牙周-正畸-牙体联合治疗1例预后无望上前牙患者的长期疗效观察

位于美学区的上前牙因重度牙周炎、牙周牙髓联合病变、牙外伤等原因丧失大量牙周支持组织、出现移位及明显松动时，常被临床医生评估为“预后无望”［1］，此类患牙的治疗计划包括试保留、拔除后种植、拔除后修复等。要选择一个合适的治疗计划，临床医生需要综合考虑患者的牙周状况、牙周生物型、局部解剖结构、面部结构、美学要求、经济状况、社会心理状况等诸多因素。因外伤、根折、龋坏等原因被评估为“预后无望”的上前牙，患牙的牙体组织损坏严重，而牙周组织损失量相对较少，采用拔除后种植或修复的治疗方案往往能达到良好的功能和美学效果，但因牙周炎、牙周牙髓联合病变等原因被评估为“预后无望”的上前牙，患牙的牙体组织完整，而牙周软硬组织丧失严重，若采用种植/修复治疗的策略，难度较大，治疗效果可能不佳，随着牙周再生性手术日渐成熟，许多以往被认为“预后无望”的牙齿得以长期健康保留。Cortellini等［2］的研究结果表明，预后无望的重度垂直型骨吸收患牙经过完善的牙周基础治疗与牙周再生治疗后可以长时间健康存留。 此外，上前牙美学区的重度牙周炎患牙往往伴随牙齿伸长、移位、继发性咬合创伤等问题，这不仅会进一步加重牙周组织的破坏，也会影响牙周再生手术的治疗效果。随着牙周与多学科联合治疗的普及，对于发生重度牙周破坏并伴有牙齿移位、咬合创伤的患牙，牙周再生手术与正畸联合治疗可以获得良好的治疗效果。本文将分析1例上颌中切牙重度牙周炎、牙齿移位的典型病例，详细介绍如何通过牙周基础治疗、正畸治疗与牙周再生治疗联合应用的方法，重建上前牙周围牙周支持组织，改善咬合关系，达到长期的健康和美学效果。

Combination of periodontal,orthodontic and endodontic therapy in upper anterior teeth with hopeless prognosis and long-time follow-up:a case report

It is complicated to decide the treatment plan of hopeless anterior teeth in esthetic zone due to severe periodontitis, periodontal-endodontic combined lesion or teeth trauma.The optional treatment plan for this kind of teeth includes retention after periodontal treatment, extraction and implant treatment, extraction and prosthodontic treatment and so on.To make an appropriate treatment plan, patients'' periodontal conditions, periodontal biotype, local anatomy, esthetic demand, economic condition and social psychological status should be comprehensively considered.A combine of periodontal, endodontic and orthodontic therapy may achieve a good treatment effect in hopeless anterior teeth with severe periodontal destruction, tooth extrusion and occlusal trauma.In this case, a 20-year-old female who presented with symptoms of bleeding on brushing and upper incisors loosening for 1 month came to the Department of Periodontology, Peking University School and Hospital of Stomatology.The clinical examinations revealed that the patient''s right upper incisor had signs of mobility (Ⅲ°), intrusion of 1-2 mm, and probing depth (PD) of 9-10 mm.The periapical radiograph showed that the alveolar bone of right upper incisor absorbed horizontally to the apex.And the patients showed Angle Ⅱ° malocclusion with Ⅱ° overbite in anterior teeth and maxillary protrusion.A diagnosis of aggressive periodontitis and Angle Ⅱ° malocclusion was made.The treatment of this patient lasts for 5 years which include periodontal initial therapy, orthodontic therapy, guided tissue regeneration (GTR) of right upper incisor and supportive periodontal therapy and the clinical result is fine.A hopeless upper incisor was successfully retained and the longtime clinical condition was stable.The strategy of retention of hopeless upper anterior teeth, the relationship of periodontal treatment and orthodontic treatment, and the indications of periodontal and orthodontic combined therapy were also discussed on the basis of this case.Generally, the positive factors in retention of hopeless teeth includes young age, absence of systemic conditions, strong motivation for maintaining the tooth, single root anatomy, integrated dentition, good response to cause-related therapy, intrabony alveolar bone defect, thick periodontal biotype, and regular supportive periodontal therapy.And in the progress of orthodontic therapy, regular supportive periodontal therapy and good plaque control is extremely important.