糖尿病患者的围手术期治疗华西口腔医学院颌面外科郑谦

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1 南京医科大学口腔医学院 College of Stomatology, Nanjing Medical University 江苏省口腔医院 Jiangsu Province Stomatological Hospital 地址 : 南京市汉中路 136 号邮编 : 电话 : 网址 : Add: No.136, Hanzhong Rd, Nanjing, Jiangsu,, China Tel :

2 儿童牙外伤南京医科大学口腔医学院儿童牙病科梅予锋

3 Dental Trauma in Children Yufeng Mei DDS. PhD. Department of Dentistry for Children School of Stomotology Nanjing medical University

4 外伤? 牙外伤? 一切机械力造成的损伤都称作外伤牙齿外伤 : 是指牙齿受急剧创伤, 特别是打击或撞击所引起的牙体牙髓和牙周组织损伤

5 EPIDEMIOLOGY Dental trauma in childhood and adolescence is common. At 5 years of age 31-40% of boys and 16-30% of girls, and at 12 years of age 12-33% of boys and 4-19% of girls will have suffered some dental trauma. Boys are affected almost twice as often as girls in both the primary and the permanent dentitions.

6 AETIOLOGY Key points: The most accident prone times are between 2 and 4 years for the primary dentition and 7 and 10 years for the permanent dentition.

7 AETIOLOGY Key points: In the primary dentition co-ordination and judgement are incompletely developed and the majority of injuries are due to falls in and around the home as the child becomes more adventurous and explores its surroundings.

8 AETIOLOGY Key points: In the permanent dentition most injuries are caused by falls and collisions while playing and running, although bicycles are a common accessory. The place of injury varies in different countries according to local customs but accidents in the school yard remain common.

9 Anatomical Consideration Dentoalveolar trauma involves many tissues and structures. recognizing the normal configuration of teeth and their supporting tissues is helpful when assessing the effects of trauma, planning corrective treatment and evalution the outcome.

10 Tooth and Peridontium

11 An immature root and Peridontium Around the Apex

12 Classfication (orofacial trauma) Extra-oral soft tissue. Facial Skeleton. Dental tissues and pulp. Periodontal tissue. Alveolar bone. Gingival and oral mucosa.

13 Classfication The WHO Classfication of diseases has been modifided according to Andreasen's recommendation

15 Classfication Enamel Infraction 釉质裂纹 An incomplete fracture of the enamel without an Enamel defect (crack) is called an infraction

16 Classfication Enamel Fracture 单纯釉质折断 An enamel fracture is a small chip of enamel only

17 Classfication Crown fracture without pulpal involvement (enamel dentin fracture) 简单冠折 This type of crown fracture involves only enamel and dentin with no direct pulp exposure

18 Classfication Crown fracture with pulpal involvement (complicated crown fracture) 复杂冠折 This fracture involves enamel,dentin, and direct exposure of the pulp

19 Classfication Crown-root fracture 冠根折断 1. Uncomplicated crown-root fracture 简单冠根折 This fracture involves enamel, dentin, and cementum and may not involve pulpal exposure 2. Complicated crown-root fracture 复杂冠根折 This fracture involves enamel, dentin, and cementum and pulpal exposure

20 Classfication Root fracture 根折 This fracture involves dentin, cementum and pulp. Special attention is required because root fracture and luxation injury may occur simultaneously

21 Classfication Concussion 牙震荡 Concussion is a minor injury of the peridontium with no displacement of the tooth nor mobility

22 Classfication Subluxation 不完全脱位 Subluxation is an injury of the peridontium without displacement of the tooth but with slight mobility. Damage to the blood supply of the pulp and the peridontium is usually minor but pulpal problems occasionally result.

23 Classfication Extrusive Luxation 脱出性脱位 This injury is displacement of the tooth in extrusive direction involving the periodontal suppout and the pulpal blood supply

24 Classfication Lateral Luxation 侧方脱位 The tooth is diaplaced from its long axis, usually with the apical end diaplaced labially and coronal part palatally. The pulpal blood supply is uaually completely severed.

