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学术前沿

国际牙外伤协会的年轻恒牙外伤管理指南1(2007年版)(张增方译制初稿完善中)

发表者:张增方 8261人已读

Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth

牙外伤指南1 恒牙折断及脱位


 好大夫工作室儿童口腔科张增方

 

Fig 1. (a) A 9-year-old girl visiting the emergency dental clinic 30 min after falling from a bicycle. (b) (close up view of Fig. 1a) Clinical examination showing lateral luxation of the left central incisor with fracture of the alveolar process. The incisor is luxated to a superior and labial position.

图1(a)9岁女孩儿从单车上摔下,30分钟后到急诊科就诊。临床检查可见左上中切牙侧方脱位,伴有牙槽突骨折。中切牙向上唇侧方向脱位。

Fig. 2. Crown fracture of right central incisor and crown-root fracture of left central incisor.

图2   右侧上中切牙冠折及左侧上中切牙冠根折

Fig. 3. Intrusive luxation of right lateral and central incisors. Crown fractures are seen on both intruded incisors and the

adjacent left central incisor.

图3 右侧侧切牙及中切牙挫入性脱位。两个挫入牙及左侧中切牙见冠折。

 

一、    年轻恒牙牙折及牙槽突骨折的治疗指南

Treatment guidelines for fractures of teeth and alveolar bone

Clinical findings

Radiographic findings

Treatment

Uncomplicated crown fracture

Fracture involves enamel or dentin and enamel; the pulp is not exposed.

Sensibility testing may be negative initially indicating transient pulpal damage;

monitor pulpal response until a definitive pulpal diagnosis can be made

非复杂性冠折

牙折累及釉质或釉本质;未露髓。

敏感试验最初可能阴性,意味着暂时性的牙髓创伤,需监控牙髓反应直到诊断明确

 

The 3 angulations described in radiographic examination to rule out displacement or fracture of the root.

Radiograph of lip or cheek lacerations is recommended to search for tooth fragments

or foreign material

 

三角度牙片??来明确牙移位及根折情况。

建议唇颊部软组织影像来排除牙碎片及异物

 

If tooth fragment is available, it can be bonded to the tooth.

Urgent care option is to cover the exposed dentin with a material such as glass ionomer or a permanent restoration using a bonding agent and composite resin.

Definitive treatment for the fractured crown may be restoration with accepted dental restorative materials

如果能找到冠折片可将其粘结于牙齿。

紧急处理措施是尽快覆盖暴露的牙本质,可用玻璃或粘结剂加永久树脂恢复冠外形。

明确的治疗方案是:用可接受的材料恢复冠外形。

 

Complicated crown fracture

Fracture involves enamel and dentin and the pulp is exposed.

Sensibility testing is usually not indicated initially since vitality of the pulp can be

visualized. Follow-up control visits after initial treatment includes sensibility testing to monitor pulpal status

复杂性冠折

牙折累及釉质或釉本质;已露髓。

 ??最初的敏感试验常常

不明确因为可见活髓。

初诊治疗结束后应多次复诊进行明显敏感试验仪明确牙髓状态

The 3 angulations described in radiographic examination to rule out displacement or fracture of the root. Radiograph of lip or cheek lacerations is recommended to search for tooth fragments

or foreign material.

The stage of root development can be determined from the radiographs

三角度牙片??来明确牙移位及根折情况。

建议唇颊部软组织影像来排除牙碎片及异物

影像学可明确牙根的发育阶段

In young patients with immature, still developing teeth, it is advantageous to

preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide and MTA (white) are suitable materials for such procedures.

 

 

In older patients, root canal treatment can be the treatment of choice, although pulp capping or partial pulpotomy may also be selected.

 

 If too much time elapses between accident and treatment and the pulp becomes necrotic, root canal treatment is indicated to preserve the tooth.

 

 In extensive crown fractures a decision must be made whether treatment other than extraction is feasible

对于年轻恒牙应尽量通过盖髓术或冠髓切断术来保存活髓;

对于牙根发育完全的年轻患者也可采取通过盖髓术或冠髓切断术来保存活髓

氢氧化钙或MTA是合适的材料;

 

对于年龄稍大的患者可考虑选择RCT,然而仍可采用盖髓术或冠髓切断术。

 

如果外伤就诊时间太迟已经发生牙髓坏死, RCT是明确的治疗方案。

对于大面积的冠折,应考虑是否治疗还是拔除。?

