根管治疗后冠部修复

1、F面是讲座的题目及时间。Restoration of theEndodontically TreatedToothEric M. RiveraMilton Friedman AuditoriumUriversidad Francisco MarroquinGuatemala. August 6(2009下面是部分讲座内容的截屏及翻译，译文仅供参考，建议大家看英文内容。 根管治疗后，当一个牙齿组织缺失并失去牙髓活力后，标准的处理是桩核修复。Aecons-triKiar忖Brokan Down and En dExtonti caHy Traled TeethSTANDARD OF CAREIfi

2、Tp桩核：根管治疗后的牙齿经常因为龋坏、根管治疗或者先前的修复体导致牙齿缺失相当 部分牙体组织。RortslrueLin mrM 忖ffntf 刖忻泸* Tml4 TwfliPOST AND CORE缺失的牙体组织还导致修复体的固位出问题，并增加了牙齿折断的风险。Ftechsinuctifljg Brokwi Down avd Endc3o 亞亡*乌 Trewtrf Twih6wnrikv ” H-JlILOSS OF TOOTHSTRUCTURE牙本质肩领：充分的牙本质肩领对成功的核固位的修复体是必需的；肩领效应是一个环绕的360度的平行的牙本质肩领并伸展到冠方牙体预备肩台的1.5-2mm形

3、成的。肩领的宽度跟长度对预防牙根折裂同样重要。AeEMinslrLKiinig Broken! Cown and Endodonb caily Tre&ted Teeth An adcutc fciruli：is ncceary 1Asuctodiil poat-jvtained restuFiJitipn, A ferrule clYttt isAcellar uf 560 suiroundinA.pdralld vinlb ofdr宿ir andcxEcndin 1.5 mm2.0 nimCODA! u?rhc finishline oF the preparation.* Ffr

4、ulv 1丸】淨h has a留r野ucr i於山亡雅金殆口the斤目灯时c牌衬京二ot在在root resiorcd with a post than the pose length. Ferrule width is just as impafiant as ferrule length on thefracure resistancc.这个就是所说的牙本质肩领。 如果有人不明白，建议翻翻看看新近的教科书。听过一个牙医抱怨说，纤维桩容易断，所以不用。其实如果有牙本质肩领的话，什么样的桩核都不应该断 的，除非咬合有问题；纤维桩断裂反而保护了牙体，否则就是牙体折裂了。不知大家有没有或者见没见过

5、铸造桩核烤瓷冠因咬合力量过大导致牙体纵折的案例？这里的教科书建议，如果没有足够的牙体组织做肩领，就必须做冠延长。冠的边缘必须粘结在牙体组织上，而不是修复材料上。AeEMinslrLKiinig Broken! Cown and Endodonb caily Tre&ted Teeth欧洲2006根管学会指导标准根管治疗后效果欠佳的几种情况:直esbDwgn对ffiw .n*xtoina&aJly Tn&ateO Tooth - Motfwm Ktotennha.牙齿有感染的症状及表现根管治疗后根尖随后出现X光可见的病变或者先前的病变尺寸增加病变尺寸不变或者仅仅在4年的随

6、访中才消失存在牙根持续吸收的状况European Society of EndodontologyGuidelines 2006* Root匚anal Treaimeat has art unfavouratileQUtcome when于出芒tXt卜治古対出:临址制wrth sigrii Ahd yrtiptCrths df infect ramA tntirolOiillv vhi feds* I斛i( (m iidl如曲彷悶帘Mb紬quent io treatment ar a pre-existing liori liasincre-asd ih size.A lesion ha&am

7、p; rerrlined iht sameze crhasi only diminished in sizeduringth-e4-yoaf -a*ess-mblist of rubber dim-Mjrmvi rary m5；ry men1 0i?infecricn wih sotii*m hypMhlori忖O.SSi-S.25%-WdliMi; amd QbiuradcriYirriulTiple viiit NO 4s.rtritSi1T d fltftrif, wch昭昭icminci cleF;)tndodcMil 2002Us冠方封闭的重要性Ray及Trope1995年的对101

8、0颗根管治疗的牙齿的研究表明，冠方修复体的质量比根管 治疗对根尖的健康更重要；研究包括没有桩核固位的直接修复体。ResJaraton ef ma EfioadMbeally TfubNS Tacffih - Modem hMtnalA韵丽字#*卜歯* af Vbr 卜時 dj 4 翼 1|*-gHJBMth9 Bi ，舄8K1 二 ；Importance of coronal seal ft a/ and Trope 1995一1010 endodontically treated teelh.-匚onctuson quality of ooronai restoraiion mor? fmp