25 Classfication Intrusive luxation 挫入性脱位 This most serious of luxation injuries results in the tooth being displaced apically, lead - ing to a crushing of the neuro -vascular bundle entering the pulp and severe damage to the cementum and periodontitum

26 Classfication Avulsion (Exarticulation) 完全脱位 An avulsed tooth is completely diaplaced from the alveolus with total disruption or the pulpal blood supply.

27 Classfication Soft tissue injury and fracture of alveolar bone Soft tissue injury involves the gingiva, oral mucosa, and lips. Fractures involve the alveoli and the jaw bones

28 Ellis 分类 ElliS 和 Davey 根据牙外伤的不同临床表现和治疗原则于 1970 年提出了以下分类 :

29 1 类轻度牙冠折断 : 牙釉质折断或仅达牙本质表层 2 类中度牙冠折断 : 牙冠折断达牙本质, 未暴露牙髓 3 类重度牙冠折断 : 牙冠折断达牙本质, 伴露髓 I 分类 - 可行直接盖髓治疗 Ⅱ 分类 - 需作活髓切断术治疗 4 类外伤引起牙髓病变, 牙冠可有或无折断 I 分类 - 活髓牙, 牙髓有炎症 Ⅱ 分类 - 由于冠折髓腔开放, 牙髓坏死 Ⅲ 分类 - 无冠折及髓腔开放, 牙髓坏死

30 5 类外伤造成牙齿丧失 Ⅰ 分类 - 可直接修复缺失牙 Ⅱ 分类 - 用正畸方法移动邻牙后修复缺失牙 6 类牙根折断伴有冠折或单纯根折 7 类牙齿移位 : 不伴有冠根折 I 分类 - 局部轻度移位 Ⅱ 分类 - 局部严重移位 Ⅲ 分类 - 牙完全脱出 8 类牙冠完全折断及其修复

31 李宏毅牙外伤分类牙齿震荡 (tooth concussion ) ( 牙周损伤牙髓损伤牙体损伤) 牙齿折断 (tooth fracture ) 牙冠折断 (tooth crown fracture ) 牙根折断 (tooth root fracture ) 冠根折断 (tooth crown-root fracture ) 牙齿移位 (tooth displacement ) 牙齿挫入 (tooth intrusion ) 牙齿侧向移位 (tooth lateral luxation ) 牙齿部分脱出 (tooth partial extrusion ) 牙齿完全脱出 (tooth total extrusion )

32 诊断与治疗 Diganosis and Treatment

33 牙齿外伤, 无论伤势轻重, 都会造成牙周和牙髓组织的损伤通常牙髓的损伤是首先要考虑的问题牙髓或牙周损伤能否恢复正常, 取决于诊断是否正确, 治疗是否及时, 措施是否恰当由于儿童是处于生长发育期, 牙髓牙周和牙槽骨组织在解剖生理学上与成年人有一定的差异, 因此, 在治疗方法的选择上, 以及治疗的预后等方面与成人有一定的区别

34 一检查 EXAMINATION

35 ( 一 ) 外伤史 HISTORY 对于因牙外伤来就诊的患儿详细询问病史是非常重要的, 应向患儿及家长或陪伴来院者详细了解患儿的年龄性别外伤的原因受伤的时间受伤的地点受伤的状况等同时询问受伤后的经过做过何种处理及既往史, 并确认全身状态, 还要了解并记录患儿有无自发痛冷热刺激痛咀嚼痛等自觉症状

36 ( 二 ) 临床检查 EXAMINATION 1. 视诊 : 患牙有无折断, 如有折断, 应确认折断部位范围有无露髓探诊有无反应牙齿是否变色以及牙齿有无位置变化, 应检查口腔软组织的损伤程度和范围, 有无口腔周围颜面头部的损伤, 周围软组织出血或肿胀等情况, 还应特别注意患儿咬合状态和咀嚼功能情况 2. 触诊和叩诊 : 先通过触诊了解牙齿移位的程度有无牙根折断及牙槽骨骨折的可能等