Crown-root fracture

Fracture involves enamel, dentin and root structure; the pulp may or may not be

exposed. Additional findings may include loose, but still attached, segments of the tooth (Fig. 2).

Sensibility testing is usually positive

冠根折

牙折累及釉质,牙本质及根部;可能露髓或未露髓;检查可及松动,但折断片仍与牙连接(图2)

敏感试验阳性

 

As in root fractures, more than one radiographic

angle may be necessary to detect fracture lines in the root (see radiographic examination)

必要时可采用多角度牙片判断根折线的位置

Treatment recommendations are the same as for complicated crown fractures (see above).

In addition, attempts at stabilizing loose segments of the tooth by bonding may be advantageous, at least as a temporary measure, until a definitive treatment plan can be formulated

治疗建议同复杂性冠折

 

另外,可尝试固定粘结折断片,只少可做为在明确治疗方案之前的一种临时性的方法

 

《牙外伤手册》26页中B建议切除腭侧牙槽骨,是否值得这么做,种植医师的意见??

 

冠根折的治疗目的多是为后期做桩核冠修复而延长根使其达龈上做准备

Root fracture

The coronal segment may be mobile and may be displaced.

The tooth may be tender to percussion.

Sensibility testing may give negative results initially, indicating transient or permanent pulpal damage; monitoring the status of the pulp is recommended. Transient crown discoloration (red or grey) may occur

根折

冠断片可能松动或移位,叩痛明显,最初敏感试验阴性,意味着牙髓创伤,建议监测牙髓状态,可能出现暂时性的牙冠变色

The fracture involves the root of the tooth and is in a horizontal or diagonal plane. Fractures that are in the horizontal plane can usually be detected in the regular 90_ angle film with the central beam through the tooth. This is usually the case with fractures in the cervical third of the root. If the plane of fracture is more diagonal, which is common with apical third fractures, an occlusal view is more likely to demonstrate the fracture including those located in the middle third

根部涉及水平吧或斜面的折断。水平折断常常可由90度投照可见,此种折断常见于颈部根折;呈斜面的折断在根中或根尖部折断常见,可采用咬合片协助诊断

Reposition, if displaced, the coronal segment of the tooth as soon as possible. Check position radiographically. Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). It is advisable to monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth

若存在移位,尽可能将冠方部分复位,并拍定位牙片,将患牙弹性固位4周。

若根折靠近牙颈部,应将固定时间延长(可4个月以上)。

复查牙髓状态1年,若出现牙髓坏死,行冠方部分RCT以保留患牙。

??为什么只做冠方部分,若颈部及中不折断也是这样吗??根部髓不会感染吗??不会残髓炎吗?临床具体怎么操作?才知道刚刚好做到了根折处。

Alveolar bone fracture

The fracture involves the alveolar bone and

may extend to adjacent bone. Segment mobility and dislocation are common findings. An occlusal change due to

misalignment of the fractured alveolar segment is often noted. Sensibility testing may or may not be

Positive

牙槽突骨折

骨折累及牙槽骨,且可累及临骨??

常存在折断片松动及移位,咬合关系改变,

牙敏感试验阴性或阳性

Fractures lines may be located at any level,

from the marginal bone to the root apex.

The panoramic technique is of great help in determining the course and position of fracture lines

骨折线可能位于从骨边缘(牙颈部)到根尖的任何水平。

全景片可明确骨折线的位置及走向。

Reposition any displaced segment and then

splint. Stabilize the segment for 4 weeks

 

移位断片复位及夹板固定。

固定4周后拆除。


恒牙折断及牙槽突折断的复查程序


Time

4 weeks

6–8 weeks

4 months

6 months

1 year

 

5 years

Uncomplicated crown fracture

 

C(1)

 

 

C(1)

 

Complicated crown fracture

 

C(1)

 

 

C(1)

 

Crown-root fracture

 

C(1)

 

 

C(1)

 

Root fracture

S + C(2)

C(2)

S(*) + C(2)

C(2)

C(2)

 

C(2)

Alveolar fracture

S + C(3)

C(3)

C(3)

C(3)

C(3)

C(3)

S, splint removal.

S (*), splint removal in cervical third fractures.

C, clinical and radiographic examination

 

恒牙折断及牙槽突折断一些好的或坏的预后情况


 

Favorable outcome

Unfavorable outcome

1

Asymptomatic; positive response to pulp testing; continuing root

development in immature teeth. Continue to next evaluation

无症状;活力测阳性;

年轻恒牙牙根继续发育;

继续评估;

Symptomatic; negative response to pulp testing; signs of apical

periodontitis; no continuing root development in immature teeth.

