臺灣博碩士論文加值系統

植牙手術中使用光固化式3D列印手術模板，能有效協助醫師掌握植體位置，減少因植入錯位造成植牙手術失敗，且模板上的套環，更可協助植牙鑽針沿著套環長軸尋找中心位置，但常因患者開口度限制，造成後牙區空間不足而阻礙手術進行，故出現改變套環設計以解決此問題，但其功效未見系統性研究。本研究比較標準型和C型兩種不同套環設計手術模板，使用體外下顎標準模型，由牙醫師模擬植入左側第一大臼齒，測量植體頸部 (Implant neck)、植體底端 (Implant apex)的位置偏差及軸向角度(Axial angulation)偏差以探討使用不同套環設計之術後效果。
本實驗共分為兩個部分，第一部份目標為決定手術環境，以一位經驗豐富的醫師，利用每組五支植體及標準型套環手術模板，分別在口外環境及模擬口內環境進行植入以探討不同手術環境下的差異；第二部分為探討套環樣式對於植體植入結果的影響，並由醫師經驗、植體置入方式不同進行探討，此部分邀請10位醫師，在模擬口內環境中以上述兩種套環手術模板，各依植體置入方式不同分別進行電腦輔助置入和徒手置入；所有植入結果進行記錄並分析以下參數分別為：植體頸部 (Implant neck)、植體底端 (Implant apex)的平均位置偏差量和植體軸向角度(Axial angulation)平均偏差量。統計分析中第一部分使用配對t檢定 (Paired t-test)進行，第二部分則使用Three-way ANOVA配合配對t檢定。(αlevel = 0.05)
經上述實驗後所得，口外及模擬口內環境在植體底端 (Implant apex) 的平均位置偏差量呈現顯著差異，其中又以模擬口內環境所得結果為佳，並由此可了解到手術環境會影響植入後的結果，在本實驗中為能更貼近臨床使用情境而選擇模擬口內環境。在不同套環樣式方面則是植體頸部 (Implant neck)及植體底端 (Implant apex)的平均位置偏差量呈現顯著差異，其中C型套環相對於標準型套環在植體頸部 (Implant neck)及植體底端 (Implant apex)上有更往頰側偏移的情形，但在角度上則相對於標準型套環表現為差；不同置入方式造成植體底端 (Implant apex)平均位置偏差量及植體軸向角度(Axial angulation)平均偏差量有顯著差異的出現，又以電腦輔助置入可比徒手置入得到更精準的結果；醫師經驗上則無顯著差異的產生，由此可推測兩種套環都可協助經驗較淺的醫師達到有經驗醫師的植入水準。

Steroligthographic surgical guide could provide accurate position in implant surgery. However, it would be restricted in surgical space of posterior region for maximum mouth opening limitation. Types of sleeves were used to solve the problem, but the accuracy between different kinds of sleeves was unknown. The aim of this study was using surgical templates with master and C type sleeves to get the deviation of implant neck, implant apex, axial angulation from actual implant placement. To compare the accuracy for types of sleeves.
There were two parts in this experiment. The target in the first part was to decide the environment of experiment, and the target in the second part was to probe using types of sleeves to realize the accuracy of implant in the different situations as surgeon experience and implant placement. The first part with one experienced surgeon was separated to two groups for the condition of extraoral and intraoral, and it would use five implants and master sleeve surgical template in every group. The second part was invited ten surgeons, and every surgeon carried out the four circuit for master sleeve in computer-aided placement, master sleeve in free hand placement, C type sleeve in computer-aided placement and C type sleeve in free hand placement. All the implants were measured by coordinate measuring machine after surgery, and the spatial relations were constructed by CAD software. The parameters were got from the mean distance deviation of implant neck, implant apex and axial angulation of implant. Statistical analysis in the first part was used Paired t-test, and in the second part were used Three-way ANOVA with paired-t-test. (p<0.05)


The results of the environment of experiment had significant differences in the mean deviation of implant apex. To speculate that the environment of experiment would affect the results of accuracy, and we chose the condition of intraoral to intimate the situation of clinical. The factor of sleeve types had significant differences in the mean deviation of implant neck and implant apex, and C type sleeve would be toward in buccal side than master sleeve in implant neck and implant apex. However, the axial angulation was not especially good in C type sleeve. The factor of implant placement had significant differences in the mean deviation of implant apex and axial angulation, and it was demonstrated the results of computer-aided placement in good accuracy. The factor of surgeon experience did not appear any significant differences, and it was showed that novice surgeon could get the level of experienced surgeon by two type of sleeves.