37 3. 牙髓检查 : 牙齿外伤后可通过外伤的经过时间, 受损伤状态和局部污染的情况, 及通过电活力测验和温度检查等状况来判断牙髓状态由于外伤后疼痛软组织损伤及出血, 临床上很难得出正确结果, 但很有必要将牙髓检查结果记录在病历上要特别注意, 刚外伤的牙齿牙髓可能处于休克状态, 牙髓检查无任何反应, 应定期进行牙髓检查大多数外伤牙可在受伤后 3 个月内牙髓恢复反应牙髓恢复反应时间的长短和外伤时患牙牙根形成状态有关

38 ( 三 )X 线检查 Radiographic Examination 有条件情况下应该对每一个外伤牙齿都要拍 X 线片, 确认患牙有无根折移位情况和牙槽骨有无损伤还应注意对邻牙和对牙合牙进行检查, 通过 X 线片主要观察以下几个方面 :

39 ( 三 )X 线检查 Radiographic Examination 1. 牙冠牙根有无折断及其状态 2. 牙槽骨颌骨有无骨折及其状态 3. 牙周组织情况 4. 邻牙牙胚的情况 5. 牙根形成与吸收情况 6. 乳牙与继承恒牙关系 7. 陈旧性外伤应注意牙根有无吸收及吸收方式

40 诊断与治疗原则 Diganosis and treatment

41 支持组织损伤 (Injuries to the supporting tissue )

42 支持组织损伤一牙槽骨骨折 (fracture of the mandibular or maxillary alveolar process ) 骨折发生与牙槽突至牙根尖部之间, 骨折线通常通过牙槽窝外伤时一般涉及多个牙齿同时松动, 发生牙齿挫入与侧方移位时, 可同时伴有牙槽骨骨折临床仔细地检查和 X 线片分析易于诊断同时复位牙齿和牙槽骨, 固定 2~3 个月

43 支持组织损伤二颌骨骨折 (fracture of mandible or maxilla ) 通常为上下颌骨体部与下颌骨升支部的更广泛骨折, 一般均包含有牙槽骨骨折的存在外伤后出现牙齿错位咬牙合或无法咬牙合时, 即使没有牙齿的异常变化发生, 也应充分考虑到颌骨骨折存在的可能性发现病人发生了上下颌骨骨折, 应当请颌面外科进行处理

45 支持组织损伤三牙龈与口腔黏膜的损伤 (injuries to gingiva or oral mucosa ) 擦伤 (abrasion of gingiva or oral mucosa ) : 临床检查发现, 只有表面上皮组织被摩擦或划破, 没有皮肤深部组织的损伤, 一般可出现疼痛挫伤 (contusion of gingiva or oral mucosa ) : 只有皮下组织的出血而没有上皮的撕裂, 一般为组织受到较大的外力撞击所致撕裂伤 (laceration of gingiva or oral mucosa ) : 组织被锐利器具切割而致一般通过视诊和触诊可以确定外伤的大小深度与出血程度特别是发生撕裂伤时要注意伤口内是否有牙体组织碎片或其它异物存在, 必要时拍摄 X 线片对帮助排除异物的存在十分有用软组织的外伤, 在急诊时都应清创, 但手法要轻柔, 要嘱咐家长和儿童保持口腔卫生必要时应注射破伤风抗血清

46 支持组织损伤面部擦伤

47 支持组织损伤上唇挫伤

49 支持组织损伤牙龈撕裂伤

50 上唇系带撕裂伤

51 牙齿震荡 (Concussion) 牙齿外伤只影响牙周膜和牙髓组织, 没有造成牙体硬组织缺损牙折断或牙移位时, 称为牙震荡发生牙齿震荡的牙齿可能只出现釉质裂纹牙齿震荡有轻有重, 轻症一般无临床症状, 或只有轻微症状患者在受伤时往往很少来医院就诊轻症较易恢复, 但远期发生牙髓坏死的病例也不少见

