牙周炎是我国成年人失牙的主要原因。种植治疗近年来逐步发展成为牙列缺损后的一种常规修复方法。上颌磨牙邻近上颌窦，牙周炎患牙拔除前牙槽骨已有严重 、不规则的吸收，加上牙槽窝在自然愈合过程中牙槽骨的高度及宽度均会发生不同程度的降低，因此常无法满足种植所需的骨组织条件。针对无法保留需要拔除的牙周炎上颌磨牙在拔牙后如何实现 剩余牙槽嵴的保存及牙槽窝的重建成为目前的研究热点。牙槽嵴保存即在拔牙同期进行拔牙窝内生物材料移植、支撑和充填牙槽窝，以阻断或减缓牙槽嵴吸收，实现软硬组织保存或增量的手术。
本研究的目的包括：
1.探讨针对罹患重度牙周炎上颌磨牙，通过彻底清创、微创拔牙后，微翻瓣和应用去蛋白牛骨基质颗粒及可吸收膜、胶原蛋白海绵覆盖拔牙创牙槽嵴保存术后，软硬组织变化以及种植时需要骨增量手术的比例。
2.探讨罹患重度牙周炎上颌磨牙牙槽嵴保存术后不同愈合时间骨组织形态学特点及相关因素分析。
3.通过临床及影像学指标评价罹患重度牙周炎上颌磨牙拔牙牙槽嵴保存与自然愈合后实施种植修复 1-4 年种植体存留率、成功率、种植体周软组织情况以及边缘骨水平变化。
围绕上述研究目标，采用临床回顾性研究，通过临床检查与影像学评价罹患重度牙周炎上颌磨牙牙槽嵴保存后软硬组织变化，以及后续种植治疗及修复负重 1-4 年后临床疗效。此外，通过骨组织切片的组织学和形态计量学分析牙槽嵴保存愈合后骨组织形态学特点。
通过以上研究，可以得出以下结果和结论：
1.罹患重度牙周炎无法保留的上颌磨牙拔牙牙槽嵴保存后，可以改善该部位牙槽嵴骨高度、骨宽度及牙槽窝体积，从而减少 自然愈 合后种植治疗阶段进行骨增量手术的比例，减少种植治疗阶段的创伤性和复杂性。
2.罹患重度牙周炎上颌磨牙拔除后应用去蛋白牛骨基质颗粒及可吸收膜 、胶原蛋白海绵覆盖拔牙创牙槽嵴保存后愈合 6 个月，骨组织切片形态计量学结果显示新生骨、残留的去蛋白牛骨基质颗粒与结缔组织大约各占 1/ 3 ，约一半的去蛋白牛骨基质颗粒与新生骨组织直接接触。
3.罹患重度牙周炎的上颌磨牙拔牙牙槽嵴保存术 经 过 6 个月的愈合时间 ，新生骨百分比、残留去蛋白牛骨基质颗粒百分比和去蛋白牛骨基质颗粒与新生骨接触周长百分比 与患者年龄、性别、牙位（第一磨牙或第二磨牙）、拔牙窝愈合时间 、种植体初期稳定性系数和骨质无显著相关关系。
4.罹患重度牙周炎上颌磨牙拔牙牙槽嵴保存术后实施种植修复并负重 1-4 年时种植体存留率、成功率、种植体周软组织健康状况和种植体周边缘骨丧失结果与自然愈合类似。
5. 在罹患重度牙周炎上颌磨牙拔除后行 牙槽嵴保存术，在种植修复观察期内效果肯定，是一种可靠的骨增量方式。
上述结论为深入开展罹患重度牙周炎上颌磨牙区拔牙牙槽嵴保存术及后续种植治疗的推广应用提供了临床和影像学证据及一定的生物学基础，对于未来牙周病的治疗设计和牙周病患者的种植 治疗，具有 十分重要的临床参考价值。

Periodontitis is the main cause of tooth loss in Chinese adults. In recent years, implant therapy has gradually developed into a routine restoration method after dentition defect. Maxillary molars are adjacent to maxillary sinus The alveolar bone has been seriously and irregularly absorbed before the extraction due to severe periodontitis. In addition, the height and width of the alveolar bone will decrease to varying degrees during the natural healing process of the alveolar socket. Thus it is often unable to meet the bone tissue conditions required for implantation. How to preserve the remaining alveolar ridge and reconstruct the
alveolar socket after tooth extraction have become an important topic of research. Ridge preservation was defined as any procedures that takes place immediately after tooth extraction to preserve or increase ridge volume within or beyond the skeletal envelope that exists at the time of extraction.
The objectives of this retrospective human clinical study were to investigate the changes of soft and hard tis sues of maxillary molars suffering from severe periodontitis after thorough debridement, minimally invasive tooth extraction, microflap, application of deproteinized bovine bone mineral particles, absorbable membrane and collagen sponge to cover the tooth extraction wound, and the proportion of bone augmentation surgery during implantation. Secondly, this study aimed to explore the histomorphometric characteristics and related factors of bone tissue at different healing time after alveolar ridge preservation.
Thirdly, this study aimed to evaluate the survive rate, success rate, soft tissue conditions and marginal bone level changes of implants following alveolar ridge preservation at maxillary molars extraction sockets with severe periodontitis, compared to natural healing.
Focusing on the above research objectives, this retrospective study evaluated the changes of soft and hard tissues of maxillary molars with severe periodontitis after alveolar ridge preservation, as well as the clinical efficacy of subsequent implant treatment and
restoration with 1-4 years follow up. In addition, histological biopsies were evaluated in terms of histological and histomorphometric outcomes.
Within the limitation of this study, we can draw the following conclusions:
1. Alveolar ridge preservation of maxillary molars suffering from severe periodontitis can improve the height, width and volume of alveolar ridge, thus reducing the proportion of bone augmentation surgery and the trauma and complexity of implant treatment, compared to natural healing.
2. Histomorphometric results of bone core samples showed that new bone, residual deproteinized bovine bone mineral particles and connective tissue a ccounted for about 1/3 each, and about half of residual deproteinized bovine bone mineral particles were in contact with new bone tissue directly.
3. After 6 months' healing time, the percentage of new bone, the percentage of residual deproteinized bovine bone mineral particles and the percentage of contact between deproteinized bovine bone mineral particles and new bone have stabilized, which
was not affected by the patient's age, sex, tooth position (first molar or second molar) and healing time, and didn't affect the initial stability quotient and bone quality in the subsequent implant treatment.
4. The survival rate, success rate, soft tissue conditions and marginal bone loss of implants following alveolar ridge preservation at maxillary molars extraction sockets with severe periodontitis were similar to those of natural healing.
5. Preservation of alveolar ridge after extraction of maxillary molars with severe periodontitis is a reliable way of bone augmentation.
The above conclusions provide clinical and imaging evidences and a certain biological basis for the promotion and application of alveolar ridge preservation and subsequent implant therapy in maxillary molars extraction sockets with severe periodontitis, and have a very important clinical reference value for the treatment plan and implant therapy for patients with severe periodontitis.

