国际口腔医学杂志

国际口腔医学杂志 ›› 2020, Vol. 47 ›› Issue (4): 373-382.doi: 10.7518/gjkq.2020056

• 专家笔谈 •    下一篇

原发性牙根纵裂的诊治策略

李继遥1(),郑广宁2   

  1. 1.口腔疾病研究国家重点实验室 国家口腔疾病临床医学研究中心四川大学华西口腔医院牙体牙髓病科 成都 610041
    2.口腔疾病研究国家重点实验室 国家口腔疾病临床医学研究中心四川大学华西口腔医院口腔放射科 成都 610041
  • 收稿日期:2020-02-21 修回日期:2020-03-27 出版日期:2020-07-01 发布日期:2020-07-10
  • 通讯作者: 李继遥
  • 作者简介:李继遥,教授,博士<br/>专家简介:<br/>李继遥,口腔医学博士,教授,博士研究生导师。现任四川大学华西口腔医学院口腔内科学系主任,担任中华口腔医学会牙体牙髓病学专业委员会常务委员、四川省口腔医学会口腔美学专业委员会主任委员、四川省口腔医学会牙体牙髓病学专业委员会副主任委员。主要研究领域为牙体牙髓病的病因与防治、牙体硬组织仿生矿化。发表学术论文50余篇,主编专著2部、主译专著1部。先后负责或参与了国家自然科学基金项目,国家“十五”、“十一五”、“十二五”科技支撑计划项目,国家卫生健康委员会临床重点建设项目等10余项。作为主要完成人之一获国家科技进步二等奖1项、教育部科技进步一等奖3项、四川省科技进步一等奖2项、国家发明专利6项。擅长牙体牙髓病的现代治疗,尤其在牙体微创美学修复方面具有特色
  • 基金资助:
    四川省科技厅重点研发项目(2017SZ0030)

Spontaneous vertical root fracture: a diagnosis and treatment challenge

Li Jiyao1(),Zheng Guangning2   

  1. 1. State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cariology and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
    2. State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral Radiology, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
  • Received:2020-02-21 Revised:2020-03-27 Online:2020-07-01 Published:2020-07-10
  • Contact: Jiyao Li
  • Supported by:
    This study was supported by Sichuan Province Science and Technology Support Program(2017SZ0030)

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摘要：

非根管治疗相关的牙根纵裂又被称为原发性牙根纵裂（SVRF）,是牙科临床难症。由于临床症状、体征、早期影像学表现缺乏特征性,即便是对于经验丰富的牙医,诊断SVRF也极具挑战性;当SVRF确诊后,又面临截断、修复纵裂牙根或者拔除纵裂患牙的抉择,而拔牙后的修复时机、修复方式也是需要评估的问题。笔者根据文献复习和近3年的临床病例研究结果,对SVRF的早期诊断与鉴别诊断要点、治疗原则与方案进行讨论,以期帮助牙医们提升对SVRF的辨识能力,为临床有效诊断和治疗SVRF提供借鉴。

关键词: 原发性牙根纵裂, 临床诊断, 鉴别诊断, 治疗策略, 影像学特征

Abstract:

Vertical root fracture in non-endodontically treated teeth, also known as spontaneous vertical root fracture (SVRF), is an intractable disease for most dental practitioners. Due to the lack of pathognomonic clinical manifestation and radiographic presentation in the early stage, the diagnosis of SVRF is extremely challenging even for experienced dentists. Even if SVRF is determined to be present, it is hard to make decision between treatment options including root resection, repairing the fractured root or tooth extract. Timing and method of restoration after tooth extraction also need to be considered. The aim of this paper was to discuss early diagnosis, differential diagnosis, the principles of treatments and the specific treatment plans of SVRF in the light of literature review and a 3-years clinical study, to help clinician to discern SVRF and to act as a reference for better clinical diagnosis and treatment.