52 牙齿震荡 (Concussion) 一般认为牙齿震荡是指牙外伤时只有牙周组织的轻微损伤, 而没有牙齿的移位与松动发生 ; 牙齿半脱位是指牙周组织的损伤, 没有牙齿的移位发生, 但有牙齿的轻度松动出现外伤造成牙髓与牙周组织供应的血管损伤较小, 但是也可能引起牙髓的损伤这两类牙外伤在临床表现 X 线片检查上并无特殊分别, 治疗原则与治疗方法也无明显区别, 绝对分辨清晰对临床诊断治疗并无特别帮助, 所以我们参考李宏毅教授分类法, 将二者合并叙述

53 ( 一 ) 牙周损伤临床表现主要为牙齿的酸痛, 上下颌牙齿咬合时有不适感, 可能有轻或重的叩痛或叩诊不适感 X 线片检查为牙周膜间隙无明显异常或只有稍许增宽, 也有可能只表现为牙周膜间隙的清晰度降低而影像显示稍模糊

54 ( 二 ) 牙髓损伤牙髓损伤的临床表现可有近期和远期改变但其特点不同 : 近期牙髓可有充血出血和感觉丧失 ; 远期可能有牙髓钙化牙齿吸收和创伤性囊肿, 甚至出现根尖周脓肿 1. 充血 2. 牙髓出血 3. 牙齿感觉丧失 4. 牙髓钙化 5. 牙齿吸收 6. 外伤性囊肿 7. 外伤性牙根发育异常

55 ( 三 ) 牙体损伤牙齿遭受硬物直接打击后, 很容易造成牙齿釉质的裂纹临床除极重度者在釉质表面能发现有裂痕外, 一般照明条件下裂纹多不易看清, 因而常会被漏诊任何情况下的牙齿外伤, 都可能伴有釉质裂纹, 一般多发生在切牙裂纹在釉质表面的走向没有一定的规律, 主要与打击的力量方向物体的形状和大小有关系采用平行光由切缘投射, 并平行于牙长轴照射, 或由舌侧透照, 可以发现光线变暗的裂纹 ; 在体视镜下斜射光的照射下, 可见清晰明亮的裂纹

56 牙齿移位 (Displacement) 前牙因受打击或撞伤造成的移位, 与儿童的年龄和牙齿的发育程度有直接关系正在形成期的牙齿牙根体积较小, 外形粗短, 根端开敞, 牙周和牙槽骨组织疏松因此, 当牙齿遭受打击时, 即使力量不是很大, 也容易造成牙齿移位而同样的力量加在牙根已完全形成或基本形成的牙齿上, 就可能造成牙冠折断或牙根的折断这也是牙外伤时幼儿和少儿多发生牙齿移位的原因牙齿外伤因受打击的方向和力量不同, 移位的类型也不同

57 ( 一 ) 牙齿挫入 (Intrusion) 牙齿挫入是因外伤, 牙齿被嵌入牙槽窝内, 一般移位方向与牙齿的长轴基本一致, 有时伴有牙槽窝骨板的破裂或折断

58 挫入程度 <3 毫米 3~6 毫米 >6 毫米描述轻度挫入中度挫入重度挫入

59 牙齿挫入

60 挫入牙齿的治疗方案目前主要有 3 种 : 1. 等待牙齿自主萌出 2. 外科手术复位 3. 主动牵引复位

61 临床操作要点 : 1. 检查与诊断要正确认识牙齿挫入牙槽骨的损伤情况和其它与牙外伤相关的问题 2. 局部麻醉 3. 牙齿复位 ( 必要时 ) 4. 固位与固定有牙槽骨折断等外伤时要同时进行处理, 进行牙龈缝合与固定 5. 牙髓治疗一般须 2 周后进行, 最初的根管充填材料最好为氢氧化钙 6. 复诊观察与拆除固定定期复诊观察, 一般愈合顺利时 2~3 个月后拆除固定装置 7. 永久性根管充填使用永久性根管充填剂充填来替代氢氧化钙根充剂 8. 修复治疗成年后利用修复方法解决美观与功能问题

