单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,14,牙周牙髓联合病变,Periodontal-Endodontic Combined Lesions,14-1,牙周组织和牙髓的解剖通道,Anatomical Interrelations of Peridontium and Pulp,根尖孔,Apical foramen,1,14牙周牙髓联合病变Periodontal-Endodo,根管侧支,Lateral root canal,或副根管,Accessory canal,根尖,1/3,处最多,根分叉区,20-60%,有,2,根管侧支Lateral root canal或副根管A,3,3,4,4,The pulp was non-vital and the tooth was endodontically treated.After prosthetic therapy,5,The pulp was non-vital and t,The pulp was non-vital and the tooth was endodontically treated.After prosthetic therapy(c),the 2-year follow-up radiograph in(d)shows bone fill in the previous angular bony defect,whereas the marginal bone remains at the same level.On careful examination one can see that a lateral canal communicating with the lateral bone defect was filled.,6,The pulp was non-vital and the,牙本质小管,Dentinal tubules,解剖异常,Anatomical abnormalities,腭侧沟 牙根外吸收 根裂,7,牙本质小管 Dentinal tubules解剖异常 Ana,14-2,牙周,-,牙髓联合病变的临床类型,Clinical Patterns of Periodontal-Endodontic Combined Lesions,1,，,根尖感染经牙周组织途径排除，有人称之为逆行性牙周炎,(retrograde periodontitis),牙髓根尖周病对牙周组织的影响,influence of endodontic lesions on the periodontium,8,14-2 牙周-牙髓联合病变的临床类型 Clinical,根尖脓肿沿牙周的可能排脓途径,Schematic illustration demonstrating possible pathways for drainage of a periapical abscess into the gingival sulcus/pocket.,(a)periodontal ligament fistulation.,(b)extraosseous fistulation,9,根尖脓肿沿牙周的可能排脓途径Schematic illust,periodontal ligament fistulation,.,此型在临床上易被误诊为牙周脓肿,特点：,死髓牙,窄而深的牙周袋，无明显的牙槽嵴吸收,only a narrow opening of the fistula into the gingival sulcus/pocket and may not be detected unless careful probing of the sulcus is carried out at multiple sites.,邻牙一般无严重的牙周炎,X,片显示烧杯型或日晕型病变,10,10,after 18 M,In multirooted teeth a periodontal ligament fistulation can drain off into the furcation area,11,after 18 M In multirooted t,12,12,，牙髓治疗过程中或治疗后造成的牙周病变,根管侧穿，髓室底穿，髓室或根管内的药物（砷戊二醛塑化液干髓剂等）,During endodontic treatment,and in conjunction with preparation of root canals for the insertion of posts,instrumentation can accidentally cause perforation of the root and wounding of the periodontal ligament,13,，牙髓治疗过程中或治疗后造成的牙周病变根管侧穿，髓室底,Angular bone defect at the distal root surface of a mandibular premolar(arrows).The root is per,forated.Conceivably,this occurred in conjunction with,preparation of the root canal for a post and core.Clinical,symptoms included drainage of pus from the pocket and increased tooth mobility.The tooth was extracted.,14,Angular bone defect at the dis,Perforation of the pulpal floor of the mandibular first molar occurred in conjunction with a search for root canal openings(a).The perforation was immediately sealed with gutta-percha(b).One month after treatment a slight radiolucency appeared at the perforation site(arrow)in the periodontium(c).After an observation period of 2 years,normal periodontal conditions were re-established both clinically and radiographically,15,Perforation of the pulpal floo,16,16,17,17,RCT,治疗后可发生牙根纵裂,:,主要由于扩根过度,桩核不当,过大合力等,共同特点,:,牙髓无活力,病变局限于单个牙，局限于患牙的局部,病变呈烧杯状，,邻牙基本正常,Vertical root fracture,结局,:,Vertical root fractures that involve the gingival sulcus/pocket area usually have a hopeless prognosis due to continuous bacterial invasion of the fracture space from the oral environment.,18,RCT治疗后可发生牙根纵裂:主要由于扩根过度,桩核不当,19,19,20,20,21,21,External Root resorption,22,External Root resorption 22,Surface resorption,A surface resorption is initiated subsequent to injury of the cementoblastic cell layer.Osteoclasts are attracted by substances from the damaged tissue on the denuded root surface and resorb the hard tissue,These resorptions may be caused by a localized,injury in conjunction with external trauma(Andreasen,1981)and by trauma from occlusion.Resorption,may also result from excessive orthodontic forces.,This type of resorption is common,self-limiting and reversible,23,Surface resorptionA surface re,Replacement resorption,This type of resorptive process results in a replacement of the dental hard tissues by bone,hence the name,Replacement resorption and ankylosis are often used as synonyms.,Clinically,ankylosis is diagnosed by absent tooth mobility and by a percussion tone that is higher than in a normal tooth,24,Replacement resorptionThis typ,External inflammatory resorption,The term external inflammatory resorption suggests the presence of an inflammatory lesion in the periodontal tissues adjacent to a resorptive process,25,External inflammatory resorpti,14-3,治疗原则,Treatment strategies for vombined endodontic and periodontal lesions,确定原发原因。,联合病变的预后往往取决于牙周病损的预后，牙周破坏不严重，牙齿不松动，预后较好,1,，由牙髓根尖病变引起的牙周病变,清除感染源的牙髓消除袋内感染完善,RCT,First observe the result of this therapy and institute periodontal therapy later if necessary,26,14-3 治疗原则 Treatment strategi,2,，逆行性牙髓炎主要看患牙能否保留,牙髓初步治疗，如病变可以控制，牙髓牙周同时治疗,27,2，逆行性牙髓炎主要看患牙能否保留27,