

林詩韻莊淑芬................................................................ 1

● Direct Class II Composite Restoration with Bio-mimic Characterized Pit and Fissure of Posterior Teeth – A Case Report

以複合樹脂暨仿真溝隙染色直接復形後牙二級窩洞 -病例報告

黃菁菁姜昱至............................................................. 11

● 以複合樹脂修復斷裂正中門牙及後牙瓷嵌體治療之病例

報告

Restoring a fractured incisor with composite resin and using ceramic inlay to restore posterior tooth

汪昇朋陳敏慧 ............................................................ 18

中華民國牙體復形學會雜誌第四卷第一期 2014 1

concurrent chemoradiotherapy (CCRT)

Introduction

Cancers have been diseases of high prevalence in the population. According to the statistics research of Health Promotion Administration in Taiwan, malignant neoplasm has become the leading cause of death since 1982. Newly diagnosed cancer patients in 2010 reached 906491. The treatments for the cancer patient include surgery, radiation, chemotherapy, concurrent chemoradiotherapy (CCRT), or the combination of these treatments. However, radiotherapy for these patients may induce damage to the salivary glands and cause several side effects, such as mucositis, xerostomia, radiation caries and osteoradionecrosis2. Cervical and incisal "radiation caries" lesions can develop

soon after treatment3. But if chemoradiotherapy induce oral complications is still controversial. Most evidences support that the mucosal changes specially induced by chemotherapy are usually acute, and healing occurs within weeks of cessation of cytotoxic chemotherapy4. In contrast, radiotherapy induces acute and chronic changes in the oral mucosa as a result of epithelial atrophy, fibrosis of connective tissues, neurologic sensitization, and/or neuropathy, which may also predispose oral tissues to ulceration following trauma or injury4. After radiotherapy with or without chemotherapy, eighty-five percent of the patients were classified as suffering from salivary gland hypofunction, as well as 58.2% considered dryness of the mouth the most debilitating complication4. Trismus can be a significant side

Restorative treatment of a patient previously treated with concurrent chemoradiotherapy (CCRT)

Shih-Yun Lin1 Shu-Fen Chuang2,*

Cancers have been diseases of high prevalence in the population. Many cancer patients receive chemotherapy or concurrent chemoradiotherapy (CCRT), and subsequently experience oral complications, such as decreased salivation, impaired chewing function, and dental caries. The dental care after radiation therapy is important to maintain their life quality. In this report, the restorative dental treatment of a patient previously treated with concurrent chemoradiotherapy (CCRT) is presented. His oral manifestations included dry mouth, multiple dental caries and tooth missing. The treatment considerations about this patient include the reconstruction of occlusal scheme and post-restorative maintenance. After rehabilitation by direct restorations and fixed prostheses, the chewing function of this patient has been restored.

Key words: concurrent chemoradiotherapy (CCRT), dental caries, restorative treatment

Pei-yi Dental Clinic; MS, Institute of Oral Medicine, National Cheng Kung University1 Professor, Institute of Oral Medicine, National Cheng Kung University2

* Corresponding author: Shu-Fen Chuang, Department of Stomatology, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70428, Taiwan, ROC. Tel: 886-6-2353535#2977, Fax: 886-6-2762819, E-mail:[email protected]

中華民國牙體復形學會雜誌第四卷第一期 20142

林詩韻莊淑芬

effect of RT. Limited mouth opening can interfere with proper oral hygiene and dental treatment5.

If patients received oral hygiene instructions, dental prophylaxis and dental treatment prior to and during radiotherapy, the severity of mucositis and occurrence of candidosis were both significantly lower than patients without preventive protocols2. Although preventive dental protocols used can't fully prevent oral complications, they at least minimize the severity of some symptoms, and the lack of a dental protocol is deeply harmful to the patients2.

In this case, a patient who have received concurrent chemoradiotherapy and suffered from oral complications, asked for anterior teeth decay, and also expected for full mouth examination. The treatment plan and coursed is presented.

Case Report

General data

Mr. Wang

Age: 48

Figure 01: Frontal and occlusal views before treatment.

Figure 2: Full mouth periapical radiographs.



Chief complaint: anterior teeth decay restoration and expect for full mouth examination.

Present illness: He had full mouth caries, especially on anterior area, and suffered from dentin sensitivity.

Past medical history:

1. Nasopharyngeal cancer, CCRT on 2003.

2. Xerostomia.

3. Hypertension, under medical control.

4. Gastroesophageal reflux disease (GERD).

5. No known drug allergy.

Past dental history:

1. Tooth extraction.

2. Composite restoration.

3. Crown restoration

Problem list:

1. Sensitive gag reflex

2. Limited mouth opening, MMO: 30mm

3. Caries: #12, 11, 21, 22, 31, 32, 33, 34, 43(Figure 1, 2)

4. #25,26 ill-fitting crown with secondary caries

5. Lower anterior teeth impinge the area of upper anterior teeth as a result of multiple caries on anterior teeth and mention below (Figure 3. A):

i. Missing: #23

ii. Residual root: #44

6. Loss of posterior support as a result of (Figure 3. B,C):

i. Caries: #18, 14, 24, 28, 35, 44, 45

ii. Missing :# 15, 27, 36, 37, 38, 46, 47,48

The last two points above mentioned made his occlusal plane appeared as reverse occlusal plane and vertical dimension loss.

