基于旁路的复杂器械分离经根管取出策略探索与疗效评价

doi:10.3877/cma.j.issn.1674-1366.2025.06.003

目的

探索无直线通路、阻力复杂的根管治疗分离器械经根管内取出方法，分析基于旁路的取出要点、优势与风险，评价治疗效果。

方法

收集2017年2月至2025年1月期间就诊于中南大学湘雅口腔医院牙体牙髓科，术前影像诊断根管内器械分离，非套管法或超声法良好适应证，使用根管锉在分离器械旁疏通预备并取出分离器械，随访资料收集至术后半年以上。通过对患者基本情况、分离器械位置、长度、材质、型号、根管形态、术后影像、临床效果和随访资料等进行汇总，统计各变量例数，分析相关影响因素及治疗效果。

结果

共收集175例患者（包括176支分离器械），其中男52例（29.7%）、女123例（70.3%），最大年龄73岁，最小年龄9岁，平均28岁。分离器械不锈钢材质44例、镍钛108例、碳钢24例。平均长度4.1 mm，平均断面直径0.32 mm，断面位于根尖1/3占67.6%，其中断面位于盲区46例（26.1%），平均距离根管口5.6 mm，锉尖超出根尖孔17例，根管中重度弯曲（≥10°）占93.7%，平均弯曲角度29.3°。治疗前有根尖周阴影151例（其中86例有不适症状）、无根尖周阴影24例（其中7例有临床症状）。完整取出160例，二次分离4例，未取出6例。术后影像显示根管出现明显偏移34例（含偏移并穿孔3例），未见明显形态学偏移141例（80.6%）。随访结果，治疗前有根尖阴影且有临床症状患者取出分离器械后症状缓解或愈合83例，随访6个月仍有1例有症状及根尖周阴影；治疗前有根尖阴影且无临床症状取出分离器械后出现临床症状2例，随访6个月后仍有症状，但其中1例根尖阴影愈合；治疗前无根尖周阴影且有临床症状取出后症状缓解2例，随访6个月后仍有3例有症状，且其中1例出现阴影；治疗前无根尖周阴影且无临床症状17例取出后均无症状，随访6个月后4例出现症状，其中2例出现根尖周阴影。

结论

旁路法可作为无直线通路、阻力复杂的根管治疗分离器械经根管取出的较安全、可靠的方法。

关键词: 器械分离, 旁路法, 根管治疗并发症

Objective

To explore techniques for retrieving separated instruments from root canals without direct access and with complex resistance, analyze the key points, advantages, and risks of the bypass-based retrieval method, and evaluate treatment outcomes.

Methods

Cases were collected from the Department of Endodontics at Xiangya Stomatological Hospital, Central South University, between 02/2017 and 01/2025. Preoperative imaging confirmed instrument separation within the root canals, where non-sleeve or ultrasonic methods were not indicated. Instead, endodontic files were used to bypass and prepare the canals around the separated instruments for retrieval. Follow-up data were collected for at least six months postoperatively. Patient demographics, instrument location, length, material, type, root canal morphology, postoperative imaging, clinical outcomes, and follow-up data were summarized. The frequency of each variable was recorded, and relevant influencing factors and treatment outcomes were analyzed.

