遗传性牙龈纤维瘤病牙周-正畸联合治疗1例

2020-07-17 苗磊 李玉超 潘亚萍 中国实用口腔科杂志

遗传性牙龈纤维瘤病(hereditary gingival fibromatosis,HGF)又名家族性或特发性牙龈纤维瘤病,是一种较为罕见的疾病,表现为牙龈组织的广泛纤维增生,其可单独出现或作为综合

遗传性牙龈纤维瘤病(hereditary gingival fibromatosis,HGF)又名家族性或特发性牙龈纤维瘤病,是一种较为罕见的疾病,表现为牙龈组织的广泛纤维增生,其可单独出现或作为综合征的一部分出现。HGF可在幼儿时发病,发生于乳牙萌出后;大多于恒牙萌出后发病,表现为牙龈广泛缓慢增生,可累及全口的龈缘、龈乳头及附着龈,甚至达到膜龈联合处。增生的牙龈可覆盖部分或整个牙冠,其颜色正常、组织坚韧、点彩明显、表面光滑、不易出血,挤压牙齿可导致牙齿移位。

在严重的情况下,牙龈组织可能会覆盖整个牙冠,影响患者美观及咀嚼功能。HGF的病因尚不明确,但其有典型的病理特征,表现为牙龈上皮棘层增厚,上皮钉突明显增长,结缔组织体积增大,细胞外基质蛋白过度聚积,其中Ⅰ型胶原最多,炎症不明显。

HGF可导致患者牙列不齐、恒牙迟萌、发音和咀嚼障碍等,会对患者的美观和心理造成不利影响,长期的牙龈纤维瘤病还会导致牙周疾病。目前该病尚未发现有无损的治疗方法,临床治疗主要以牙龈成形术为主,有复发的可能性。本文报道的1例HGF患者,经牙周-正畸联合治疗后,其牙周组织及牙列获得了良好形态及功能。

1.病例资料

1.1病史与检查

患者男,17岁,于2010-10-08以“全口牙龈肿胀影响进食,牙齿移位,口唇闭合困难及影响美观”为主诉来中国医科大学附属口腔医院牙周病科就诊。患者自述全口牙龈肿胀十年余,且随年龄的增长逐渐加重;现患有白癜风,否认其他全身系统性疾病,无药物长期服用史及过敏史;外祖父牙龈增生明显。

全身检查:全身发育正常,智力正常,心、肺、腹未见明显异常,四肢活动正常,未见指(趾)远端畸形及指(趾)甲发育不全等。口内检查:全口卫生状况一般,软垢指数Ⅰ度,龈上牙石Ⅰ度,可探及少量龈下牙石,增生的牙龈颜色正常、表面光滑、质地较韧。全口上下颌牙龈广泛增生,波及龈乳头、游离龈、附着龈达膜龈联合处,双侧上下颌后牙区牙龈增生达到咬合面。上颌前牙散在间隙,牙列不齐。见图1。


辅助检查:全口曲面断层片示牙槽骨吸收在根长1/3以内,8778近中阻生,4扭转。Florida电子探针检查:可见多处深牙周袋及牙龈增生,牙周探诊出血(bleeding on probing,BOP)阳性;62112366356探诊深度(probingdepth,PD)4~7mm,附着丧失(attachment loss,AL)0~1mm。见图2。


1.2诊断

慢性牙周炎伴HGF;错牙合畸形。

1.3预后判断

根据Ferreira Gon?alves等制定的预后判断标准,患者无根分叉病变及牙齿松动,预后良好。

1.4治疗方案

与患者充分沟通后,制定治疗方案。患者需进行牙周基础治疗、牙周手术治疗、牙周维护治疗和正畸治疗。

1.5治疗过程

1.5.1牙周基础治疗

口腔卫生宣教,指导患者正确使用牙刷、牙线等。分两次实行全口龈上洁治、龈下刮治、根面平整。牙周基础治疗后2周,患者菌斑显示30%,同时强化口腔卫生宣教。

1.5.2牙周手术治疗

牙周基础治疗后1个月,增生的牙龈组织未见明显消退,上颌后牙及下颌行牙龈成形术,去除增生的牙龈组织及大量的肉芽组织。上、下颌牙龈成形术前软组织情况及术后8周恢复情况见图3。

