年轻恒牙复杂冠折及冠根折的诊疗策略

年轻恒牙牙根未发育完全，复杂冠折及冠根折造成的牙体缺损、牙髓暴露可造成牙髓感染坏死甚至牙根发育停止，影响患牙保留和永久性修复。文章结合2020年国际牙外伤学会颁布的指南和牙外伤临床研究报道深入剖析年轻恒牙复杂冠折及冠根折的诊疗策略，旨在通过汇总分析当前诊疗方法，优化临床治疗规范，为年轻恒牙复杂冠折及冠根折的治疗提供最佳临床路径。     

年轻恒牙外伤后的牙髓处理

牙齿外伤包括牙体硬组织损伤、牙髓组织损伤和牙周组织损伤。牙髓组织损伤可存在于牙齿折断、牙齿移位和牙齿全脱臼。外伤后,牙髓组织的转归可分为牙髓存活、髓腔钙化、牙髓坏死。7～15岁是儿童恒牙外伤的高发年龄,此时其牙齿尚处于生长发育中,牙外伤的治疗和预后远比成人复杂。本文针对年轻恒牙的特点,提出外伤后牙髓损伤判断和处置的对策。     

Partial pulpotomy in crown-fractured permanent incisor with hyperplastic pulpitis: a case report

Abstract Hyperplastic pulpitis, which is regarded as one type of asymptomatic irreversible pulpitis, occurs usually in young teeth where pulps are exposed by caries or trauma. If apices are mature, root canal therapy is recommended. In this case, the success of partial pulpotomy in a crown-fractured permanent incisor with hyperplastic pulpitis, which had been contaminated with oral microflora for six months is reported.     

IPS Empress铸瓷贴面修复上颌年轻恒切牙冠折的临床观察

目的:评价IPSEmpress铸瓷贴面修复上颌年轻恒切牙冠折的临床效果。方法:对冠折未露髓的上颌年轻恒切牙采用IPSEmpress铸瓷贴面修复后的临床效果观察2～3年。结果:31例患者共35颗牙齿瓷贴面修复,在观察期间瓷贴面完整无缺损,无边缘及表面着色,无继发龋,2颗与邻牙颜色有轻度颜色不调,3颗轻中度的牙龈炎症,其余与邻牙颜色协调,边缘适合性好,没有继发牙髓炎症。结论:用IPSEmpress铸瓷贴面修复年轻恒切牙冠折,可以快速恢复其外形和美观,最大可能地保护了牙体牙髓组织,不需待成年后二次修复。     

固定修复对深龋牙髓健康影响的临床研究

目的 探讨固定修复术对深龋牙髓健康的影响。方法 124颗需要固定修复的患牙以年龄、性别、牙位配对分成深龋组（64颗）与对照组（64颗），记录两组在两年中的牙髓状况。结果 深龋组在两年观察中8例发生牙髓炎，发生率12．7％；对照组l例牙髓炎，发生率1．6％；经誓检验差异有极其显著的统计学意义。结论 深龋惠牙采用固定修复应慎重。     

年轻恒前牙活髓切断术后根髓的组织学改变

目的观察活髓切断术后根髓的组织学特点，为临床已行活髓切断术并且牙根形成后是否需及时做根管治疗提供依据。方法选取因外伤后行活髓切断术、牙根已形成且修复需髓腔根管固位的29颗恒前牙，同时用正畸减数拔除的、牙根已形成的30颗恒前磨牙作为正常对照。对两组牙的根髓分别进行HE染色、I型胶原和Ⅲ型胶原的免疫组织化学染色。结果活髓切断术后的根髓可发生成牙本质细胞空泡性变及均质化，牙髓细胞减少、核固缩、纤维性变、玻璃样变、钙化等一系列退行性表现。正常根髓中I型胶原分布弥漫，钙化物呈阳性表达，而Ⅲ型胶原在根髓周缘表达很弱，钙化物呈阴性表达；活髓切断术后根髓中I、Ⅲ型胶原的表达均明显增强，纤维成束增加，血管壁I型胶原表达增强，Ⅲ型胶原表达减弱。结论年轻恒前牙活髓切断术后其牙本质桥下方的根髓组织呈现出一系列退行性改变，所以年轻恒前牙已行活髓切断术并且牙根形成后，临床不宜观察时间过长，应实施根管治疗术，以利于髓腔根管固位修复。     

Surgical extrusion of a crown-root fractured immature permanent incisor: 36 month follow-up

Crown-root fracture is defined as a fracture involving enamel, dentin and pulp and can be classified as either complicated or uncomplicated. The tooth with crown-root fracture presents a lot of problems during coronal restorations and extraction was formerly used in many cases. But loss of a permanent incisor in a young patient may create severe emotional problems and alternative treatment approaches must be considered. This report presents the successful results of a surgical extrusion of a complicated crown-root fractured, immature permanent incisor in a 9-year-old boy. Examination 36 months after the trauma indicated that the treatment had provided functional and esthetic results.     

