症例　１９） 4部分欠損症への即時荷重６年後の報告 下顎遊離端６歯欠損ポステリアバイトコラプスに対しての治療報告 KIRG4期生　松元　教貢 目的 現在即時荷重は、下顎無歯顎前歯部のみにエビデンスが認められ、単独や部分欠損では得られていない。　　今回、下顎右側遊離端欠損６本連続に対し即時荷重を行い、６年経過したので報告を行う。 症例の概要 初診時50歳女性。下顎右側残存歯が揺れ、義歯を嫌い、インプラントを希望。全顎的に歯が動揺、臼歯部咬合支持が失われ、前歯も(＋＋)の動揺を示す。患者は前歯部の動揺に強い不安を抱き、早期のインプラントを希望。医療面接の結果、前例のない事を承知の上、下顎右側は抜歯し、４週後インプラント植立し、即時に暫間ブリッジを入れられたら入ると計画し、同意を得る。 治療内容 臼歯部咬合支持を失い、その為全顎的に動揺が生じ、このままでは完全なすれ違い咬合となり、更に治療が困難を極めると診断、説明。同意を得て、同日同部位歯牙抜歯即時義歯を装着。残存歯はスーパーボンドで強固に固定、咬合調整を精密に行う。が、義歯への嫌悪感強く、軟組織治癒後すぐに植立する事に決定。残存歯の歯周初期治療を徹底、４週後植立手術を行う。歯槽頂切開で全層弁形成し、植立。骨欠損部はホール形成で得た骨?、皮質骨削合で得た自家骨にHAを混ぜて充填。メンブレン等は行わない。即時にソリッドヘッドを35Nで装着、ステント兼用暫間ブリッジをマージン調整し、松風テンポラリーハードにて装着。減張切開を加えながら、創を完全閉鎖。全顎的咬合調整を精密に行う。その後、他部位の治療を進めた。常に歯肉と咬合のコントロールを細心に配慮する。手術後８ヶ月経過、全顎最終補綴に着手。同部位は良好なオッセオインテグレーションを示す。セラモメタルブリッジをセメント合着する。 経過と考察 全顎補綴は初診後１年で終了。翌週より、ナイトガードを使用させる。臼歯部咬合支持が確立、メインテナンスで経過を追うが、同部位を始め、全顎的に現在に到るまで、特に問題は生じていない。が、左側犬歯の根露出が気になるとの事で、被覆術を４年後に追加した。即時荷重は、初期固定35N以上で強固に得られた後、インプラント体に歪み応力を与えないソリッドヘッドと暫間補綴で行い、更に常に歯肉と咬合のコントロールが精密に行われるなら、充分可能であると考える。逆に硬軟組織の再生も非常に良好なのは、咬合支持が暫間補綴で得られるので、両組織の安静が保たれる為と考えている。 結論 インプラントの要望の最も多い部分欠損に対し、即時荷重が可能となる事は非常に良い事と考える。35N以上の初期固定、歯肉咬合のコントロールが鍵であると考えている。その後、200症例を超え、手術手技も改良進化し、更なる良好な結果を得られている事からも、即時荷重は充分可能と考えている。 Immediate Implant Loading in the Partial Edentulous Region:37 Cases Report Since 2000. Dr.Noritsugu Matsumoto 2F Inoue Bldg. 3-18-3 Sannou Ohtaku Tokyo 143-0023 Japan. Tel&Fax : t81(0)3-3775-0044 Email : kmdental21-genmatsumoto@yahoo.co.jp Purpose : One remaining problem of implant treatment is the immediate loading in the partial edentulous region. This report evaluates the implant success rate, peri-implant tissue response, and esthetic outcome of immediately load mandibulary partial edentulous region, anterior to posterior. And the protocols are proposed. Materials and Methods :27 patients(7 men , 20 women ) an average age of 64 years old (range 37 to 74 ) were included in this study. Posterior : 76 implants. 　　Anterior : 10 implants. The most cases are three teeth lost including removed teeth simultaneously and some implants loaded. Total 37 cases by ITI SLA implant and solid head abutment. Initial preparation of periodontics had been done completely. Implant placement surgery, including of illness teeth removed, and loading. Provisional restorations were cemented on the abutments. After two months, the osseointegration was investigated each implant. Then the final restorations were placed. The patients were evaluated clinically and radiographicaly at implant placement, at 2.6. and 12 months. Evaluation : (1) Inflammation of the gingiva (2) Radiographics (3) PeriotestR+5> Excellent : All conditions were satisfactory. Good : Two conditions were satisfactory. Fair :One conditions were satisfactory Poor : Lost and re-operation. One year after surgery, all implants were evaluated. Results : 98.8% implants remained osseointegration at two months. 12 months after surgery as follow. Excellent : 77 implants. 89.53% (70 post. 7ante ) Good : 4 implants. 4.65% ( 2 post. 2ante ) Fair : 4 implants . 4.65% ( 3 post. 1ante ) Poor : 1 implants. 1.16% ( post. ) The "Good" group showed recession of gingiva. The "Fair" group showed recession both the bone and the gingiva. A rough surface seemed to stop bone recession. The "Poor" was lost because of the inflammation of the gingiva and replaced with new implant. All patients were satisfied with this treatment. Discussion and Conclusion : Although both the bone and the gingival minor alternation continued for one year, the alternation did not progress. Immediate implant loading in the partial edentulous region is the good method, for the patients who had lost both the function and the esthetic teeth. High surgical techniques and sophisticated prosthetic treatment are key issue for the successful outcome. Anatomical diagnosis, implant designs and prosthetic plans are very important. The protocols were proposed, as follows. (1) Insertion 35N over (2) Long and Wide implants (3) One more placement implant (4) Solid abutment and cemented (5) Strong provisional restorations. (6) Each implant parallel (7) Minimum movement controlled : PeriotestR+5> (8) Occlusal correction carefully 4 weeks after surgery. (9) PMTC any time. (10) Wait for enough days before the final restorations. Pre-operation Panoramic radiographic photograph. The partial dentures could not be used for this patient .18.20.21.23 teeth were removed gently the day. 4 weeks after the Extraction of teeth. Soft tissue were healed completely. Implants placement surgery on the both right and left sites. Left sites tooth removed simultaneously. Implants were placed on 18.19.21.22 sites Each implants stands as parallel as possible. This is the key tissue of the immediate loading implant treatment. Provisional restorations were placed on the solid abutments with temporary cements. Soft tissue had be closed tenderly. Minor bone grafts had been performed under the pedicle flap around implants. Right sites immediate loading implants and left site immediate placement implants. This shows the gaining posterior support on right site mandibular and maxilla anterior teeth were reduced occlusal influence. 3.5 years have gone in this radiographic photograph. Please look at carefully, There is no recession in the bone level. On the contrary, the bone quantity has increased on right site implants. This photograph shows the final restorations on the day. There is no inflammation on the soft and hard tissue around the implants. Patient was satisfied with this treatment very much 2.5 years have gone in this photograph. There is no alteration on the right mandibular and the final restorations. Same-day up radiographic. Please compare neighboring photograph.