牙龈成形术后3个月4321123牙龈增生,波及龈缘、龈乳头、附着龈,上唇系带附丽低。局麻下对4321123行二次牙龈成形术,上唇系带修整术,术后恢复较好。

1.5.3牙周维护治疗

牙周维护治疗贯穿整个治疗过程。基础治疗后1个月牙周治疗再评估,Florida电子探针检查发现全口牙龈增生状况改善,BOP阳性率降低和PD减少,但上、下颌牙龈增生程度仍较重,考虑行牙龈成形术治疗。基础治疗后3个月复诊,口腔卫生状况一般,软垢Ⅰ度,龈上牙石Ⅰ度,BOP阴性,牙龈色粉红、质韧,龈乳头略增生,全口行超声龈上洁治。

1.5.4正畸治疗

待全口牙龈炎症基本控制、PD<4mm后,患者至正畸科就诊,错牙合畸形表现为安氏Ⅰ类错牙合、牙列拥挤、深覆牙合、深覆盖、左侧锁、上前牙牙轴唇倾、创伤。制定正畸治疗计划为:直丝弓固定矫治,排齐牙列,调整咬合,矫治周期约3年。正畸过程中嘱患者每4~6周至牙周病科复诊,但患者依从性较差,6~9个月复诊1次,复诊时查牙龈未见明显增生,口腔卫生状况一般,对患者进行全口龈上洁治,强化口腔卫生宣教。正畸治疗3年后,去除矫治器,与正畸前对比,患者牙列拥挤、深覆、深覆盖均明显改善,左侧锁纠正,创伤消失。但仍有轻度深覆,中线略不齐,右侧磨牙近中关系,嘱患者佩戴保持器。口腔卫生状况一般,BOP阳性,龈乳头略红肿。见图4。


1.6治疗结果

嘱患者于正畸治疗结束后每3~6个月于牙周病科复诊,但患者未遵医嘱,于正畸治疗结束后2年复诊,查口腔卫生状况一般,牙龈组织状况得到极大改善,牙龈略有增生,牙列较整齐,咬合基本稳定,形态美观,患者获得了极大的自信心。见图5。


行全口超声龈上洁治,继续强化口腔卫生宣教。

2.讨论

牙龈纤维瘤病的病因不明,有的患者有家族史,但也有的患者并无家族史,怀疑为常染色体显性遗传,偶见常染色体隐性遗传。HGF的诊断为牙龈增生的范围达到或超过5颗牙齿,至少覆盖临床牙冠的1/3;有家族史;未服用可诱导牙龈增生的各类药物;未有明显的其他全身性疾病;组织病理学检查符合HGF的特征。

本病例患者属于重度牙龈增生,其诊断时需与其他疾病鉴别:(1)药物性牙龈增生。该病有服药史而无家族史,一般累及龈乳头、游离龈,不波及附着龈。其牙龈增生程度较轻,一般覆盖牙冠1/3,多伴有慢性炎症。(2)以增生为主要表现的慢性龈炎。该病一般不波及附着龈,主要侵犯龈乳头和龈缘,增生程度较轻,一般覆盖牙冠1/3,多伴有慢性炎症,局部刺激因素明显,无长期服药史及家族史。

关于HGF的治疗时机,有学者提倡早期手术,可避免牙列不齐、乳牙滞留、影响美观和咀嚼等问题,并对患儿心理发育有积极作用,但复发率较高。若恒牙萌出后手术,复发率可降低,一部分患者在青春期后牙龈可停止增生。总体来说,HGF应尽早治疗,避免牙齿的移位。术前和术后维护期需严格控制菌斑,减少细菌总量,减少复发。

本病例值得思考之处在于,患者在正畸治疗中及正畸治疗结束后未按时复诊,尤其在正畸治疗结束后2年首次牙周复诊时,口腔卫生状况一般,牙龈略增生,未坚持戴保持器,导致上前牙出现间隙,右上后牙略拥挤,可见依从性对于HGF患者十分重要,需在每次复诊时强化口腔卫生宣教。手术过程中是否需要对增厚的骨质进行修整,目前说法尚未统一,本病例患者治疗后可见牙槽骨骨板较厚,以下前牙区和后牙区为主,修整牙槽骨可能会使治疗效果更加明显,但对牙周炎的良好预后可能也是一个重要的挑战。

原始出处:

苗磊,李玉超,潘亚萍.遗传性牙龈纤维瘤病牙周-正畸联合治疗1例报告[J].中国实用口腔科杂志,2019(08):509-512.
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    2020-07-19 grace5700
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    2020-07-17 wxl882001

    了解一下

    0