Diagnosis:

1. Limited mouth opening

2. Dental caries due to xerostomia after receiving CCRT

3. Tooth erosion due to GERD

4. Chronic apical periodontitis

5. Vertical dimension loss

Treatment considerations:

In this case, the treatment process are not easy, the patient has a strong gag reflex because of GERD, even a small amount of water made him vomit. Although rubber dam was used to prevent water irritation when cavity preparation, the complication of limited mouth opening still made the preparation difficult.

The patient suffers from limited mouth opening, xerostomia. He expected to have comfortable and convenient dental prosthesis, and preferred fixed prosthesis. His treatment plan is list as follow (Figure 4):

On maxilla, the treatments included #18, 28 extraction, #25, 26 root canal treatment & crown restoration, and #12, 11, 21, 22, 24 crown restoration without root canal treatment. For #25 26, crown lengthening was necessary

Figure 3: Study model analysis. A. lower anterior teeth impinge the area of upper anterior teeth B&C. loss of posterior support


林詩韻莊淑芬

before endodontic treatment for the reason of isolation. On mandible, #44 extraction followed by #43x45crown and bridge fabrication. For #46, 47, 36 missing teeth, there are two treatment options. The first one is to have Kennedy classⅠRPD (Figure 5), another was implant prosthesis on #46, 47, 36 areas (Figure 6).

After discussing with the patient, the final treatment plan included direct composite resin filling on carious teeth, extraction of #18, 28, 44, root canal treatment on #25, 26, crown restoration on #12, 11, 21, 22, 24, 25, 26 and bridge fabrication on #43x45.

Summary of the treatment course: (Figure 7, 8,9,10,11)

2010.11 Full mouth scaling, OHI, study cast impression, diagnostic wax up

#13, 14, 31, 32, 33, 34, 35, 41, 42, 43, composite resin filling Fluoride tray delivery

2010.12 #25, 26 crown removal, temporary crown fabrication

#12, 11, 21, 22, 24 caries removal, composite resin filling

Figure 04: Illustration of treatment plan

Figure 05: Treatment option 1: removable partial denture



#12, 11,21,22,24 temporary crown fabrications, occlusion elevation 1 mm

2011.01 #18, 28, 44 extractions

#25, 26 crown lengthening

#25, 26 temporary crown reline and adjustment

2011.02~05 #25, 26 re-Endo

#43x45 temporary crown fabrication

#12, 11, 21, 22 final impressions,

final cementation

#25, 26 casting post fabrication and cementation

2011.06~08 #45 root canal treatment, casting post fabrication and cementation

#24, 25, 26 final impressions, final cementation

#43x45 final impression, final cementation

Figure 06: Treatment option 2: implant prosthesis

Figure 07: A. rubber dam application to decrease gad reflex B,C,D&E. wax up, temporary crown fabrication


林詩韻莊淑芬

Discussion

As mentioned, the main challenge in treating this patient was reverse occlusal plane and vertical dimension loss. There are two options for overcome these problems (Figure 12)6. The first option is to increase vertical

dimension of occlusion. The second one is to reduce crown length (Table 1). The pro of increasing vertical dimension of occlusion is to obtain enough anterior space, but may induce temporomandibular disorders and more teeth will be involved. The second option is to reduce crown length. This method improved crown-root

Figure 08: A. before CLP & re-RCT B. after #25 CLP C. After #25,26 RCT D. before #44 extraction and #45 RCT E. After #44 extraction and #45 RCT

Figure 09: A&B. crown preparation and final impression C&D stone model of anterior PFM crowns



ration, but finally smiling curve is still reversed. After discussed with patient, we choose to increasing vertical dimension of occlusion.

After deciding the treatment option of anterior teeth, another question is how to restore posterior teeth (Table 2). The removable partial denture (RPD) is an economic choice

which needs less treatment time and avoids the preprosthetic surgery. Since the patient has a serious condition of xerostomia and ridge resorption due to teeth loss for a long time, RPD is not considered. The second treatment plan is the implant prosthesis. The advantages of implants are good function and easy clean,

Figure 10: A&B. anterior coping trying C&D. posterior coping trying

Figure 11: Intraoral color slides after treatment


林詩韻莊淑芬

but ridge augmentation and possible risk of osteoradionecros should be considered. After discussion, patient decides to have implant prosthesis in the later days.

Patients should keep routine follow-up after dental treatments. The motivation and oral hygiene is crucial for long term prognosis3. Patients after receiving radiotherapy should be closely evaluated for radiation caries3. Daily diet, oral hygiene and fluoride use needs to be monitored and need appropriate consultations3.

Fluoride use including fluoride mouthwash, high concentration fluoride toothpaste, GC Tooth Mousse® and use of fluoride applicator trays are suggested7. Chlorhexidine gel applied using trays for 5 minutes each night for a 2-week period and repeated every 3 months may be helpful in reducing the dominance of cariogenic bacteria7.

Conclusion

For patients undergoing radiotherapy for treatment of head and neck cancer, the

treatments remain challenge. Both preventive dental treatments and post-treatment dental care are crucial. Good oral hygiene and fluoride usage will increase prognosis.

