臺灣博碩士論文加值系統

臨床上，當自然牙與人工植體相鄰時，在某些生理解剖條件下將不避免的需利用固定式牙橋的方式將兩者連結，然而由於兩端的動搖度不同導致臨床上發生補綴牙冠脫落、植體支台鬆脫/斷裂、骨質流失等等的失敗病例，然後若植體所連結的對象為經過根管治療後之結構、強度均較自然牙脆弱之根管治療牙齒，其生物力學行為則更加複雜，可能導致治療失敗的原因包括根柱冠心的脫落、牙根斷裂、植體鬆脫/斷裂、骨質流失、牙冠脫落等等現象，除此之外是否有其他之失敗現象尚無一定論，就目前所遭遇之臨床失敗病例除上述幾種以外，尚有因黏著層崩解破裂造成補綴牙冠連同根柱脫落之現象，因此關於其破裂模式亦需進一步探討。而影響根管治療牙齒/植體連結系統失敗之原因可能包括咬合方式、連結之植體系統種類、黏著層材料強度等等，為進一步瞭解其失敗原因及破壞模式，故有必要針對影響根管治療牙齒/植體連結系統之參數以及連結系統之力學行為及破壞模式進行探討。因此本研究將利用CT、Micro-CT及電腦輔助設計(CAD)等技術建構根管治療牙齒/人工植體連結系統之有限元素實體模型並針對以下參數進行有限元素靜態模擬分析：參數一、咬合負載：(1)牙齒端側向負載100N及植體端側向負載200N；(2) 牙齒端軸向負載100N及植體端軸向負載200N；(3) 牙齒端側向負載100N；(4) 牙齒端軸向負載100N；參數二、植體系統：(1) ITI；(2) Prima；(3) Frialit-2。且為了進一步瞭解黏著層破裂崩解造成補綴牙冠連同根柱脫落之現象，本研究亦結合有限元素法提供之元素增生/隱沒技術及參數化語言開發出可模擬黏著層破裂成長模式，並以體外實驗進行趨勢比對。研究結果顯示，當根管治療牙齒連結人工植體後，系統之動搖度有明顯之降低，而當負載條件為側向咬合時，系統中之牙本質、根柱冠心、植體系統、下顎骨及黏著層的應力值均較軸向負載高(約1.5-10倍)。而進一步探討發現由於植體系統內外部構造、支台/植體連接方式不同，造成植體植入後造成之應力分佈、傳遞方式均不同；在同一負載下，連結ITI植體系統時，在下顎骨及黏著層有較高之應力分佈，而連結Friali-2植體系統時，對牙本質、根柱冠心及人工植體系統本身有較高之應力趨勢。而在黏著層破裂成長模擬部份，則發現系統中之黏著層初始破壞點主要位於植體端之補綴物/植體支台之黏著介面底部，並隨著每一次的疊代計算，發現其破裂成長方向將由補綴物/支台底部開始漸漸往上及往植體舌側破裂，且亦漸漸往牙齒端延伸。而體外實驗的部份，經過動態疲勞負載的的實驗樣本，以染色切片的方式取得植體及根管治療牙齒切面，並以顯微鏡進行黏著層破壞之微滲漏情形，同樣發現植體端之補綴物體/植體支台底部有染劑滲透發生，而在牙齒端之補綴物/剩餘齒質黏介面底部亦有些微滲透現象。整體而言，若將根管治療後的牙齒與相鄰的人工植體以連結的方式進行治療，則有較佳的改善，包括動搖度降低以及根柱、牙根的應力降低；然而，對黏著層、植體及週邊骨質而言，將造成其應力的增加，因此可能有植體斷裂、骨質流失以及黏著層崩解破裂而導致補綴物脫落失敗的可能，尤其在當連結系統承受側向負載時更為明顯，根據上述結果，建議臨床醫師在調整咬合時，應減少連結系統在側向的咬合負載，而連結的植體系統建議選用one-piece形式的植體為較佳。此外，應注意黏著層的崩解破壞導致補綴物脫落的現象，建議選用黏著強度較高的黏著劑為佳。

