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学术前沿

国际牙外伤协会的乳牙外伤管理指南(2007年版)(张增方译制初稿完善中)

发表者:张增方 7089人已读

    Guidelines for the management of traumatic dental injuries. Ⅲ. Primary teeth


          牙外伤指南 Ⅲ.乳牙外伤部分好大夫工作室儿童口腔科张增方


     Trauma to the primary dentition present special problems and the management is often different as compared with permanent teeth. An appropriate emergency treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this third article out of three,  the IADT Guidelines for the management of traumatic injuries in the primary dentition, are presented.

   乳牙外伤有特殊的临床表现,治疗也常常不同于恒牙。适当的急诊处理计划对好的预后至关重要。指南以有效的方式提供了尽可能最好的治疗方案。国际牙外伤协会通过文献综述和小组审核讨论,制定了共识声明。该小组成员包括了各专业的科研人员和临床医师。在无确凿数据支持的案例中,治疗建议都是基于国际牙外伤协会成员的共识。该指南代表了基于文献和专家意见的当前最好的证据。在三篇指南的第三篇,呈现给大家的是乳牙外伤的管理。

 

   Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment (1–4). In preschool injuries, head injuries make up as much as 40% of all somatic injuries (1–4). Among all facial injuries, dental injuries are the most common (1–4). As much as 18% of all somatic injuries are seen in the oral region in children 0–6 years old (1–4).

   口腔外伤发生频繁,比例约占所有外伤求助的5%,在幼儿园,头部外伤占身体外伤的40%,在面部外伤中,牙外伤是最为常见的,0到6岁孩子的外伤中18%是口腔外伤。

 

   An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for dentists and other healthcare professionalsin delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions.


First aid and treatment of trauma to the primary dentition 

一、 急救和乳牙外伤的急诊处理


   Depending on the severity of injuries, usually, the parents will seek treatment at the Emergency Room or will call the pediatrician. Dentists should be willing to give appropriate advice to healthcare professionals and those who closely work or supervise children, about first aid for injuries affecting the primary dentition.(5, 6) The following recommendations will help for the best care of the child: Keep calm and concentrate in the child wellbeing. Wash the wound carefully with plenty of running water. Generally, dental trauma includes injuries to the adjacent soft tissue (Fig 1). Stop bleeding by compressing the injured area with gauze or cotton for 5 min. Seek emergency treatment from a pediatric dentist.

   视外伤的严重程度,家长常常先到急诊室就诊并请儿科医师协助。在影响乳牙的外伤急救方面,牙科医生应给予医务人员和监护人员适当的建议。

以下几点建议有助于患儿的治愈:

保持冷静,集中精力于患儿的健康;

用大量清水仔细清洗创口;

一般来说,牙外伤多伴有邻近的软组织外伤 (Fig 1);

用纱布或棉球压迫受伤部位5min以止血;

寻求儿牙专科医师的急诊处理。

Fig(1)


Guidelines for the Emergency Room

二.急诊科处理指南


   In more severe injuries, especially, when there is bleeding of the lips and intra-oral soft tissue, the parents will seek treatment at the Emergency Room where physicians will give the first treatment (Fig 2). After suture of soft tissue lacerations, the child should be referred to a pediatric dentist or a general dentist who treats children for a general evaluation of teeth injuries.

   Intra-oral trauma affecting the lips, gums, tongue, palate, and severe tooth injuries in children <5 years old, should be examined and suspect of child abuse (7–9). In such cases, the patient should also be examined by a pediatric dentist on call or oral surgeon who will give the diagnosis of primary teeth injuries and prognosis for the developing permanent dentition. The child should be referred for follow-up controls to a pediatric dentist. It is important to explain the parents that the permanent dentition may have long-term consequences that may be seen many years later, at the time of eruption of the permanent incisors.

   在严重创伤,尤其存在唇或口内软组织出血时,家长常常先到急诊科就诊,急诊医师多给予初步的处理,在软组织撕裂伤缝合后,应转给儿牙医师或全科医师对患儿牙外伤进行评估.