Direct pulp capping with mineral trioxide aggregate: an observational study

BACKGROUND: Pulp capping in carious teeth has been considered unpredictable and therefore contraindicated. A recently developed material, mineral trioxide aggregate (MTA), resists bacterial leakage and may provide protection for the pulp, allowing repair and continued pulp vitality in teeth when used in combination with a sealed restoration. METHODS: Forty patients aged 7 to 45 years accepted pulp-capping treatment when they received a diagnosis no more severe than reversible pulpitis after undergoing cold testing and radiographic examination. The primary author removed caries using a caries detector dye and sodium hypochlorite solution for hemostasis and placed MTA over the exposures and all surrounding dentin. The operator then restored the teeth provisionally with unbonded Clearfil Photocore (Kuraray Medical, Okayama, Japan). During a second visit, the operator restored the teeth with bonded composite after sensibility testing and confirmed MTA curing. At recall appointments, patients were evaluated for reparative dentin formation, pulpal calcification, continued normal root development and evidence of pathosis. RESULTS: Over an observation period of nine years, the authors followed 49 of 53 teeth and found that 97.96 percent had favorable outcomes on the basis of radiographic appearance, subjective symptoms and cold testing. All teeth in younger patients (15/15) that initially had open apexes showed completed root formation (apexogenesis). CONCLUSIONS: MTA can be a reliable pulp-capping material on direct carious exposures in permanent teeth when a two-visit treatment protocol is observed. PRACTICE IMPLICATIONS: Vital pulp therapy using MTA is a treatment option for teeth diagnosed with a condition no more severe than reversible pulpitis.     

Vital pulp therapy of mature permanent teeth with irreversible pulpitis from the perspective of pulp biology

The American Association of Endodontists (AAE) Consensus Conference Recommended Diagnostic Terminology states that mature permanent teeth clinically diagnosed with irreversible pulpitis are treated with pulpectomy and root canal filling because inflamed vital pulp is not capable of healing. Histological studies have demonstrated that clinically diagnosed irreversible pulpitis does not involve the entire pulp. A recent International Endodontic Journal Editorial suggested clinical diagnosis of pulp disease should be reassessed because of the poor correlation between clinical symptoms and pulp sensibility testing and the actual histological status of the pulp. This review identified studies in a PubMed search that provide evidence for vital pulp therapy (VPT) of mature permanent teeth with irreversible pulpitis is predictable if correctly diagnosed and properly treated. A narrative review was undertaken to outline the correlation between the clinical symptoms/signs and pulp sensibility testing and the histological findings of the pulp. Treatment procedures for permanent teeth are outlined.     

年轻恒牙活髓保存治疗

年轻恒牙活髓保存的目的是为了保护冠部或根部剩余牙髓组织的活性和功能,促进牙根生理性发育。传统观点认为,活髓保存只适用于牙髓正常或可逆性牙髓炎、无根尖病变的患牙,以保留患牙剩余未被感染的健康牙髓组织。但迄今为止,并没有可靠的手段能准确判断牙髓状态。此外,多个研究显示龋源性露髓、伴有不可逆性牙髓炎及根尖周感染的患牙活髓保存治疗成功。临床上应充分利用年轻恒牙牙髓组织再生修复能力强的组织学特点,对年轻恒牙牙髓治疗采取更为保守的方法,以期获得更好的预后。     