Structure strength is a major complication for endodontically treated teeth that usually restored with post and core to recover its function. While endodontically treated tooth is splinted to an implant in edentulous region for some clinical situations, complex biomechanical aspects of an endodontically treated tooth/implant-supported system are derived from the dissimilar mobility between the osseointegrated implant and the tooth and the weak structure strength of endodontically abutment tooth. Significant problems such as, loss of osseointegration, abutment screw loosening, prosthesis fracture and adhesive interface debonding between tooth and post arise due to the higher bending moment caused by the cantilever effect especially for the case of compromised periodontal support (not enough post length in alveolar bone). The aim of this study was to investigate the biomechanical aspects for endodontically treated tooth splinted to different implant system (ITI, Prima and Frialit-2 implant system) under four loading conditions: (1)OTOI: 100N oblique load (45o) on tooth and 200N oblique load on implant, (2)OT: 100N oblique load (45o) on tooth, (3)ATAI: 100N axial load on tooth and 200N axial load on implant, (4)AT: 100N axial load on tooth, using non-linear finite element (FE) approach. Moreover, to simulation the crack propagation of the cement, element birth and death technique and parametric design language provided in FE method was then adopted. The results showed the higher stability of the system after endodontically treated tooth splinted to the implant system but the stress values of the implant system, alveolar bone, and adhesive cement also increased. In addition, the stress values in the remaining dentin, post and core, implant system, alveolar bone and adhesive cement increased significantly for splinted system with receiving oblique load. On the other hand, the stress values of bone and cement increased when splinting to ITI implant, and the stress values of dentin, post, and implant system itself increased when splinting to Frialit-2 implant system . As for the crack propagation of the cement, the results showed that the initial crack of the cement lied on the bottom between the prosthesis and abutment, and the crack grew upward along the abutment, then turn toward to the cement between prosthesis and remaining tooth. On the whole, occlusal adjustments need to perform to reduce lateral load for decreasing the stress distribution in different components (bone, adhesive cement, prosthesis and implant) of the splinted system. Moreover, in choosing the implant, the Prima system is recommended.

目錄
指導教授推薦書
口試委員會審定書
長庚大學碩博士論文著作授權書
誌謝 IV
中文摘要 V
ABSTRACT VII
第一章 緒論 1
1.1研究背景 1
1.1.1根管治療 1
1.1.2根柱冠心 1
1.1.3圍箍效應 2
1.1.4人工植體 7
1.1.5自然牙與人工植體連結系統 11
1.1.6根管治療後牙齒與人工植體連結系統 11
1.1.7探討根管治療牙齒/植體連結系統之研究方法 12
1.1.8 元素增生/隱沒技術 15
1.2研究動機 16
1.3文獻回顧 17
1.3.1不同人工植體設計 17
1.3.2破裂成長模擬分析 19
1.3.3文獻總結 21
1.4研究目的 22
第二章研究方法 23
2.1研究流程概述 23
2.2有限元素模型建構 24
2.2.1支台齒/補綴物備製 24
2.2.2顎骨臼齒補綴物掃描 24
2.2.4系統有限元素模型建構 29
2.3非線性有限元素靜態模擬分析 34
2.4破裂成長模擬分析 39
2.5動態疲勞測試與破壞檢測 41
2.5.1實驗試件製備 41
2.5.2各組試件動態疲勞測試 42
2.5.3各組試件破壞檢測 43
2.6電腦模擬分析及體外實驗比對驗證 44
第三章 結果 47
3.1有限元素靜態模擬分析 47
3.1.1根管治療牙齒/人工植體分析結果比較 47
3.1.2根管治療牙齒/人工植體連結系統分析結果 57
3.2有限元素破裂成長模擬分析與體外實驗 64
3.2.1有限元素破裂成長模擬分析 64
3.2.2體外實驗 65
3.2.3電腦模擬分析與體外實驗結果比較 70
第四章 討論 71
4.1 電腦模擬分析結果討論 71
4.1.1 靜態模擬分析 71
4.1.2黏著層之破裂成長模擬分析 73
4-2動態疲勞破壞實驗 74
4.3研究限制與未來方向 74
第五章結論 77
參考文獻 79

表目錄
表一、有限元素材料特性 36
表二、有限元素分析參數及組數 37
表三、根管治療牙齒端與人工植體端之補綴物位移量及位移比 49
表四、根管治療牙齒/人工植體連結與未連結系統之各部位應力值　51