   5岁以下儿童的涉及牙龈、腭部、唇部、舌部及严重牙外伤的口内外伤应仔细检查并应怀疑虐童可能。在这些病例中,患儿还应由儿牙医师及口外医师检查,来确定乳牙外伤的诊断及恒牙胚的预后。儿牙医师应跟进患儿的后续治疗,很重要的是应向家长说明在多年后恒切牙萌出时可能出现的远期后果。


Special considerations for trauma to primary teeth

三、乳牙外伤的特殊考虑


   The management of traumatic injuries to primary teeth differs from that used for permanent.  It is important to keep in mind that there is close relationship between the apex of the root of the injured primary tooth and the underlying permanent tooth germ. Tooth malformation, impacted teeth and eruption disturbances in the developing permanent dentition are some of the consequences that can occur following severe injuries to primary teeth and/or alveolar bone (Fig 3). Because of these potential sequelae, treatment selection should such as to avoid any additional risks of further damaging the permanent successors.

   乳牙外伤的管理不同于恒牙,留心这一点非常重要:外伤乳牙的根尖?与继承恒牙胚的关系非常密切。发育中恒牙发生的牙畸形、牙阻生及萌出异常可能是由乳牙外伤或牙槽骨外伤所致。由于这些潜在的后遗症,治疗方案的选择应避免增加任何加重继承恒牙损伤的风险。 

Fig. 2. Acute trauma to oral soft tissues and primary teeth. A 2-year-old girl fell on the floor. Suture of the lower lip laceration was the immediate treatment carried out at the Emergency Room and antibiotics were prescribed. The patient was referred to a pediatric dentist. (a) Bleeding from gingival and frenum laceration is seen. Tooth 51 has been laterally luxated in a mesial position and is mobile. The parents were instructed to follow a careful tooth brushing technique. (b) The X-ray shows the displaced position of tooth. (c) Clinical appearance 9 days after trauma. The tooth is almost in its original position, has slight mobility and good oral hygiene is observed。

图2 口腔软组织和乳牙的急性外伤。一个2岁女孩在地板跌倒,在急诊科立即进行了下唇撕裂伤清创缝合,并注射了抗生素。(a)可见牙龈出血及系带撕裂,51可见近中侧向脱位及松动。教育父母小心刷牙技巧.(b)X-ray示51牙移位.(c)外伤9天后的临床表现,牙齿几乎恢复到原位,有轻度的松动,口腔卫生良好。 

 

Fig. 3. Injuries to the developing teeth. An 8-year-old girl sought treatment because of delayed eruption of tooth 21. The history revealed that she fell three steps from the stairs while using the baby walker. Recommendations on oral hygiene and followup controls were given at the Emergency Room. Teeth 51 and 61 apparently were not affected and had normal resorption at the time of shedding. (a) Hypoplasia of tooth 11 affecting the incisal third of the crown. Crown dilacerations is seen in tooth 21. (b) Clinical appearance of tooth malformation affecting both central incisors: hypoplasia with loss of tooth structure in tooth 11 and delayed eruption is observed in tooth 21. (c) After completion eruption, crown dilaceration is seen in tooth 21.

图3 年轻恒牙外伤  8岁女孩因21迟萌就诊,病历显示患儿曾在使用学步车时从三级台阶摔下,予口腔卫生宣教,及在急诊科随诊观察。51 61未受到明显的影响,脱落时有正常的牙根吸收。(a)11发育不全影响了牙冠的切1/3,21可见牙冠钙化不良;(b)牙畸形的临床表现,影响到了中切牙导致牙体结构的缺失如图中11,还有牙齿的迟萌如图中21;(c)21在萌出后可见牙冠的钙化不全。

 

Fig. 4. (a) A 2 year and 6 month-old boy fell while he was jumping on the bed. The mother noticed that the left central incisor was displaced and sought emergency treatment immediately. Instructions on oral hygiene, including topical use of chlorhexidine gel using cotton swabs for one week, were given to the mother. Also, it was recommended a soft diet for 2 weeks along with restricting the use of pacifier. (b) An occlusal view at the time of injury shows an overlapping of the primary roots and the developing permanent incisors; however, it is possible to observe an apical increased periodontal ligament space. (c) Spontaneous reposition of tooth 61 at two and a half months follow-up control.

