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Prevent unnecessary endo tx
1.
如何避免 不必要之根管治療
2.
3.
Death spiral of
tooth Pascal Magne 2010 No Post No Crown - Biomimetic Restorative Dentistry(DVD)
4.
•4-6 years success
rate without apical RL: 93%(PAI 1 and 2) 現實⾯面… Long-term outcome of Endo?
5.
•10 years? 20
years? 更久之後的endo成功率? 現實⾯面…更久之後…? Long-term outcome of Endo?
6.
10年 20年 30年
7.
30年,我們平均會喪失幾顆⽛牙?
8.
http://www.nih.gov/ -4.6 如果全⼝口endo,我們會只剩…12顆⽛牙⿒齒左右
9.
更⻑⾧長時間的追蹤下, Endo的成功率明顯下降! Endo治療應只在必要時執⾏行
10.
What should we
do before Endo? •Deep caries •Cracked tooth •Sealing fail 這三種情況的臨床指引,全部都不是⾺馬上根管治療喔!
11.
Diagnosis Concept •Deep caries management •Cracked
tooth management •Sealing is the deal Outline
12.
Deep caries management
13.
Ole Fejerskov and
Edwina Kidd, 2008, Dental Caries, 2nd Ch3
14.
軟的 硬的⼿手感?!
15.
軟的 硬的⼿手感?! 234 1
16.
怎麼挖,是⾨門學問! 挖乾淨 分次挖 留點不要挖
17.
18.
Deep caries Resin or GIC
base Inlay conventional excavation Complete caries removal He WH, 2013
19.
6 months f/u stepwise
excavation technique affected dentin remineralized dentin GI application Bjørndal L, 2002
20.
ultraconservative excavation Deep caries Well sealing 2.5y
5y Gruythuysen R., 2010
21.
conventional excavation時 ⽛牙醫師常要扮演超⼈人! 其實,滿累的… @@ III conventional excavation
22.
primary dentin secondary dentin enamel tertiary
dentin
23.
conventional excavation stepwise excavation technique ultraconservative excavation ⼈人⼈人都可以是超⼈人
24.
2002 4th 2011
6th2006 5th 觀念的變遷
25.
2002 4th 2011
6th2006 5th partial caries excavation and indirect pulp capping 觀念的變遷 Caries control technique
26.
Deep caries治療⽅方式⽐比較 • ⽐比較不同deep
caries dentin處理⽅方式的結果 1、complete caries removal(⼀一次挖乾淨) 2、stepwise excavation (分次挖乾淨) 3、partial caries removal (部分挖) 4、no dentinal caries removal (不挖)
27.
⼀一次 vs 分次 347
154 407 126 325 166 101 79 單位1/1000
28.
全挖 vs 部分挖 219
50 47 13 62 21 單位1/1000
29.
全挖 vs 不挖 50
10 370 30 單位1/1000
30.
Dentinal caries… 似乎挖越少,越安全! 重點是優良的sealing 防⽌止caries⼜又呈活性 實際操作時… 袐訣是什麼?
31.
秘訣是:Enamel margin 傳統型enamel margin 無奈型enamel
margin
32.
Dentinal caries… 似乎挖越少,越安全! 但是…留很多dentinal caries, 會使⽛牙⿒齒整體結構弱化!!! 造成leakage,
cusp變形等等 Schwendicke F, 2014 但是…
33.
• 若深度蛀⽛牙危及⽛牙髓,現今教科書的建議步驟: 階段1、 1, 先評估是否可直接OD復形(若⼀一定要crwon,則另外考量) 2,
若可,靠近pulp部分蛀⽛牙不要全拿掉 3, 建⽴立完整乾淨的窩洞邊緣 4, GIC或RMGI先補起來(要不要⽤用氫氧化鈣都可) 階段2、 1, 等12週左右 2, 切削表層GIC,讓正式填補物有⾜足夠厚度及強度 3, GIC不建議全部拿掉! 階段1、2 的間隔為評估期(2-6個⽉月), 依治療反應再訂定最終治療計畫 整理
34.
