以牙髓及根尖周状况指导修复体拆除后患牙治疗方案的选择  

The principle of choosing treatment plan for the affected teeth after removal of previous restorations based on the endodontic and periapical situation

作　　者：何云娇 赵笑 杨帆[1] 张晓[1] 王晓燕[2,3] 刘云松 HE Yunjiao;ZHAO Xiao;YANG Fan;ZHANG Xiao;WANG Xiaoy-an;LIU Yunsong(Department of Prosthodontics,Peking University School and Hospital of Stomatology,Beijing 100081,China;Department of Endodontics,Peking University School and Hospital of Stomatology,Beijing 100081,China;National Center of Stomatology,National Engineering Laboratory for Digital and Material Technology of Sto-matology,National Clinical Research Center for Oral Diseases,Beijing Key Laboratory of Digital Stomatology,Beijing 100081,China)

机构地区：[1]北京大学口腔医学院·口腔医院修复科,北京100081 [2]北京大学口腔医学院·口腔医院牙体牙髓科,北京100081 [3]国家口腔医学中心,口腔生物材料和数字诊疗装备国家工程研究中心,国家口腔疾病临床研究中心口腔数字医学北京市重点实验室,北京100081

出　　处：《口腔疾病防治》2023年第2期131-136,共6页Journal of Prevention and Treatment for Stomatological Diseases

基　　金：国家自然科学基金面上项目(82170929);北京大学口腔医院国家重大疾病多学科合作诊疗能力建设项目(PKUSS⁃NMP⁃202004,PKUSSNMP⁃201901);国家临床重点专科建设项目(PKUSSNKP⁃202107)。

摘　　要：修复体拆除后患牙的重新修复是口腔临床中的常见问题,修复体拆除后患牙的情况复杂多样,常常需要多个学科协作诊疗。然而,修复体拆除后患牙治疗方案的选择尚缺乏系统而简洁的指导原则。笔者结合修复临床工作经验及牙体牙髓专业专家的意见,系统地阐述了未行根管治疗(root canal therapy,RCT)的患牙、曾行RCT的患牙及曾行桩核修复的患牙修复体拆除后可能存在的问题,并根据其牙髓及根尖周状态、RCT质量等情况,总结了以下治疗建议。①对于未行RCT的患牙,拆冠后需要评估牙髓活力、是否发生牙髓病/根尖周病、以及再次预备量大小的情况,综合判断是否需要RCT。②对于曾行RCT的患牙,若RCT完善且无根尖病变,可考虑直接修复;若RCT不完善但无根尖病变,应视情况行根管再治疗(root canal retreatment,re⁃RCT)、观察或直接修复治疗,必要时与牙体牙髓专业医师共同制定治疗方案;若患牙RCT不完善且有根尖病变,建议re⁃RCT后再行修复治疗。③对于曾行桩核修复的患牙,若RCT完善且无根尖病变,可考虑直接修复;若患牙RCT不完善但无根尖病变,建议观察或直接冠修复,必要时与牙体牙髓专业医师共同制定治疗方案;若患牙RCT不完善且有根尖病变,如果桩细而根管壁较厚,可尝试拆桩后re⁃RCT,如果桩粗而根管壁薄,可保留桩核,尝试根尖手术。对于牙体缺损过大或牙周条件极差难以保留者,建议拔除患牙。笔者将上述建议精炼成一套诊疗流程,以期为修复体拆除后患牙治疗方案的选择提供参考。Restoration of teeth after removal of previous restorations is a common problem in the dental clinic.The situation of teeth after removal of previous restoration is complex and often requires multidisciplinary cooperation.How⁃ever,there is a lack of systematic and concise guidelines for determining the treatment plan for those teeth.Through a combination of restorative clinical experience and the opinions of endodontic specialists,the author systematically de⁃scribed the problems that may exist after the removal of previous restorations in the teeth that have not undergone or have undergone root canal treatment(RCT)and those with post and core restorations.And summarized the corresponding treat⁃ment recommendations according to their pulpal and periapical status,the quality of RCT and the presence or absence of post and core restorations.①For teeth without RCT,the vitality of the pulp,the occurrence of pulpal/periapical disease and the amount of re⁃preparation need to be assessed to determine whether RCT is necessary.②For teeth with RCT,if the quality of RCT is good and no periradicular lesion exists,direct restorative treatment can be considered.If the quality of the RCT is unsatisfactory but no periradicular lesion exists,root canal retreatent(re⁃RCT),follow up or direct restor⁃ative treatment should be performed as appropriate and treatment plan can be developed in conjunction with the endodon⁃tist if necessary.If the quality of the RCT is unsatisfactory and periradicular lesion exists,re⁃RCT is necessary before re⁃storative treatment.③For teeth with post and core restorations,if the quality of RCT is good and no periradicular lesion exists,direct restorative treatment can be considered.If the quality of the RCT is unsatisfactory but no periradicular le⁃sion exists,follow up or direct restorative treatment should be performed as appropriate and treatment plan can be devel⁃oped in conjunction with the endodontist if necessary.If the quality of RCT is unsatisfactory and periradicular

关 键 词：口腔医学 牙修复 牙冠 牙髓 根尖周病 牙修复失效 根管治疗 再治疗 桩核技术 根尖手术 

分 类 号：R78[医药卫生—口腔医学]