图4 (a)2岁6月大的男童在床上跳跃时摔下。患儿母亲发现患儿左侧中切牙以为立即到急诊科就诊。予口腔卫生宣教,并嘱外用洗必泰宁静棉棒擦拭一周,并建议软食两周及限制使用奶嘴。外伤后的咬合片显示乳牙根与发育中恒牙的切端重叠,然而该片可观察根部牙周膜间隙的增宽,(c)2个半月复查时可见61自发回位

The child’s maturity and ability to cope with the emergency situation, the time for shedding of the injured tooth and the occlusion, are important factors that influence treatment selection.

患儿的成熟度,应对急诊的能力,外伤牙脱落的时间,以及咬合关系都是影响治疗抉择的重要因素.


Guidelines for the clinician

四、临床治疗指南:


The Guidelines contain recommendations for diagnosis and treatment of traumatic injuries in the primary dentition for caries-free or sound primary teeth using proper examination procedures:

指南为应用正确诊疗程序对外伤乳牙进行诊断和治疗提供了建议

A.   Clinical examination.

临床检查。

   Information ab out examination of traumatic injuries in the primary dentition can be found in a number of current textbooks (1, 5, 10).

B.   Radiographic examination

影像学检查

   Depending on the child’s ability to cope with the procedure and the type of injury suspected, several angles are recommended:

• 90_ horizontal angle, with central Occlusal view (size 2 film, horizontal view).

• Extra-oral lateral view of the tooth in question, which is useful to reveal the relationship between the apex of the displaced tooth and

the permanent tooth germ as well as thedirection of dislocation (size 2 film, vertical view).

C. Patient instructions

医嘱

   Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Parents should be advised on how best to care for their children’s primary teeth after an injury. (Fig 4). Brushing with a soft brush after each meal and applying chlorhexidine (0.1%) topically to the affected area(s) with cotton swabs twice a day for one week, is beneficial to prevent accumulation of plaque and debris. Along with recommending a soft diet for 10–14 days, restrict the use of pacifier. If there are associated lip injuries, use of lip balm during the healing period will avoid dryness. Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs such as swelling of the gums and bring the children in for treatment. Document in the chart that the parent has been opment of the permanent teeth, especially following intrusion, avulsion and alveolar fracture injuries sustained in children under 3 years of age. For further reading we recommend some recent good review articles and original papers on child abuse (7–9), epidemiology (11–13), pulp therapy (14–17), intrusive luxation (18, 19) and tooth abnormalities (20–22). All relevant new and old references can be found in the recent textbook andatlas by Andreasen et al. (1)

 

Treatment guidelines for fractures of teeth and alveolar bone in the primary dentition

五、乳牙列中牙折及骨折的治疗指南


Clinical findings

临床表现

Radiographic findings

影像学表现

Treatment

治疗

Uncomplicated crown fracture

Fracture involves enamel or dentin and enamel; the pulp is not exposed.

非复杂性冠折

牙折累及釉质或釉质及牙本质,未露髓

The relation between the fracture and the pulp chamber will be disclosed.

关注髓室与牙折的关系

Smooth sharp edges. If possible the tooth can be restored with glass ionomer filling material or composite.

修整锐利边缘

可考虑用玻璃或树脂恢复牙外形

Complicated crown fracture

Fracture involves enamel and dentin an

the pulp is exposed.

复杂性冠折

牙折累及牙釉质和牙本质,露髓

One exposure is useful to rule out the extent of fracture and stage of root development.

有助于明确牙折范围和牙根发育阶段

In very young children with immature, still developing roots, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed roots. Calcium hydroxide is a suitable material for such procedures. Both treatments should be considered whenever possible, otherwise extraction is indicated.

乳牙根尚未发育完成的低龄患儿应采取盖髓或活切来保留活髓;

乳牙根已发育完成的患儿也可采取盖髓或活切来保留活髓;

氢氧化钙适于此治疗;

尽可能采用保髓治疗,否则考虑拔除。

Crown-root fracture

Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed.Additional findings may include loose, but still attached, fragments of the tooth.There is minimal to moderate tooth displacement

冠根折

牙折累及釉质、牙本质及牙根,可能露髓或未露髓。

可能存在松动,但折断片仍与牙体相连。

In laterally positioned fractures,the extent in relation to the gingival margin can be seen.