要等多久才能重新進⼊入? 補充
35.
Cracked Tooth
36.
裂⿒齒症的 治療對策
37.
AAE, 2008, Cracking
the cracked tooth code
38.
治療⺫⽬目標 • 防⽌止裂痕leakage • 結構加強及保護
39.
• 鄰接⾯面:可以視情況去除裂痕, 但不超過CEJ • 窩洞底部:除⾮非有蛀⽛牙或裂到pulp裡了, 不然不必挖 請儘量別挖這裡!!! AAE,
2008, Cracking the cracked tooth code 防⽌止裂痕leakage:裂痕的移除原則
40.
Banerji S, 2010 結構加強及保護:裂⽛牙的緊急處理⽅方式
41.
Banerji S, 2010 •
without cusp coverage (ClassII OD) • with cusp coverage (onlay, overlay) 利⽤用CRF補強的⽅方式 結構加強及保護:裂⽛牙的緊急處理⽅方式
42.
? ? 裂痕正式處理⽅方式
43.
? ? 酸呀~
44.
? ? ?
45.
Crown coverage • Endo轉診的cases中,cracked
teeth佔9.7% (796/8175) • 127⼈人為reversible pulpitis(皆以crown治療) 其中21⼈人在58天後轉為irreversible pulpitis 其中6⼈人在149天後轉為necrotic pulp reversible pulpitis的cases,有20%在半年內需要Endo tx.
46.
⾞車磨Full crown有何疑慮? • ⾞車⽛牙產⽣生的熱會傷害pulp,full-coverage crown製作後的⽛牙⿒齒,有3-22%的機會需Endo Karlsson
S, 1986 Valderhaug J, 1997 Saunders WP, 1998 • ⾞車⽛牙時需light force、充⾜足噴⽔水、新的burs Hilton TJ., 2013
47.
Indirect Onlay coverage •
resin onlay黏著後進⾏行觀察 第⼀一週:88.37%不會疼痛,4.65%對冷及咬合敏感 第四週:93.02%不會疼痛,2.32%對冷及咬合敏感 共6.89%需要根管治療 • resin onlay 6年成功率:93.02%
48.
Direct composite splinting- Cusp
coverage or not? • 受測共40顆,cracked tooth直接以樹脂進⾏行填補 • 分為兩組:cusp coverage vs. without cusp coverage
49.
cusp coverage without cusp
coverage 成功率100% 成功率94%
50.
• immediate direct
composite resin overlay的中期(7年)成功率⾼高, 具有不錯的臨床治療價值(將來也可再換成ceramic) • onlay/overlay兼顧保護功能及保守性治療 • 若有reversible pulpitis,建議不要直接跳到做full crown,以減少 需根管治療的機會(20% Endo…討厭的事是他不會⾺馬上發⽣生!!!) • 治療指引中,cracked teeth無預防性根管治療的必要 整理
51.
Diagnosis
52.
• 能不能留住⽛牙⿒齒? 怎麼留? •
能不能留住⽛牙髓? 怎麼留? 診斷,因為我們想知道:
53.
1、X光⽚片
54.
55.
2.6mmEnamel margin
56.
0-2.5mm Caries margin 2nd, 3rd
dentin…
57.
順序: 1 2
3 4 Rubber dam 2、活性測試 測死最準測不到時最準 測活最準最⽅方便
58.
3、咬合測試
59.
Cracked or leakage? Biting
pain… before removing the restoration
60.
cracked tooth biting pain(+/-)
biting pain(+) biting pain(-) test with direct composite coverage without bonding
61.
step 1 cracked
tooth biting pain(++) biting pain(-) test with direct composite coverage without bonding
62.
step 2 leakage or
gap biting pain(+/-??) biting pain(+)
63.
step 3 If biting
pain in both situations…!? + percussion test
64.
