儿童及青少年牙和支持组织的外伤.ppt

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,*,*,*,儿童及青少年牙和支持组织的外伤,口腔预防儿童科,池政兵,1/31/2026,chi,2,Trauma to the Teeth and Supporting Tissues,Dental Trauma,How to Diagnosis,Treatment to the Dental Trauma,1/31/2026,chi,3,概 论,1/31/2026,chi,4,参考书,Mc Donald RE and Avery DR.,Dentistry for the Child and,Adolescent,6,th,ed.,st,.Louis:C.V.Mosby,Co,1994.,Andreason,JO and,Andreason,FM.,Essentials of traumatic injuries to the teeth,.Denmark:,Laursen,A/S,Tnder,1990.,Endodontics,and Dental,Traumatology,1/31/2026,chi,5,The International Association of Dental Trauma(IADA),国际牙外伤协会,1/31/2026,chi,6,牙外伤,(Dental Trauma or Injuries),是指牙齿受到急剧的创伤，特别是打击、撞击等所引起的牙体、牙髓和牙周组织的损伤。（急性的）,1/31/2026,chi,7,儿童牙外伤的特点,年龄特点：儿童及青少年的发病率高,年龄高峰：乳牙,1,3,岁 恒牙,7,9,岁,发生部位：切牙尖牙磨牙,上颌 下颌,性别比较：男性 女性,1/31/2026,chi,8,乳牙外伤后,影响后继恒牙的发育：釉质发育不全,or,钙化不全 修复性牙本质形成 弯曲牙 部分牙根停止发育,影响后继恒牙的正常萌出,影响恒牙列的正常形成,1/31/2026,chi,9,恒牙外伤后,牙体组织的缺失或缺损,接触点,邻牙倾斜；间隙的丧失；对颌牙的伸长（替牙期的患者影响更大）,1/31/2026,chi,10,牙外伤后,外伤牙本身预后的,不定性,，儿童生长发育的,活跃性,，诊断的,困难性。,当时口腔局部的创伤；以后机体的生理和心理上的创伤,牙医：作出快速、正确、全面的诊断；作出正确的处理；减少后遗症。,牙外伤的诊断,？,1/31/2026,chi,12,牙外伤的诊断,病史,临床检查,发射性,X,线片的检查,1/31/2026,chi,13,病 史,年龄，性别，外伤原因，作用力的大小和方向，发生地点及环境污染情况，外伤确切的时间，对冷热的反应，是否影响咬合，就诊前脱位牙的保存情况，是否经过一段无意识期，有无恶心、呕吐，全身有无影响治疗的疾患：血友病等，以前有无牙外伤史,问,查,1/31/2026,chi,14,临床检查,电活力测定,两种观点,新的、陌生的仪器,儿童,害怕；有效性（髓休克,3,个月）,机会；首次电活力意义（,Rock,等在,1974,年报道,1,年后,82,有活力）,积极治疗；微不足道的刺激,冷热诊,常适用乳牙,光透射情况,（光束由舌侧向唇侧照射）,其它：,松动度检查 多个牙一起动提示,？,叩诊检查,metallic/dull percussion tone,提示,？,1/31/2026,chi,15,放射性,X,线片检查,患牙与邻牙、对侧同名牙作比较,比较髓腔、根管的大小、形态以及发育情况,根折的检出率：,（假阴性）,X,线透射中心的射线与牙折线一致或平行,夹角,15,20,夹角,15,20,无法显示,若怀疑有根折，改变角度，加拍,2,3,张牙片,牙外伤的治疗,？,1/31/2026,chi,17,Treatment to the Dental Trauma,Injury to the Primary Dental,Crown Fractures,Crown-Root Fractures,Root Fractures,Avulsion,Concussion and,Subluxation,Extrusion,Lateral,Luxation,Intrusion,Fracture of the Alveolar Process,1/31/2026,chi,18,治疗原则,乳牙外伤,冠折,根折,冠根联合折,牙完全性脱位,牙震荡,牙伸长,牙侧向移位,牙嵌入,牙槽骨骨折,软组织外伤,1/31/2026,chi,19,Injuries to the Primary Dentition,Verify eventual collision between a displaced primary tooth and its permanent successor,If this has occurred,remove the displaced incisor,If not,observation,Monitor healing regularly with routine clinical and radiographic examination,1/31/2026,chi,20,乳 牙 外 伤,儿童的牙槽骨韧性较好，临床上以外伤移位多见,处理上要谨慎,乳牙外伤发生移位，伤及后继恒牙胚,乳牙外伤继发感染，伤及后继恒牙胚,1/31/2026,chi,21,乳 