發(fā)布時(shí)間：2018-06-15 04:15

  本文選題：顯微CT + 旋轉(zhuǎn)速度��； 參考：《山東大學(xué)》2017年博士論文

【摘要】：研究背景及研究目的:根管治療術(shù)被認(rèn)為是牙體牙髓病領(lǐng)域中極為重要的治療技術(shù),它有效提高了牙齒的保留率和生存時(shí)間,最大程度保證了患者的咀嚼效率和生活質(zhì)量。在臨床治療中,由于種種原因,如根管復(fù)雜的解剖形態(tài),患牙冠部的滲漏、根管內(nèi)殘留感染物、根尖周炎癥及全身因素的影響,都會(huì)導(dǎo)致根管治療的失敗。此時(shí),非外科的根管再治療術(shù)是保留患牙的首選方法。根管再治療的主要目的是在不損傷軟硬組織形態(tài)功能的前提下,通過徹底清除根管系統(tǒng)內(nèi)的壞死組織、細(xì)菌以及原有充填材料,保持根管系統(tǒng)的無菌狀態(tài),并再次建立通暢的根管通路。影響根管再治療成功率的原因有很多,其中根管形態(tài)的復(fù)雜性和根管再治療方法的差異性是重要因素,它們會(huì)導(dǎo)致根管再治療過程中出現(xiàn)大量的根尖溢出碎屑,這是造成術(shù)后炎癥反應(yīng)的主要原因。另外根管再預(yù)備不徹底,殘留根充材料和壞死組織,導(dǎo)致持續(xù)存在根管內(nèi)的感染也可以造成再治療的失敗。因此,為了有效地解決以上兩個(gè)主要問題,從而獲得良好的再治療效果,選擇具有理想再治療特性的器械和安全、高效的再治療方法極為重要。目前,國(guó)內(nèi)外關(guān)于根管再治療的研究很多,在再治療過程中碎屑產(chǎn)生量的控制、根管原有充填材料的清除效果,以及在治療過程中對(duì)根管原有形態(tài)的影響方面是研究的主要方向。在以往的研究中,有多種根管再治療的方法被采用,如應(yīng)用手用擴(kuò)大器械、攜熱器械、激光、超聲器械,以及根管充填材料溶解劑的輔助應(yīng)用等。這些技術(shù)各有優(yōu)缺點(diǎn),但不同程度地都會(huì)導(dǎo)致根尖部碎屑溢出,且均不能完全去除根充材料,導(dǎo)致根管內(nèi)殘留充填材料及感染物,因而根管再治療技術(shù)的標(biāo)準(zhǔn)化治療流程、操作規(guī)范和質(zhì)量評(píng)定標(biāo)準(zhǔn)至今沒有制定。近年來,隨著鎳鈦旋轉(zhuǎn)器械的興起,在牙體牙髓領(lǐng)域引起了一場(chǎng)革命,它的獨(dú)特功能和特性提高了根管預(yù)備的效果和效率。在應(yīng)用于根管預(yù)備領(lǐng)域取得巨大成功后,鎳鈦旋轉(zhuǎn)器械又被試用于根管再治療領(lǐng)域中,產(chǎn)生了一些專用于再治療的旋轉(zhuǎn)器械,如ProTaper再治療系統(tǒng)、Self-Adjusting再治療銼等,其主要依據(jù)是利用它們獨(dú)特的設(shè)計(jì)、旋轉(zhuǎn)作用和鎳鈦金屬具有的物理特性,提高清除根充材料的能力和效率,在彎曲根管再治療中減少對(duì)根管壁牙本質(zhì)的過度切削,并減少根尖碎屑的產(chǎn)生和溢出,從而預(yù)防治療期間炎癥的發(fā)生,保證再治療療效,它代表了根管再治療技術(shù)今后的研究方向。此外,以往再治療實(shí)驗(yàn)多涉及直根管,但臨床上彎曲根管造成再治療困難的情況最為常見,主要有兩個(gè)方面的原因:一,鎳鈦旋轉(zhuǎn)器械在根尖部會(huì)造成嚴(yán)重的根管偏移,進(jìn)而導(dǎo)致無法在根尖彎曲處徹底清除根充材料。二,操作者在操作中由于根管彎曲度的限制嚴(yán)重影響視野,即使在根管顯微鏡的輔助下,也無法直視到根管每一區(qū)域。因此根管過高的彎曲程度提升了再預(yù)備的操作難度,增加了操作過程中根尖碎屑的產(chǎn)生量。本研究采用重度彎曲根管作為研究樣本,為今后臨床上根管再治療技術(shù)的實(shí)際應(yīng)用提供理論指導(dǎo)和參考依據(jù)。由于以往鎳鈦旋轉(zhuǎn)器械由于受到自身物理特性和加工工藝的限制,使的有利于提高再治療效果的某些性能不能得到充分體現(xiàn),如器械旋轉(zhuǎn)速度、彈性等,也影響了再治療技術(shù)的發(fā)展。本研究根據(jù)以往研究經(jīng)驗(yàn),選用新型的根管預(yù)備系統(tǒng)Twisted Files(TF;卡瓦盛邦,美國(guó))作為根管再預(yù)備的主要器械。它具有特殊的器械設(shè)計(jì)理念,擁有良好的彎曲特性,抗循環(huán)疲勞的能力,以及特殊的尖端設(shè)計(jì)和工作螺紋,有利于順利進(jìn)入彎曲根管,預(yù)備效果良好,能最大限度地順應(yīng)根管的原有形態(tài),避免產(chǎn)生臺(tái)階、穿孔和根管偏移等現(xiàn)象,在復(fù)雜根管預(yù)備中表現(xiàn)出了優(yōu)于其它預(yù)備器械的特點(diǎn),另外作為高速旋轉(zhuǎn)器械,它的工作速度遠(yuǎn)遠(yuǎn)高于其他品牌產(chǎn)品,預(yù)期可以提高根管再預(yù)備的工作效率,較高旋轉(zhuǎn)速度產(chǎn)生的熱量可能會(huì)促進(jìn)根充材料的有效清除,并減少根尖碎屑的產(chǎn)生量,具備根管再治療器械所應(yīng)該具有的特質(zhì)。關(guān)于TF在根管再治療過程中根管充填材料清除效果的的研究,至今罕有報(bào)道。本研究的目的是通過對(duì)其根管再治療特性的體外研究,評(píng)價(jià)根管鎳鈦旋轉(zhuǎn)器械在不同旋轉(zhuǎn)速度下對(duì)彎曲根管進(jìn)行再治療充填材料的清除效果,并計(jì)算溢出根尖孔的碎屑質(zhì)量,以及根管內(nèi)殘余充填材料的比例,同時(shí)記錄操作時(shí)間,初步評(píng)估其再治療的性能,為提高根管再治療清除效果提供理論依據(jù)和數(shù)據(jù)支持,從而確立未來根管再治療技術(shù)的研究方向。材料與方法:選用因?yàn)檠乐懿《纬木哂袕澢a側(cè)根管的離體下頜第一磨牙48顆作為實(shí)驗(yàn)牙齒。要求牙體形態(tài)完整、牙根發(fā)育完成僅有單一根管孔,未進(jìn)行過牙體牙髓治療。