62 ( 二 ) 牙齿侧向移位 (Lateral Luxation) 牙齿侧向移位是牙齿被推向牙齿长轴以外的方向, 为牙齿移向唇侧或舌 ( 腭 ) 侧, 通常为牙冠侧方移位至舌 ( 腭 ) 侧, 而牙根移位向唇侧, 此时牙齿根尖犹如被卡在牙槽窝内, 有时伴有牙槽骨的折断或折裂根尖部牙齿供应的血管神经扭曲断裂, 造成局部出血淤血, 牙齿颈部牙周膜组织受压, 而牙根尖部牙周膜组织出现缺如

63 牙齿侧向移位及复位固定

64 临床操作要点 : 1. 检查与诊断 2. 复位与固定复位后一般固定 2~3 周时间 3. 牙髓治疗当出现牙髓坏死等症状时需进行牙髓治疗, 但一般情况下不要早于复位固定后 2 周牙根发育完成牙可行根管治疗术 ; 年轻恒牙应选择根尖诱导形成术 4. 定期复查观察 5. 必要时作美观修复

65 ( 三 ) 牙齿部分脱出 (Partial avulsion ) 牙齿只是部分脱出牙槽窝, 牙齿明显伸长, 称为牙齿部分脱出, 其牙周组织出现损伤或破坏, 多发生于上颌中切牙, 临床处理首先应将牙齿复位在这类损伤中, 牙齿复位后往往仍会脱出伸长, 因此, 复位后的固定极为重要最好采用全牙列牙合垫固定法固定因其固定后不仅防止再脱出, 并在下颌运动时不受覆牙合的影响, 减少患牙创伤, 同时能维持必要的生理活动度, 保持适度的功能性刺激, 对促进牙周组织的修复减少远期牙齿的外吸收等情况的发生均具有较好的效果

66 牙齿部分脱出

67 ( 四 ) 牙齿完全脱出 ( 牙脱臼 ) Complete diplacement (Avulsion) 牙齿完全脱出

68 临床操作要点一即刻再植 1. 脱位牙齿保存 2. 检查与诊断 3. 脱位牙齿清洗 4. 清理牙槽窝 5. 再植与固定 6. 牙髓治疗 7. 复诊观察与拆除固定 8. 根管充填 9. 必要时美观修复

69 临床操作要点二延迟再植 1. 脱位牙齿清洗 2. 口外完成根管治疗 3. 清理牙槽窝 4. 再植与固定 5. 拆除固定 6. 定期复诊观察疗效 7. 再植牙被吸收后处理

70 三牙齿折断牙齿折断 (tooth fracture) 主要可分为三种类型 : 牙冠折断 (crown fracture) 牙根折断 (root fracture) 冠根联合折断 (crown-root fracture)

71 ( 一 ) 牙冠折断 (Crown Fracture) 牙冠折断又可分为下述三种情况发生牙外伤时, 首先应作全面的临床检查和 X 线检查, 以排除软组织损伤牙齿移位或牙根折断的可能性

72 1 单纯釉质折断 ( enamel fracture ) 主要是受硬物直接打击牙冠所造成, 多见于前牙区, 折断部位多发生在切角或切缘, 但是没有暴露牙本质临床检查时应当注意是否有牙釉质裂纹 (enamel infraction or crack) 有时牙釉质裂纹细微, 有时在断面呈粉碎性裂纹, 这种情况可以通过反射光或透射光进行临床检查年轻恒牙由于牙根尚未发育完成, 一般较少发生牙根的折断

73 单纯釉质折断及磨改术后

74 2 釉质折断暴露牙本质 ( enamel dentin fracture ) 当釉质折断牙本质暴露或牙本质同时折断, 常出现冷热刺激痛有些患儿因缺损不大, 症状不明显而被忽视需要强调的是, 年轻恒牙的牙本质较薄, 离牙髓腔近, 加之牙本质小管较粗大, 任何外界刺激都会通过牙本质小管很快地侵入牙髓细菌及细菌产物, 也可以通过暴露的牙本质小管进入牙髓组织, 进而引起牙髓的炎症反应虽然牙髓组织有一定的防御和修复功能, 但是存在较大的局限性, 因此, 年轻恒牙外伤后暴露牙本质时, 不论暴露的面质积大小, 一定要进行护髓处理