9、crtant anenti&elcntrc treatment tarpripital h电Rih-Induced rto post retained jestoratrons根管治疗后的因素44613颗牙齿2年及以上随访表明，直接充填修复的牙齿有6.28%被拔除，而做过牙冠修复的牙齿有2.54%被拔除。ReKwawn出才曹EncQCg&e曲yT&rfn - F.odiMn htmatsiFactors affecting endodontic success Post endodontic factors-Intra-cororal乃cuspa ccverag-e r

10、estoration-Lazarski et al: i Endodont 200L 44613 teeth followd tor 2 years cr rnore. 6.28% extractedafter direct placement reration vs 2.54 ?& forcrowned teeth桩核固位的修复体测试了铸造桩核，成品桩，铝的临时桩及预制的临时冠，显示临时修复的周围有很明显的微渗漏，因此作者建议用预制桩在根管治疗后做即刻修复。RfrsisaTiMion a? Sw nwdonbeaRy treaflftd Tocth i.-IMem Lta-reOaP

11、ost retained restorations Fox and Gutteridge 1997 rentedCast po?-t and cores-PreMbricated posutcmpojry posts ?ri(l prrfHbriGtcd tcffiixjrtiycrowns S gnihcntly rriorhakmg电around tmpcrari AMthors advised immediate restoration kvithpfeFa breated post失败的原因根管治疗的不完全充填不良的冠边缘密合性高的龋坏发生率纵折根管的过度预备咬合应力被削弱的冠方牙体组

12、织侧穿根吸收侵占生物学宽度 一修复体边缘与牙槽嵴间要最少2mm距离af X陀ally Tf毋血Taeth LIMem KAaEt-Reas on fofailure incomplete obturation ofroot canal Poorly fitting crownmargins High caries riskReMOfdgn g(6Q Er2QOntKolty Tre： 丁 hWzFwReasons for failure Vertical toothfracture Over-preparationof canals Occlusal stresses Weakened cor

13、onaltooth tissueVlM.coytRe-Ksuauar：捕：h*T的Toolh - Nloa商狛Reasons for failureRoot resorption矗BsPniMKi of 3isfl EgoOonW卑Tne曰激ToWi - Modem母Reasons for failureInvasion ofbiological width At least 2mtndistancebet vueeArstijrativmdrgii白ndalveolar ridg-e修复体不同类型的平均寿命完全覆盖的冠修复一25年传统烤瓷桥一20年桩核冠一13年，多数因为根折失败PtwsSQ

14、rartffiei -oFlT-BTrwCKS Tooff- -Reasons for failure (Sood et al 1995. Rview of treatment atEastman Dental Institute by staff* Average I ife span for tvps of restararion-Full coverage crown - 25 vars-Conventional bridge- 20 yearsPo$t crown Y，旧0rnmn dtip to root f i.ifture根折原因预备过的牙齿抗力减弱根管预备一揭髓室顶及根部牙本质

15、的预备& EM-Holly Ff嶺d T&eth Madorri klabt-fiai-Prepared teeth areweakened一Cavity preparations-Marginal ridges-Undermined Cusps-亡U5R ftexion Fndnricintic propsrATinn-Putpal roof-! ilrd-fddrLuldr dtriLiTiu去除旧的修复体:根管治疗前所有的修复体都应该去除。因为有可能有继发龋、裂纹、或者修复材料折裂，这些都需要去除冠后再重新评估。在加拿大有很多牙医为了给患者省去重新做冠的钱，或者应患者要求

16、，直接从冠方穿过冠修复体做根管治疗，之后再用树脂充填， 这就有可能导致有裂纹的牙齿因看不到折裂线，随后发展为纵折。本来应该拔除的牙齿再次根管治疗，失败是早TfCTvy dwb TBIT VangReasons for root fracture晚的事情了；还有如果先前的牙齿近中或者远中或者颊舌向倾斜，不去除牙冠很容易造成某些部位过多切割牙体。 想必国内有很多牙齿也是直接穿过牙冠后做根管治疗，提醒大家一定要多多注意纵折的风险的。如果冠本来做得就不理想，还是拆了重做一个为好。Remove old restorations All restorations should be removed pri

17、or to endodontic treatment咬合：是根折的最可能的主要原因。修复的关键是要建立组牙功能合，用Shimstock咬合纸在最大牙尖交错位测试，侧方合要形成尖牙保护合，前伸合时前牙要有合引导。OcclusionMost likely 10 be primarv cause of rootfracture _宝诗IW AU*Ertfodrilfcatiy TnptfMTKJCI_ 岬占BE祖1；1仙pMflHOcclusion M-ost Ifikety to be primary cause of rant fracture Aim for mutualty protecte