Vascular status in human primary and permanent teeth in health and disease

The present study sought to compare the vascular status of human primary teeth with that of human permanent teeth, and to determine whether caries or painful pulpitis was associated with changes in vascularity. Coronal pulps were removed from 62 primary and 62 permanent mandibular molars with a known pain history. Teeth were categorized as intact, moderately carious or grossly carious. Pulp sections were labelled with Ulex europaeus I lectin (UEIL), which is a marker of human vascular endothelium. Image analysis was then used to quantify the percentage area of UEIL-labelled tissue (vascularity) and the number of blood vessels present within three regions: the pulp horn, the subodontoblastic region, and the mid-coronal pulp. Only the mid-coronal region of the primary tooth pulp was found to be significantly more vascular than the corresponding area of the permanent tooth pulp. Both dentitions showed a significant increase in vascularity within the pulp horn region with caries progression, but this was not accompanied by an increase in vessel number. There was no correlation between vascularity and pain symptoms. These findings suggest that the primary tooth pulp is more vascular than its successor within the mid-coronal region. However, the functional and clinical significance of this finding remains speculative.     

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牙外伤包括牙体硬组织损伤、牙髓组织损伤和牙周组织损伤。牙髓损伤常见于牙齿折断、牙齿移位和牙齿全脱出中,可见牙髓损伤几乎在所有的牙齿外伤中都存在。外伤后,牙髓组织的转归可分为牙髓存活、牙髓钙变和牙髓坏死3种。牙髓组织的转归与以下因素有关:(1)外伤冲击力对牙髓组织的损伤;(2)外伤后外界不良刺激;(3)牙齿发育程度、个体差异等。儿童恒牙外伤后牙齿尚处于生长发育中,其治疗和预后远比成人复杂。本文针对年轻恒牙的特点,提出外伤后牙髓损伤判断和处置的对策。     

MTA pulpotomy of human permanent molars with irreversible pulpitis

The histological success of mineral trioxide aggregate (MTA) pulpotomy for treatment of irreversible pulpitis in human teeth as an alternative treatment was investigated in this study. Fourteen molars which had to be extracted were selected from patients 16–28 years old. The selection criteria include carious pulp exposure with a history of lingering pain. After isolation, caries removal and pulp exposure, MTA was used in pulpotomy treatment. Patients were evaluated for pain after 24 h. Two patients were lost from this study. Twelve teeth were extracted after 2 months and were assessed histologically. Recall examinations confirmed that none of the patients experienced pain after pulpotomy. Histological observation revealed that all samples had dentin bridge formation completely and that the pulps were vital and free of inflammation. Although the results favour the use of MTA as a pulpotomy material, more studies with larger samples and a longer recall period are suggested to justify the use of MTA for treatment of irreversible pulpitis in human permanent teeth.     

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?? The purpose of vital pulp therapy for immature permanent tooth is to protect activity and function of the crown or root residual pulp tissue?? and promote the root physiological development. It has been recommended that vital pulp therapy should be performed only to preserve the healthy pulp tissue in teeth with normal pulp or teeth with reversible pulpitis or teeth without periapical lesions. But up to now?? there is no reliable means that can precisely reflect the pulp condition. Currently?? several studies have reported successful outcome of vital pulp therapy in vital teeth with cariously exposed pulp??or with signs and symptoms of irreversible pulpitis or with periapical lesions. In clinics?? we should make full use of the fact that pulp tissue in immature permanent teeth has strong ability of tissue repair and regeneration. So a more conservative pulp therapy should be taken for young permanent teeth in order to obtain a better prognosis.     

Pulp changes in deciduous teeth associated with deep carious dentine.

Serial sections of carious deciduous molar teeth were examined and it was found that inflammation of the pulp occurred when the average thickness of remaining dentine between the most deeply penetrating bacteria and the pulp was 0·6 mm, and the maximal width of dentine between the pulp and the most deeply penetrating bacteria associated with pulpitis was 1·8 mm. The comparable figures for permanent teeth noted by Shovelton (1968) were 0·3 mm and 0·8 mm. This indicates that the deciduous pulp responds more rapidly to the effects of dentine caries than does the permanent tooth, and emphasizes the value of preventing caries of deciduous teeth or at least providing early restorative care.     

Immunohistochemical localization of LIM mineralization protein 1 in pulp-dentin complex of human teeth with normal and pathologic conditions

LIM mineralization protein 1 (LMP-1) is an essential positive regulator of osteoblast differentiation and maturation and bone formation. However, the expression and distribution of LMP-1 in human teeth are largely unknown. The aim of this study was to detect the expression of LMP-1 in normal healthy human teeth and human teeth with various pathologic conditions. LMP-1 expression was determined by immunohistochemistry in all of the samples including 12 healthy teeth, 10 teeth with caries, 12 teeth with pulpitis, and 4 teeth with pulp calcification. We found that LMP-1 was expressed primarily in predentin, odontoblasts, and endothelial cells of the blood vessels of healthy teeth. In addition, LMP-1 expression was also found in unmineralized reparative dentin, odontoblast-like cells, and pulp fibroblasts in teeth with caries and pulpitis. Furthermore, we found LMP-1 expression on the surface of the pulp stone or in the residual predentin of teeth with pulp calcification. Our data suggest that LMP-1 plays a role in odontoblast differentiation and dentin matrix mineralization of human teeth with normal and pathologic conditions.     