圖目錄
圖 1-1 牙齒構造圖 4
圖1-2 根管治療過程：(A)牙髓受創；(B)開口製備；(C)根管清創修形；(D)牙冠補綴 4
圖1-3根柱冠心 5
圖1-4圍箍設計 5
圖1-5圍箍作用：(A)抵抗咬合造成之槓桿力量；(B)抵抗根柱置入造成之楔形作用及側向力量 6
圖1-6牙根及根柱受力因彎曲度不同造成應力集中 6
圖1-8各類人工植體系統 10
圖1-7人工植體與自然牙 10
圖1-9根管治療牙齒/人工植體連結系統 14
圖1-10有限元素分析流程 14
圖2-1 研究流程圖 23
圖2-2試件製備：(A)完整小臼齒蒐集；(B)小臼齒定位包埋；(C)小臼齒根管修形；(D)補綴物鑄造黏著 27
圖2-3 MICRO-CT掃瞄儀器：SKYSCAN 1076 27
圖2-4小臼齒影像掃瞄重組及輪廓擷取：(A)MICRO-CT影像；(B)影像輪廓擷取；(C)影像重組平滑化；(D)輪廓資料規劃擷取 28
圖2-5植體系統三維 CAD模型建構：(A) 植體MICRO-CT影像掃描及尺寸量測；(B) PRIMA IMPLANT；(C) ITI IMPLANT；(D) FRIALIT-2 IMPLANT 28
圖2-6 (A)根管治療牙齒/人工植體連結系統之有限元素模型及不同人工植體系統；(B) 根管治療牙齒/人工植體牙冠無連結之有限元素模型 31
圖2-7 根管治療牙齒/人工植體連結系統剖面及組成元件 32
圖2-8 根管治療牙齒/人工植體有限元素模型網格化 33
圖2-9植體內部元件接觸部份：(A) FRIALIT-2系統：接觸部分介於支台、螺絲及植體兩兩之間；(B) ITI系統：接觸部份介於支台與植體之間。 38
圖2-10 有限元素模型負載與邊界條件：(A)負載方式；(B)邊界條件　　38
圖2-11 (A)材料破裂成長模擬程式界面；(B)材料破壞模擬程式疊代運算流程圖 40
圖2-12 疲勞試驗儀器/試件架設圖 45
圖2-13試件切片染色過程：(A)試件染色；(B)二次包埋；(C) 試件切片觀察 46
圖3-1、根管治療牙齒與人工植體連結/未連結系統之位移比直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 　　　　　50
圖3-2、根管治療牙齒與人工植體連結/未連結系統之牙本質應力直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 52
圖3-3、根管治療牙齒與人工植體連結/未連結系統之根柱冠心應力直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 53
圖3-4、根管治療牙齒與人工植體連結/未連結系統之人工植體應力直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 54
圖3-5、根管治療牙齒與人工植體連結/未連結系統之下顎骨應力直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 55
圖3-6、根管治療牙齒與人工植體連結/未連結系統之黏著層應力直方圖：(A) ITI；(B) PRIMA；(C) FRIALIT-2 56
圖3-7、根管治療牙齒連結不同植體在不同負載下之各材料之應力直方圖：(A)牙本質；(B)根柱冠心；(C)人工植體；(D)週邊骨質；(E)黏著層。 59
圖3-8、根管治療牙齒/人工植體連結系統之牙本質、根柱、下顎骨及黏著層之應力分佈圖：(A)牙本質及根柱冠心；(B)下顎骨；(C)黏著層 60
圖3-9、根管治療牙齒連結ITI 植體系統應力分佈：(A)整體系統剖面圖；(B)植體應力分佈圖；(C)補綴物及植體週邊骨質應力分佈圖。 61
圖3-12、負載為OTOI時，黏著層破裂成長模擬迭代結果 66
圖3-13、負載為OT時，黏著層破裂成長模擬迭代結果 67
圖3-14、負載為AT時，黏著層破裂成長模擬迭代結果 68
圖3-15、利用光學顯微鏡觀察根管治療牙齒/人工植體連結系統之黏著層介面破裂及染劑滲漏情況：(A)根管治療牙齒補綴物/剩餘齒質之微滲漏；(B)植體之補綴物/支台介面微滲漏。 69

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