Root canal treatment is indicated

有临床症状;活力测阴性;有根尖周炎的迹象;年轻恒牙牙根未能继续发育;需RCT

2

Positive response to pulp testing (false negative possible up

to 3 months). Signs of repair between fractured segments.

Continue to next evaluation

 

Negative response to pulp testing (false negative possible up to

3 months). Clinical signs of periodontitis. Radiolucency adjacent to

fracture line. Root canal treatment is indicated only to the line of

fracture(临床上怎么操作达到这个?)

活力测阴性(可能3月以上假阴性??),有根尖周炎的临床症状;邻近折断线处见低密度影。RCT只达折断处,保留根髓

3

Positive response to pulp testing (false negative possible up to

3 months). No signs of apical periodontitis. Continue

to next evaluation

活力测阳性(3月以上假阴性);

无根尖周炎的signs迹象

继观评估

Negative response to pulp testing (false negative possible up to

3 months). Signs of apical periodontitis or external inflammatory resorption. Root canal treatment is indicated

活力测阴性(可能3月以上假阴性);

有根尖周炎及根外表吸收的迹象;(见《牙外伤手册》51页关于“感染引起根吸收的治疗”)

行RCT。


二、    牙脱位治疗指南

Treatment guidelines for luxation injuries

Clinical findings

Radiographic findings

Treatment

Concussion

The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility.

Sensibility tests are likely to give positive results

牙震荡

牙齿轻触敏感,叩痛明显,无移位及松动。敏感试验阳性。

No radiographic abnormalities

无影像学异常

No treatment is needed. Monitor pulpal condition for at least 1 year

无需处理。复查牙髓状况至少一年。

Subluxation

The tooth is tender to touch or tapping and has increased mobility; it has not been displaced.

Bleeding from gingival crevice may be noted.

Sensibility testing may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made

亚脱位(牙松动)

牙齿轻触敏感,叩痛明显;有一定松动但无移位;

可见龈沟出血;

敏感试验最初可阴性,表示暂时性牙髓创伤;

需复查牙髓反应直到明确牙髓诊断

Radiographic abnormalities are usually not found

影像学常无异常。

A flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks

采用弹性夹板固定至少2周,以减轻患者不适。

Extrusive luxation

The tooth appears elongated and is excessively

mobile.

Sensibility tests will likely give negative results.

 In mature teeth, pulp revascularization some times

occurs. In immature, not fully developed teeth,

pulpal revascularization usually occurs

牙部分脱位

牙伸长,松动明显。

敏感试验可能阴性。

在发育完成的恒牙有时也可出现牙髓血管再生;在年轻恒牙常可出现牙髓再生。

 

Increased periodontal ligament space apically

根尖部可见牙周膜间隙增宽

Reposition the tooth by gently re-inserting it

into the tooth socket. Stabilize the tooth for

2 weeks using a flexible splint. Monitoring the

pulpal condition is essential to diagnose root

resorption. In immature developing teeth, revascularization

can be confirmed radiographically by

evidence of continued root formation and pulp

canal obliteration and usually return to response

to sensibility testing. In fully formed teeth, a

continued lack of response to sensibility testing

should be taken as evidence of pulp necrosis

together with periapical rarification and sometimes

crown discoloration

用轻柔力将脱位牙复位于牙槽窝;弹性夹板固位脱位牙2周;

??定期复查牙髓状态对诊断根吸收是必要的(?牙髓坏死感染是造成根吸收的原因)(恒牙出现根吸收的机会不大吧?预后一般是:年轻恒牙出现根管闭锁,成熟恒牙出现牙髓坏死,且年轻恒牙预后要好些)

对于年轻恒牙可通过X线片复查确定是否出现牙髓血管再生,如果有再生则牙根会继续发育及出现根管闭锁,而且常常会出现敏感试验恢复正常。

对于成熟恒牙,持续的敏感试验无反应就意味着牙髓坏死,可能伴随出现根尖周rarification??,有时还会出现牙冠变色。

Lateral luxation

The tooth is displaced, usually in a palatal/lingual or labial direction (Fig. 1a, b). It will be immobile and percussion usually gives a high, metallic

(ankylotic) sound.

Sensibility tests will likely give negative results.

