StomaTeam > Články > Protetika > Intraorální opravy sklokeramických náhrad

Intraorální opravy sklokeramických náhrad

27. 6. 2023 | Prof. Dr. Jürgen Manhart, Mnichov (Německo)

Materiálová věda a klinický postup

Intraorální opravy malých a snadno dostupných defektů sklokeramických náhrad nabyly v posledních letech ve stomatologii na značném významu. Oproti kompletní výměně náhrady má její oprava pomocí kompozitních materiálů tu výhodu, že lze zpravidla zachovat velké, dosud neporušené části původní náhrady a není nutno více narušit tvrdé zubní tkáně a zvyšovat riziko pro dřeň u vitálních zubů. V porovnání s kompletní výměnou náhrady jsou intraorální opravy zpravidla jednodušší, ekonomičtější a mnohem rychlejší – lze je provést během jedné návštěvy pacienta.

Úvod

Keramické náhrady
Keramické, respektive celokeramické náhrady mají řadu výhod, jako jsou příznivé optické vlastnosti v kombinaci s vynikající estetikou, dobrá odolnost proti opotřebení a barevná stálost, inertní chemické chování a z toho vyplývající vysoká biokompatibilita i možnost opětovné stabilizace oslabené struktury zubu díky adhezivní fixaci, díky kterým si za posledních 30 let získaly velkou oblibu jak u lékařů, tak u pacientů [1–14]. Mnoho pacientů navíc vyjadřuje touhu po estetických náhradách v barvě zubů a nekovových alternativách k tradičním protetickým postupům [15].

Keramika je podle definice nekovový, anorganický materiál [16]. Keramiku používanou v rekonstrukční stomatologii lze podle složení a struktury rozdělit do následujících skupin [17–18]:

Silikátová keramika (živcová keramika a sklokeramika, přírodní nebo synteticky vyráběná živcová skelná matrix se zapuštěnými krystaly leucitu nebo lithium disilikátu).
Oxidová keramika infiltrovaná sklem (porézní báze většinou z Al₂O₃ infiltrovaná skelnou fází).
Polykrystalická oxidová keramika (Al₂O₃ nebo ZrO₂bez skelné fáze).

Mezi nejčastější klinické indikace celokeramických náhrad patří inleje, onleje, částečné korunky, monolitické korunky, můstky a fazety – významnými se také stávají distálníokluzní fazety (table tops) [17, 19–31]. Celokeramické náhrady dosáhly velmi vysokého standardu kvality a staly se nepostradatelnými pro moderní rekonstrukční stomatologii, a to jak v esteticky náročné frontální oblasti, tak v laterální oblasti chrupu, která nese okluzní zátěž. Vědecká literatura dokumentuje vysokou úroveň spolehlivosti a vynikající klinické údaje o funkčnosti celokeramických náhrad, pokud je na začátku léčby stanovena správná indikace a jsou zohledněna omezení materiálu nebo pacienta a je z různých dostupných typů keramiky zvolen správný materiál pro konkrétní případ. Kromě bezchybného výrobního procesu náhrady by měla být použita precizní preparace proteticky ošetřovaného zubu a vhodná technika upevnění náhrady [15, 28, 32–51]:

Poškození související s frakturami
Přes své příznivé vlastnosti mohou celokeramické náhrady samozřejmě selhat, a to kdykoli během klinického období používání v důsledku biologických (např. sekundární kaz, endodontické nebo parodontologické problémy) a mechanických či technických příčin (např. odštípnutí či kompletní fraktura keramiky, fraktura ošetřovaného zubu, ztráta retence náhrady) [52]. Selhání v důsledku fraktur (úplné fraktury a tříštivé fraktury) se staly v posledních letech významným problémem vzhledem k velké a stále rostoucí oblibě a širokému uplatnění celokeramických náhrad ve stomatologii [53]. Ve srovnání s kovovými náhradami jsou slabinami keramických náhrad křehkost, relativně nízká pevnost v tahu a potenciální problém tvorby a šíření trhlin v keramických materiálech [11, 28]. Tyto faktory ohrožují integritu keramických materiálů za klinických podmínek, zejména pokud dojde k chybám při výrobě náhrad nebo k nesprávné indikaci [54]. Jako hlavní příčiny katastrofálního selhání keramických náhrad jsou uváděny chyby v technologickém procesu jejich výroby a strukturální vady (póry, cizí inkluze, trhliny atd.) v mikrostruktuře keramiky [55–57].

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Díky těmto defektům, které jsou kritické pro maximální dosažitelnou pevnost keramiky, dochází ke zvýšení napětí v materiálu vlivem vnějšího zatížení s nestabilním růstem trhlin vedoucím ke křehkému lomu keramiky [58].

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