75 影响护髓治疗效果的因素有三个 : (1) 牙本质暴露的时间 ; (2) 从折断面到牙髓腔间遗留的牙本质的厚度 ; (3) 牙根的发育状态

77 即刻树脂预成冠修复

79 3 冠折露髓 (complicated crown fracture ) 由于牙髓暴露, 一般临床症状较明显, 可有冷热刺激痛, 触痛明显, 患儿甚至不敢用舌头舔触患牙, 影响进食

80 牙齿冠折露髓时, 牙髓的组织病理学状况变化可能存在有下列情况 : (1) 牙髓暴露的时间 (2) 外伤前的牙髓健康状态 (3) 露髓孔的直径大小 (4) 患者年龄 (5) 牙根发育状态 (6) 是否合并牙齿脱位

82 牙齿冠折露髓

84 牙冠折断 ( 露髓 ) 与活髓切断术

85 光敏复合树脂修复

86 断冠再粘结修复

87 ( 二 ) 牙根折断 (Root Fracture) 年轻恒牙由于牙根尚未发育完成, 牙根相对较粗短, 儿童的牙槽骨也较成年人疏松, 因此, 外伤造成的牙根折断相对较少, 而造成牙齿震荡或牙齿脱位则相对较多青少年在牙齿完全萌出, 牙根基本形成或完全形成后, 由于受剧烈碰撞可能造成牙根折断

88 根折治疗的一般原则和方法 : (1) 断端复位 : 根折后折断的两个断面可能是密合的, 也可能是分离等, 并有不同程度的空隙存在根折的愈合情况与折断后两断面的密合程度有关, 因此应使断端复位并使两断面尽可能密合, 然后再进行固定 (2) 消除咬合创伤 : 调磨对合牙只适用于咬合创伤极轻的状况, 大多数情况下需要做全牙列合垫由于儿童后牙萌出的高度不足, 前牙的覆合较深是常见现象, 合垫可使后牙垫高, 保证前部根折牙不受深覆牙合的影响, 还可以固定患牙, 有利于根折的愈合 (3) 固定患牙 : 外伤牙的固定方法很多, 可以根据牙外伤的具体情况及医疗条件进行选择

89 牙根折断的愈合方式 (1) 多数学者认为, 牙根折断后, 典型的愈合过程是首先有血液及组织液存在折断牙根的两断面之间的间隙中无论间隙的大小, 在近根管侧有牙髓组织来源的纤维和成纤维细胞, 在近牙周膜腔侧有牙周膜来源的纤维和成纤维细胞向间隙内增生, 然后发生机化, 并各自形成牙本质骨样牙本质和类牙骨质即骨痂形成, 而牙髓通常是生活状态的这种愈合方式多发生于年轻恒牙因为年轻恒牙的根管粗大牙髓及牙周组织血管丰富防御与修复能力均较强 (2) 有时可能发生在折断断面间隙内只有散在的牙本质或牙骨质的沉积, 而结缔组织增生明显, 且这些结缔组织主要来自于牙周组织临床检查可以发现, 折断的牙齿叩诊反应与牙齿的松动度正常, 但 X 线影像表现为牙根的折断线仍较明显此类愈合方式多发生于根折的两断端间间隙较宽的年轻恒牙 (3) 也有可能出现根折两断端间有骨样组织沉积, 同时在牙髓腔内发生沉积, 牙根的折断面被牙骨质样组织覆盖临床上表现为折断牙齿稳固, 牙髓可以有活力存在, 牙本质牙骨质或骨质样组织沉积在临床 X 线影像的表现上无法分清 ; 同时骨质样组织的沉积与牙髓腔的钙化表现也易混淆, 各种临床表现不尽相同 (4) 当根折冠方断端严重脱位和牙髓被污染时, 就可能发生牙髓坏死, 一般根折的冠段牙髓已经坏死, 而尖断牙髓仍然保持活力坏死的牙髓可能在根折线内引起炎性肉芽组织形成, 炎症还能扩展至牙根折断线附近的牙槽骨, 使其发生炎症性吸收 X 线片上可见根折线必宽和根折处附近牙槽骨的吸收影像临床上可见牙齿松动叩痛, 牙齿可能变黑并稍向切方脱出这些是失败病例的表现