18、d occlusion. Hold Shimstock on rndjonty of teeth, at nidxifBum inlercuipdliDn Canine guidan匚Eimmediately on lateral excursionGuidance on anterior teeth on protrusive movement最后的修复方案冠内修复体一银汞合金或复合树脂牙尖覆盖式修复体一全冠或者高嵌体覆盖义齿的基牙ReKsrati&fl Df x总鈕&WJ亡显Jy TreaM TMih - Modftfn Ma Inna la亠li MR I*I Defin

19、itive Restorative Options* Intra-coronal restoration-Zkirtalgam-Composite resin匚iBpdl coverage restoration-Crown-Onia/ Overdenture aubutment根管治疗的成功率（调查了1200颗牙齿）%冠修复无冠修复总计94.875.8上颌前牙87.585.4上颌前磨牙93.956FJX尸7 =巾上颌磨牙97.850下颌前牙97.594.4下颌前磨牙93.862.5下颌磨牙96.857.7RjwtwHm rf Eh-s EnocxkjfihcaHy Trusoad Toett

20、i-械 xbeMrirltaf Mi4.Success of Endo修复体的功能:对咬合力的防护防止细菌的侵入，因为树脂及牙胶充填都会有微渗漏顺应现存的咬合组合患者的美观接受性Functions of restoration-Protection from occlusal Ioad-s Prevent bacte ri a I ingress Compl/ with e)ciiti/ig occluwl ichetrteRDsestheTicalfy accptablt?怕patient冠内修复体：银汞合金一充填压力有可能引起根管壁的折裂，银汞合金充填需要粘结复合树脂一美观性更好，但有聚合

21、收缩，会引起充填后的微渗漏ftestwatw-时BwT reartid Tecffi - WedBm tsIerLiteIntra-coron刘restoration Amalgam-ConiJensat on lerees-rieed for bonding* Ccmpcsite resin-Aesthetical J v better-Polympn &3tion hrink ftexuF*t* Microloahig*牙尖覆盖修复的考虑原则：涉及前磨牙的一个边缘嵴涉及磨牙的两个边缘嵴，尤其是缺损大于牙尖间距的ft:esionSon Ot:Mi jfacfcxtoMfcBBjr T

22、eoffa Tge -片WSEhtat凹50%BM*叵ndad-tfibeaUy Treabed Tgesii Modem扎gteca色Rule of thumb- to consider When to cons id er匚uspaf coverage-Involving one marginal ridge in premolarteth invo Iving both margi nai ridges in molar teeth,panicularly when above 50% of intercuspilNayyar核:一种根管治疗后的后牙银汞合金冠根的楔核技术，用根管的冠方2

23、-3mm来固位修复体的方法牙尖覆盖修复体:高嵌体全冠核冠Flo雷w白gn & Sfihfi- EmaErtionbeaEl-j- Trtai*d Toccn -LhiefiaiiCuspal Coverage Restoration Only Crown Post crown桩的选择：桩会对核的提供固位一般来讲冠方牙体组织有限的单根牙需要桩的修复像Nayyar核在多根牙中固位良好fteslKHatM-n奇T hi申空nOog祀Wy THMM Tcxsth - higBL祖盲戸耳理Post Choice“ Post provide additional retention to cere

24、 Posts呂enerally required for single rootedteeth with limited coronal tooth tissue Cors in multi-rooted teeth retained祚Nayyar core桩的选择：患者定做的或者预制的。患者定做的桩，密合性好，能协助形成箍效应，但花费高；成品 桩，可即刻封闭缺损，但技术要求高主动就位或被动就位，主动就位的核会增加根部牙体组织的应力，被动就位的核需要粘结平行桩或锥形桩，实验室研究表明平行桩会增加固位力，锥形桩跟牙根形态一致Post Choices Custom-made or prefabri

25、catedActive or passive PraHel ar tapered MTprial compositionH.0- 4 jp-i.il uKLi*口be rcLixfirdlR科如TlKfi 6罚呻: 4ll y 7rw?rtCl- -?orate ferrule亠Expen&e Prefabricated-irtflrediaui of cavity-Technique誨nsititf电Restoration of the Enocoonocny Trwned Tooth Mooem F.tatenafcs Passive-Requires bondingReHxeos

26、 of Ge Enoodonbcalfy Treated Tooth - Modem hZecaHUlG快6 AM Active一Increased stress on root structuref.C( (WVIV/VWJLWtfMirr*ftestootteU*voatk8q80iReol8q80iReol幻98810169881016农吋雹THBAM wtii - R18BE罄吐那号* PraNI亠Laboratory studies ind：icate improwcci r(jtnstructing Broken Down and Endodontically Treated Tee