用Schneider法以及Schafer法,對(duì)下頜第一磨牙近中頰根根管彎曲程度進(jìn)行評(píng)估,彎曲角度用α表示,彎曲半徑用r表示。選用25° ≤ α ≤35°,r≤10mm的根管作為實(shí)驗(yàn)對(duì)象。應(yīng)用10號(hào)K型擴(kuò)大銼通暢根管至根尖,清除牙面上附著的軟組織、牙石和色素,并儲(chǔ)備在0.09%的生理鹽水中。應(yīng)用ProTaper機(jī)用鎳鈦銼以冠向下預(yù)備法,對(duì)樣本根管進(jìn)行初次預(yù)備后,選用熱牙膠連續(xù)波充填技術(shù)完善充填根管,冠部封閉后置于37℃水浴中2周備用。并將樣本隨機(jī)分為四組,應(yīng)用TF機(jī)用鎳鈦銼以500rpm、1000rpm、1500 rpm的旋轉(zhuǎn)速度,分別對(duì)A、B、C組進(jìn)行二次預(yù)備,去除根管充填材料。應(yīng)用手動(dòng)器械對(duì)D組進(jìn)行二次預(yù)備。用預(yù)先稱重的離心管收集溢出根尖孔的碎屑,比較并計(jì)算再治療前后離心管的質(zhì)量差,得出碎屑量。另外采用顯微CT技術(shù),對(duì)二次預(yù)備前后的樣本進(jìn)行掃描,評(píng)估各組根管內(nèi)各部分殘留根管充填材料的百分比例,同時(shí)比較各組工作時(shí)間。應(yīng)用單因素方差分析法對(duì)各組實(shí)驗(yàn)結(jié)果進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:1.根尖溢出碎屑本實(shí)驗(yàn)中所有再治療技術(shù)均能產(chǎn)生根尖碎屑,手工器械組(D組)產(chǎn)生的碎屑量(0.69±0.04mg)明顯多于其他應(yīng)用旋轉(zhuǎn)器械各組(A:0.54±0.05mg;B:0.48±0.04 mg;C:0.42±0.03 mg;all P0.001)。C組產(chǎn)生的溢出碎屑量最少,與其他各組碎屑量有顯著差異。鎳鈦器械旋轉(zhuǎn)速度越快,溢出的碎屑量也就越少。A、B、C三組之間的數(shù)據(jù)差異有統(tǒng)計(jì)學(xué)意義(Avs.B:P=0.006;Bvs.C:P0.001;A vs.C:P0.001)。2.根管殘余充填材料結(jié)果顯示,本實(shí)驗(yàn)中所有應(yīng)用的再治療技術(shù)均不能完全清除根充材料。剩余材料比例在4%-8%之間。與其它各組相比,C組剩余的殘余充填材料比例(4.01±0.68)明顯少于其各組(A:5.78±0.93;B:5.28±0.53;D:5.03±0.60;all P0.01),有顯著差異,尤其在根尖5mm處尤為明顯(A:7.72±0.76;B:6.95±0.78;C:6.04±0.79;D:6.90±0.75;all P0.01)。手動(dòng)器械組與A、B組剩余充填材料比例之間無統(tǒng)計(jì)學(xué)意義。3.工作時(shí)間各分組再治療器械首次到達(dá)工作長(zhǎng)度所耗時(shí)間(T1)相比:C組所耗時(shí)間最少,各分組之間的數(shù)據(jù)差別有統(tǒng)計(jì)學(xué)意義(Avs.B:P0.001;B vs.C:P0.001;A vs.C:P0.001;A vs.D:P=0.036).各分組完成根管再預(yù)備所耗時(shí)間(T2)相比:手工器械組(D組)操作時(shí)間(19.70±0.30)明顯多于其他應(yīng)用旋轉(zhuǎn)器械各組(A:8.08±0.23min;B:5.80±0.26min;C:3.53±0.33min)。4組間均有統(tǒng)計(jì)學(xué)差異(P0.01)。結(jié)論:本研究對(duì)減少根尖溢出碎屑的產(chǎn)生,以及如何提高根管再治療清除效果提供了重要的參考依據(jù),并得出以下結(jié)論:1.第一部分實(shí)驗(yàn)中,各組均有根尖碎屑溢出,TF的旋轉(zhuǎn)速度越快,根尖產(chǎn)生碎屑越少,較高的旋轉(zhuǎn)速度與低速以及手動(dòng)器械相比,可以顯著減少根尖碎屑的產(chǎn)生,旋轉(zhuǎn)速度與碎屑產(chǎn)生量呈正相關(guān)關(guān)系。2.在第二部分實(shí)驗(yàn)中,所有分組均留有殘余充填材料,TF旋轉(zhuǎn)速度1500rpm時(shí),殘余的根管充填材料比例最少,其余各組殘余材料比例之間無顯著性差異。在重度彎曲根管中,當(dāng)旋轉(zhuǎn)速度達(dá)到一定要求時(shí),較高的旋轉(zhuǎn)速度與低速以及手動(dòng)器械相比,可以帶來更佳的再治療效果。在較低旋轉(zhuǎn)速度l000rmp以下時(shí),尚不能達(dá)到預(yù)期的清除效果。3.TF的旋轉(zhuǎn)速度越快,所需要的再治療的操作時(shí)間越少。在1500rpm時(shí),所用的操作時(shí)間最少。綜上所述,鎳鈦器械的旋轉(zhuǎn)速度有可能成為影響根管再治療效果的重要因素。在一定的速度范圍內(nèi),同一旋轉(zhuǎn)速度對(duì)根尖碎屑的產(chǎn)生和殘余根充材料比例的影響程度并不完全一致。在今后,我們還需要進(jìn)一步改進(jìn)離體實(shí)驗(yàn)設(shè)計(jì),盡可能模擬體內(nèi)環(huán)境,對(duì)器械的旋轉(zhuǎn)速度以及影響根管再治療療效的各種因素作進(jìn)一步的深入評(píng)估,找出最適宜的工作速度和工作方式,在減少根尖碎屑產(chǎn)生和減少殘余充填材料,以及提高工作效率等方面同時(shí)達(dá)到理想效果,建立根管再治療的標(biāo)準(zhǔn)化操作流程。
