国际口腔医学杂志

国际口腔医学杂志 ›› 2020, Vol. 47 ›› Issue (3): 336-344.doi: 10.7518/gjkq.2020042

• 综述 • 上一篇    下一篇

完全脱位牙再植的牙髓、牙周膜愈合：从生物学基础到牙外伤指南

马心笛,陈蕾()   

  1. 南方医科大学口腔医院综合急诊科 广州 510220
  • 收稿日期:2019-07-05 修回日期:2019-12-09 出版日期:2020-05-01 发布日期:2020-05-08
  • 通讯作者: 陈蕾
  • 作者简介:马心笛,硕士,Email：373693149@qq.com

Pulp and periodontal ligament healing of tooth avulsion replantation: from biological basis to guidelines

Ma Xindi,Chen Lei()   

  1. Dept. of Oral Emergency, Stomatological Hospital, Southern Medical University, Guangzhou 510220, China
  • Received:2019-07-05 Revised:2019-12-09 Online:2020-05-01 Published:2020-05-08
  • Contact: Lei Chen

RichHTML

98

PDF (PC)

1232

摘要：

牙完全脱位又称牙撕脱伤,是一种严重的牙外伤,指在外力作用下,牙齿从牙槽窝中脱出,导致牙髓血运中断,牙周膜细胞暴露于体外。首选治疗方法是根据国际牙外伤协会（IADT,2012年）和美国牙髓病协会（AAE,2013年）修订的完全脱位牙再植治疗指南对患牙进行再植,以增大牙周膜愈合及牙髓血运重建的可能。但是完全脱位牙的预后受到多种临床因素影响。在某些情况下,即使按照指南进行规范治疗,完全脱位牙的术后并发症仍无法完全避免。因此,本文详细介绍牙外伤指南制定的相关生物学基础,结合临床病例,帮助临床医生理解和应用上述指南来治疗完全脱位牙及评估患牙的预后,以期为临床提供参考。

关键词: 牙完全脱位, 牙髓愈合, 牙周膜愈合, 生物学基础, 牙外伤指南

Abstract:

Tooth avulsion is a serious traumatic tooth injuries and is characterized by the complete displacement of the tooth from its alveolar socket due to trauma. The avulsed tooth has severe damaged pulp and periodontal tissue, and the treatment plan is immediate replantation to its original position with possibility of periodontal ligament regeneration and pulp revascularization. However, the prognosis of tooth avulsion is influenced by many clinical factors. In some cases, the complications are unavoidable even with standardized treatments for avulsed tooth according to the recommended guidelines of the International Association of Dental Traumatology (2012) and American Association of Endodontics (2013). Basing on the advancement in biological research and some clinical cases, this review attempts to help clinical doctors understand and apply the guidelines into practice.

Key words: tooth avulsion, pulp healing, periodontal ligament healing, biological basis, the guidelines to treat tooth avulsion

中图分类号: 

  • R782.12

图 1

患牙未行根管治疗发生迅猛的炎症性吸收 A：再植前X线片,示21牙牙槽窝空虚,未见明显牙槽突骨折;B：再植后X线片,示21牙就位良好;C：再植后2周X线片,示21牙牙周膜略增宽,尚未见牙根明显吸收影像;牙髓电活力测试显示21牙无活力,患儿家属拒绝根管治疗;D：再植3.5个月后X线片,示21牙牙根吸收至牙颈部。"

图 2

根管内部分闭锁 A：完全脱位后全景片截图,示11牙缺失,未见明显牙槽突骨折;B：再植1个月后X线片,示11牙牙周膜宽度正常,根尖孔开放（箭头）,髓腔宽大,根尖未见明显异常;C：再植9个月后X线片,示根管壁较图B增宽,髓腔变窄,根尖孔继续发育（箭头）,根尖区未见明显异常,临床牙髓电活力测试同对照牙;D：再植3年后X线片,示11牙根尖孔未闭合,根管壁增厚,髓腔较正常牙缩窄,根尖形态不规则（箭头）,临床牙髓电活力测试数值为38,较对照牙略迟钝;E：再植1个月后口内照;F：再植3年后口内照。"

图 3

牙周愈合方式示意图 A：牙周膜愈合;B：表面吸收愈合;C：炎症性吸收;D：替代性吸收。"

图 4

表面吸收 A：再植前锥形束计算机断层扫描（cone beam computed tomography,CBCT）,示21牙牙槽窝空虚,唇侧牙槽骨骨折;B：再植后1周,X线示断裂线消失,根尖区未见明显异常;C：再植后5周,X线示根管内高密度影像密实恰填,根尖区未见明显异常;D：再植后6个月,X线示根尖1/3有小面积牙骨质范围吸收凹陷（箭头）,根尖区未见明显异常。"

