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正畸治疗伴上中切牙特发性牙根吸收及尖牙阻生1例

2018-10-18 王璐 李任 温黎明 临床口腔医学杂志

患者,王某,女,12岁,因“牙齿不齐,兜齿”来院就诊。临床检查:面型为方圆型,面部左右基本对称,侧面观面下呈凹面型,下颌平面角均角。全口恒牙列,右侧磨牙近中关系,左侧磨牙中性关系,13位于12根部唇侧,未萌出,前牙反牙合,23唇向错位,上颌中线居中,下颌中线左偏3mm。11、21无牙体缺损或充填体,无深牙周袋,牙齿无松动。牙龈无明显红肿,口腔卫生一般。

1.病例报告
 
患者,王某,女,12岁,因“牙齿不齐,兜齿”来院就诊。临床检查:面型为方圆型,面部左右基本对称,侧面观面下呈凹面型,下颌平面角均角。全口恒牙列,右侧磨牙近中关系,左侧磨牙中性关系,13位于12根部唇侧,未萌出,前牙反牙合,23唇向错位,上颌中线居中,下颌中线左偏3mm。11、21无牙体缺损或充填体,无深牙周袋,牙齿无松动。牙龈无明显红肿,口腔卫生一般。
 
经询问病史,患者无系统性疾病,无牙根吸收家族史,无口腔不良习惯,无正畸治疗史,无外伤史,11、21无牙体牙髓治疗史,无调牙合史。X线曲面断层片示:13近中阻生;11、21根尖片显示:牙根吸收明显11、21牙根短小,11冠根比大于1:1,21冠根比约为1:1,根尖呈楔形状,两牙牙周膜连续完整;上下颌第三磨牙胚均存在;头颅侧位片显示:Ⅲ类骨面型(图1)。
 
图1  矫治前资料。矫治前X线片
 
诊断:安氏Ⅲ类错牙合;毛氏Ⅱ1+Ⅰ1+Ⅴ类错牙合;骨性Ⅲ类;11、21特发性牙根吸收,为Levander等的牙根吸收分度法中的4度根吸收(图2);13近中阻生。
 

图2  Levander 等的牙根分度法
 
治疗过程:采用0.022英寸系统的MBT直丝弓矫治器进行矫治,总疗程为36个月。依次用0.012,0.014,0.016英寸镍钛圆丝,0.016×0.022英寸镍钛方丝排齐整平上下牙列;用0.016×0.022英寸不锈钢方丝,关闭下颌间隙,12、14间置推簧,扩大13间隙,12、32上置牵引钩,斜行牵引,纠正中线,同时配合Ⅲ类牵引;待13萌出,粘结其托槽,排齐牙列,精细调整。整个矫治过程需格外注意11、21动度,中期拍摄根尖片观察其牙根情况,牙齿松动度增加时停止加力(图3)。
 
图3  矫治过程中X线根尖片
 
治疗结果:矫治结束后患者为直面性,面型良好,上下前牙覆牙合覆盖正常,牙齿排列整齐,上下牙基本为尖窝相对状态,上下中线基本居中对齐,13牙齿形态良好,11、21无松动。X线片示:牙根平行排列,未见明显牙根吸收(图4)。治疗前后头影测量值(表1)。
 
图4  治疗结束后资料

 
2.讨论
 
根据患者的个人情况,前牙反牙合,Ⅲ类骨面型,13阻生,虽有11,21的不明原因重度牙根吸收,结合家属意见,同意一旦出现进一步牙根吸收甚至松动脱落时,接受后期的11,21种植修复治疗,因此综合考虑为患者进行固定矫正治疗。本例患者为前牙反牙合,13阻生,治疗前X线片示11、21已有明显的牙根吸收,为Levander等的牙根吸收分度法中的4度———极重度牙根吸收,吸收量超过根长的1/3。该患者无系统性疾病,无牙外伤,无咬合创伤和牙周组织炎症,亦无牙体牙髓治疗史、正畸治疗史等,即其牙根吸收没有明确已知的局部或系统性因素,11,21为特发性牙根吸收。国内外大量研究已证实,牙根吸收为正畸固定矫治的并发症之一,其吸收量与患者的年龄,拔牙与否,错牙合类型等有密切关系。
 
由于特发性牙根吸收病因尚未明确,矫治过程中有牙根继续吸收的可能,因此如何减少正畸治疗过程中的上颌中切牙牙根吸收成为本病例的难点。此类病例常见的拔牙方案有:①拔除上颌第二前磨牙和下颌第一前磨牙;②拔除2个下颌前磨牙。
 
本病例采取拔除4个第二前磨牙。该患者上颌拥挤度为Ⅲ度拥挤,且尖牙阻生,前牙反牙合,上颌拥挤集中在上颌前部,如果拔除上颌第一前磨牙有利于拥挤度的解除与排齐右上颌阻生尖牙,但此方案会增大上中切牙移动的距离,增加牙根吸收的风险,且不利于反牙合的纠正,故决定拔除2颗上颌第二前磨牙。而对于下颌,其下切牙牙冠已舌向代偿性倾斜,前牙覆盖较小,患者能轻松退下颌至切对切状态,且患者Ⅲ类面型并不明显,故拔除下颌第二前磨牙。
 
该病例成功矫治了反牙合伴前牙特发性牙根吸收及尖牙阻生,且矫治完成后特发性牙根吸收的11,21并无进一步松动,采用WinCeph8.0软件测量矫治前后11,21冠根比分别增加了26.5%和17.3%,与国内学者研究得出的正常上颌中切牙矫治前后冠根比增加24%相近。结束矫治1年后的随访显示咬合稳定,牙根无进一步吸收。该病例实属个案,特发性牙根吸收病因尚不明确,3~4级的牙根吸收已致牙根长度大为减短,不当的正畸矫治力极有可能加速牙根吸收,导致牙齿松动甚至脱落。故矫治治疗前,医生应对上颌切牙特发性牙根吸收的患者进行充分评估与沟通,矫治过程中定期拍摄根尖片,小范围移动前牙,细丝轻力,最粗弓丝使用到0.017×0.025英寸,患者每次复诊高质高效,将主动治疗时间控制在2年,从而达到良好而稳定的治疗效果。

原始出处:

王璐,李任,温黎明,李金源,李瑛. 正畸治疗伴上中切牙特发性牙根吸收及尖牙阻生1例[J]. 临床口腔医学杂志,2017,33(01):44-46.

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    2018-10-18 lietome2

    好文,值得点赞!认真学习,应用于实践!谢谢分享给广大同好!

    0

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