牙 外 伤,冠折：治疗原则同恒牙,冠根联合折：拔牙，残留牙根（生理性吸收）,根折：固定困难，拔除,侧向移位：观察,/,拔除,嵌入：观察,/,拔除,完全性脱位：,不作再植术,1/31/2026,chi,22,Crown Fractures,Fractures of enamel,Grinding,Composite restoration,Fractures of enamel and dentin,Composite restoration,Re-attachment of the crown fragment,Pulp exposures,Pulp capping,Pulpotomy,1/31/2026,chi,23,冠 折,Crown Fractures,仅累及牙釉折层：磨改、树脂修复,累及牙本质：间接盖髓后，作牙折片再粘、树脂修复,累及牙髓腔：直接盖髓术或活髓切断术后，作冠修复,1/31/2026,chi,24,Pulp Capping,Isolate the pulp exposure,Cover the pulp with a calcium hydroxide material,Restore the teeth either immediately or after 3 month period,1/31/2026,chi,25,Pulpotomy,Isolate the pulp exposure,Amputate the pulp to a level approximately 2 mm below the exposure,site,or,to where fresh bleeding is seen,Restore the tooth either immediately or after a 3-month period,1/31/2026,chi,26,Crown-Root fractures,Removal of the coronal fragment with subsequent restoration above gingival level,Removal of the coronal fragment supplemented by,gingivectomy,and,osteotomy,and subsequent restoration with a post-retained crown,Removal of the coronal fragment and surgical extrusion of the root,Removal of the coronal fragment and subsequent orthodontic of the root,1/31/2026,chi,27,冠 根 联 合 折,crown root fractures,拔除冠折片，龈上冠修复,拔除冠折片，龈、骨切除术，冠修复,拔除冠折片，外科牙根伸长法，冠修复,拔除冠折片，正畸牙根伸长法，冠修复,纵折：拔除,1/31/2026,chi,28,Root Fractures,Check for,pulpal,complications after 3 weeks,6 weeks and 3 months,Reposition the coronal fragment and use firm splinting for 3 months,Root:crown1/3 middle1/3 apical1/3,1/31/2026,chi,29,根 折,root fractures,颈,1/3:,拔除“牙折冠”，根管治疗后，龈切或牵引冠修复,中,1/3:,复位固定,3,个月,尖,1/3:,观察或复位固定,3,个月,1/31/2026,chi,30,Avulsion,Replantation,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.T,1/31/2026,chi,31,牙完全脱位,avulxion,再植术,复位固定,1,2,周,(,无,PDL,者,6,周）,氢氧化钙糊剂作暂时性根充,抗炎治疗：普鲁卡因青霉素,60,80,万单位,2,次,/,日 肌肉注射,TAT,注射,1/31/2026,chi,32,牙完全脱位,avulxion,再植术治疗要点,脱位牙的保存情况：牛奶、,NS,等,脱位牙的脱位时间：,30min,2hour,牙周膜的处理：保留与否,牙槽窝的处理：清除血凝块，,NS,冲洗,1/31/2026,chi,33,牙完全脱位,avulxion,再植术治疗效果取决于,外伤牙的保存 湿润,/,干燥,外伤牙的脱位时间,30,分钟以内：,2,年或更长，,90,无牙根内吸收,2,小时以外：,95,牙根发生内吸收,1/31/2026,chi,34,Concussion and Subluxation,Occlusal,relief(e.g,.by selective grinding of opposing teeth)and a soft diet,Immobilization of the involved teeth may be appropriate for patient comfort,2 weeks