图 5

替代性吸收 A：完全脱位13年后X线片,示21牙远中牙颈部吸收达髓腔（箭头）;B：完全脱位15年后X线片,示21牙牙颈部吸收累及整个牙颈部,牙冠折断。"

图 6

替代性吸收病例 A：再植前X线片,示21牙牙槽窝空虚,未见明显牙槽突骨折;B：再植后X线片,示21牙就位良好,根管充填物恰填;C：再植后2周X线片,示21牙根尖区牙周膜间隙开始变得模糊;D：再植19个月后X线片,示21牙根尖1/3牙周膜影像消失,牙根替代性吸收影像（箭头）,根尖区未见明显低密度影;E：再植前口内照,21牙牙槽窝空虚,21牙牙龈缘略高于11牙;F：再植19个月后口内照。"

图 7

替代性吸收及牙槽骨吸收 A：再植前X线片,示11、12牙牙槽窝空虚,未见牙槽骨骨折线;B：再植1个月后X线片,示11、12牙根管充填影像密实、恰填,牙周膜影像清晰,根尖未见明显异常;C：再植后18个月X线片,示11牙根尖、根中1/3牙根吸收,牙周膜影像不清,牙槽嵴顶吸收至根中1/3（箭头）,根尖周未见明显低密度影。"

图 8

牙根粘连导致垂直向生长受到抑制 A：再植前CBCT,示11牙牙槽窝空虚（圆圈）;B：再植后1个月X线片,示近中根尖1/3牙根密度减低,其余牙周膜影像清晰;C：再植后3个月X线片,示根尖1/3牙根出现替代性吸收,根中1/3牙周膜影像消失（箭头）;D：再植后10个月X线片,较图C吸收面积增大（箭头）;E：再植后15个月X线片,较图D吸收面积增大（箭头）;F：再植后18个月X线片,较图E吸收面积增大（箭头）;G：再植后3个月口内照,示11牙切端低于邻牙切缘<1 mm;H：再植后18个月口内照,示11牙切端低于邻牙切缘>1 mm,11牙周围牙槽骨垂直向生长受到抑制。"