Reference

1. Cancer registry annual report, 2010 Taiwan, Bureau of Health Promotion Department of Health the Executive Yuan Taiwan February 2013. Available at: http://www.hpa.gov.tw/BHPNet/Web/Stat/Statistics.aspx

2. Fátima R. Nunes de Souza; Lira Marcela Monti; Francisco Isaak N. Ciesielski , Alvimar Lima de Castro; Gilceu Pace and Elerson Gaetti-Jardim Júnior, Influence of Preventive Protocols on Side Effects of Radiotherapy for Treatment of Head and Neck Cancer.International Journal of Odontostoma, 2009.3(2):167-172

3. Vinod K. Joshi, Dental treatment planning and management for the mouth cancer patient. Oral Oncology, 2010. 46(6): p.475-479

Figure 12: Treatment options



4. Aline Lima da Silva Deboni, Adelmo José Giordani, Nilza Nelly Fontana Lopes, Rodrigo Souza Dias, Roberto Araujo Segreto, Siri Beier Jensen, Helena Regina Comodo Segreto, Long-term oral effects in patients treated with radiochemotherapy for head and neck cancer, Care Cancer, 2012.20(11):2903–2911

5. Carol Anne Murdoch-Kinch, Samuel Zwet chkenbaum, Dental Management of the Head and Neck Cancer Patient Treated with Radiation Therapy, Journal of the Michigan Dental Association, 2011.93(7):28-37

6. Jaafar Abduo, Safety of increasing vertical dimension of occlusion: A systematic review, Quintessence International, 2012.43(5):369-380

7. Lorna K McCaul, Oral and Dental Management for Head and Neck Cancer Patients Treated by Chemotherapy and Radiotherapy, Dental update 2012.39(2) 135–140

Table 1. Comparison of two optionsOption 1 Option 2

Increasing vertical dimension of occlusion Reduction of crown length

Pros Anterior space obtained Crown-root ratio improvement

Cons Temporomandibular disordersMore teeth involved Reverse smiling curve

Table 2. Comparison of two treatment plansTreatment plan 1 Treatment plan 2

RPD Implant

ProsCost lessLess time involvedNo surgery

Good functionEasy clean

Cons XerostomiaRidge resorption

Ridge augmentationPossible osteoradionecrosis


林詩韻莊淑芬

接受合併化學及放射線治療患者之復形病例治療

林詩韻1 莊淑芬2,*

摘要

癌症已成為人口中高發生率的疾病，許多癌症患者接受合併化學及放射線治療後，出現口

腔併發症，像是唾液分泌減少、咀嚼功能不良及蛀牙；因此，在放射線治療後的口腔照護，對

維持患者生活品質來說非常的重要。在本病例中，患者曾接受合併化學及放射線治療，口腔表

徵包括：口乾症、多顆蛀牙及牙齒喪失，在治療該患者時，需同時考量咬合關係的重建與術後

的維持；在以複合樹脂直接填補及固定贋復物治療後，修復了患者的咬合功能。

關鍵詞：合併化學及放射線治療蛀牙復形治療

沛宜牙醫診所醫師國立成功大學口腔醫學研究所碩士1 國立成功大學口腔醫學研究所教授兼所長成大附設醫院牙體復形科主任2，國立成功大學附設醫院口醫部*通訊作者：莊淑芬，台南市勝利路138號，電話：(06)2353535#2977，傳真：(06)2762819， E-mail:[email protected]


Bio-mimic Direct Class II Composite Restoration

Introduction

By the 1980s, posterior tooth-colored restorations had been introduced, and these have continued to evolve to offer improved physical properties, user-friendliness and esthetics1. Paralleling the evolution of posterior composite resin materials, cavity designs, bonding systems and armamentarium have also developed rapidly to successfully employ composite resins in Class II situations2. With the increasing clinical use of composites, it is important to optimize every step of direct composite resin filling, from cavity preparation, matrix selection, isolation, bonding placement and selection, composite placement or filling, and management of polymerization shrinkage for achieving a durable, long-lasting direct Class II composite filling that is esthetically indistinguishable from natural tooth

structure. This present case report describes the clinical procedures for rehabilitating the posterior teeth with large Class II cavity by using direct composite resin.

Case Report

A 60-year-old female patient who denied of major systemic diseases and known food or drug allergy presented with two major concerns: food impaction and restoration fracture over the lower right molars area. She wanted to replace the defective amalgam filling with tooth-colored filling. According to the patient's statement, she received dental examination and full mouth scaling once or twice every 12 months. Upon intra-oral examination, an existing mesio-disto-occlusal amalgam filling with biologically

Direct Class II Composite Restoration with Bio-mimic Characterized Pit and Fissure of Posterior Teeth

– A Case Report

Ching-Ching Wong1 Yu-Chih Chiang2,*

1 DDS, MS, Training Resident, Department of Restorative and Esthetic Dentistry, School of Dentistry and Graduate Institute of Clinical Dentistry, National Taiwan University and National Taiwan University Hospital.

2 DDS, MS, PhD, Assistant Professor, Department of Restorative and Esthetic Dentistry, School of Dentistry, National Taiwan University and National Taiwan University Hospital.