Key words: spontaneous vertical root fracture, clinical diagnosis, differential diagnosis, treatment strategy, radiographic featur

中图分类号: 

  • R781.05

图 1

根管治疗后牙根纵裂 男,54岁。全景片示46根管治疗及冠修复后牙根纵裂,折片移位,根周大范围牙槽骨吸收。"

图 2

未经根管治疗的SVRF 女,46岁。X线片示46牙冠完好,根管空虚无充填物,近中根根管内径增宽,根尖孔扩大,牙周膜间隙增宽,牙根近中及根分叉区牙槽骨吸收。"

图 3

无症状的SVRF（组织学牙根纵裂） 男,44岁。X线片示46近中根根管内径增宽及根尖孔扩大。"

图 4

SVRF与慢性牙周炎患牙的牙周探诊检查 A：男,56岁。36确诊为SVRF,颊侧中份牙周袋深度为5 mm（UNC-15探针）,探诊时牙周袋袋口狭窄,袋壁张力大,牙龈发白。B：男,46岁。47慢性牙周炎,颊侧中份牙周袋深度为6.5 mm（CPI探针）,探诊时牙周袋袋口宽大,袋壁松弛,易于探入。"

图 5

SVRF近龈缘的窦道 男,58岁。46经锥形束CT确诊为SVRF。A：46口内照,见46颊侧近中近龈缘处窦道;B：X线片见46近中根根管内径增宽、根尖孔扩大、牙周膜间隙增宽及根分叉区骨吸收影。"

图 6

SVRF早期影像学表现 男,49岁。46经锥形束CT确诊为颊舌向的SVRF,X线片示46近中根根管内径增宽、根尖孔扩大及牙周膜间隙增宽。"

图 7

SVRF相关性“J”形骨吸收 男,62岁。46经锥形束CT确诊为颊舌向SVRF,X线片示根管中下段内径增宽、根尖孔扩大及包绕根尖部的“J”形骨吸收。"

图 8

SVRF患牙牙根一侧角形骨吸收 男,54岁。46经锥形束CT确诊为颊舌向的SVRF,见46近中根根管内径增宽、根尖孔扩大、近中牙槽骨呈角形吸收,其骨吸收影与近中根根面呈锐角。"

图 9

SVRF患牙牙根双侧角形骨吸收 女,72岁。36近中根纵裂,见根管内径增宽、根尖孔扩大、根双侧角形骨吸收均累及根中份水平。根分叉区骨吸收影与角形骨吸收影融合。"

图 10

SVRF晚期牙根折裂片移位 男,73岁。X线片示36近中根自根尖至根颈部完全纵裂,折裂片向近中移位,根尖周大范围骨吸收影。"

图 11

早期SVRF与牙内吸收 女,64岁。A：46确诊SVRF,X线片示近中根根管内径自根尖至根管中份线性均匀增宽,根管壁厚度不变;B：46为牙内吸收,X线片示46远中根根管中份似椭圆形的膨大,根管壁变薄。"

图 12

牙内吸收伴SVRF 男,44岁。X线片示36近中根根管中份椭圆形膨大,根管壁变薄,下方见根管内径均匀增宽,近中见牙槽骨角形吸收,最终锥形束CT诊断为牙内吸收伴SVRF。"

图 13

SVRF患牙的牙根及根周骨组织变化 男,46岁。锥形束CT轴位示46近中根中份横断面线状低密度影贯通颊舌侧根管壁及牙根外表面。"

图 14

SVRF患牙的多角度投照X线片及不同位锥形束CT图片 男,73岁,47诊断为SVRF。A~C：不同角度投照的X线片,A（分角线投照）示近中根内径增大,B（偏近中投照）、C（偏远中投照）未见明显异常;D~F：分别为锥形束CT矢状位、冠状位及轴位图片,可见47为颊舌向纵裂,裂纹自根尖孔往上延伸至牙根中段。"

图 15

SVRF患牙延迟拔除造成牙槽骨进行性破坏 男,63岁。A~E：2013年锥形束CT图片;F~K：2018年锥形束CT图片。2013年36牙经锥形束CT证实为SVRF,患者拒绝拔牙,5年来36牙槽骨进行性吸收,牙槽骨颊舌侧贯通破坏,骨水平高度明显降低。"

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