目錄
致謝 i
摘要 ii
ABSTRACT iv
目錄 vi
圖目錄 viii
表目錄 x
第一章 前言 1
1-1 植牙 2
1-2 植體位置與角度關係 5
1-3 手術模板 7
1-3-1 靜態導引 9
1-3-2 動態導引 11
1-4 植體置入方式 11
1-5 開口度 12
1-6 套環 14
1-7 手術環境 15
1-8 目的 16
第二章 材料與方法 17
2-1 實驗材料 18
2-1-1 下顎模型 18
2-1-2 人工假骨 19
2-1-3 手術模板 20
2-1-4 植體及手術器械 22
2-1-5 執行者 23
2-2 實驗方法 24
2-2-1 手術環境 25
2-2-2 套環差異 26
2-3 數據量測 26
2-3-1 參數的選用 26
2-3-2 量測與計算 27
2-3-3 座標重建 29
2-4 資料統計分析 31
第三章 結果 32
3-1 手術環境 32
3-2 套環差異 34
3-2-1 分析結果 34
3-2-2 植體頸部 (Implant neck) 35
3-2-3 植體底端 (Implant apex) 37
3-2-4 軸向角度 (Axial angulation) 40
3-2-5 套環差異散佈圖 42
第四章 討論 43
4-1 與前人實驗相比 43
4-2 偏差產生 45
4-3 手術環境 46
4-4 套環差異 47
4-5 其他誤差來源 49
4-6 限制與假設 50
第五章 結論 51
參考文獻 52
 
圖目錄
圖1、自然牙與植體結構與組件 3
圖2、(a) 骨膜內植體 (b) 骨膜上植體 (c) 穿骨式植體 3
圖3、植牙手術流程 4
圖4、臨床植牙失敗案例 (a) 植體外露 (b) 機械性斷裂(c) 骨整合失敗 4
圖5、Weinberg學者提出植體與力矩關係 (a) 角度關係 (b) 水平位移關係 5
圖6、口內分區 6
圖7、以CBCT制定3D治療計畫 7
圖8、傳統手術模板 8
圖9、電腦輔助靜態導引 (a) 電腦導引鑽孔系統 (b) STL系統 [30] 9
圖10、(a) 翻瓣手術 (b) 不翻瓣手術 12
圖11、最大開口度測量 13
圖12、標準套環與C型套環 (a) 套環樣式 (b) 傾斜方式進入 14
圖13、口外環境 15
圖14、模擬口內環境 15
圖15、實驗流程圖 17
圖16、牙科訓練假人 18
圖17、模型準備流程 (a) 原始下顎模型 (b) 牙科掃描技術儀器 19
(c) 電腦輔助設計軟體出需加工的區域 (d) 實驗用模型 19
圖18、聚氨酯塊 (a) 切削前 (b) 切削後 19
圖19、聚氨酯塊工程圖 (a) 設計圖 (b) 剖面圖 20
圖20、下顎標準模型掃描圖 21
圖21、植牙手術計畫軟體 (a) 上視圖 (b) 左側視圖 21
圖22、手術模板設計圖 (a) 標準型套環 (b) C型套環 21
圖23、3D列印快速成型機 22
圖24、STL系統手術導板 22
圖25、AB tech implant (Ø4.2× 10，A.B. Dental Inc, Ashdod, Israel) 23
圖26、手術器械 (實線：植牙手術鑽針，虛線：載鑽針器械) 23
圖27、植牙手術流程 24
圖28、(a)口外環境 (b)模擬口內環境 25
圖29、最大開口度設置 25
圖30、參數的設定 ①植體頸部位移 ②植體頂端位移 ③植體角度變化 26
圖31、(a) 三次元測量儀 (b) 固定方式 (c)工程座標原點位置 28
圖32、原始長軸的建立 (a) 固定方式 (b) 量測方式 (c) 示意圖 28
圖33、近遠心長軸的建立 28
圖34、量測過程 (a) 頸部中心點 (b) 圓柱狀支台體 (c)回推底端中心點 29
圖35、測偏移計算示意圖 30
圖36、口內座標示意圖 30
圖37、不同手術環境 (a)平均位置偏差 (b)平均角度偏差 33
圖38、不同手術環境中植體頸部及植體底端位置散佈圖 34
圖39、植體頸部平均位置偏差 36
圖40、依套環樣式進行配對t檢定 37
圖41、植體底端平均位置偏差 38
圖42、依套環樣式進行配對t檢定 39
圖43、依置入方式進行配對t檢定 39
圖44、植體軸向平均角度偏差 41
圖45、依置入方式進行配對t檢定 41
圖46、套環差異下植體頸部及植體底端位置散佈圖 42
圖47、前人體外實驗 44
圖48、植入過程視野 (a) 標準型套環 (b) C型套環 48

表目錄
表1、電腦導引鑽孔系統與STL系統偏差比較 10
表2、台灣地區最大開口度 13
表3、手術流程與手術模板使用 24
表4、不同手術環境位置偏差 33
表5、不同手術環境角度偏差 33
表6、Three-way ANOVA 35
表7、兩種套環植體頸部平均位置偏差 36
表8、兩種套環植體底端平均位置偏差 38
表9、兩種套環植體軸向平均角度偏差 40
表10、與前人實驗結果比較 44

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