* Corresponding author: Yu-Chih Chiang, Tel: ++886-2-23123456 Ext.67866, Email: [email protected]

Presently, the increasing demand for tooth colored restorations, cosmetic dental procedures, conservation of tooth structure together with dramatic advances in the field of adhesive technology has led to widespread application of direct composite restorations. Comparing to conventional amalgam filling or indirect restorations, direct composite restorations are conservative, minimally invasive and a viable alternative clinical choice of treatments, if proper protocol is followed. We presented a case report which focuses primarily on illustrating the necessary procedures required to achieve an anatomical, functional and esthetic direct Class II composite resin restoration.


黃菁菁姜昱至

unacceptable marginal leakage, probe-detectable secondary caries and open distal interproximal contact on tooth 46 were found, whereas tooth 47 had a large, deep mesio-occlusal defective amalgam filling with fractures on the restoration and tooth structure were noted.

Both tooth 46 and 47 were within normal response to thermal test and electric pulp test, no palpation pain or percussion pain were shown. The bitewing radiographic examination showed that the old restorations of both teeth were large and close to pulp. The periodontal tissue of tooth 47 was in good health, with a probing depth ranging from 2 to 3 mm and without tooth mobility. Tooth 46 had a grade I buccal furcation involvement (Glickman's classification, 1953), but no tooth mobility was found. According to the results of clinical and radiographic examinations, the diagnosis given was: tooth 46 discoloration with corrosive amalgam filling and secondary caries, and tooth 47 fractures of tooth and amalgam filling with marginal gap.

After a thoroughgoing discussion with patient, the patient expressed the desire to restore tooth 46, tooth 47 with direct composite resin

Figure 1: Preoperative horizontal bitewing X-rays film of first visit showed the defective amalgam fi l l ing on tooth 46 and tooth 47. The high radiopacity of amalgam was an obstacle to the caries detection.

Figure 2: Intra-oral photos performed before treatment.



filling. The treatment plan given was replacing the amalgam on tooth 46, tooth 47 with direct composite restoration. After full mouth scaling and oral hygiene instructions, initial data

was collected. Tooth 46 and tooth 47 direct composite resin filling was then accomplished within two appointments. The following was the summary of the treatment course:

1. The composite of choice was the Filtek™ Z350 XT Universal Restorative Composite (3M ESPE, St. Paul, MN, USA). This composite is a nanocomposite resin, which provides unsurpassed esthetics, acceptable strength and wear resistance for posterior use3. After anesthesia, a shade was chosen. Shade A3B was the shade of choice of dentin layer, whereas shade A3E and shade W was chosen to be the shade of enamel layer.

2 . An occlusa l ana lys is was done wi th articulating paper to determine the patient's centric stops and to note if there were any working or non-working interferences. Any lateral interference should be removed and none should be created with the new restoration.

3. The existing amalgam (Figure 5A) was removed by using round diamond bur and ultrasonic device. Then, the caries and infected dentin were removed by low speed carbide round bur. The preparation was

Figure 3: Instruments and materials were applied for the treatment.

Figure 4:Schematic representation of the layering composite resin increment (layer 1-4) in order to reduce shrinkage stress of composite resin. B: Buccal aspect. L: Lingual aspect.

Figure 5 – Clinical procedures of tooth 46 and tooth 47 direct composite resin filling.(A) Initial condition of tooth 46, tooth 47. Arrow represents tooth and amalgam fracture.(B) Removal of old amalgam filling and caries, and cavity preparation of tooth 47(C) Composite resin filling and superficial staining of tooth 47 to mimic the pit and fissure.(D) Removal of old amalgam filling and caries, and cavity preparation of tooth 46(E) Staining and painting of tooth 46 and 47 to mimic the pits and fissures. Final polished composite resin restorations were presented.


黃菁菁姜昱至

refined by using cylinder diamond bur and hand instruments (such as enamel hatchet and gingival margin trimmer) for composite restorations where there was no free enamel, fin and bevel. (Figure 5B, 5D)

4. A rubber dam was placed to isolate the lower right quadrant area.

5. The self-contoured sectional metallic matrix band was placed, following by a wooden wedge, and the separating ring of Palodent System (Dentsply, Konstanz, Germany) applied to optimize an interproximal contour and contact between the teeth as well as to provide adequate cervical adaptation.

6. The cavity surface was etched with a total etch technique using DenFil™ Etchant-37 (Vericom Co., Ltd., Korea), blue-colored 37% phosphoric acid etchant. An etchant layer was first placed around the enamel layer at the cavosurface for 5 seconds prior to the remaining portion of the preparation being filled with phosphoric acid for another 10 seconds. A total of 15 seconds was utilized for the amount of etching time. This was rinsed with a copious amount of water, and then gently blot dried with a mini sponge

before air-blow gently for keeping moisture dentin.

7. AdperTM Single Bond 2 Adhesive (3M ESPE, St. Paul, MN, USA) was applied for the bonding step. It is a single component adhesive with ethanol/water-based and nanofiller. A 1-2 consecutive coat of adhesive was applied to etched enamel and dentin for 15 seconds with gentle agitation using a fully saturated applicator. Then, gently air thinned for 2-5 seconds to evaporate solvents and light cured the preparation site for 10 seconds.

