兒童及青少年牙和支持組織的外傷

1、兒童及青少年牙和支持組織的外傷口腔預(yù)防兒童科18/20/2022chi2Trauma to the Teeth and Supporting TissuesDental TraumaHow to DiagnosisTreatment to the Dental Trauma28/20/2022chi3概 論38/20/2022chi4參考書Mc Donald RE and Avery DR. Dentistry for the Child and Adolescent,6th ed. st. Louis: C.V.Mosby,Co,1994. Andreason JO and Andreaso

2、n FM. Essentials of traumatic injuries to the teeth. Denmark: Laursen A/S, Tnder, 1990. Endodontics and Dental Traumatology48/20/2022chi5The International Association of Dental Trauma (IADA)國(guó)際牙外傷協(xié)會(huì)58/20/2022chi6牙外傷(Dental Trauma or Injuries)是指牙齒受到急劇的創(chuàng)傷，特別是打擊、撞擊等所引起的牙體、牙髓和牙周組織的損傷。（急性的）68/20/2022chi7兒

3、童牙外傷的特點(diǎn)年齡特點(diǎn)：兒童及青少年的發(fā)病率高年齡高峰：乳牙 13歲 恒牙79歲發(fā)生部位：切牙尖牙磨牙 上頜 下頜性別比較：男性 女性78/20/2022chi8乳牙外傷后影響后繼恒牙的發(fā)育：釉質(zhì)發(fā)育不全 or 鈣化不全 修復(fù)性牙本質(zhì)形成 彎曲牙 部分牙根停止發(fā)育影響后繼恒牙的正常萌出影響恒牙列的正常形成88/20/2022chi9恒牙外傷后牙體組織的缺失或缺損 接觸點(diǎn) 鄰牙傾斜；間隙的喪失；對(duì)頜牙的伸長(zhǎng)（替牙期的患者影響更大）98/20/2022chi10牙外傷后外傷牙本身預(yù)后的不定性，兒童生長(zhǎng)發(fā)育的活躍性，診斷的困難性。當(dāng)時(shí)口腔局部的創(chuàng)傷；以后機(jī)體的生理和心理上的創(chuàng)傷牙醫(yī)：作出快速、正確、

4、全面的診斷；作出正確的處理；減少后遺癥。10牙外傷的診斷？118/20/2022chi12牙外傷的診斷病史臨床檢查發(fā)射性X線片的檢查128/20/2022chi13病 史 年齡，性別，外傷原因，作用力的大小和方向，發(fā)生地點(diǎn)及環(huán)境污染情況，外傷確切的時(shí)間，對(duì)冷熱的反應(yīng)，是否影響咬合，就診前脫位牙的保存情況，是否經(jīng)過(guò)一段無(wú)意識(shí)期，有無(wú)惡心、嘔吐，全身有無(wú)影響治療的疾患：血友病等，以前有無(wú)牙外傷史問(wèn) 查138/20/2022chi14臨床檢查電活力測(cè)定 兩種觀點(diǎn)新的、陌生的儀器 兒童 害怕；有效性（髓休克3個(gè)月）機(jī)會(huì)；首次電活力意義（Rock等在1974年報(bào)道1年后82有活力） 積極治療；微不足道的

5、刺激冷熱診 常適用乳牙光透射情況 （光束由舌側(cè)向唇側(cè)照射）其它：松動(dòng)度檢查 多個(gè)牙一起動(dòng)提示？叩診檢查 metallic / dull percussion tone提示？148/20/2022chi15放射性X線片檢查患牙與鄰牙、對(duì)側(cè)同名牙作比較比較髓腔、根管的大小、形態(tài)以及發(fā)育情況根折的檢出率：（假陰性） X線透射中心的射線與牙折線一致或平行 夾角1520 夾角1520 無(wú)法顯示 若懷疑有根折，改變角度，加拍23張牙片15牙外傷的治療？168/20/2022chi17Treatment to the Dental TraumaInjury to the Primary DentalCrow

