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中华口腔医学研究杂志(电子版) ›› 2023, Vol. 17 ›› Issue (03) : 153 -161. doi: 10.3877/cma.j.issn.1674-1366.2023.03.001

所属专题: 总编推荐 口腔医学

中青年专家笔谈

根管治疗器械分离的临床管理
王祥柱1,()   
  1. 1. 中南大学湘雅口腔医学院·口腔医院牙体牙髓科·口腔健康研究湖南省重点实验室,长沙 410008
  • 收稿日期:2023-02-08 出版日期:2023-02-21
  • 通信作者: 王祥柱

Clinical management of instrument separation during endodontic therapy

Xiangzhu Wang1,()   

  1. 1. Department of Conservative and Endodontic Dentistry, Xiangya School and Hospital of Stomatology, Central South University & Hunan Key Laboratory of Oral Health Research, Changsha 410008, China
  • Received:2023-02-08 Published:2023-02-21
  • Corresponding author: Xiangzhu Wang
  • Supported by:
    Natural Science Foundation of Hunan Province(2021JJ40906)
引用本文:

王祥柱. 根管治疗器械分离的临床管理[J/OL]. 中华口腔医学研究杂志(电子版), 2023, 17(03): 153-161.

Xiangzhu Wang. Clinical management of instrument separation during endodontic therapy[J/OL]. Chinese Journal of Stomatological Research(Electronic Edition), 2023, 17(03): 153-161.

器械分离是根管治疗最常见的并发症之一,也是困扰口腔医生的临床难题。本文就根管治疗器械分离发生的原因、处理决策、临床处置流程、常用取出技术要点和处理后的临床问题进行总结,以期探讨根管治疗器械分离的合理处置方案,探索器械分离取出操作规范,提高患牙保留率与治疗成功率。

Instrument separation is one of the most common complications of root canal treatment, and it is also a clinical problem that plagues many dentists. This article summarized the causes of root canal instrument separation, handling decisions, clinical disposal process, the removal techniques commonly used in clinics, and the post-treatment problems that may arise following root canal treatment. It aimed to investigate the rational disposal options for endodontic instruments that have been separated. In addition, this article also explored the specifications for removing separated instruments, so as to improve the success rate of treatment and increase tooth survival.