8. The filling technique used was described in Figure 4.

9. Staining of the grooves and fissures was characterized by using Tetric Color (Ivoclar Vivadent, Amherst, New York).

10. Once the contouring was accomplished, the rubber dam was removed and the occlusion was checked.

11. Kerr-Hawe Polishing Kit, OptiDisc and OptiShine Polishing Brush (Kerr, Bioggio, Switzerland) were used in succession for polishing the restorations.

Figure 6 - One month follow up(A) Occlusal view of tooth 46, tooth 47(B) Buccal view of tooth 46, tooth 47(C) Post-operative horizontal bitewing X-ray film.



12. Clinical check showed the morphologic and color integration of the restorations. (Figure 4E)

13. One month follow-up (Figure 6A to 6C), no symptom/sign over tooth 46 and tooth 47, the composite restorations were in good integrity and color stability, and harmonious with periodontal and pulp tissues.

Discussion

To fulfill the patient 's need, the old amalgam restorations were replaced by direct composite resin filling in this case. As we know, the poor esthetic results provided by amalgams and amalgams staining of the tooth over time are a major reason why patients increasingly prefer the use of direct posterior composite resin4. Corrosion is also an issue. Comparing to amalgam restoration or indirect restoration, composite restorations are repairable, thermally nonconductive, conservative and adhesive to tooth structure5. When it is used properly, composite resin has demonstrated the ability to perform as well as amalgam in posterior restorations for up to 12 years6.

In this case, there were several treatment options for tooth 46 and tooth 47 which can satisfy patient's esthetic demand, such as direct composite filling, ceramic onlay, or intentional endodontic treatment and crown fabrication. However, due to the economic consideration and preservation of tooth structures, patient determined to rehabilitate tooth 46 and tooth 47 with direct composite filling. It was explained that if a fracture of either the composite resin or tooth structure occurs, then an indirect ceramic onlay restoration will be placed or intentional endodontic treatment and crown fabrication will be needed.

It is difficult to directly compare the longevity of direct and indirect restorations for various reasons7. This may be due to variables in study design, differences in clinical procedures and materials used and variations in study characteristics. Longitudinal studies on posterior composite restorations over a period of 8 years or more reveal an annual failure rate of 1%-6% compared to 0%-7% for amalgam8. Opdam et al. concluded that when operators who are skilled in both amalgam and composite techniques placed restorations, the annual failure rates of both materials were comparable9. The longevity of restorations depends on clinical technique, materials and patient care10.

Conclusion

Direct composite filling have benefited from advances in their physical and bio-mimic characteristics, made possible the use of composite where we previously would only consider more invasive prosthetic solutions and enabling more predictable results to be achieved for most of the clinical indications. Direct composite techniques undoubtedly gained maturity and offer a wide range of successful applications; however, it remains our duty to select their indications with proper judgment and diagnosis. And the last but not the least, meticulous handling techniques and thoroughly understandings of material properties remain the keys to success for direct composite restorations.

References

1. Da Rosa Rodolpho, P.A., et al., A clinical e v a l u a t i o n o f p o s t e r i o r c o m p o s i t e restorations: 17-year findings. J Dent, 2006. 34(7): p. 427-35.


黃菁菁姜昱至

2. Chan, K.H., et al., Review: resin composite filling. Materials, 2010. 3(2): p. 1228-1243.

3. Dietschi, D., Optimising aesthetics and facilitating clinical application of free-hand bonding using the 'natural layering concept'. Br Dent J, 2008. 204(4): p. 181-5.

4. Soares, A.C. and A. Cavalheiro, A review of amalgam and composite longevity of posterior restorations. Revista Portuguesa de Estomatologia, Medicina Dentária e Cirurgia Maxilofacial, 2010. 51(3): p. 155-164.

5. George Freedman, Contemporary Esthetic Dentistry, Elsevier Mosby, St. Louis, 2012; p36

6. Opdam, N., et al., 12-year survival of composite vs. amalgam restorations. Journal of Dental Research, 2010. 89(10): p. 1063-1067.

7. Brunthaler, A., et al., Longevity of direct resin composite restorations in posterior teeth: a review. Clinical oral investigations, 2003. 7(2): p. 63-70.

8. Pallesen, U., et al., A prospective 8-year follow-up of posterior resin composite restorations in permanent teeth of children and adolescents in Public Dental Health Service: reasons for replacement. Clinical oral investigations, 2013: p. 1-9.

9. Opdam, N.J., et al., A retrospective clinical study on longevity of posterior composite and amalgam restorations. Dental Materials, 2007. 23(1): p. 2-8.

10. Demarco, F.F., et al., Longevity of posterior composite restorations: not only a matter of materials. Dental Materials, 2012. 28(1): p. 87-101.