横断位的牙折时可见牙折范围与龈缘的关系

Treatment recommendation is tooth extraction. Care must be taken to prevent trauma to the subjacent tooth bud.

建议拔除,注意避免损伤下方的恒牙胚

Root fracture

The coronal fragment is mobile and may be displaced.

根折

冠部松动甚至移位

The fracture is usually located mid-root or in the apical third.

根折常位于中1/3或尖1/3

If the coronal fragment is displaced, extract only that fragment. The apical fragment should be left to be resorbed.

如果冠折段移位,则只拔除冠折段,残根保留待后期吸收。

Alveolar fracture

The fracture involves the alveolar bone.

The tooth-containing segment is mobile.

and usually displaced.

Occlusal interference is often noted.

牙槽突根骨折

累及牙段松动移位,常存在咬合干扰

The horizontal fracture line to the apices of

the primary teeth and their permanent successors will be disclosed. A lateral radiograph may also give information about the relation between the two dentitions and if the segment is displaced in labial direction.

可见乳牙根尖部的水平骨折线,以及继承恒牙胚。

侧位片可见上下牙列的关系,以及骨折片是否存在唇向移位。

Reposition any displaced egment and then splint. General anesthesia is often indicated. Monitor teeth in fracture line.

断片复位及固定;

常常需在全麻下治疗;

监控骨折线上牙齿的状况。


Treatment guidelines for luxation injuries in the primary dentition

六、乳牙列外伤脱位治疗指南


Clinical findings

临床表现

Radiographic findings

影像学表现

Treatment

治疗

Concussion

The tooth is tender to touch; it has no increased

mobility or sulcular bleeding.

牙震荡

牙齿轻触痛,无松动或龈沟出血

No radiographic abnormalities.

Normal periodontal space.

影像学无异常。

牙周膜间隙正常

No treatment is needed. Observation.

不需处理,观察

Subluxation

The tooth has increased mobility but has not been displaced.

Bleeding from gingival crevice may be noted.

亚脱位(牙松动)

牙齿动度增加,但无移位。可见龈沟出血。

Radiographic abnormalities are usually not found.

Normal periodontal space.

影像学常无异常。

牙周膜间隙正常。

No treatment is needed. Observation.

影像学无异常。

牙周膜间隙正常。

Extrusive luxation

The tooth appears elongated and is excessively mobile.

牙部分脱出

表现为牙伸长、松动明显

 

Increased periodontal ligament space apically.

根尖牙周膜间隙增宽

Treatment decisions are based on the degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation. For minor extrusion (<3 mm) in an immature developing tooth, careful repositioning or leaving the tooth for spontaneous alignment are acceptable treatment options. Extraction is the treatment of choice for severe extrusion In a fully formed primary tooth.

治疗方案的选择取决于牙移位程度,松动程度,牙根发育情况及患儿的配合情况。

对于年轻乳牙的轻度脱位(<3mm):可选择小心复位或待其自行稳固;

对于牙根发育完全的严重脱位的乳牙可选择拔除;

Lateral luxation

The tooth is displaced, usually in a palatal/lingual direction.

It will be often immobile.

牙齿侧方脱位

牙腭侧或唇侧移位,一般不松动。

 

Increased periodontal ligament space apically is best seen on the occlusal exposure.

咬合片可见牙周膜间隙增宽

If there is no occlusal interference, as is often the case in anterior open bite, the tooth

is allowed to reposition spontaneously.

When there is occlusal interference, with the use of local anesthesia, the tooth can be gently repositioned by combined labial and palatal pressure.

 In severe displacement, when the crown is dislocated in a labial direction, extraction is the treatment of choice. If minor occlusal interference, slight grinding is indicated.

如果没有咬合干扰,常常在前牙开牙合时,牙齿可自行复位。

如果有咬合干扰,可在局麻下联合唇向或腭向力予以轻柔复位。

轻度咬合干扰,可调牙合处理。

如果牙冠严重唇向移位,可选择拔除。

应以是否伤及恒牙胚为指导原则!!