Results

A total of 175 patients (175 teeth, 176 fractured instruments) were included, comprising 52 males (29.7%) and 123 females (70.3%). The oldest patient was 73 years old, while the youngest was nine years old, and the average age was 28 years. Separated instruments were made of stainless steel in 44 cases, nickel-titanium in 108 cases, and carbon steel in 24 cases with an average length of 4.1 mm and an average fragment diameter of 0.32 mm. The fragments were located in the apical third of 67.6% of cases, with 46 cases (26.1%) occurring in the blind zone. The average distance from the canal orifice was 5.6 mm. The file tip extended beyond the apical foramen in 17 cases. Moderate to severe root canal curvature (≥10°) was observed in 93.7% of cases, with an average curvature angle of 29.3°. Preoperative periapical radiolucency was observed in 151 cases (86 of which had symptoms), while 24 cases showed no periapical radiolucency (seven of which had clinical symptoms). Complete retrieval was achieved in 160 cases. Secondary separation occurred in four cases, and retrieval failed in six cases. Postoperative imaging revealed significant canal deviation in 34 cases (including three cases with deviation and perforation), while no significant morphological deviation was observed in 141 cases (80.6%). Follow-up results showed that among patients with preoperative periapical radiolucency and symptoms, 83 cases experienced symptom relief or healing after retrieval, while one case still had symptoms and periapical radiolucency after six months. Among asymptomatic patients with preoperative periapical radiolucency, two cases developed symptoms after retrieval, and two cases still had symptoms after six months, though one of these showed healing of periapical radiolucency. Among symptomatic patients without preoperative periapical radiolucency, two cases experienced symptom relief after retrieval, while three cases still had symptoms after six months, with one of these developing radiolucency. Asymptomatic patients without preoperative periapical radiolucency (17 cases) remained symptom-free after retrieval, though four cases developed symptoms after six months, with two of these showing periapical radiolucency.

Conclusion

The bypass technique can serve as a safe and reliable method for retrieving separated instruments from root canals with complex resistance but direct access.

Key words: Instrument separation, Bypass, Complications of root canal treatment

图1 旁路法取分离器械流程模拟图　A：术前分析分离器械与牙根解剖相关问题；B：分离器械断面上段根管预备；C：机用镍钛锉在狭区侧逐号预备（C1：旁路完全绕过分离器械；C2：旁路不能完全绕过，疏通至阻力最大处）；D：超声震荡，工作尖被动置于旁路，震荡分离器械；E：分离器械较短或根管较直，超声直接取出分离器械；F：分离器械较长且位于弯曲下段，主动跳出阻力大，H锉（编织）取出。

表1 175例根管内器械分离患者及176支分离器械基本情况

患者特征	例数	百分比（%）
性别
男	52	29.7
女	123	70.3
年龄[岁，M（P₂₅，P₇₅）]	28（22，38）
牙位
前牙	5	2.8
前磨牙	12	6.9
磨牙	158	90.3
根管弯曲度（°）
<10	11	6.3
10≤弯曲度<30	80	45.7
≥30	84	48.0
平均弯曲度[°，Mean（max，min）]	29.3（2，64）
器械材质
不锈钢（K锉+H锉）	44	25.0
镍钛	108	61.4
碳钢（拔髓针）	24	13.6
器械型号
25号	37	21.0
20号	77	43.8
<20号	62	35.2
断裂长度（mm）
<3	6	3.4
3≤长度<5	121	68.8
≥5	49	27.8
平均长度[mm，Mean（max，min）]	4.1（1.5，10.8）
器械断面直径（mm）
<0.4	131	74.4
0.4≤直径<0.7	44	25.0
0.7≤直径<1.0	1	0.6
≥1.0	0	0
平均断面直径[mm，Mean（max，min）]	0.32（0.18，0.75）
断面位置
根上1/3	2	1.1
根中1/3	38	21.6
根尖1/3	119	67.6
锉尖超出根尖孔	17	9.7
断面距根管口平均长度[mm，Mean（max，min）]	5.6（1.1，11.7）
断面可视性
镜下可直视	130	73.9
镜下不可直视（断面位于盲区）	46	26.1
术前根尖周阴影
有	151	86.3
无	24	13.7
术前有根尖周阴影患者是否出现临床症状
有	86	57.0
无	65	43.0
术前无根尖周阴影患者是否出现临床症状
有	7	29.2
无	17	70.8