以複合樹脂暨仿真溝隙染色直接復形後牙二級窩洞 -病例報告

黃菁菁1 姜昱至2,*

現今，隨著牙科黏著系統的發展與創新，牙科美學和微創牙醫學亦備受重視，加上現代

人對齒色復形物的需求逐漸提升，使得複合樹脂填補材料的應用也日益廣泛。只要依循正確的

操作流程，相較於傳統的汞齊合金充填或間接復形物，直接式複合樹脂填補無疑是一保守與微

創兼備的臨床首選治療方法。本報告將以一病例說明利用複合樹脂直接充填二級窩洞，達到結

構、功能和美觀三者兼具的齒色復形物所必需的標準操作流程和方法。

關鍵字：複合樹脂，牙科黏著系統，微創牙醫學，齒色復形物

台灣大學牙醫專業學院臨床牙醫學研究所碩士，國立台灣大學附設醫院牙體復形暨美容牙科代訓住院醫師1，台灣大學牙醫專業學院牙科系助理教授，國立台灣大學附設醫院牙體復形暨美容牙科主治醫師2

*通訊作者：姜昱至，國立台灣大學附設醫院牙體復形暨美容牙科電話：(02)23123456#67866，E-mail:[email protected]


汪昇朋

以複合樹脂修復斷裂正中門牙及後牙瓷嵌體治療之病例報告

汪昇朋1 陳敏慧2,*

今日牙科材料學的進步，使得我們在修復壞損齒質的治療上，可以有多樣化的材料選

擇。但如何兼顧美觀，修復強度，與治療預後。就必須針對齒質損壞程度、牙齒位置與材

料美觀性、物理性質、黏著方式做通盤性的考量，進而得到理想的治療結果。本報告中提

出的兩個病例，病例一為意外撞裂左上正中門齒的小女孩，要求復形治療。由於病人將來

考慮會接受全口矯正治療，因此決定先以複合樹脂而非瓷貼面來進行治療。病例二是用瓷

嵌體修復兩顆下顎小臼齒，病人先前接受過銀粉與樹脂復形，最後均告斷裂失敗，在考量

強度與美觀條件下，決定以瓷嵌體復形。

前言

近年來牙科材料日新月異，尤其在全

瓷系統的發展更臻成熟，其應用範圍也越來

越廣。這幫助了牙醫師們可以藉由不同復形

材料的選擇，來滿足病人在修復齒質的美觀

要求。而在材料選擇的考量上，除了美觀因

素，還有齒質損壞程度、牙齒位置與功能、

黏著方式、材料物理性質與強度。

因此牙醫師的治療計畫，必須針對病人

的需求，與臨床現況，來選擇所使用的修復

方式，同時和病人保持良好的溝通，適切的

執行治療選擇，這樣才能得到理想的治療效

果與預後。

本報告中分享了兩個病例，病例一為13歲的小女孩，因為意外，撞斷了左上正中門

牙。由於小女孩齒列不整，預計青春期過後

會接受全口齒顎矯正，故在該仍為活性牙的

斷裂齒治療考量上，我們採取以複合樹脂直

接復形的方式。在治療計畫中，也針對該

牙的排列，做出適當的修復形態，以利將來

矯正治療的進行。同時為了美觀，在樹脂堆

築時，採取不同色調、彩度、透明度的樹脂

互相配合，以複製出鄰牙顏，以期達到最自

然美觀的效果。病例二為45歲女性，左下顎

第一小臼齒曾接受過複合樹脂復形，但其後

斷裂。第二小臼齒則曾接受銀粉填補，但有

滲漏與二次蛀牙發生。在和病人詳細溝通之

後，為兼顧美觀與強度需求，決定以陶瓷嵌

體修復。

病例

病例一

病患：

13歲，健康女性。

主訴：

國立台灣大學醫學院附設醫院專科訓練醫師，台北城東牙醫診所主治醫師¹，國立台灣大學附設醫院牙科部教授2

*通訊作者：陳敏慧，100台北市常德街一號牙科2樓 246室，電話:(02)2312-3456#67701E-mail:[email protected]