• 樹脂加⾼高1-1.5mm幫助診斷 • 直接樹脂加⾼高黏著3個⽉月創造咬合空間 •
製作最終復形物 • 131 / 151成功 • 20例失敗 做endo:11 resin咬裂:5 受不了咬合加⾼高:4
65.
Immediate resin overlay能提供 ⼀一個相當可信賴的診斷及治療效果預測 ?
66.
4、光照檢查 整圈都要檢查⼀一次
67.
重點:marginal ridge
68.
簡易光源DIY
69.
70.
71.
5、染⾊色:caries & crack 幫助清出乾淨的magin,以得到完美sealing 三年的成功率,乳⽛牙96%,恆⽛牙93%
72.
? 幫助定位margin上 crack line的深度
73.
The seal is
the deal! ?
74.
Sealing的迷思… • Bonding =
Sealing? 兩者是不同喔! • Ranking of sealing ability? 那種材料的sealing能⼒力好? 要先知道要sealing的東⻄西是什麼! immediate dentin “sealing” (IDS)? “resin coating” “protection”
75.
Sealing為什麼重要呢? • 減少術後敏感 • 填補物的⻑⾧長期成功 Cohen's
pathways of the pulp 10Ed, Ch12
76.
77.
Trowbridge HO, 1982 ⿒齒質結構與sealing 息息相關!
78.
79.
Dentin要視為不均質的有機活組織 性質因不同位置⽽而有不同
80.
我們如何⽤用⼀一個簡單名詞去表述: 深層及淺層dentin、通透性、離pulp遠近的概念呢? RDT
81.
有2mm就沒在怕的啦~ Remaining Dentinal Thickness(RDT) •定義: 窩洞最深處和pulp的距離, RDT越⼩小,距pulp越近 •不同厚度RDT能 阻隔不同程度外界對⽛牙髓的刺激 0.5mm---------75% 1mm-----------90% 2mm-----------~100%
82.
Etching過的dentin就像…
83.
淺層dentin 像草原…
84.
像沼澤… 深層dentin
85.
深層dentin + total
etching… Pashley DH., 1987
86.
RDT與bonding強度 淺層dentin,RDT⼤大 深層dentin,RDT⼩小 bonding像是在抓草…
87.
深層dentin 淺層dentin 分別是GIC及Resin bonding
system 皆是⽐比較RDT<2 mm; 2≤RDT<3 mm; 3≤RDT<4 mm; RDT≥4 mm時的bonding強度 皆顯⽰示:RDT越⼤大(淺層dentin),bonding越強 RDT與bonding強度
88.
Deep dentin選何種bonding? 但不論⽤用何種bonding, 效果是不太好的… Tay FR,
2004
89.
Tay FR, 2004
90.
Tay FR, 2004 Water
Tree
91.
Sealing ability: GIC
vs. Resin Sarah N, 2014
92.
Sealing ability: GIC
vs. Resin Sarah N, 2014
93.
Sealing ability: GIC
vs. Resin Sarah N, 2014
94.
Sealing ability of
MTA Sarkar, 2005 1, MTA進⾏行⽔水合作⽤用(hydration) 產⽣生calcium silicate hydrate, calcium hydroxide等等 2, 在⽔水合產物表⾯面產⽣生Apatite-like precipitates —>sealing MTA和Dentin之間的gap
95.
MTA需多厚才能sealing?
96.
MTA需多厚才能sealing? ⽤用三種⽅方式去填MTA 結果平均dye滲透了1.3mm —>厚度2mm以上的MTA及dentin之間較 能保証sealing
97.
MTA-dentin之間 有完美的sealing… 但dentin本⾝身有通透性 需要2mm的距離得到好的sealing ✴ Cavity safe
margin的原理
98.
2mm? 剛好像有提過…
99.
