牙周牙髓联合病变.ppt

14,牙周牙髓联合病变Periodontal-EndodonticCombinedLesions,14-1牙周组织和牙髓的解剖通道AnatomicalInterrelationsofPeridontiumandPulp,根尖孔Apicalforamen,根管侧支Lateralrootcanal或副根管Accessorycanal,根尖1/3处最多根分叉区20-60%有,Thepulpwasnon-vitalandthetoothwasendodonticallytreated.Afterprosthetictherapy,Thepulpwasnon-vitalandthetoothwasendodonticallytreated.Afterprosthetictherapy(c),the2-yearfollow-upradiographin(d)showsbonefillinthepreviousangularbonydefect,whereasthemarginalboneremainsatthesamelevel.Oncarefulexaminationonecanseethatalateralcanalcommunicatingwiththelateralbonedefectwasfilled.,牙本质小管Dentinaltubules,解剖异常Anatomicalabnormalities,腭侧沟牙根外吸收根裂,14-2牙周-牙髓联合病变的临床类型ClinicalPatternsofPeriodontal-EndodonticCombinedLesions,1，根尖感染经牙周组织途径排除，有人称之为逆行性牙周炎(retrogradeperiodontitis),牙髓根尖周病对牙周组织的影响influenceofendodonticlesionsontheperiodontium,根尖脓肿沿牙周的可能排脓途径,Schematicillustrationdemonstratingpossiblepathwaysfordrainageofaperiapicalabscessintothegingivalsulcus/pocket.(a)periodontalligamentfistulation.(b)extraosseousfistulation,periodontalligamentfistulation.此型在临床上易被误诊为牙周脓肿特点：死髓牙窄而深的牙周袋，无明显的牙槽嵴吸收onlyanarrowopeningofthefistulaintothegingivalsulcus/pocketandmaynotbedetectedunlesscarefulprobingofthesulcusiscarriedoutatmultiplesites.邻牙一般无严重的牙周炎X片显示烧杯型或日晕型病变,after18M,Inmultirootedteethaperiodontalligamentfistulationcandrainoffintothefurcationarea,，牙髓治疗过程中或治疗后造成的牙周病变,根管侧穿，髓室底穿，髓室或根管内的药物（砷戊二醛塑化液干髓剂等）,Duringendodontictreatment,andinconjunctionwithpreparationofrootcanalsfortheinsertionofposts,instrumentationcanaccidentallycauseperforationoftherootandwoundingoftheperiodontalligament,Angularbonedefectatthedistalrootsurfaceofamandibularpremolar(arrows).Therootisperforated.Conceivably,thisoccurredinconjunctionwithpreparationoftherootcanalforapostandcore.Clinicalsymptomsincludeddrainageofpusfromthepocketandincreasedtoothmobility.Thetoothwasextracted.,Perforationofthepulpalfloorofthemandibularfirstmolaroccurredinconjunctionwithasearchforrootcanalopenings(a).Theperforationwasimmediatelysealedwithgutta-percha(b).Onemonthaftertreatmentaslightradiolucencyappearedattheperforationsite(arrow)intheperiodontium(c).Afteranobservationperiodof2years,normalperiodontalconditionswerere-establishedbothclinicallyandradiographically,RCT治疗后可发生牙根纵裂:主要由于扩根过度,桩核不当,过大合力等,共同特点:牙髓无活力病变局限于单个牙，局限于患牙的局部病变呈烧杯状，邻牙基本正常,Verticalrootfracture,结局:Verticalrootfracturesthatinvolvethegingivalsulcus/pocketareausuallyhaveahopelessprognosisduetocontinuousbacterialinvasionofthefracturespacefromtheoralenvironment.,ExternalRootresorption,Surfaceresorption,Asurfaceresorptionisinitiatedsubsequenttoinjuryofthecementoblasticcelllayer.Osteoclastsareattractedbysubstancesfromthedamagedtissueonthedenudedrootsurfaceandresorbthehardtissue,Theseresorptionsmaybecausedbyalocalizedinjuryinconjunctionwithexternaltrauma(Andreasen1981)andbytraumafromocclusion.Resorptionmayalsoresultfromexcessiveorthodonticforces.,Thistypeofresorptioniscommon,self-limitingandreversible,Replacementresorption,Thistypeofresorptiveprocessresultsinareplacementofthedentalhardtissuesbybone,hencethename,Replacementresorptionandankylosisareoftenusedassynonyms.,Clinically,ankylosisisdiagnosedbyabsenttoothmobilityandbyapercussiontonethatishigherthaninanormaltooth,Externalinflammatoryresorption,Thetermexternalinflammatoryresorptionsuggeststhepresenceofaninflammatorylesionintheperiodontaltissuesadjacenttoaresorptiveprocess,牙周病变对牙髓的影响Iinfluenceofperiodontaldiseaseonthepulp,1,逆行性牙髓炎Retrospectivepulpitis,2，长期存在的牙周病变：轻者修复性牙本质重者炎症变性钙化坏死因牙周炎拔除的无龋牙，64%有牙髓的炎症或坏死，与PD成正比,3，牙周治疗对牙髓的影响Influenceofperiodontaltreatmentmeasuresonthepulp,14-3治疗原则Treatmentstrategiesforvombinedendodonticandperiodontallesions,确定原发原因。联合病变的预