图1 根管内器械分离的根尖片与锥形束CT(CBCT)的不同表现 A:根尖片显示36近中、远中根根尖区各1段高密度异物影像(红色箭头示);B:CBCT冠状面显示36近中颊侧根管根尖区高密度影;C:CBCT矢状面显示36近中颊侧根管根尖区高密度影;D:CBCT冠状面显示36远中舌侧根尖区高密度影;E:CBCT轴面显示近中颊侧根管、远中舌侧根管内高密度影。可见根尖片更便于判断分离器械的密度及直径、锥度等形态特征,CBCT更便于评估根管的具体形态、分离器械在根管内的三维位置,二者通常缺一不可。
图2 编织法取分离器械示意图 A:手用锉旁路绕过分离器械后进行根管预备;B:2支以上手用锉从分离器械不同方向同时绕过分离器械;C:编织已经绕过分离器械的手用锉至感受到有轻微阻力,保持编织扭力并同时快速拔出所有手用锉;D:分离器械被编织的手用锉带出根管;E:2支以上手用锉即使在分离器械一侧进行编织,也可以产生较大的阻力便于带出分离器械;F:多支手用锉绕过分离器械后编织的X线影像特征。
图3 套管/套索法取分离器械示意图 A:使用GG钻预备分离器械上段通道与断面平台;B:使用镍钛锉预备分离器械上段通道与断面平台;C:完全暴露一定长度分离器械后,使用套管提取器夹持;D:套管夹持的机械原理;E:套管夹持取出分离器械;F:完全暴露一定长度分离器械后,使用套索圈住分离器械;G:套索提取分离器械原理;H:套索拉紧并取出分离器械。
图4 尖段个性化预弯、磨改的超声工作尖 A:超声工作尖可根据根管的弯曲形态进行预弯;B ~ C:当分离器械与根管壁之间无明显间隙时,可将超声工作尖进行打磨使其更尖锐,便于在分离器械旁微创去除牙本质,松解分离器械;D ~ E:可将超声工作尖打磨成匙形,提高松解分离器械的效率。
图5 超声法取不同形态根管内分离器械示意图 A ~ E:超声法取Ⅰ类根管内分离器械示意图;F ~ J:超声法取Ⅱ类根管内分离器械示意图;K ~ O:超声法取Ⅲ类根管内分离器械示意图;A、F、K:纵面观不同形态根管内分离器械;B、G、L:纵面观超声工作尖切削位置;C、H、M:轴面观分离器械周围无间隙时超声工作尖主动切削器械周围牙本质,有间隙时被动进入狭区切削增隙;D、I、N:轴面观虚线区域为超声工作尖在不同形态根管内切削区域;E、J、O:轴面观粉色区域为去除分离器械周围牙本质后的间隙。
图6 超声法取重度弯曲根管下段分离器械示意图 A:重度弯曲根管下段器械分离;B:镍钛锉沿根管弯曲相反方向拉开上段通道;C:上段拉开后根管弯曲度相对减小;D:超声工作尖沿分离器械在弯曲内侧去除牙本质;E:去除内侧牙本质后分离器械逐渐松解;F:不建议在弯曲外侧增加间隙;G:沿分离器械外侧增加间隙会使分离器械横躺,增加取出难度。
图7 超声法取右上第一磨牙近颊根管根尖段分离器械 A:根尖片显示16近颊根管根尖段重度弯曲,弯曲下段高密度影(红色箭头示);B:锥形束CT(CBCT)分析分离器械的长度、根管形态、分离器械与根管三维方向的位置关系;C:沿根管弯曲方向预弯15#超声K锉;D:使用预弯超声锉在分离器械的弯曲内侧去除牙本质,松解分离器械并取出;E:取出的分离器械,长度约3 mm,蓝色镍钛材料;F:取出分离器械后根尖片显示根管内无残留;G:根充完成后根尖片;H:超声法取右上第一磨牙近颊根尖段分离器械操作视频(扫码观看)。
图8 超声法取左下第一磨牙远舌根管根尖段分离器械 A:根尖片显示36远舌根管根尖段重度弯曲,弯曲下段高密度影(红色箭头示);B:锥形束CT(CBCT)分析分离器械的长度、根管形态、分离器械与根管三维方向的位置关系;C:CBCT分析取出远舌根尖段分离器械需去除的牙本质量;D:预弯10# ~ 15#超声K锉,沿分离器械弯曲内侧去除牙本质,松解分离器械并取出;E:取出的分离器械,长度约4.5 mm,发生解螺旋的K锉;F:取出分离器械后根尖片显示根管内无残留;G:根充完成后根尖片。
图9 旁路法取左上第一前磨牙根管中下段分离器械 A:根尖片显示24双根管均重度弯曲,弯曲下段各见一段高密度影(红色箭头示);B:锥形束CT(CBCT)分析颊侧根管内分离器械的长度、根管形态、分离器械与根管三维方向的位置关系;C:CBCT分析舌侧根管内分离器械的长度、根管形态、分离器械与根管三维方向的位置关系;D:预弯8# C+锉,沿分离器械旁路疏通根管,建立旁路后超声取出分离器械;E:取出的分离器械,长度分别约2 mm、2.5 mm;F:取出分离器械后根尖片显示根管内无残留;G:根充完成后根尖片。
图10 蟹爪钳取左上第一磨牙远颊根超出根尖孔分离器械 A:根尖片显示26远颊根管内较长高密度影超出根尖孔(红色箭头示);B:锥形束CT(CBCT)分析器械长度、根管形态、分离器械与根管三维方向的位置关系,见较长大锥度器械超出根尖孔,大部分位于上颌窦;C:超声松动分离器械后,蟹爪钳夹取分离器械末端并取出;D:取出的分离器械,长度约16.5 mm,大锥度镍钛锉;E:取出分离器械后根尖片显示根管内无残留;F:根充完成后根尖片。
图11 磁铁吸引取右上第二磨牙腭根根尖孔外分离器械 A:根尖片显示17腭根根尖孔外高密度异物影(红色箭头示);B:锥形束CT(CBCT)分析器械长度、根管形态、分离器械与根管三维方向的位置关系,见较短高密度异物影位于根尖孔外;C:钕铁硼强磁棒吸引取出分离器械;D:取出的分离器械,长度约2 mm;E:取出分离器械后根尖片显示无残留;F:根充完成后根尖片。
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