[Abstract]:Research background and purpose: root canal therapy is considered as a very important treatment in the field of dental pulp disease. It effectively improves the retention and survival time of the teeth, maximally guarantees the chewing efficiency and quality of life of the patients. In clinical treatment, because of the species, such as the complex anatomical shape of the root canal, the crown part Leakage, residual infection in the root canal, periapical inflammation and systemic factors will lead to the failure of root canal therapy. At this time, non surgical root canal retherapy is the first choice to retain the affected teeth. The main purpose of root canal retherapy is to eliminate the damage in the root canal system without damaging the shape and function of the soft and hard tissue. Dead tissue, bacteria and original filling materials keep the aseptic state of the root canal system and reestablish a smooth root canal pathway. There are many reasons for the success rate of root canal retreatment, in which the complexity of root canal morphology and the difference in root canal retreatment are important factors, which can lead to a large number of root canal retreatment processes. The root tip spilt debris, which is the main cause of the postoperative inflammatory response. Besides, the root canal is not prepared thoroughly, the residual root filling material and necrotic tissue can lead to the persistent infection in the root canal, which can also cause the failure of retreatment. Therefore, in order to effectively solve the above two major problems, a good retreatment effect can be obtained. At present, there are many studies on root canal retreatment at home and abroad, the control of the amount of debris in the process of retreatment, the removal of the original filling material of the root canal, and the effect of the original shape of the root canal in the treatment process is the main research. Direction. In previous studies, a variety of root canal retreatment methods have been used, such as the use of hand expanded instruments, heat carrying instruments, lasers, ultrasonic instruments, and the auxiliary applications of root canal filling materials. These techniques have advantages and disadvantages, but can lead to the spillover of the root apex to varying degrees, and can not completely remove the root charge material. The standard treatment process of root canal retreatment, operation specification and quality assessment standards have not been formulated so far. In recent years, with the rise of nickel and titanium rotating instruments, a revolution has been made in the field of dental pulp. Its unique functions and characteristics have improved the effect of root canal preparation. After a great success in the field of root canal preparation, the nickel titanium rotary instrument has been tried in the field of root canal retreatment and produced some revolving instruments for retreatment, such as the ProTaper retreatment system, and the Self-Adjusting retreatment file, which