Management of recurrent fracture of central incisor with internal resorption using light transmitting (luminex) post

The normal root canal anatomy may be altered in various pathological processes and making it very difficult and at times impossible to achieve ideal obturation by normal methods. Internal resorption is one among them. There are several treatment protocols advised for this pathological condition. A crown-root fracture is defined as a fracture involving enamel, dentin and cementum and accounts for 5% of all traumatic injuries to the permanent dentition. In anterior teeth, these fractures are usually caused by direct trauma and often complicated in fully erupted teeth. In cases where the fracture line extends down along the long axis of the root, extraction of the tooth is indicated. The purpose of this report is to present the use of light transmitting post system to reinforce the crown root fractured maxillary central incisor due to trauma and internal resorption.     

Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review

Objective: Coronal pulpotomies were recently re-investigated as an alternative to root canal treatment in vital permanent teeth. General dentists may be interested in knowing how to perform full pulpotomy, in particular in face of difficult endodontic cases of vital teeth.

Material and methods: A systematic review was undertaken on the PubMed and Cochrane databases in order to determine which procedure should be applied for pulp capping and coronal restoration in routine dental practice. Fifty-three publications were included and allocated to one of two methodological categories: histological and clinical studies.

Results and conclusions: There is no evidence to recommend one single procedure for full pulpotomy in vital permanent teeth that can be indicated for different pulpal diagnoses which differ greatly in terms of the inflammation process from healthy teeth to irreversible pulpitis. For each clinical case, all actions aiming to prevent pre-operative contamination, to control per-operative infection and to achieve a complete seal above the radicular pulp sections are unavoidable steps that should be complied with. Reproducing procedures adopted in high quality trials could insure high success rates.     

Predictable management of cracked teeth with reversible pulpitis

Background: The aims of this study were to assess symptoms and signs caused by cracks in teeth and to assess a conservative management protocol. Methods: The symptoms and signs of 100 consecutive teeth that had reversible pulpitis associated with cracks were compared to findings from other reports. Teeth were managed with a conservative protocol which involved removal of cracks, caries and restorations, followed by placement of a sedative lining and interim restoration unless there were pulp exposures or insufficient tooth structure remaining. Teeth were monitored for pulp healing after three months and for up to five years. Results: Eighty teeth did not require endodontic treatment. One tooth had an uncertain pulp status at review appointments. Fifteen teeth required endodontic treatment at the initial appointment because of carious pulp exposures (4 teeth), cracks extending into the pulp (2), and posts required (9). Four other teeth required endodontic treatment later following conservative pulp treatment due to continued pulpitis under the temporary restoration (1), pulpitis after core restoration (2), and pulp necrosis diagnosed at the review (1). Conclusions: Provided there is an accurate diagnosis of the pulp status and its cause, teeth with reversible pulpitis due to cracks can be treated conservatively without endodontic treatment in about 80 per cent of cases.     

Re-eruption of an intruded immature permanent incisor with necrotic pulp: a case report

Intrusive luxation is a serious dental injury that causes damage to the pulp and supporting structures of a tooth because of its dislocation into the alveolar process. This paper presents the case of the re-eruption of a severely intruded immature permanent incisor with a crown-root fracture. A 9-year-old boy was referred to the clinic 1 day after a fall. Clinical and radiographic examinations revealed intrusive luxation of the immature left permanent incisor and a crown-root fracture without pulp exposure. Palatal gingivectomy was done 2 weeks later to facilitate re-eruption. Root canal therapy with intracanal calcium hydroxide paste was initiated during the first month owing to severe spontaneous pain. Six months later, the tooth re-erupted to a normal position, after which root canal obturation and a final esthetic restoration were done. The present case demonstrates the possibility of obtaining re-eruption of intruded immature permanent teeth with interim medication (calcium hydroxide) in the root canal.