6、n FracturesCrown-Root FracturesRoot FracturesAvulsionConcussion and SubluxationExtrusionLateral LuxationIntrusionFracture of the Alveolar Process178/20/2022chi18治療原則乳牙外傷冠折根折冠根聯(lián)合折牙完全性脫位牙震蕩牙伸長(zhǎng)牙側(cè)向移位牙嵌入牙槽骨骨折軟組織外傷188/20/2022chi19Injuries to the Primary DentitionVerify eventual collision between a displac

7、ed primary tooth and its permanent successorIf this has occurred, remove the displaced incisorIf not ,observationMonitor healing regularly with routine clinical and radiographic examination198/20/2022chi20乳 牙 外 傷兒童的牙槽骨韌性較好，臨床上以外傷移位多見處理上要謹(jǐn)慎乳牙外傷發(fā)生移位，傷及后繼恒牙胚乳牙外傷繼發(fā)感染，傷及后繼恒牙胚208/20/2022chi21乳 牙 外 傷冠折：治療原

8、則同恒牙冠根聯(lián)合折 ：拔牙，殘留牙根（生理性吸收）根折： 固定困難，拔除側(cè)向移位： 觀察/拔除嵌入： 觀察/拔除完全性脫位： 不作再植術(shù)218/20/2022chi22Crown FracturesFractures of enamel Grinding Composite restoration Fractures of enamel and dentin Composite restoration Re-attachment of the crown fragmentPulp exposures Pulp capping Pulpotomy 228/20/2022chi23冠 折Crown

9、 Fractures僅累及牙釉折層：磨改、樹脂修復(fù)累及牙本質(zhì)：間接蓋髓后，作牙折片再粘、樹脂修復(fù)累及牙髓腔：直接蓋髓術(shù)或活髓切斷術(shù)后，作冠修復(fù)238/20/2022chi24Pulp CappingIsolate the pulp exposureCover the pulp with a calcium hydroxide materialRestore the teeth either immediately or after 3 month period248/20/2022chi25PulpotomyIsolate the pulp exposureAmputate the pulp

10、to a level approximately 2 mm below the exposure site,or to where fresh bleeding is seenRestore the tooth either immediately or after a 3-month period 258/20/2022chi26Crown-Root fracturesRemoval of the coronal fragment with subsequent restoration above gingival levelRemoval of the coronal fragment s

11、upplemented by gingivectomy and osteotomy and subsequent restoration with a post-retained crownRemoval of the coronal fragment and surgical extrusion of the rootRemoval of the coronal fragment and subsequent orthodontic of the root268/20/2022chi27冠 根 聯(lián) 合 折crown root fractures拔除冠折片，齦上冠修復(fù)拔除冠折片，齦、骨切除術(shù)，

12、冠修復(fù)拔除冠折片，外科牙根伸長(zhǎng)法，冠修復(fù)拔除冠折片，正畸牙根伸長(zhǎng)法，冠修復(fù)縱折：拔除278/20/2022chi28Root FracturesCheck for pulpal complications after 3 weeks,6 weeks and 3 monthsReposition the coronal fragment and use firm splinting for 3 monthsRoot : crown1/3 middle1/3 apical1/3288/20/2022chi29根 折root fractures頸1/3:拔除“牙折冠”，根管治療后，齦切或牽引冠修復(fù)中

13、1/3:復(fù)位固定3個(gè)月尖1/3:觀察或復(fù)位固定3個(gè)月298/20/2022chi30AvulsionReplantation procedure Place the avulsed tooth in saline Examine the socket area Rinse the periodontal ligament and apical foramen with saline Flush the socket with saline Replant the tooth Splint the tooth for 12 weeks Antibiotic therapy T.A.T308/20

