儿童及青少牙和支持组织外伤.ppt

儿童及青少年牙和支持组织的外伤,口腔预防儿童科池政兵,2019/12/7,chi,2,TraumatotheTeethandSupportingTissues,DentalTraumaHowtoDiagnosisTreatmenttotheDentalTrauma,2019/12/7,chi,3,概论,2019/12/7,chi,4,参考书,McDonaldREandAveryDR.DentistryfortheChildandAdolescent,6thed.st.Louis:C.V.Mosby,Co,1994.AndreasonJOandAndreasonFM.Essentialsoftraumaticinjuriestotheteeth.Denmark:LaursenA/S,Tnder,1990.EndodonticsandDentalTraumatology,2019/12/7,chi,5,TheInternationalAssociationofDentalTrauma(IADA)国际牙外伤协会,2019/12/7,chi,6,牙外伤(DentalTraumaorInjuries),是指牙齿受到急剧的创伤，特别是打击、撞击等所引起的牙体、牙髓和牙周组织的损伤。（急性的）,2019/12/7,chi,7,儿童牙外伤的特点,年龄特点：儿童及青少年的发病率高年龄高峰：乳牙13岁恒牙79岁发生部位：切牙尖牙磨牙上颌下颌性别比较：男性女性,2019/12/7,chi,8,乳牙外伤后,影响后继恒牙的发育：釉质发育不全or钙化不全修复性牙本质形成弯曲牙部分牙根停止发育影响后继恒牙的正常萌出影响恒牙列的正常形成,2019/12/7,chi,9,恒牙外伤后,牙体组织的缺失或缺损接触点邻牙倾斜；间隙的丧失；对颌牙的伸长（替牙期的患者影响更大）,2019/12/7,chi,10,牙外伤后,外伤牙本身预后的不定性，儿童生长发育的活跃性，诊断的困难性。当时口腔局部的创伤；以后机体的生理和心理上的创伤牙医：作出快速、正确、全面的诊断；作出正确的处理；减少后遗症。,牙外伤的诊断,？,2019/12/7,chi,12,牙外伤的诊断,病史临床检查发射性X线片的检查,2019/12/7,chi,13,病史,年龄，性别，外伤原因，作用力的大小和方向，发生地点及环境污染情况，外伤确切的时间，对冷热的反应，是否影响咬合，就诊前脱位牙的保存情况，是否经过一段无意识期，有无恶心、呕吐，全身有无影响治疗的疾患：血友病等，以前有无牙外伤史问查,2019/12/7,chi,14,临床检查,电活力测定两种观点新的、陌生的仪器儿童害怕；有效性（髓休克3个月）机会；首次电活力意义（Rock等在1974年报道1年后82有活力）积极治疗；微不足道的刺激冷热诊常适用乳牙光透射情况（光束由舌侧向唇侧照射）其它：松动度检查多个牙一起动提示？叩诊检查metallic/dullpercussiontone提示？,2019/12/7,chi,15,放射性X线片检查,患牙与邻牙、对侧同名牙作比较比较髓腔、根管的大小、形态以及发育情况根折的检出率：（假阴性）X线透射中心的射线与牙折线一致或平行夹角1520夹角1520无法显示若怀疑有根折，改变角度，加拍23张牙片,牙外伤的治疗,？,2019/12/7,chi,17,TreatmenttotheDentalTrauma,InjurytothePrimaryDentalCrownFracturesCrown-RootFracturesRootFracturesAvulsion,ConcussionandSubluxationExtrusionLateralLuxationIntrusionFractureoftheAlveolarProcess,2019/12/7,chi,18,治疗原则,乳牙外伤冠折根折冠根联合折牙完全性脱位牙震荡,牙伸长牙侧向移位牙嵌入牙槽骨骨折软组织外伤,2019/12/7,chi,19,InjuriestothePrimaryDentition,VerifyeventualcollisionbetweenadisplacedprimarytoothanditspermanentsuccessorIfthishasoccurred,removethedisplacedincisorIfnot,observationMonitorhealingregularlywithroutineclinicalandradiographicexamination,2019/12/7,chi,20,乳牙外伤,儿童的牙槽骨韧性较好，临床上以外伤移位多见处理上要谨慎乳牙外伤发生移位，伤及后继恒牙胚乳牙外伤继发感染，伤及后继恒牙胚,2019/12/7,chi,21,乳牙外伤,冠折：治疗原则同恒牙冠根联合折：拔牙，残留牙根（生理性吸收）根折：固定困难，拔除侧向移位：观察/拔除嵌入：观察/拔除完全性脱位：不作再植术,2019/12/7,chi,22,CrownFractures,FracturesofenamelGrindingCompositerestorationFracturesofenamelanddentinCompositerestorationRe-attachmentofthecrownfragmentPulpexposuresPulpcappingPulpotomy,2019/12/7,chi,23,冠折CrownFractures,仅累及牙釉折层：磨改、树脂修复累及牙本质：间接盖髓后，作牙折片再粘、树脂修复累及牙髓腔：直接盖髓术或活髓切断术后，作冠修复,2019/12/7,chi,24,PulpCapping,IsolatethepulpexposureCoverthepulpwithacalciumhydroxidematerialRestoretheteetheitherimmediatelyorafter3monthperiod,2019/12/7,chi,25,Pulpotomy,IsolatethepulpexposureAmputatethepulptoalevelapproximately2mmbelowtheexposuresite,ortowherefreshbleedingisseenRestorethetootheitherimmediatelyoraftera3-monthperiod,2019/12/7,chi,26,Crown-Rootfractures,RemovalofthecoronalfragmentwithsubsequentrestorationabovegingivallevelRemovalofthecoronalfragmentsupplementedbygingivectomyandosteotomyandsubsequentrestorationwithapost-retainedcrownRemovalofthecoronalfragmentandsurgicalextrusionoftherootRemovalofthecoronalfragmentandsubsequentorthodonticoftheroot,2019/12/7,chi,27,冠根联合折crownrootfractures,拔除冠折片，龈上冠修复拔除冠折片，龈、骨切除术，冠修复拔除冠折片，外科牙根伸长法，冠修复拔除冠折片，正畸牙根伸长法，冠修复纵折：拔除,2019/12/7,chi,28,RootFractures,Checkforpulpalcomplicationsafter3weeks,6weeksand3monthsRepositionthecoronalfragmentandusefirmsplintingfor3monthsRoot:crown1/3middle1/3apical1/3,2019/12/7,chi,29,根折rootfractures,颈1/3:拔除“牙折冠”，根管治疗后，龈切或牵引冠修复中1/3:复位固定3个月尖1/3:观察或复位固定3个月,2019/12/7,chi,30,Avulsion,ReplantationprocedurePlacetheavulsedtoothinsalineExaminethesocketareaRinsetheperiodontalligamentandapicalforamenwithsalineFlushthesocketwithsalineReplantthetoothSplintthetoothfor12weeksAntibiotictherapyT.A.T,2019/12/7,chi,31,牙完全脱位avulxion,再植术复位固定12周(无PDL者6周）氢氧化钙糊剂作暂时性根充抗炎治疗：普鲁卡因青霉素6080万单位2次/日肌肉注射TAT注射,2019/12/7,chi,32,牙完全脱位avulxion,再植术治疗要点脱位牙的保存情况：牛奶、NS等脱位牙的脱位时间：30min2hour牙周膜的处理：保留与否牙槽窝的处理：清除血凝块，NS冲洗,2019/12/7,chi,33,牙完全脱位avulxion,再植术治疗效果取决于外伤牙的保存湿润/干燥外伤牙的脱位时间30分钟以内：2年或更长，90无牙根内吸收2小时以外：95牙根发生内吸收,2019/12/7,chi,34,ConcussionandSubluxation,Occlusalrelief(e.g.byselectivegrindingofopposingteeth)andasoftdietImmobilizationoftheinvolvedteethmaybeappropriateforpatientcomfort,2weeksfixation,2019/12/7,chi,35,牙震荡/亚脱臼concusion/subluxution,概念牙震荡：牙周lig内出血、水肿，完整，牙一般无松动亚脱臼：牙周lig内出血、水肿，部分撕裂，牙一般有松动、伴龈沟出血调合，软饮食（2周），一般不需要固定（若固定，应2周）,2019/12/7,chi,36,Extrusion,RepositioningFixation23weeks,2019/12/7,chi,37,牙伸长extrusion,（局麻）复位固定23周牙髓存活情况牙根形成的：50存活牙根未形成的：90以上存活根管治疗时机：观察期间，X线检查一旦发现根尖牙根、牙槽骨有炎性吸收,2019/12/7,chi,38,LateralLuxation,LocalanestheticRepositioningFixation3weeksIfradiographicexaminationrevealsatemporarybreakdownofthemarginalbone,maintainfixationforupto2months,2019/12/7,chi,39,牙侧向移位lateralluxation,（局麻下）复位固定3周根管治疗时机：观察期间，X线检查一旦发现根尖牙根、牙槽骨有炎性吸收,2019/12/7,chi,40,Intrusion,ImmaturerootformationAwaitspontaneousre-eruption,usuallytakes24monthsMonitorpulpalhealingradiographically3,4and6weeksafterinjuryMaturerootformationAwaitspontaneousre-eruptionorextrudeorthodonticallyoveraperiodof23weeksExtirpatethepulp2weeksafterinjury,usingcalciumhydroxidepasteasaninterimdressing,2019/12/7,chi,41,牙嵌入intrusion,诊断：病史、叩诊（metallic音)、X线检查牙髓坏死率牙根未形成：50牙根已形成：100牙根吸收牙根未形成：58%牙根已形成：70,2019/12/7,chi,42,牙嵌入intrusion,牙根尚未形成：观察24月（再萌）牙根已形成：观察（10天）和/或正畸牵引（23周）OR外科拔牙复位固定4周氢氧化钙糊剂作暂时性根充,2019/12/7,chi,43,FractureoftheAlveolarProcess,LocalanestheticRepositioningFixation34weeks,2019/12/7,chi,44,牙槽骨骨折,局部的牙槽骨骨折局麻下，复位固定（34周）根尖锁住（ApicalLock),2019/12/7,chi,45,软组织外伤,清创缝合TAT注射抗炎治疗,2019/12/7,chi,46,牙外伤常见的几种治疗方法,2019/12/7,chi,47,牙外伤常见的几种治疗方法,复合树脂修复技术（直接、间接）盖髓术活髓切断术根尖成行术根管治疗术（复位）固定术,2019/12/7,chi,48,活髓切断术,适应证：露髓比较多，时间比较长，估计牙髓炎症局限于冠髓或根髓的冠1/3以内,2019/12/7,chi,49,根尖成形术,适应证：根尖尚未形成，牙髓无法保留年轻恒牙,2019/12/7,chi,50