tooth-colored restorations

左上正中門齒斷裂，尋求治療。

過去病史：

無全身性系統疾病，亦無食物，藥物過

敏

過去牙科病史：

拔牙，牙體復形

口內檢查：

1.齒列關係：上下顎牙弓均為卵圓形外觀

2.咬合關係：a.兩側均為安格式第一級(Angle c l a s s I ) 犬齒關係與第二級

(Angle class II)臼齒關係b.垂直覆咬：3mm；水平覆咬：

2mm

診斷及問題列表：

1.齒列不整，混合齒列，中線右側偏移2mm

2.全口慢性牙齦炎

3.左上正中門齒斷裂

治療計畫：

1.全口洗牙及口腔衛教，改善病人牙齦發炎

情形

2.複合樹脂復形：病人欲等到青春期後，進

圖1：治療前，X光片可見斷裂處未直接侵犯牙髓

圖2：牙齒長軸分析

圖3：齒質修磨製備


汪昇朋

行全口矯正，因此現階段決定以複合樹脂

修復斷裂的左上正中門齒

治療摘要：

100-07-11：患者至本科求診，當天先進行全

口洗牙及口腔衛教，改善牙齦發炎。並與家

長討論治療計畫後，確定以複合樹脂直接修

復。

100-07-18：患者回診，觀察牙齦恢復情形。

拍攝全口攝影記錄，並印製診斷模型，以提

供後續治療計畫的設計與擬訂。分析牙齒排

列與比例後，在模型上製作診斷蠟型，以預

測治療結果。在診斷模型上分析，該顆牙的

近遠心空間和右側正中門齒雖是對稱，但其

牙冠近心側略微向頰側旋轉，因此在復形

時，需注意必須修復此一狀況，以利將來全

口矯正治療時，能使左右兩顆正中門齒形態

對稱。詳細蠟型分析之後，並以silicone印模

材壓製出牙齒復形的導引。

100-07-25：以複合樹脂修復左上顎斷裂正

中門齒

1.橡皮障隔離上顎五顆前牙，以高速手機與

鑽針進行表面齒質的修磨，在頰側依據其

斷裂的型態做出適當的長斜面，並使表面

不規則的齒質平順

2.使用teflon tape保護鄰牙後，進行表面齒質

酸蝕

3.使用3MZ350樹脂，逐層填補，並以silicone index做為型態輔助。在顎側選擇A2E與

切端CT，以模仿琺瑯質，在主要的dentin body則使用A3B，頰側表層則以A2E和CT配合，並創造出切緣透明層。另外，接近

切緣1/3的頰側面，使Kerr kolor plus的白色

染劑，染出些許白斑。

4.復形完成後進行咬合調整與磨光

100-08-01：病患回診，並無任何不適與敏感

圖4：使用修形導引逐層完成樹脂填補，逐層採用不同顏色與透明度的樹脂完成堆築，完成後進行咬合調整



情形

100-09-02：一個月後回診，表面無染色，樹

脂和牙齒間顏色的blending effect仍相當理想

病例二

病患：

45歲，健康女性

主訴：

尋求左下顎第一及第二小臼齒復形治

療。左下顎第一小臼齒曾接受銀粉與樹脂填

補治療，後填補物斷裂失敗。於口腔檢查

時，X光片上可看樹脂填補物下方仍有未清

除乾淨的舊銀粉填補物。左下第二小臼齒曾

接受銀粉填補治療，於口腔檢查時，可見邊

緣滲漏與二次蛀牙。

過去病史：

無全身性系統疾病，無食物過敏，藥物

方面對 erythromycin曾有過敏。

過去牙科病史：

牙體復形，根管治療，拔牙，固定假

牙，洗牙，人工植牙

口內檢查：

1.齒列關係：上牙牙弓均呈現卵圓形外觀

2 . 咬合關係： a . 兩側均為安格式第一級

(Angle c lass I )犬齒關係與右側第二級 (Angle class II)臼齒關係 b.水平覆咬與垂直

覆咬均為2mm

診斷及問題列表：

1.全口慢性牙齦炎

2.左下顎第一大臼齒缺牙

3.邊緣不密合之左下第二大臼齒臨時假牙

4.左下第一及第二小臼齒蛀牙

治療計畫：

1.全口洗牙及口腔衛教

圖5：填補後與一個月回診

圖6：治療前，X光片檢查可發現第一小臼齒仍殘留先前之銀粉填補物，齲齒侵犯範圍皆相當大


汪昇朋

2.左下顎第一及第二小臼齒瓷嵌體製作：經

和病患詳細溝通，為提供更好的材料強度

與美觀，同意以瓷嵌體復形

3.左下顎第一大臼齒植牙

4.左下顎第二大臼齒固定假牙製作

治療摘要：

針對左下顎第一及第二小臼齒瓷嵌體復

形治療

100-03-10：全口洗牙以及口腔衛教，改善

牙齦發炎情形

100-03-17：瓷嵌體印模

1.去除原有填補物以及二次蛀牙，確認蛀

牙深度，並未侵犯到牙髓

2.瓷嵌體修形，為避免過度破壞齒質，使用

流動性樹脂，封閉窩洞微細倒凹

3.以additional silicone精確印模，術後予以暫

時填補物

100-03-24：瓷嵌體試戴與黏著，黏著劑使用

Multilink automix(Ivoclar Vivadent)，為一dure curing resin cement

1.去除窩洞暫時填補物，並以橡皮障隔絕

牙齒

2.試戴IPS e.max瓷嵌體，確認邊緣密合度與

鄰接面鬆緊度

3.瓷嵌體表面以5%氫氟酸做表面處理以增加

micromechanical bonding，牙齒表面則以磷

酸處理

4.瓷嵌體表面塗上矽烷耦合劑silane，增加化

學黏著

5.牙齒表面塗佈以Multilink primerA&B劑，後

以Multilink automix黏著

6.以光聚合完成黏著後，去除橡皮障，清理

多餘的cement之後，調整咬合，並做表面

拋光處理

圖7：去除舊有填補物，齒質修磨製備，印製主模

圖8：口內試戴完成，以resin cement完成黏著



100-04-07：病患回診，無任何不適與術後敏

感發生

討論

病例一

前牙的意外斷裂，常發生在孩童以及

青少年身上。此時我們可以採用的治療方

式，有多種選擇。可以是黏著斷裂齒質、複

合樹脂修復、抑或瓷貼面與瓷牙冠。決定的

因素，除了前面提到和齒質缺損程度、牙齒

位置與功能、美觀需求度、材料物理性質、

黏著方式等相關外，還要考慮到生長問題，

牙齒萌發程度。

本案例為13歲女孩，考量其因齒列不

整而需接受全口矯正治療的可能性，而決定

以複合樹脂復形。其優點為保留較多齒質，

治療時間短，費用低，若操作得宜，可得到

理想的美觀結果。缺點則是將來可能出現變

色、邊緣滲漏、磨損、斷裂等問題。

在治療過程中，為達到理想的美觀效

果，在牙齒的型態方面，需注意到牙齒的長

軸方向、3D比例、表面發育溝與質感、切

角與線角的表現、磨損與其他特徵的存在與

否。本案例中，左上正中門牙的近心側有著

些許的向頰側旋轉，因此在復形時，必須

考慮到整個旋轉角度帶來的視覺差異，並且

妥善重建牙齒結構，以利將來矯正醫師在

排列牙齒的對稱性。在顏色方面的考量，則

要考慮到不同齒質層的厚度給整體顏色帶

來的影響，以及不同齒質與部位的光學性

質，如 translucency、transparency、opacity、

opalescence、 fluorescence.甚至牙齒的內染色

與外染色都是需要一併在治療中結合的。

本案例中，依著不同齒質厚度與部位，

筆者使用不同光學性質與色調的樹脂層層堆

築，配合染色劑的使用，最終達到模仿鄰

牙自然美觀的目的。

病例二

面對後牙的缺損，我們所經常使用的