[1] 钱虹 . 儿童牙外伤的风险因素及其预防策略[J]. 口腔疾病防治, 2017,25(8):477-481.
Qian H . Risk factors and prevention strategies of traumatic dental injury in children[J]. J Dent Prev Treat, 2017,25(8):477-481.
[2] Moradi Majd N, Zohrehei H, Darvish A , et al. Con-tinued root formation after delayed replantation of an avulsed immature permanent tooth[J]. Case Rep Dent, 2014,2014:832637.
doi: 10.1155/2014/832637 pmid: 24900928
[3] Zhao YH, Zhang M, Liu NX , et al. The combined use of cell sheet fragments of periodontal ligament stem cells and platelet-rich fibrin granules for avulsed tooth reimplantation[J]. Biomaterials, 2013,34(22):5506-5520.
doi: 10.1016/j.biomaterials.2013.03.079 pmid: 23639531
[4] Najeeb S, Siddiqui F, Khurshid Z , et al. Effect of bis-phosphonates on root resorption after tooth replanta-tion—a systematic review[J]. Dent Traumatol, 2017,33(2):77-83.
doi: 10.1111/edt.12316 pmid: 27960049
[5] Zaleckiene V, Peciuliene V, Brukiene V , et al. Trau-matic dental injuries: etiology, prevalence and possi-ble outcomes[J]. Stomatologija, 2014,16(1):7-14.
pmid: 24824054
[6] Jain N, Srilatha A, Doshi D , et al. Knowledge of emergency management of avulsed tooth among intern dental students: a questionnaire based study[J]. Int J Adolesc Med Health, 2018. doi: 10.1515/ijamh- 2017-0203.
doi: 10.1515/ijamh-2017-0203 pmid: 30118438
[7] 蔡文姬, 王佐林 . 牙周膜对于牙槽骨吸收影响的初步研究[J]. 口腔颌面外科杂志, 2016,26(5):311-316.
Cai WJ, Wang ZL . Periodontal membrane and al-veolar bone resorption: a pilot study[J]. J Oral Maxil-lofac Surg, 2016,26(5):311-316.
[8] 孙翔, 陈蕾, 童方丽 . 1例完全脱位3小时的年轻恒牙再植及术后观察[J]. 口腔疾病防治, 2018,26(1):52-55.
Sun X, Chen L, Tong FL . Replantation of immature avulsed teeth with 3-hours extra-oral time: a case report[J]. J Prev Treat Stomatol Dis, 2018,26(1):52-55.
[9] Saoud TM, Mistry S, Kahler B , et al. Regenerative endodontic procedures for traumatized teeth after horizontal root fracture, avulsion, and perforating root resorption[J]. J Endod, 2016,42(10):1476-1482.
doi: 10.1016/j.joen.2016.04.028 pmid: 27576211
[10] Hammel JM, Fischel J . Dental emergencies[J]. Emerg Med Clin N Am, 2019,37(1):81-93.
[11] Kling M, Cvek M, Mejare I . Rate and predictability of pulp revascularization in therapeutically reim-planted permanent incisors[J]. Endod Dent Traumatol, 1986,2(3):83-89.
doi: 10.1111/j.1600-9657.1986.tb00132.x pmid: 3460802
[12] Kristerson L, Andreasen JO . Influence of root deve-lopment on periodontal and pulpal healing after re-plantation of incisors in monkeys[J]. Int J Oral Surg, 1984,13(4):313-323.
doi: 10.1016/s0300-9785(84)80039-3 pmid: 6434451
[13] Cvek M, Cleaton-Jones P, Austin J , et al. Pulp reva-scularization in reimplanted immature monkey in-cisors: predictability and the effect of antibiotic systemic prophylaxis[J]. Endod Dent Traumatol, 1990,6(4):157-169.
doi: 10.1111/j.1600-9657.1990.tb00412.x pmid: 1723381
[14] Cvek M, Cleaton-Jones P, Austin J , et al. Effect of topical application of doxycycline on pulp revascu-larization and periodontal healing in reimplanted monkey incisors[J]. Endod Dent Traumatol, 1990,6(4):170-176.
doi: 10.1111/j.1600-9657.1990.tb00413.x pmid: 1723382
[15] Skoglund A, Tronstad L . Pulpal changes in replanted and autotransplanted immature teeth of dogs[J]. J Endod, 1981,7(7):309-316.
doi: 10.1016/S0099-2399(81)80097-0 pmid: 6166699
[16] Trope M . Clinical management of the avulsed tooth: present strategies and future directions[J]. Dent Trau-matol, 2002,18(1):1-11.
doi: 10.1046/j.1600-4469.2001.00001.x pmid: 11841460
[17] Tronstad L . Root resorption: etiology, terminology and clinical manifestations[J]. Endod Dent Traumatol, 1988,4(6):241-252.
doi: 10.1111/j.1600-9657.1988.tb00642.x pmid: 3078294
[18] Andreasen FM, Kahler B . Pulpal response after acute dental injury in the permanent dentition: clinical implications—a review[J]. J Endod, 2015,41(3):299-308.
doi: 10.1016/j.joen.2014.11.015 pmid: 25601716
[19] Krug R, Kremeier K, Krastl G . Long-term retention of avulsed maxillary permanent incisors replanted after prolonged non-physiological storage[J]. Dent Traumatol, 2019,35(2):147-152.
doi: 10.1111/edt.12445 pmid: 30296000
[20] Andreasen JO, Borum MK, Jacobsen HL , et al. Re-plantation of 400 avulsed permanent incisors. 4. Fac-tors related to periodontal ligament healing[J]. Endod Dent Traumatol, 1995,11(2):76-89.
