1、同济大学口腔医学院教案编号： 课程名称 牙体牙髓病学 授课日期 09-03-27 学时 2授课章节或题目 牙髓病治疗学授课教师 赵守亮 技术职称 教授 教师资格证号 正在办理中专业年级 2006 级口腔本科 授课方式 理论（2 ） ；实验(习)：（ ）授 课 内 容 方法、手段、时间目的和要求：掌握盖髓术的适应症和治疗方法掌握牙髓切断术的适应症和治疗方法掌握根管治疗术的原理和原则了解牙髓塑化疗法了解根管外科治疗方法授课内容：牙髓病治疗学（Endodontic Treatment）无髓牙的生理 无髓牙死牙无髓牙仍有新陈代谢感染问题无髓牙仍能承担咀嚼压力无髓牙的感觉活髓保存直接盖髓术 间接盖髓术活
2、髓切断术无髓牙保存干髓术根管治疗术（去髓术）牙髓塑化疗法大课讲授，动画、图片，临床典型病例分析复习 5min牙髓根尖周病治疗概述5min(补充)盖 髓 术（Pulp Capping）适应症(Indications)间接盖髓术 直接盖髓术In-direct Direct深龋/可复性牙髓炎 牙外伤露髓初期慢性闭锁性牙髓炎 窝洞制备时意外穿髓轻度初期急性牙髓炎 新鲜露髓直径诊断性治疗 不超过 1mm （可疑性牙髓炎） （龋坏穿髓者不适用）方 法间接盖髓术 直接盖髓术去龋,制洞,隔湿 冲洗后立即隔湿覆盖间接盖髓剂 覆盖直接盖髓剂 充填窝洞 充填窝洞盖髓剂间接盖髓术 直接盖髓术Ca (OH )2 Ca
3、(OH )2暂 汀 暂 汀生物盖髓剂 生物盖髓剂（BMP，TGF-） （BMP，TGF-） 注意事项间接盖髓术 直接盖髓术操作轻，防止穿髓 严格控制适应症必要时暂补观察 保护穿髓点术后自发痛可改行去髓术或干 髓术组织愈合间接盖髓术 直接盖髓术第三期牙本质 第三期牙本质Tertiary Dentin Tertiary Dentin（反应性为主） （修复性为主）Reactionary Reparative 活髓切断术（Pulpotomy）适应症（青少年） 病变仅限于部分冠髓的牙髓炎23min2 个动画12min意外露髓点大,不能行直接盖髓术者牙冠折断而牙根未发育完成者 操作步骤局麻下（1）去除龋坏
4、组织（2）清洗、消毒、隔湿（3）开髓，切除冠髓至根管口下 1mm （4）冲洗窝洞，盖髓剂（1mm）覆盖于牙髓断面（5）永久充填或暂封（防湿、无菌操作）组织学愈合变化 （1）牙本质桥封闭根管口（2）骨性硬组织封闭根管口（3）骨样硬组织封闭根管口（4）少量骨样硬组织形成根髓： 退变，慢性炎症 （ 根管内吸收 ）影响盖髓、切髓疗效的因素 （1）病例选择（病变范围、程度、性质）（2）细菌感染或污染（3）盖髓剂（Ca(OH)2）（4）牙髓断面出血 干 髓 术（Pulp Mummification）适 应 症 凡冠髓未全部化脓或坏死的各类牙髓病（后牙）因修复需要 操作步骤 （1）牙髓失活（2）揭髓室顶，去
5、冠髓至根管口下 1mm（3）髓室干燥，根管口放置干髓剂（4）垫置锌基、银汞合金充填 根管治疗术（Root Canal Therapy）( 牙髓摘除术 Pulpopectomy)适 应 症 1 个动画（第 1 学时结束）补充：7min1 个动画10min不能保存活髓的各类牙髓病各类尖周病外伤牙折因其他治疗需要主要操作步骤根管预备 （根管清洁、成形）根管消毒 （消除感染）根管充填 （消灭死腔，封闭根尖孔）根管预备原则无痛、无菌下操作局限在解剖根尖孔内管径扩大并有一定锥度，保持原有解剖位置根管冠 13 充分扩大近根尖孔处形成根尖挡操作方法 （去髓术）（1）局部麻醉，去龋，预备洞型，揭髓室顶（2）隔湿
6、（3）拔髓（4）根管预备，消毒，充填 牙髓塑化治疗（resinifying therapy）采用液态塑化剂注入已去除大部分牙髓的根管，使根管内病源刺激物塑化成为对人体无害的物质，从而达到防治根尖周病的目的适应症成年人根尖孔已完全形成的患牙无法采用常规根管治疗的患牙（乳牙，年轻恒牙，前牙禁用）操作方法根管预备配制塑化剂塑化（严格隔湿）封闭根管口充填窝洞并发症及处理塑化剂烧伤 粘膜充血、糜烂处理： 擦去塑化液，涂甘油残髓炎 症状轻重不一1 个动画8min处理： 局麻下或失活后去除残髓化学性尖周炎 持续性痛，轻度咬合痛处理： 调合观察重新治疗急性根尖周炎 较剧烈的胀痛，咬合痛处理： 建立引流通道，调
7、合慢性根尖周炎 根尖周骨质破坏，一般无明显症状处理： 改行根管治疗术专业外语PulpotomyIs the surgical removal of the coronal pulp and has as its objective the preservation of vitality of the radicular pulp and the relief of pain in patients with acute pulpalgiaCalcium hydroxide PulpotomyThe materials usually used to promote healing of th
8、e pulp are calcium hydroxide and zinc oxide and eugenol. Calcium hydroxide is used because of its predictability in bridge formation and maintenance of vitality of the residual pulp. In contrast, zinc oxide-eugenol cement causes a persistent chronic inflammatory response when applied directly to the