復形治療方式有銀粉填補、複合樹脂填補、

複合樹脂鑲嵌體、陶瓷鑲嵌體、黃金鑲嵌

體..等。在本案例中，在考量到美觀與材料

強度，且病患並無不良咬合習慣與磨牙情形

下，選擇了以陶瓷鑲嵌體復形。這種間接復

形方式的優點是可以減少微滲漏的發生、具

有比較好的機械性質、復形體的型態上可以

具備較好的解剖構造、邊緣密合度、鄰接面

密合度、與良好的表面質感。

瓷嵌體本身的材料性質，則提供了良好

的生物相容性與組織反應，較之復合樹脂，

陶瓷本身較不易有牙菌斑附著。另外的優點

還包含較低的磨耗，和牙齒結構相近，可以

取代缺損的齒質，並強化結構，恢復齒質的

圖9：調整咬合圖10：完成拋光


汪昇朋

硬度。較之複合樹脂，瓷嵌體在臨床上有較

好的表現。

本病例中，我們所使用的全瓷系統為IPS e.max，其主要成分為lithium dusilicate，製成

方式可為heat-press或是CAD/CAM，其強度

flexural strength為360~400MPa，可廣泛運用

於嵌體、瓷貼面、單顆牙冠、植體牙冠、以

及前牙三單位牙橋。這種材質也同時提供了

四種不同透明度，可達成美觀的治療結果，

在本案例中採用的即是e.max HT(高透明度) monolithic heat-pressed inlay。

結論

隨著材料科技的不斷演進，與病患美

觀意識的抬頭，美容牙科材料的運用，已成

為當今牙醫界的主流思考。但在選擇材料之

際，如何能綜合各項條件，包含病患的咬合

功能、咬合習慣、齒質損壞程度、黏著方

式、牙齒位置與美觀考量、甚至顏面部整體

美觀設計，進一步和病患溝通，給予最適合

的治療計劃，並妥善執行，而達到最理想的

治療目標，實是我們努力的方向。

參考文獻

1. Fundamentals of operative dentistry, 3rd edition 2006. p266~270,p522~534

2. Burkard Hugo, Esthetics with resin composite 2009. p30~36,p47~55

3. Antonio Bello, Ronald H. larvis. A review of esthetic alternatives for the restoration of anterior teeth. The journal of Prosthetic Dentistry 1997;78:437-40

4. ROBERT C. MARGEAS, Keys to Success in Creating Esthetic Class IV Restorations. J Esthet Restor Dent. 2010 Feb;22(1):66-71

5. Stefano Ardo, Biomimetic direct composite

stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167-174

6 .ALFRED0 MEYER FILHO, Ceramic Inlavs and Onlavs: Clinical Procedures for Predictable Results. Journal of Esthetic and Restorative Dentisty 2003; 15:338-352

7.Conrad et al; Current ceramic materials and systems with clinical recommendations: A s y s t e m a t i c r e v i e w J P r o s t h e t D e n t 2007;98:389-404

8.Gustavo M.S., Composite Resin Restorations of Permanent Incisors with Crown Fractures. Pediatr Dent 2009;31:102-9



Restoring a fractured incisor with composite resin and using ceramic inlay to restore posterior tooth

Sheng-Peng Wang1 Min-Huey Chen2,*

According to the advance of dental technology, we have lots of materials to choose to restore the broken teeth. With using tooth-colored restorative materials, we can not only recover the function of teeth but also satisfy the increasing demands of esthetics. In this report, the first case is a 13 y/o girl who just suffered falling accident and broke her upper left central incisor. She came to our OD department for help. Because she plans to recieve orthodontic treatment in the future. We choose composite resin but not porcelain veneer to restore the tooth. The other case is a 45y/o female patient who had old fillings on lower left 1st, 2nd premolars. Secondary caries, fractured lines were noted during full mouth examination. We decided to restore these 2 teeth with ceramic inlays for strengthening the tooth structure.

key words: esthetic dentistry, dental trauma, ceramic inlay.

1 Taipei-smile dental clinic, Taipei2 Professor, Department of Hospital Dentistry, National Taiwan University* Corresponding author: Min-Huey Chen, 246 Room, 2F, No.1, Chang-Te Street, Taipei100, Taiwan, R.O.C.

Tel: ++886-2-23123456 Ext.67701, Email: [email protected]

MEMO

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