第一章 文献综述 1
1.1 磨牙拔牙牙槽嵴保存的效果评价及影响因素 1
1.1.1 磨牙拔牙窝自然愈合后形态学改变 1
1.1.2 磨牙拔牙牙槽嵴保存的效果评价 3
1.1.3 拔牙窝愈合和牙槽嵴保存效果的影响因素 9
1.2 磨牙拔牙牙槽嵴保存应用去蛋白牛骨基质的组织学与免疫组织化学研究 10
1.2.1 组织学研究 11
1.2.2 免疫组织化学研究 13
1.3 磨牙拔牙牙槽嵴保存后种植修复效果评价 18
1.3.1 种植修复效果评价指标 18
1.3.2 磨牙拔牙牙槽嵴保存后种植修复效果研究进展 19
1.4 总结 21
第二章 引言 22
第三章 罹患重度牙周炎上颌磨牙拔牙牙槽嵴保存效果评价 24
3.1 研究目的 24
3.2 材料与方法 24
3.2.1 研究对象 25
3.2.2 分组 25
3.2.3 个人基本情况及临床记录指标 26
3.2.4 影像学检查 27
3.2.5 统计分析 29
3.3 结果 30
3.3.1 研究对象基本情况 30
3.3.2 自然愈合组和牙槽嵴保存组愈合后牙槽骨高度及宽度的变化 31
3.3.3 自然愈合组和牙槽嵴保存组上颌窦底气化情况 31
3.3.4 自然愈合组和牙槽嵴保存组愈合后牙槽骨体积的变化 32
3.3.5 自然愈合组和牙槽嵴保存组颊侧角化组织宽度变化 33
3.3.6 自然愈合组和牙槽嵴保存组种植阶段骨增量手术比例 33
3.3.7 自然愈合组和牙槽嵴保存组颊腭侧骨壁高度变化值的相关因素分析 34
3.4 讨论 37
3.5 结论 38
第四章 罹患重度牙周炎上颌磨牙拔牙牙槽嵴保存组织学 研究 39
4.1 研究目的 40
4.2 材料与方法 40
4.2.1 主要仪器设备 40
4.2.2 主要试剂材料 40
4.2.3 研究对象 41
4.2.4 骨组织样本留取 41
4.2.5 种植手术记录指标 41
4.2.6 骨组织样本脱钙冲洗 包埋切片 42
4.2.7 苏木精伊红染色步骤 42
4.2.8 苏木精伊红染色定性分析 42
4.2.9 苏木精伊红染色形态计量学分析 43
4.2.10 统计分析 43
4.3 结果 43
4.3.1 研究对象基本情况 43
4.3.2 苏木精伊红染色结果定性分析 44
4.3.3 苏木精伊红染色形态计量学分析 45
4.3.4 不同愈合时间的骨形态计 量学结果 46
4.3.5 骨形态计量学结果与患者及种植位点结果的相关关系 46
4.4 讨论 47
4.5 结论 49
第五章 罹患重度牙周炎上颌磨牙拔牙牙槽嵴保存后种植修复效果评价 51
5.1 研究目的 51
5.2 材料方法 52
5.2.1 研究对象 52
5.2.2 种植手术 52
5.2.3 种植 II 期手术及修复 52
5.2.4 随访复查 53
5.2.5 统计分析 54
5.3 结果 55
5.3.1 研究对象基本情况 55
5.3.2 自然愈合组和牙槽嵴保存组种植体临床指标变化 56
5.3.3 自然愈合组和牙槽嵴保存组颊侧角化组织宽度变化 58
5.3.4 自然愈合组和牙槽嵴保存组种植体边缘骨丧失情况 58
5.3.5 自然愈合组和牙槽嵴保存组种植体存留率及成功率 59
5.4 讨论 59
5.5 结论 61
第六章 结论与展望 62
6.1 主要结果与结论 62
6.2 主要创新点 62
6.3 本研究的不足之处 63
6.4 进一步工作设想 63
参考文献 64
致谢 78
北京大学学位论文原创性声明和使用授权说明 79
个人简历、在 学 期 间发 表的 学术论文与研究成果 81

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