表1 175例根管内器械分离患者及176支分离器械基本情况

患者特征	例数	百分比（%）
性别
男	52	29.7
女	123	70.3
年龄[岁，M（P₂₅，P₇₅）]	28（22，38）
牙位
前牙	5	2.8
前磨牙	12	6.9
磨牙	158	90.3
根管弯曲度（°）
<10	11	6.3
10≤弯曲度<30	80	45.7
≥30	84	48.0
平均弯曲度[°，Mean（max，min）]	29.3（2，64）
器械材质
不锈钢（K锉+H锉）	44	25.0
镍钛	108	61.4
碳钢（拔髓针）	24	13.6
器械型号
25号	37	21.0
20号	77	43.8
<20号	62	35.2
断裂长度（mm）
<3	6	3.4
3≤长度<5	121	68.8
≥5	49	27.8
平均长度[mm，Mean（max，min）]	4.1（1.5，10.8）
器械断面直径（mm）
<0.4	131	74.4
0.4≤直径<0.7	44	25.0
0.7≤直径<1.0	1	0.6
≥1.0	0	0
平均断面直径[mm，Mean（max，min）]	0.32（0.18，0.75）
断面位置
根上1/3	2	1.1
根中1/3	38	21.6
根尖1/3	119	67.6
锉尖超出根尖孔	17	9.7
断面距根管口平均长度[mm，Mean（max，min）]	5.6（1.1，11.7）
断面可视性
镜下可直视	130	73.9
镜下不可直视（断面位于盲区）	46	26.1
术前根尖周阴影
有	151	86.3
无	24	13.7
术前有根尖周阴影患者是否出现临床症状
有	86	57.0
无	65	43.0
术前无根尖周阴影患者是否出现临床症状
有	7	29.2
无	17	70.8

表2 175例根管内器械分离旁路法取出器械术后效果评估情况

评估项目	例数	百分比（%）
总体取出情况
旁路法完整取出（含二次分离）	160（4）	91.4（2.3）
部分取出	9	5.2
未取出	6	3.4
术中并发症
明显根管偏移	31	17.7
穿孔	3	1.7
无明显形态学偏移	141	80.6

表2 175例根管内器械分离旁路法取出器械术后效果评估情况

评估项目	例数	百分比（%）
总体取出情况
旁路法完整取出（含二次分离）	160（4）	91.4（2.3）
部分取出	9	5.2
未取出	6	3.4
术中并发症
明显根管偏移	31	17.7
穿孔	3	1.7
无明显形态学偏移	141	80.6

表3 175例根管内器械分离患者旁路法取出器械术后症状与影像随访结果（例）

术前情况	例数	有症状		术后6个月影像随访
术前情况	例数	取出时	6个月后（无症状组新发）	阴影变化情况	失访
有根尖阴影
有症状	86	3	1（0）	愈合/缩小55、无变化1	30
无症状	65	2	2（2）	愈合/缩小34、变大3	28
无根尖阴影
有症状	7	5	3（0）	出现阴影1、无阴影5	1
无症状	17	0	4（4）	出现阴影2、无阴影7	8

表3 175例根管内器械分离患者旁路法取出器械术后症状与影像随访结果（例）

术前情况	例数	有症状		术后6个月影像随访
术前情况	例数	取出时	6个月后（无症状组新发）	阴影变化情况	失访
有根尖阴影
有症状	86	3	1（0）	愈合/缩小55、无变化1	30
无症状	65	2	2（2）	愈合/缩小34、变大3	28
无根尖阴影
有症状	7	5	3（0）	出现阴影1、无阴影5	1
无症状	17	0	4（4）	出现阴影2、无阴影7	8

视频1 旁路预备直接带出分离器械手术操作视频（扫码观看）

图3 16近中颊根器械分离旁路法治疗术前后及随访图像资料　A：术前根尖片；B：术前锥形束CT（CBCT）矢状面；C：术前CBCT冠状面；D：术前CBCT轴面（弯曲下段）；E：术前CBCT轴面（弯曲上段）；F：分离器械取出后即刻根尖片；G：根管充填术后即刻根尖片；H：完整取出的分离器械；I：术后36个月随访根尖片。

视频2 旁路预备后H锉取出分离器械手术操作视频（扫码观看）

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Exploration and efficacy evaluation of a bypass-based strategy for retrieving complex separated instruments from root canals

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Exploration and efficacy evaluation of a bypass-based strategy for retrieving complex separated instruments from root canals