左下颌离体第二前磨牙畸形牙根1例

2019-08-06 古宏健 古斐清 全科口腔医学电子杂志

患者女,37岁,汉族,自由职业,35龋齿疼痛,在住地诊所没有X线片检查反复根管治疗术3个月有余,进食时仍疼痛难忍,严重影响生活质量,强烈要求拔除患牙。检查:患者精神疲惫,面型左右对称,颌骨无异常;35OD面洞,髓腔空虚,探诊(-﹚,叩诊﹙+﹚,松动﹙±﹚,颊侧根尖区黏膜充血、压痛、无肿胀。曲面断层全景片示:左下颌骨正常,35牙根异常影像,牙根分叉、尖区模糊透射影(图1)。

1. 病例报告
 
患者女,37岁,汉族,自由职业,35龋齿疼痛,在住地诊所没有X线片检查反复根管治疗术3个月有余,进食时仍疼痛难忍,严重影响生活质量,强烈要求拔除患牙。检查:患者精神疲惫,面型左右对称,颌骨无异常;35OD面洞,髓腔空虚,探诊(-﹚,叩诊﹙+﹚,松动﹙±﹚,颊侧根尖区黏膜充血、压痛、无肿胀。曲面断层全景片示:左下颌骨正常,35牙根异常影像,牙根分叉、尖区模糊透射影(图1)。



诊断为35慢性根尖周炎;在利多卡因局部浸润麻醉下拔除35。离体牙解剖形态35牙冠形态与45基本相似,带表游标卡尺测冠长6 mm,冠宽约5.8 mm,冠厚7.2 mm,全长17 mm,牙根长11 mm;畸形单根,与曲面断层全景片影像存在差异。牙根舌侧面:根干5.5 mm,在根干至根尖方欲分近中根和远中根,在根颊侧没有完全分开,形成根尖1/2“C”型牙根(图2-B)。牙根颊面:有明显纵形凹陷(图2-A)。离体牙X线牙片示:根管从髓底一个根管口发出,至根1/2处分三条根管,分别开口三个根尖孔(图2-C),分别B颊侧、ML近中舌侧、DL远中舌侧。



2. 讨论
 
35离体牙小于中国人35平均值;牙根形态畸形,有明显外形变异,趋向分叉;颊侧根面沟较深;导致曲面断层全景片图像的重叠和失真。容易影响临床医师判断、误诊。此类病例,在实施拔牙术时应慎重施加旋转力,控制摇动幅度和力度,避免牙根折断。如果折断将会延长手术操作,加重创伤。本例如以正常牙体形态行根管治疗术,易误判实际根管长度,造成根尖口过预备,致使超充填、欠充填、充填不严实而治疗失败。X线片是研究离体牙方法之一。本例35离体牙X线显示髓底一根管发出,中途分三根管,分别开孔根尖部。与有关文献报道相同属Ⅶ型-3根管型。
 
根管数目多而复杂,根管治疗清理难度大,容易遗漏;变异较少,易被忽视;因此导致治疗失败,引发残髓炎、慢性根尖炎。此类病例,在实施完善根管治疗时,采取术前多角度X线投照片分析,CBCT等综合评估;选择适合机械;次氯酸钠溶液,EDTA使用;超声振荡冲洗术;以及热牙胶充填技术,能明显提高疗效。
 
在完善的根管治疗后,需牙体修复,常用根管桩或钉增加固位力、强度,考虑牙根形态畸形、根管系统复杂,慎重选择根管桩或钉的长度、直径及种入方向和深度,避免侧穿而致修复失败。曲面断层全景片(图1)显示,44、45与35牙根影像有类似,须防止如同35情况发生。建议患者注意口腔卫生保健,预防龋齿;发生龋齿时应正确处理避免治疗失败。同时,全面熟悉了解正、异常牙体解剖、牙髓形态,对指导临床操作有重要意义。
 
原始出处:

古宏健,古斐清.左下颌离体第二前磨牙畸形牙根1例[J].全科口腔医学电子杂志,2018,5(23):116+119.

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    2020-02-11 xlysu
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    2019-08-06 phoebeyan520

    学习了

    0