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1、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,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,2,3,4,The pulp was non-vital and the tooth was endodontically treated. After prosthetic therapy,5,T
2、he 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 comm
3、unicating with the lateral bone defect was filled.,6,牙本质小管 Dentinal tubules,解剖异常 Anatomical abnormalities,腭侧沟 牙根外吸收 根裂,7,14-2 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 lesi
4、ons on the periodontium,8,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,eriodontal 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
5、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,after 18 M,In multirooted teeth a periodontal ligament fistulation can drain off into the furcation a
6、rea,11,12,，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,Angular bone defect at
7、 the distal root surface of a mandibular premolar (arrows). The root is perforated. Conceivably, this occurred in conjunction withpreparation of the root canal for a post and core. Clinicalsymptoms included drainage of pus from the pocket and increased tooth mobility. The tooth was extracted.,14,Per
8、foration 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)
9、. After an observation period of 2 years, normal periodontal conditions were re-established both clinically and radiographically,15,16,17,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/p
10、ocket area usually have a hopeless prognosis due to continuous bacterial invasion of the fracture space from the oral environment.,18,19,20,21,External Root resorption,22,Surface resorption,A surface resorption is initiated subsequent to injury of the cementoblastic cell layer. Osteoclasts are attra
11、cted by substances from the damaged tissue on the denuded root surface and resorb the hard tissue,These resorptions may be caused by a localizedinjury in conjunction with external trauma (Andreasen1981) and by trauma from occlusion. Resorptionmay also result from excessive orthodontic forces.,This t
12、ype of resorption is common, self-limiting and reversible,23,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 absen
13、t tooth mobility and by a percussion tone that is higher than in a normal tooth,24,External inflammatory resorption,The term external inflammatory resorption suggests the presence of an inflammatory lesion in the periodontal tissues adjacent to a resorptive process,25,14-3 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RCTFirst observe the result of this therapy and institute periodontal therapy later if necessary,26,2，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,