fixation,1/31/2026,chi,35,牙震荡,/,亚脱臼,concusion/subluxution,概念,牙震荡：牙周,lig,内出血、水肿，完整，牙一般无松动,亚脱臼：牙周,lig,内出血、水肿，部分撕裂，牙一般有松动、伴龈沟出血,调合，软饮食（,2,周），一般不需要固定（若固定，应,2,周）,1/31/2026,chi,36,Extrusion,Repositioning,Fixation 23 weeks,1/31/2026,chi,37,牙 伸 长,extrusion,（局麻）,复位固定,2,3,周,牙髓存活情况,牙根形成的：,50,存活,牙根未形成的：,90,以上存活,根管治疗时机：观察期间，,X,线检查一旦发现根尖牙根、牙槽骨有炎性吸收,1/31/2026,chi,38,Lateral Luxation,Local anesthetic,Repositioning,Fixation 3 weeks,If radiographic examination reveals a temporary breakdown of the marginal,bone,maintain,fixation for up to 2 months,1/31/2026,chi,39,牙 侧 向 移 位,lateral,luxation,（局麻下）复位固定,3,周,根管治疗时机：观察期间，,X,线检查一旦发现根尖牙根、牙槽骨有炎性吸收,1/31/2026,chi,40,Intrusion,Immature root formation,Await spontaneous re-,eruption,usually,takes 24 months,Monitor,pulpal,healing,radiographically,3,4 and 6 weeks after injury,Mature root formation,Await spontaneous re-eruption or extrude,orthodontically,over a period of 2 3 weeks,Extirpate the pulp 2 weeks after,injury,using,calcium hydroxide paste as an interim dressing,1/31/2026,chi,41,牙 嵌 入,intrusion,诊断：,病史、叩诊（,metallic,音,),、,X,线检查,牙髓坏死率,牙根未形成：,50,牙根已形成：,100,牙根吸收,牙根未形成：,58%,牙根已形成：,70,1/31/2026,chi,42,牙 嵌 入,intrusion,牙根尚未形成：观察,2,4,月（再萌）,牙根已形成：观察（,10,天）和,/,或正畸牵引（,2,3,周）,OR,外科拔牙复位固定,4,周,氢氧化钙糊剂作暂时性根充,1/31/2026,chi,43,Fracture of the Alveolar Process,Local anesthetic,Repositioning,Fixation 34 weeks,1/31/2026,chi,44,牙槽骨骨折,局部的牙槽骨骨折,局麻下，复位固定（,3,4,周）,根尖锁住（,Apical Lock),1/31/2026,chi,45,软组织外伤,清创缝合,TAT,注射,抗炎治疗,1/31/2026,chi,46,牙外伤常见的几种治疗方法,1/31/2026,chi,47,牙外伤常见的几种治疗方 法,复合树脂修复技术,（直接、间接）盖髓术,活髓切断术,根尖成行术,根管治疗术,（复位）固定术,1/31/2026,chi,48,活髓切断术,适应证：露髓比较多，时间比较长，估计牙髓炎症局限于冠髓或根髓的冠,1/3,以内,1/31/2026,chi,49,根尖成形术,适应证：根尖尚未形成，牙髓无法保留年轻恒牙,1/31/2026,chi,50,固定术,fixation,类型：复合树脂钢丝夹板固定术,固定牙数：患牙数,2,健康牙数（两端分布）,固定位置：牙冠颈、中,1/3,交界处,固定时间：具体而定,固定的钢丝粗细：具体而定,1/31/2026,chi,51,固定术,fixation,操作,根据牙弓形态用不锈钢丝弯制弓丝，长度以要固定的牙数目而定,酸处理牙面,黏结技术,上第一层树脂，放置不锈钢弓丝，固化,上第二层树脂，固化,抛光,调合,1/31/2026,chi,52,固定术,fixation,特点,直接在口腔中制作，不需长时间实验室制作,不接触龈组织，不刺激牙龈,不干扰正常咬合,容易清洁,不影响髓病治疗,能及时发现有否变色,容易去除,效果佳,1/31/2026,chi,53,牙外伤的预后,牙对外伤的反应,牙髓充血,pulp hyperemia,内出血,internal hemorrhage,牙髓钙化变性,calcific,change of pulp,内吸收,internal absorption,牙髓坏死,pulp necrosis,牙粘连,concrescence/,ankylosis,1/31/2026,chi,54,牙外伤的预后,根折愈合的四种模式,钙化愈合：,两断面由钙化组织骨性连接，外：牙骨质，内：牙本质,纤维,CT,组织：,结缔组织（,CT,）将断面分开，断面表面有牙骨质覆盖，但未能骨性连接,骨和纤维,CT,愈合：,上面两种混合,肉芽组织内沉：,慢性炎性组织长入,1/31/2026,chi,55,牙外伤的预防,注意活动时的保护，防止意外,对那些前牙前凸的儿童尤其要注意,