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研究生：	陳怡鈞 Chen, I-Chun
論文名稱：	可調控式高溫刺激移除骨整合植體的創新治療技術 Develop a novel technique to remove osseointegrated implants by controlled high temperature
指導教授：	袁國 Yuan, Kuo 李澤民 Lee, Tzer-Min
學位類別：	碩士 Master
系所名稱：	醫學院 - 口腔醫學研究所 Institute of Oral Medicine
論文出版年：	2017
畢業學年度：	105
語文別：	英文
論文頁數：	63
中文關鍵詞：	失敗植體、移除植體、熱刺激、迷你豬
外文關鍵詞：	failed dental implant, implant explantation, heat stimuli, mini-pig
相關次數：	點閱：117 下載：0
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近年來隨著牙科植體的普及,雖然回顧文獻植牙的成功率大多在九成以上, 卻延伸出許多併發症和失敗案例,成為牙醫師需要面對的重大課題。現階段移除骨整合失敗植體的方式大多為使用高反轉扭力套件逆轉植體或環形鋸切削植體周邊骨頭,然而對於已良好骨整合之植體,常導致執行困難且傷害較多周圍組織。文獻中指出當骨頭達到攝氏 47 度時,持續 1 至 5 分鐘,會使骨組織受到不可逆的破壞 ; 當溫度到達攝氏 53 至 70 度時,骨頭中的鹼性磷酸酶產生變性,造成骨頭缺血並且影響修復再生能力。而文獻病例報告中,曾運用電刀產生熱能傳導至植體破壞植體骨頭介面,促進失敗的植體移除。
因此我們運用蘭嶼迷你豬模式,以可調控式高溫和低溫刺激造成植體周遭骨頭微發炎變性的方式來促進骨整合植體移除。首先建立有限元分析模型,模擬植體在骨頭裡的熱傳導情形。另外在體外將植體植入新鮮豬下顎骨,分別以攝氏 55 和 100 度加熱,並且以熱電偶紀錄植體表面溫度的分佈與有限元素分析的結果相對照 ; 進一步於蘭嶼迷你豬進行活體實驗,在拔除第一小臼齒、第二乳臼齒、第三乳臼齒後一個月,植入 12 支鈦金屬植體,分成(1)控制組-無熱處理(2)實驗組-低溫加熱組: 55 度(3)實驗組-高溫加熱組: 100 度。等待兩個月後,
I
隨機分別以攝氏 55 和 100 度刺激,三天後犧牲。以反轉扭力測試、電子顯微鏡觀察植體表面型態和蘇木素-伊紅做組織學染色做觀察。
結果由放射線影像中可看到有九支植體植在未萌發牙胚上導致骨整合失敗。在平均反轉扭力值結果分別為控制組:18.25 牛頓- 公分; 攝氏 55 度: 11 牛頓 - 公分; 攝氏 100 度: 95 牛頓- 公分,並無因熱刺激造成植體骨頭介面破壞而降低,推測結果與植牙區骨整合與否較有相關。在電子顯微鏡下,低溫加熱組可觀察到殘餘骨塊於植體根尖處,而高溫加熱組則呈現部分植體表面毀損變形。組織學巨觀下可見攝氏 55 度組別頸部和 100 度整隻植體周圍骨頭有充血情形, 並藉由微觀切片觀察到 100 度組別比較 55 度組別有較明顯發炎細胞浸潤和骨頭細胞變化情形。而未來應建立得以達到良好植體區塊模型,繼續探討不同溫度對於骨頭刺激的反應和觀察相對應骨頭癒合情形。