9、 pulp, with less likelihood of dentin bridge formationIndicationsIs indicated in pulpally involved childrens permanent teeth in which the root apex is not completely formed. In such cases, pulp extirpation and obturation are contraindicated because of the immature root and wide-open foramenCalcium h
10、ydroxideIs used because of its predictability in bridge formation and maintenance of vitality of residual pulp.In contrast, zinc oxide-eugenol cement causes a persistent chronic inflammatory response when applied directly to the pulp, with less likelihood of dentin bridge formation.The objective of
11、pulp mummification is to preserve the radicular portion of the dental pulp in an aseptic state, so as to obviate the necessity for 20min幻灯root canal treatment and filling. We do not employ and recommend this method of treating adult teeth.Pulpectomy,or pulp extirpation is the complete removal of a n
12、ormal or pathologic pulp from the pulp cavity of a tooth.Pulpectomy is generally a more successful operation than pulpotomy, especially in adult teeth. In a series of 12 vital pulp exposure in molar teeth, Lindstrom carried out pulpectomy in one root and pulpotomy in another root of the same tooth,
13、pulpectomy was successful in 92 percent of cases and pulpotomy was successful in only 71 percent.Endodontic treatment can be divided into three main phases: biomechanical preparation of the root canal (cleaning and shaping), disinfection and obturation. The initial step for cleaning and shaping the
14、root canal is proper access to the chamber that leads to straight-line penetration of the root canal orifices. The next step is exploration of the root canal, extirpation of the remaining pulp tissue or gross debridement of necrotic tissue and verification of the instrument depth. This step is follo
15、wed by proper instrumentation, irrigation, debridement and disinfection of the root canal. Obturation usually completes the procedure.同济大学口腔医学院教案 2006 年 2 月制授 课 内 容（续） 方法、手段、时 间牙髓病治疗学教学重点、难点 各治疗方法的适应症和方法复习思考题 牙髓根尖周病各治疗方法的原理主要参考书1. 牙体牙髓病学（第二版） 樊明文主编 人民卫生出版社，20042现代口腔内科学（第二版）史俊南主编 高等教育出版社，20043Endodontic practice (eleventh edition) Louis I Grossman Lea &Febiger4. Pathways of the pulp (seventh edition) Stephen Cohen Mosby Inc.5. Endodontics -Problem-solving in clinical practice TR Pitt Ford Martin Dunits