In immature, not fully developed teeth, pulpal revascularization usually occurs

侧方移位

牙齿出现了向唇/腭向或侧方移位;(视)

牙齿不松,叩诊呈高调固连音;(触叩)

敏感试验阴性;

年轻恒牙常出现牙髓再生

The widened periodontal ligament space is best seen on eccentric or occlusal exposures

咬合片可见牙周膜间隙增宽

Reposition the tooth with forceps to disengage it from its bony lock and gently reposition it into its original location. Stabilize the tooth for 4 weeks using a flexible splint. Monitor the pulpal condition. If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption. In immature, developing teeth, revascularization can be confirmed radiographically by evidence of continued root formation and possibly by positive sensibility testing.

In fully formed teeth, a continued lack of response to sensibility testing indicates pulp necrosis, along with periapical rarification and sometimes crown discoloration

牙钳松解骨内锁结,予轻柔复位到原来的位置;

弹性夹板固定4周;

复查牙髓状态;如果出现牙髓坏死,及时行RCT以避免牙根吸收??(牙髓坏死与牙根吸收的关系,成熟恒牙也容易出现牙根吸收??临床见到的多吗?)

对于年轻恒牙可通过X线片检查牙根继续发育的情况来确定是否出现牙髓血管再生,也可通过牙髓反应来证明。

对于成熟恒牙,持续的敏感试验无反应就意味着牙髓坏死,可能伴随出现根尖周rarification??,有时还会出现牙冠变色。

Intrusive luxation

The tooth is displaced axially into the alveolar bone.

It is immobile and percussion may give a high, metallic (ankylotic) sound (Fig. 3).

Sensibility tests will likely give negative results.

In immature, not fully developed teeth, pulpal revascularization may occur

牙挫入

牙齿轴向移位至牙槽骨;

牙齿不松,叩诊呈高调固连音;

敏感试验阴性;

年轻恒牙可能出现牙髓再生

The periodontal ligament space may be absent from all or part of the root

牙周膜间隙完全消失或部分消失

1. Teeth with incomplete root formation:

Allow spontaneous repositioning to take place. If no movement is noted within 3 weeks,

recommend rapid orthodontic repositioning.

2. Teeth with complete root formation:

The tooth should be repositioned either orthodontically or surgically as soon as possible.

The pulp will likely be necrotic and root canal treatment using a temporary filling with calcium hydroxide is recommended to retain the tooth

1.     年轻恒牙:可任其自行萌出;若3周内无任何移出,建议快速正畸牵出。

(局麻下轻轻摇松解除锁结,任其自行萌出,,或正畸牵引,保证3周内复位,这样一旦发生牙髓坏死或炎性吸收可及时RCT----- 40页 《牙外伤》葛立宏译)

2.     成熟恒牙:尽快正畸复位或外科手术复位;一般都会发生牙髓坏死,应行RCT,并建议暂时用氢氧化钙充填根管以保留患牙。

不可能自行萌出;可外科复位或正畸牵引复位;正畸牵引应在3周内完成;之后行预防性牙髓摘除;需密切观察牙折牙髓并发症----40页 《牙外伤》葛立宏译

Avulsion

牙完全脱出属于另一种不同的系列  见年轻恒牙外伤指南2

 

 


Follow-up procedures for luxated permanent teeth 

脱位恒牙的复查程序


Time

至少2w

4w

6-8w

6m

1y

5y内每年复查

牙震荡/亚脱位

 

C(1)

C(1)

 

C(1)

NA

牙部分脱出

S+C(2)

C(3)

C(3)

C(3)

C(3)

C(3)

牙侧方移位

C(3)

S

C(3)

C(3)

C(3)

C(3)

牙挫入

C(4)

 

C(4)

C(4)

C(4)

C(4)

S, splint removal.夹板拆除   C, clinical and radiographic examination.临床及X线检查   NA, not applicable.


Favorable and unfavorable outcomes include some, but not necessarily all of the following

良性和不良预后


 

Favorable outcomes

unfavorable outcomes

1

Asymptomatic;

positive response to pulp testing (false negative possible up to 3 months);

continuing root development in immature teeth;

intact lamina dura??

无临床症状;

牙髓活力测阳性(可能出现3个月以上的假阳性);

年轻恒牙的牙根继续形成;

牙周膜完好?完美的根尖周表现?

Symptomatic;

negative response to pulp testing (false negative possible up to 3 months);

no continuing root development in immature teeth, periradicular radiolucencies

有临床症状;

牙髓活力测阴性(3个月以上的假阴性??);

年轻恒牙牙根停止发育;

根尖周出现低密度影;

 

2

Minimal symptoms;

slight mobility;

no excessive radiolucency periradicularly

轻微的临床症状;

轻度松动;

根尖周无低密度影

Severe symptoms;

excessive mobility;

clinical and radiographic signs of periodontitis.