doi: 10.1111/j.1600-9657.1995.tb00464.x pmid: 7641622
[21] Diangelis AJ, Andreasen JO, Ebeleseder KA , et al. International Association of Dental Traumatology Guidelines for the management of traumatic dental injuries: 1. fractures and luxations of permanent teeth[J]. Dent Traumatol, 2012,28(1):2-12.
doi: 10.1111/j.1600-9657.2011.01103.x pmid: 22230724
[22] Osmanovic A, Halilovic S, Kurtovic-Kozaric A , et al. Evaluation of periodontal ligament cell viability in different storage media based on human PDL cell culture experiments—a systematic review[J]. Dent Traumatol, 2018,34(6):384-393.
doi: 10.1111/edt.12437 pmid: 30193009
[23] 李鑫, 段建民 . 脱位牙体外保存介质的研究进展[J]. 国际口腔医学杂志, 2013,40(3):381-384.
Li X, Duan JM . Research progress on storage media for avulsed tooth in vitro[J]. J Int Stomatol, 2013,40(3):381-384.
[24] Lee W, Stover S, Rasoulianboroujeni M , et al. The efficacy of commercial tooth storage media for maintaining the viability of human periodontal li-gament fibroblasts[J]. Int Endod J, 2018,51(1):58-68.
doi: 10.1111/iej.12798 pmid: 28631388
[25] 周扬 . 日常介质保存脱位牙细胞活性的比较研究[D]. 大连: 大连医科大学, 2017.
Zhou Y . Comparative study on daily medium pre-serve activity of odontogenic cells of tooth[D]. Dalian: Dalian Medical University, 2017.
[26] Hammarström L, Blomlöf L, Lindskog S . Dynamics of dentoalveolar ankylosis and associated root resorp-tion[J]. Endod Dent Traumatol, 1989,5(4):163-175.
doi: 10.1111/j.1600-9657.1989.tb00354.x pmid: 2517781
[27] 张黎丽, 张昕, 薛亮 , 等. 外科手术拔出法治疗前牙复杂冠根折的疗效分析[J]. 口腔疾病防治, 2018,26(12):785-790.
Zhang LL, Zhang X, Xue L , et al. Therapeutic effect of surgical extraction for the treatment of complicated crown and root fracture of anterior teeth[J]. J Prev Treat Stomatol Dis, 2018,26(12):785-790.
[28] Mandel U, Viidik A . Effect of splinting on the me-chanical and histological properties of the healing periodontal ligament in the vervet monkey (cerco-pithecus aethiops)[J]. Arch Oral Biol, 1989,34(3):209-217.
[29] Barrett EJ, Kenny DJ . Avulsed permanent teeth: a review of the literature and treatment guidelines[J]. Endod Dent Traumatol, 1997,13(4):153-163.
doi: 10.1111/j.1600-9657.1997.tb00031.x pmid: 9550040
[30] Andreasen JO . Relationship between surface and in-flammatory resorption and changes in the pulp after replantation of permanent incisors in monkeys[J]. J Endod, 1981,7(7):294-301.
doi: 10.1016/S0099-2399(81)80095-7 pmid: 6942086
[31] Souza BDM, Dutra KL, Kuntze MM , et al. Incidence of root resorption after the replantation of avulsed teeth: a meta-analysis[J]. J Endod, 2018,44(8):1216-1227.
doi: 10.1016/j.joen.2018.03.002 pmid: 29866405
[32] Hasanuddin S, Reddy JS . Sequelae of delayed re-plantation of maxillary permanent incisors after avulsion: a case series with 24-month follow-up and clinical review[J]. J Indian Soc Pedod Prev Dent, 2018,36(4):410-416.
doi: 10.4103/JISPPD.JISPPD_187_18 pmid: 30324935
[33] Maslamani M, Joseph B, Gabato S , et al. Effect of periodontal ligament removal with gauze prior to delayed replantation in rabbit incisors on rate of replacement resorption[J]. Dent Traumatol, 2018,34(3):182-187.
doi: 10.1111/edt.12398 pmid: 29573129
[34] 陈宏吉, 段昌华, 黄少宏 . 佛山市禅城区小学生家长对儿童牙外伤认知的调查[J]. 口腔疾病防治, 2017,25(6):401-404.
Chen HJ, Duan CH, Huang SH . An investigation on parents knowledge of dental trauma in primary school of chancheng district, Foshan City[J]. J Prev Treat Stomatol Dis, 2017,25(6):401-404.
[1] 胡俊, 李秀芬, 华成舸, 马丽源. 24例自体牙移植的临床疗效观察[J]. 国际口腔医学杂志, 2017, 44(4): 437-439.
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed   
[1] 张京剧. 青年期至中年期颅面复合体变化的头影测量研究[J]. 国际口腔医学杂志, 1999, 26(06): .
[2] 刘玲. 镍铬合金中铍对可铸造性和陶瓷金属结合力的影响[J]. 国际口腔医学杂志, 1999, 26(06): .
[3] 王昆润. 在种植体上制作固定义齿以后下颌骨密度的动态变化[J]. 国际口腔医学杂志, 1999, 26(06): .
[4] 王昆润. 重型颌面部炎症死亡和康复病例的实验室检查指标比较[J]. 国际口腔医学杂志, 1999, 26(06): .
[5] 逄键梁. 两例外胚层发育不良儿童骨内植入种植体后牙槽骨生长情况[J]. 国际口腔医学杂志, 1999, 26(05): .
[6] 温秀杰. 氟化物对牙本质脱矿抑制作用的体外实验研究[J]. 国际口腔医学杂志, 1999, 26(05): .
[7] 杨春惠. 耳颞神经在颞颌关节周围的分布[J]. 国际口腔医学杂志, 1999, 26(04): .
[8] 王昆润. 牙周炎加重期应选用何种抗生素[J]. 国际口腔医学杂志, 1999, 26(04): .
[9] 杨儒壮 孙宏晨 欧阳喈. 纳米级高分子支架材料在组织工程中的研究进展[J]. 国际口腔医学杂志, 2004, 31(02): 126 -128 .
[10] 严超然,李龙江. 肿瘤靶向药物载体系统的研究进展[J]. 国际口腔医学杂志, 2008, 35(S1): .