Intrusive luxation

The tooth is usually displaced through the labial bone plate, or can be impinging upon the succedaneous tooth bud.

 

牙齿挫入

牙齿常唇向挫入穿出骨板(1跟受力方向有关,2跟乳前牙牙根唇向弯曲有关),或向腭侧挫入影响恒牙胚

重点

When the apex is displaced toward or through the labial bone plate, the apical tip can be visualized? and appears shorter than the

contra lateral tooth.

 

When the apex is displaced towards the permanent tooth germ, the apical tip cannot be visualized and the tooth

appears elongated.

唇向挫入穿出骨板时,根尖尖端可见,且相比对侧牙变短(图A)

腭侧挫入恒牙胚时,根尖尖端不可见,且相比对侧牙伸长(图B)

 

If the apex is displaced toward or through the labial bone plate, the tooth is left for

spontaneous repositioning.

If the apex is displaced into the developing tooth germ, extract.

若唇向穿出,可待其自行复位,暴露根尖不处理

若腭向移位影响恒牙胚,应立即拔除。

 

 

Avulsion

The tooth is completely out of the socket.

牙齿全脱出

牙齿完全脱出牙槽窝

A radiographic examination is essential

to ensure that the missing tooth is not intruded.

影像学检查很必要,以确定失牙未挫入

It is not recommended to replant avulsed primary teeth.

乳牙全脱出不进行再植

 

 

Follow-up procedures for traumatized primary teeth

七、乳牙外伤复查程序

 

Time

1w

2-3w

3-4w

6-8w

6m

1y

Each subsequent year

until exfoliation

每年检查直到脱落

Uncomplicated crown fracture

非复杂冠折

 

 

C

 

 

 

 

Complicated crown fracture

复杂冠折

C

 

 

C+R

 

C+R

 

Alveolar fracture

牙槽突骨折

C

 

C+R+S

C+R

 

C+R

(*)

Root fracture

根折

No Displacement

无移位

C

C+R

 

C+R

 

C(*)

 

Extraction

拔除

 

 

 

 

 

C(*)

 

Concussion/ Subluxation

牙震荡/亚脱位

C

 

 

C

 

 

 

Lateral luxation Extrusion

Spontaneous repositioning

侧方脱位自行复位

 

 

C

 

C+R

 

C+R

 

Intrusion

挫入

 

C

 

C+R

C

C+R

C+R

C(*)

Avulsion

全脱出

C

 

 

 

C+R

C+R

C(*)

S = Splint removal 夹板去除 ; C = Clinical exam  临床检查 R = Radiographic exam.影像学检查

 (*) = Radiographic monitoring until eruption of the permanent successor影响学监测继承恒牙的发育,直到完全萌出


References


1. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn.

Oxford: Blackwell Munksgaard; 2007.

2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55–68.

3. Glendor U, Andersson L. Public health aspects of oral diseases and disorders: dental trauma. In: Pine C, Harris R, editors. Community oral health. London: Quintessence Publishing; 2007. p. 203–14.

4. Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and

adolescents in the county of Vastmanland, Sweden. Swed Dent J 1996;20:15–28.

5. Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic dental injuries. A manual, 2nd edn. Oxford:

Blackwell Munksgaard; 2003.

6. Flores MT. Traumatic injuries in the primary dentition. Review. Dent Traumatol 2002;18:287–98.

7. Maguire SA, Hunter B, Hunter LM, Sibert J, Mann MK, Kemp AM. Diagnosing abuse: a systematic review of torn

frenum and intra-oral injuries. Arch Dis Child 2007 [Epub ahead of print].

8. Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a

community setting. Int J Paediatr Dent 2005;15:310–8.

9. Serrano Garcı′a MI, Tolosa Benedicto E, Forner Navarro L. Oral lesions due to child abuse. Identification of the

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发表于:2012-05-18 16:22

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  • 默认头像
    游** 2012-07-05 11:20:41

    不错

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    游** 2012-05-19 13:05:12

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