90 牙根折断

92 ( 三 ) 冠根折断 (Crown-Root Fracture) 牙齿的折断线贯穿牙冠和牙根, 可以分为横折与纵折两种

93 冠根折断

95 固定是牙外伤治疗的重要步骤, 稳定可靠的固定也是外伤牙治疗成功的关键因素过去普遍认为部分或全部脱位的牙齿固定时间一般需要 8~12 周而 Andreasen(1975a,b) 报道在动物和人的实验研究结果表明, 即使是完全脱位牙再植后的固定, 牙齿固定 1~2 后, 第三周一般均可以达到正常松动度水平认为较短的固定时间有助于恢复牙周膜的生理性功能, 这些功能的恢复在长期固定的牙齿上是不可能具有的外伤牙的固定 (spliting)

96 现代外伤牙齿固定的理想要求 1. 能很快应用到口腔内, 无须长时间的制作过程 ; 2. 易于应用, 而对牙齿无任何外力作用, 但牙齿固定后可有生理性的活动度, 并可以应用牙齿外伤治疗任何阶段的固定 ; 3. 不接触牙龈组织, 不产生牙龈刺激症状 ; 4. 不干扰正常的咬合关系 ; 5. 具有美学可接受度, 易于清洁, 不妨碍口腔卫生 ; 6. 使用时不损伤牙齿及牙周组织 ; 7. 能允许进行牙髓活力测定和进一步的牙髓治疗 ; 8. 易于去除

97 固定方法介绍 1. 复合树脂粘片固定

98 固定方法介绍 2. 钢丝结扎固定

99 固定方法介绍 3. 粘固夹板固定

100 固定方法介绍 4. 粘固正畸附件结扎固定

101 固定方法介绍 5. 全牙列牙合垫固定

102 固定方法介绍 6.TTS(Titanium Trauma Splint) 固定法 ( 引自 von Arx T 2001)

103 固定方法介绍 7. 简易应急固定

104 固定时限外伤类型再植牙半脱位牙挫入牙移位牙根折牙固定时间 2~3 周 2~3 周 6~8 周 6~8 周 2~3 月

105 INJURIES TO THE PRIMARY DENTITION

106 During its early development the permanent incisor is located palatally to and in close proximity with the apex of the primary incisor. With any injury to a primary tooth there is risk of damage to the underlying permanent successor.

107

108 Most accidents in the primary dentition occur between 2 and 4 years of age. Realistically, this means that few restorative procedures will be possible and in the majority of cases the decision is between extraction or maintenance without performing extensive treatment. A primary incisor should always be removed if its maintenance will jeopardize the developing tooth bud.

109 A traumatized primary tooth that is retained should be assessed regularly for clinical and radiographic signs of pulpal or periodontal complications. Radiographs may even detect damage to the permanent successor.

110 Soft tissue injuries in children should be assessed weekly until healed. Tooth injuries should be reviewed every 3-4 months for the first year and then annually until the primary tooth exfoliates and the permanent successor is in place. Traumatic injuries that occur prior to eruption of primary teeth can also interfere with their development.

111 Uncomplicated crown fracture Either smooth sharp edges or restore with an acid-etch restoration if co-operation is satisfactory.

112 Complicated crown fracture Normally, extraction is the treatment of choice. However, pulp extirpation and canal obturation with zinc oxide cement, followed by an acid-etch restoration is possible with reasonable co-operation.

113 Crown-root fracture The pulp is usually exposed and any restorative treatment is very difficult. The tooth is best extracted.

114 Root fracture Without displacement and with only a small amount of mobility the tooth should be kept under observation. If the coronal fragment becomes non-vital and symptomatic then it should be removed. The apical portion usually remains vital and undergoes normal resorption. Similarly with marked displacement and mobility only the coronal portion should be removed.

115 Concussion, subluxation, and luxation Associated soft tissue damage should be cleaned by the parent twice daily with 0.2% chlorhexidine solution using cotton buds or gauze swabs until it heals.