Root canal treatment is indicated in a closed apex tooth.

In immature teeth, apexification procedures are indicated

严重的临床症状;

严重的松动;

临床及X线支持根尖周炎;

成熟恒牙行RCT;

年轻恒牙行根尖诱导术

 

3

Asymptomatic;

clinical and radiographic signs of normal or healed periodontium; positive response to pulp testing (false negative possible up to 3 months). Marginal bone height corresponds to that seen radiographically after repositioning

无临床症状;

临床及X线检查正常,牙周愈合良好;

牙髓活力测试正常(3月以上的假阳性)

牙槽突边缘高度与刚复位时一致

 

Symptoms and radiographic sign consistent with periodontitis;

negative response to pulp testing (false negative possible up to 3 months); breakdown of marginal bone??. Splint for additional 3- to 4- week period; root canal treatment is indicated if not previously initiated??;

chlorhexidine mouth rinse

临床表现及X线显示根尖周炎;

牙髓活力测试阴性(3个月以上的假阳性);

牙槽突出现吸收,

继续夹板固定3到4周,

行RCT?

4

Tooth in place or erupting;

intact lamina dura; no signs of resorption. In mature teeth, start the root canal treatment within the first 3 weeks

牙就位并再萌;

根尖周完好?,未出现牙根吸收;

成熟恒牙在3周内开始RCT

Tooth locked in place/ankylotic tone??; radiographic signs of apical periodontitis; external inflammatory resorption or replacement resorption?

牙固连?

X线诊断根尖周炎;

外缘炎性吸收或内吸收??


Splinting guidelines for tooth/bone fractures and luxated/avulsed teeth

三、牙/骨折断及脱位/脱出的夹板固定指南

 

Splinting times 固定时间

Type of injury Splinting time

Subluxation                   2 weeks

Extrusive luxation              2 weeks

Avulsion                     2 weeks

Lateral luxation                4 weeks

Root fracture (middle third)      4 weeks

Alveolar fracture               4 weeks

Root fracture (cervical third)     4 months

 

Type of splints 固定的种类

Acid-etch bonded composite splints are recommended, e.g. wire-composite splints and TTS (titanium trauma splint). For detailed description of splinting see current textbooks and articles

推荐全酸树脂夹板固定,例如加强丝-树脂夹板或外科钛丝夹板。夹板的详细描述详见文献。


References

1. Andreasen JO, Andreasen F, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn.

Oxford: Blackwell Munksgaard; 2007.

2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55–68.

3. Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Vastmanland, Sweden. Swed Dent J 1996;20:15–28.

4. Flores MT, Andreasen JO, Bakland LK et al.. International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001;17:1–4.

5. Andreasen JO, Andreasen F, Bakland L, Flores MT. Traumatic dental injuries. A manual, 2nd edn. Oxford: Blackwell Munksgaard; 2003.

6. Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries - a review article. Dent Traumatol 2002;18:116–28.

7. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20:192–202.

8. Cvek M, Meja`re I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261–269.

9. Cvek M, Andreasen JO, Borum MK. Healing of 208 intraalveolar root fractures in patients aged 7–17 years. Dent Traumatol 2001;17:53–62.

10. Jackson NG, Waterhouse PJ, Maguire A. Factors affecting treatment outcomes following complicated crown fractures

managed in primary and secondary care. Dent Traumatol 2006;22:179–85.

11. Rafter M. Apexification: a review. Dent Traumatol 2005;21:1–8. Review.

12. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the

effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dent Traumatol 2006;22:99– 111.

13. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors, such as sex, age, stage of root development, tooth location, and extent of injury including number of intruded teeth on 140 intruded permanent teeth. Dent Traumatol 2006;22:90–8.

14. Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:83–9.

15. Filippi A, von Arx T, Lussi A. Comfort and discomfort ofdental trauma splints - a comparison of a new device (TTS)

with three commonly used splinting techniques. Dent Traumatol 2002;18:275–80.

16. Von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used

splinting techniques. Dent Traumatol 2001;17:266–74.

17. Von Arx T, Filippi A, Buser D. Splinting of traumatized teeth with a new device: TTS (Titanium Trauma Splint). Dent Traumatol 2001;17:180–4.

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发表于:2012-05-19 17:02

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