14、/2022chi31牙完全脫位avulxion再植術(shù)復(fù)位固定12周 (無(wú)PDL者 6周）氫氧化鈣糊劑作暫時(shí)性根充抗炎治療：普魯卡因青霉素 6080萬(wàn)單位 2次/日 肌肉注射TAT注射318/20/2022chi32牙完全脫位avulxion再植術(shù)治療要點(diǎn)脫位牙的保存情況：牛奶、NS等脫位牙的脫位時(shí)間： 30min 2hour 牙周膜的處理：保留與否牙槽窩的處理：清除血凝塊，NS沖洗328/20/2022chi33牙完全脫位avulxion再植術(shù)治療效果取決于外傷牙的保存 濕潤(rùn)/干燥外傷牙的脫位時(shí)間30分鐘以內(nèi)：2年或更長(zhǎng)，90無(wú)牙根內(nèi)吸收2小時(shí)以外：95牙根發(fā)生內(nèi)吸收338/20/2022ch

15、i34Concussion and SubluxationOcclusal relief(e.g. by selective grinding of opposing teeth) and a soft dietImmobilization of the involved teeth may be appropriate for patient comfort,2 weeks fixation 348/20/2022chi35牙震蕩/亞脫臼concusion/subluxution概念牙震蕩：牙周lig內(nèi)出血、水腫，完整，牙一般無(wú)松動(dòng)亞脫臼：牙周lig內(nèi)出血、水腫，部分撕裂，牙一般有松動(dòng)、伴齦

16、溝出血調(diào)合，軟飲食（2周），一般不需要固定（若固定，應(yīng)2周）358/20/2022chi36ExtrusionRepositioningFixation 23 weeks 368/20/2022chi37牙 伸 長(zhǎng)extrusion（局麻）復(fù)位固定23周牙髓存活情況牙根形成的：50存活牙根未形成的：90以上存活根管治療時(shí)機(jī)：觀察期間， X線檢查一旦發(fā)現(xiàn)根尖牙根、牙槽骨有炎性吸收378/20/2022chi38Lateral LuxationLocal anestheticRepositioningFixation 3 weeksIf radiographic examination revea

17、ls a temporary breakdown of the marginal bone,maintain fixation for up to 2 months388/20/2022chi39牙 側(cè) 向 移 位lateral luxation（局麻下）復(fù)位固定3周根管治療時(shí)機(jī)：觀察期間，X線檢查一旦發(fā)現(xiàn)根尖牙根、牙槽骨有炎性吸收398/20/2022chi40IntrusionImmature root formation Await spontaneous re-eruption,usually takes 24 months Monitor pulpal healing radiogr

18、aphically 3,4 and 6 weeks after injuryMature root formation Await spontaneous re-eruption or extrude orthodontically over a period of 2 3 weeksExtirpate the pulp 2 weeks after injury,using calcium hydroxide paste as an interim dressing408/20/2022chi41牙 嵌 入intrusion診斷：病史、叩診（metallic音)、X線檢查牙髓壞死率牙根未形成：

19、50 牙根已形成：100 牙根吸收牙根未形成：58% 牙根已形成：70 418/20/2022chi42牙 嵌 入intrusion牙根尚未形成：觀察24月（再萌）牙根已形成：觀察（10天）和/或正畸牽引（23周）OR 外科拔牙復(fù)位固定4周氫氧化鈣糊劑作暫時(shí)性根充428/20/2022chi43Fracture of the Alveolar ProcessLocal anestheticRepositioning Fixation 34 weeks438/20/2022chi44牙槽骨骨折局部的牙槽骨骨折局麻下，復(fù)位固定（34周）根尖鎖?。ˋpical Lock)448/20/2022chi45軟組織外傷清創(chuàng)縫合TAT注射抗炎治療458/20/2022chi46牙外傷常見的幾種治療方法468/20/2022chi47牙外傷常見的幾種治療方 法復(fù)合樹脂修復(fù)技術(shù)（直接、間接）蓋髓術(shù)活髓切斷術(shù)根尖成行術(shù)根管治療術(shù)（復(fù)位）固定術(shù)478/20/2022chi48活髓切斷術(shù)適應(yīng)證：露髓比較多，時(shí)間比較長(zhǎng)，估計(jì)牙髓炎癥局限于冠髓或根髓的冠1/3以內(nèi)488/20/2022chi49根尖成形術(shù)適應(yīng)證