116 Concussion Often not brought to a dentist until the tooth discolours. Subluxation If slight mobility then the parents are advised on a soft diet for 1-2 weeks and to keep the traumatized area as clean as possible. Marked mobility requires extraction. Extrusive luxation

117

118

119

120 Lateral luxation If the crown is displaced palatally the apex moves buccally and hence away from the permanent tooth germ. If the occlusion is not gagged then conservative treatment to await some spontaneous realignment is possible. If the crown is displaced buccally then the apex will be displaced towards the permanent tooth bud and extraction is indicated in order to minimize further damage to the permanent successor.

121

122 Intrusive luxation This is the most common type of injury. The aim of investigation is to establish the direction of displacement by thorough radiological examination. If the root is displaced palatally towards the permanent successor then the primary tooth should be extracted to minimize the possible damage to the developing permanent successor.

123 Intrusive luxation If the root is displaced buccally then periodic review to monitor spontaneous re-eruption should be allowed. Review should be weekly for a month then monthly for a maximum of 6 months. Most re-eruption occurs between 1 and 6 months and if this does not occur then ankylosis is likely and extraction is necessary to prevent ectopic eruption of the permanent successor.

124

125 Exarticulation (Avulsion) Replantation of avulsed primary incisors is not recommended due to the risk of damage to the permanent tooth germs. Space maintenance is not necessary following the loss of a primary incisor as only minor drifting of adjacent teeth occurs. The eruption of the permanent successor may be delayed for about 1 year as a result of abnormal thickening of connective tissue overlying the tooth germ.

126

127 SEQUELAE OF INJURIES TO THE PRIMARY DENTITION

128 Pulpal necrosis Necrosis is the commonest complication of primary trauma. Evaluation is based upon colour and radiography. Teeth of a normal colour rarely develop periapical inflammation but conversely mildly discoloured teeth may be vital. A mild grey colour occurring soon after trauma may represent intrapulpal bleeding with a pulp that is still vital. This colour may recede, but if it persists then necrosis should be suspected.

129 Radiographic examination should be 3 monthly to check for periapical inflammation. Failure of the pulp cavity to reduce in size is an indicator of pulpal death. Teeth should be extracted whenever there is evidence of periapical inflammation, to prevent possible damage to the permanent successor.

130 Pulpal obliteration Obliteration of the pulp chamber and canal is a common reaction to trauma Clinically, the tooth becomes yellow/opaque. Normal exfoliation is usual but occasionally periapical inflammation may intervene and therefore annual radiography is advisable. Root resorption Extraction is advised for all types of root resorption where there is evidence of infection

131 Injuries to developing permanent teeth Injuries to the permanent successor tooth can be expected in between 12% to 69% of primary tooth trauma and 19% to 68% of jaw fractures. Intrusive luxation causes most disturbances but avulsion of a primary incisor will also cause damage if the apex moved towards the permanent tooth bud before the avulsion.

132 Most damage to the permanent tooth bud occurs under 3 years of age during its developmental stage. However, the type and severity of disturbance are closely related to the age at the time of injury. Changes in the mineralization and morphology of the crown of the permanent incisor are commonest but later injuries can cause radicular anomalies.

133 Injuries to developing teeth can be classified as follows: 1. White or yellow-brown hypomineralization of enamel. Injury at 2-7 years 2. White or yellow-brown hypominerlaization of enamel with circular enamel hypoplasia. Injury at 2-7 years. 3. Crown dilaceration. Injury at about 2 years.

134 4. Odontoma-like malformation. Injury at <1-3 years. 5. Root duplication. Injury at 2-5 years. 6. Vestibular or lateral root angulation and dilaceration. Injury at 2-5 years. 7. Partial or complete arrest of root formation. Injury at 5-7 years. 8. Sequestration of permanent tooth germs. 9. Disturbance in eruption.

135

136

137 Key Points In primary tooth trauma: Risk of damage to permanent successors is high ¾ warn parents Intrusive injuries carry the highest risk to the permanent successors

138

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