In daily dental practice, greater use of dental implants is associated with increased number of complications and failures. Up to date, techniques of high reverse torque and trephine for bone removal around implants are utilized mostly in dealing with failed implants. However, it is a difficult task and may be a relatively traumatic procedure. The literatures indicated that heating up to 47 oC could be considered as the optimal limit that bone can withstand without necrosis and temperatures ranging from 56°C to 70°C is deleterious to bone tissue since alkaline phosphatase (AP) is denatured at that level. Besides, heat induced localized thermal necrosis for weakening the bone/implant interface by application of an ultrahigh frequency electrosurgical device was reported in some clinical cases. Therefore, we proposed that controlled high temperature may induce mild thermal stimuli to the peri-implant bone which poses mild inflammation and denaturation of collagen matrix in a porcine model for facilitating failed implants removal.
Initially, a thermal simulation model with a finite element method (FEM) was constructed to evaluate thermal distribution throughout the implant/bone interface. Additionally, titanium dental implants were installed in fresh porcine specimens and heat treated at 55°C and 100°C respectively. The temperature was monitored by the thermocouples. Later, In vivo study, bilateral deciduous mandibular molars and permanent first premolar were extracted from two mini pigs following 1-month healing. 12 titanium implants were inserted and left to heal for another 2 months. The study was divided into three different groups. (1) control group—no heat application. (2) test group—LH: low heat application (55°C). (3) test group—HH: high heat application (100°C). Heating was
III
performed randomly through the implant healing abutments. The mini pigs were euthanized 3 days later. Radiographic analysis, removal torque value (RTV) measurement, implant surface topography evaluation by scanning electron microscope (SEM) and histologic analysis were evaluated.
In finite element simulation, the outer surface of implant from LH and HH group were gradually heated to 53°C and 94°C respectively. Because of the adiabatic effect and the heat was given from the top of the implant, the heat was transferred much further over the cervical part than the apical part. In vitro study, the results shows that the 55°C group generated maximum temperatures of 53~57°C at the cervical part of the implants, while the 100°C group yielded 93~96°C. From the radiographic films, nine implants were inserted on the erupting tooth bud. Mean reverse torque value measurements were control: 18.25 Ncm; 50°C: 11 Ncm; 100°C: 95Ncm which were more relevant to the condition of predetermined implant site. Hyperemia of peri-implant bone over cervical 3rd in LH group and throughout the entire implant in HH group were observed in gross view. In histologic analysis, infiltration of inflammatory cells and osteogenic cells changes in microscale were more pronounce in HH group than LH group. Bone remodeling and healing process of heat treated bones with various heat stimuli should be further investigated in the future study.

中文摘要	I
Abstract	III
致謝	V
Contents	VI
Table contents	IX
Figure contents	X
Abbreviations	XII
Chapter 1.	Introduction	1
     1.1    Background	1
       1.1.1	Failed Dental Implants	1
       1.1.2	Removal Techniques for Failed Dental Implants	2
       1.1.3	Reaction of Bone to Thermal Stimuli	3
       1.1.4	Finite Element Method (FEM)	5
       1.1.5	Animal Selection	6
      1.2   Motivation	8
      1.3   Objective/ Aim	9
Chapter 2.	Materials and Methods	10
2.1	The Experimental Reagent	10
2.2	The Experimental Instrument	11
2.3	The Heating Element	12
2.4	Finite Element Simulation of Bone Temperatures for Heat Stimuli	12
 2.4.1	Physical and Thermal Properties of Materials	12
 2.4.2	Finite Elment Model	13
2.5	In Vitro Bone Specimen (Pig Mandible) Temperature Evaluation	15
 2.5.1	Experimental Design	15
 2.5.2	Experimental Procedure	15
2.6	Animals Study	16
 2.6.1	Animals and Anesthesia	16
 2.6.2	Surgical Procedure	17
2.7	Radiographic Analysis	18
2.8	Specimen Preparation	18
2.9	Removal Torque Value Measurement	19
2.10	Implant Topographic Observation	19
2.11	Histological Analysis	20
2.11.1 Materials	20
 2.11.2 Methods	20
Chapter 3.	Results	22
3.1	Finite Element Analysis	22
3.2	Temperature Evaluation of Bone Specimen (Pig Mandible)	22
3.3	Clinical Findings	23
3.4	Radiographic Analysis	23
3.5	Removal Torque Measurement	24
3.6	Topographic Observation	24
3.7	Gross View Analysis	25
3.8	Histologic Analysis	26
Chapter 4.	Discussion	27
4.1	Study Design	27
 4.1.1	Design of the Heating Element	27
 4.1.2	Temperature Monitoring Method	27
 4.1.3	Animal Experiment-Age and Dentition	28
 4.1.4	Healing Time and Osseointegration	30
4.2	Finite Element Analysis	33
4.3	Removal Torque Test	34
4.4	Histologic Analysis	35
Chapter 5.	Conclusion	38
Chapter 6.	References	39
Table 1.  Group Distribution and Denomination	45
Figure 1. Study Flow Chart.	46
Figure 2. Study Time Table <In Vivo Study>.	47
Figure 3. The Heating Element.	48
Figure 4. FEM Model Set Up.	49
Figure 5. In Vitro Bone Specimen (Pig Mandible) Temperature Evaluation.	50
Figure 6. Surgical Procedures: Extraction.	51
Figure 7. Surgical Procedures: Implants Insertion. 	52
Figure 8. Surgical Procedures: Omplants 2nd Stage and Heat Application.	53
Figure 9. Specimens After Sacrifice.	54
Figure 10. Removal Torque Measurement.	55
Figure 11. The Simulation of Temperature to Time.	56
Figure 12. In Vitro Experiment: Temperature Evaluation of Bone Specimen.	57
Figure 13. Radiogram.	58
Figure 14. Removal Torque Value.	59
Figure 15. Surface Topography Observed by SEM.	60
Figure 16. Results of Energy Dispersive Spectrometer.	61
Figure 17. Gross View Analysis.	62
Figure 18. Histological Analysis.	63

                                    

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