有2mm就沒在怕的啦~ Remaining Dentinal Thickness(RDT) •定義: 窩洞最深處和pulp的距離, RDT越⼩小,距pulp越近 •不同厚度RDT能 阻隔不同程度外界對⽛牙髓的刺激 0.5mm---------75% 1mm-----------90% 2mm-----------~100%
100.
整理 • RDT的觀念,可在術前X光⽚片的資訊參考應⽤用 • Deep
dentin sealing: MTA> RMGI/GIC > self-etching bonding > total etching • Enamel margin sealing resin bonding system • Dentin margin sealing RMGI • Dentin bonding穩定度 4th, 6th, GIC較佳 • MTA-Dentin之間能有很好的sealing,但仍要有2mm以上距離
101.
Case實戰時間
102.
• reversibel pulpitis •
deep caries • cracked tooth Case實戰1 Crack + Deep caries + PPP
103.
104.
Crack line 2.6mmEnamel margin Caries
margin 0-2.5mm 怎麼做? • 留enamel margin 為了sealing • partial caries removal 為了不傷⽛牙髓 • 移除部份crack line 減少leakage • Direct resin overlay 為了受⼒力結構穩定
105.
!? 移除舊填補物
106.
染⾊色 ⾞車掉 再染⾊色
再⾞車掉,再染⾊色,再⾞車掉… 別做的過度,⼩小⼼心CEJ!!! 部分移除crack line
107.
不要⾞車這裡喔~ End-cutting Bur +
Metal band
108.
只移除邊緣蛀⽛牙 2mm
109.
窩洞外形調整
110.
111.
Enamel margin Dentin sealing Resin
overlay 1mm 2mm
112.
• 術後2⼩小時,咬合回復正常 • 術後兩天,已無pulpitis的症狀 •
6 months follow up: OK!
113.
Before After, follow
6 months
114.
Case實戰II Insufficient structure • pulp
test normal • deep caries • cracked tooth
115.
空殼⽛牙
116.
117.
周邊要挖乾淨,底部⼿手下留情
118.
結構再差也可以先補起來
119.
剛補完
120.
follow 五個⽉月
121.
Onlay Preparation
122.
Onlay Preparation
123.
124.
剛補完
125.
follow 五個⽉月
126.
Onlay Try-in
127.
1年 follow
128.
Case實戰III Apical RL? • deep
caries, involve pulp • dentin margin • pulp test:normal • Periapical RL ?
129.
Before After, follow
3 weeks Periapical RL…healed!?
130.
2.6mm Dentin margin
131.
2mm
132.
133.
Before Just finished
134.
Just finished 6
months follow
135.
Before After, follow
3 weeks Periapical RL…healed!?
136.
After, follow 3
weeks follow 6 months
137.
138.
139.
類似情況,換個材料如何?
140.
2014/7/28 2014/10/13 2014/12/222014/6/19
141.
Case實戰IV 2mm dentin sealing
rule • deep caries, close to pulp • dentin margin • pulp test:normal • crown abutment
142.
143.
144.
145.
146.
147.
148.
Case實戰V What if the
P’t is your mom? • deep caries, close to pulp • dentin margin • pulp test:normal
149.
150.
151.
152.
我不是⿎鼓勵要保守到如此誇張… 只是想傳達⼀一個“可能性”
153.
154.
• 深度蛀⽛牙不必完全挖乾淨,但要建⽴立良好marginal sealing •
分階段治療,期間變化有助更準確的最後評估 • Sealing才是補⽛牙的重點,bonding不是 • Enamel margin是sealing的關鍵 • 裂⿒齒症絕⼤大多數不必根管治療,但需overlay加強 • 在適當的場合,選適當的材料,以求最好的sealing 結論(偽)
155.
156.
157.
pathway of the
pulp
158.
OD與Endo的對話… 附錄:
159.
Complete excavation Stepwise excavation Partial
caries removal Indirect pulp capping Direct pulp capping Partial Pulpotomy Pulpotomy
160.
Thanks for your
attention!
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