牙髓病学与正畸学的关系:综合治疗计划挑战的综述

Endodontic-orthodontic relationships: a review of integrated treatment planning challenges.

作者信息

Hamilton R S, Gutmann J L

机构信息

Department of Restorative Sciences, Texas A & M University Health Science Center, Baylor College of Dentistry, Dallas 75246, USA.

出版信息

Int Endod J. 1999 Sep;32(5):343-60. doi: 10.1046/j.1365-2591.1999.00252.x.

Abstract

Literature review There is a paucity of information on the concise relationship between endodontics and orthodontics during treatment planning decisions. This relationship ranges from effects on the pulp from orthodontic treatment and the potential for resorption during tooth movement, to the clinical management of teeth requiring integrated endodontic and orthodontic treatment. This paper reviews the literature based on the definition of endodontics and the scope of endodontic practice as they relate to common orthodontic-endodontic treatment planning challenges. Literature data bases were accessed with a focus on orthodontic tooth movement and its impact on the viability of the dental pulp; its impact on root resorption in teeth with vital pulps and teeth with previous root canal treatment; the ability to move orthodontically teeth that were endodontically treated versus nonendodontically treated; the role of previous tooth trauma; the ability to move teeth orthodontically that have been subjected to endodontic surgery; the role of orthodontic treatment in the provision for and prognosis of endodontic treatment; and, the integrated role of orthodontics and endodontics in treatment planning tooth retention. Orthodontic tooth movement can cause degenerative and/or inflammatory responses in the dental pulp of teeth with completed apical formation. The impact of the tooth movement on the pulp is focused primarily on the neurovascular system, in which the release of specific neurotransmitters (neuropeptides) can influence both blood flow and cellular metabolism. The responses induced in these pulps may impact on the initiation and perpetuation of apical root remodelling or resorption during tooth movement. The incidence and severity of these changes may be influenced by previous or ongoing insults to the dental pulp, such as trauma or caries. Pulps in teeth with incomplete apical foramen, whilst not immune to adverse sequelae during tooth movement, have a reduced risk for these responses. Teeth with previous root canal treatment exhibit less propensity for apical root resorption during orthodontic tooth movement. Minimal resorptive/remodelling changes occur apically in teeth that are being moved orthodontically and that are well cleaned, shaped, and three-dimensionally obturated. This outcome would depend on the absence of coronal leakage or other avenues for bacterial ingress. A traumatized tooth can be moved orthodontically with minimal risk of resorption, provided the pulp has not been severely compromised (infected or necrotic). If there is evidence of pulpal demise, appropriate endodontic management is necessary prior to orthodontic treatment. If a previously traumatized tooth exhibits resorption, there is a greater chance that orthodontic tooth movement will enhance the resorptive process. If a tooth has been severely traumatized (intrusive luxation/avulsion) there may be a greater incidence of resorption with tooth movement. This can occur with or without previous endodontic treatment. Very little is known about the ability to move successfully teeth that have undergone periradicular surgical procedures. Likewise, little is known about the potential risks or sequelae involved in moving teeth that have had previous surgical intervention. Especially absent is the long-term prognosis of this type of treatment. During orthodontic tooth movement, the provision of endodontic treatment may be influenced by a number of factors, including but not limited to radiographic interpretation, accuracy of pulp testing, patient signs and symptoms, tooth isolation, access to the root canal, working length determination, and apical position of the canal obturation. Adjunctive orthodontic root extrusion and root separation are essential clinical procedures that will enhance the integrated treatment planning process of tooth retention in endodontic-orthodontic related cases.

摘要

文献综述 在治疗计划决策过程中,关于牙髓病学与正畸学之间的确切关系,相关信息较为匮乏。这种关系涵盖了正畸治疗对牙髓的影响、牙齿移动过程中发生吸收的可能性,以及需要综合牙髓病学和正畸学治疗的牙齿的临床管理。本文基于牙髓病学的定义以及牙髓病治疗实践的范围,对相关文献进行综述,这些内容与正畸 - 牙髓病治疗计划中常见的挑战相关。我们检索了文献数据库,重点关注正畸牙齿移动及其对牙髓活力的影响;其对有活力牙髓的牙齿和先前接受过根管治疗的牙齿根吸收的影响;正畸移动已接受牙髓治疗的牙齿与未接受牙髓治疗的牙齿的能力;先前牙齿创伤的作用;正畸移动接受过牙髓手术的牙齿的能力;正畸治疗在牙髓治疗的准备和预后中的作用;以及正畸学和牙髓病学在治疗计划中保留牙齿方面的综合作用。正畸牙齿移动可在根尖形成完成的牙齿牙髓中引发退行性和/或炎症反应。牙齿移动对牙髓的影响主要集中在神经血管系统,其中特定神经递质(神经肽)的释放可影响血流和细胞代谢。这些牙髓中引发的反应可能会影响牙齿移动过程中根尖根重塑或吸收的起始和持续。这些变化的发生率和严重程度可能受到先前或正在进行的对牙髓的损伤影响,如创伤或龋齿。根尖孔未完全形成的牙齿的牙髓,虽然在牙齿移动过程中并非不会出现不良后果,但出现这些反应的风险较低。先前接受过根管治疗的牙齿在正畸牙齿移动过程中根尖根吸收的倾向较小。在正畸移动且清洁、成形良好并进行三维充填的牙齿根尖,发生的吸收/重塑变化极小。这一结果取决于是否不存在冠部渗漏或其他细菌侵入途径。一颗受过创伤的牙齿在牙髓未受到严重损害(感染或坏死)的情况下,可以进行正畸移动,吸收风险极小。如果有牙髓死亡的证据,在正畸治疗前需要进行适当的牙髓病管理。如果一颗先前受过创伤的牙齿出现吸收,正畸牙齿移动更有可能会增强吸收过程。如果一颗牙齿受到严重创伤(嵌入性脱位/牙脱位),牙齿移动时吸收的发生率可能更高。无论先前是否接受过牙髓治疗,都可能出现这种情况。对于成功移动接受过根尖周外科手术的牙齿的能力,我们了解甚少。同样,对于移动先前接受过手术干预的牙齿所涉及的潜在风险或后遗症,我们也知之甚少。尤其缺乏这种治疗类型的长期预后情况。在正畸牙齿移动过程中,牙髓治疗的实施可能受到多种因素影响,包括但不限于影像学解读、牙髓测试的准确性、患者的体征和症状、牙齿隔离、进入根管的难易程度、工作长度的确定以及根管充填的根尖位置。辅助性正畸牙根挤出和牙根分离是重要的临床操作,将有助于在牙髓病 - 正畸相关病例中增强保留牙齿的综合治疗计划过程。

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