is based on their unique design, rotation and nickel and titanium metal. It has the physical characteristics to improve the ability and efficiency of scavenging root filling material. It reduces the overcutting of root canal dentin in the retreatment of root canal, reduces the production and spillover of the root canal, thus preventing the occurrence of inflammation during the treatment, and ensures the retreatment effect. It also presents the future research direction of root canal retreatment technology. Besides, Most of the previous retreatment experiments involve the direct root canal, but the clinical flexural root canal is the most common cause of retreatment. There are two main reasons: first, the nickel titanium rotating apparatus causes serious root canal migration in the root tip, which leads to the inability to completely remove the root charge material at the root tip bending. Two, operator in operation because of root canal. The limit of curvature of the tube seriously affects the field of vision, even with the aid of the root canal microscope, which can not be directly seen in each region of the root canal. Therefore, the degree of excessive bending of the root canal increases the difficulty of the operation of the re preparation, and increases the production of the crumbs in the operation. Because of the limitations of the physical properties and processing techniques of the nickel titanium rotating instruments, some of the properties that are conducive to the improvement of the retreatment effect can not be fully reflected, such as the speed of rotation and the elasticity of the apparatus, which also affects the development of the retreatment technology. According to previous research experience, this study selects the new root canal preparation system Twisted Files (TF; kava state, United States) as the main equipment for the root canal preparation. It has a special device design concept, with good bending characteristics, anti cyclic fatigue ability, and special cutting-edge design and working thread, which is beneficial to the smooth entry. The curved root canal has good preparation effect. It can conform to the original shape of the root canal to the maximum extent, avoid the phenomena of step, perforation and root canal migration. In the preparation of complex root canal, it is superior to other preparatory instruments. In addition, as a high-speed rotary instrument, its working speed is far higher than that of other brand products, and it is expected to increase the root of the root canal. The efficiency of the repreparation of the tube, the heat generated by the higher rotation speed may promote the effective clearance of the root filling material, and reduce the amount of the root tip fragments, and have the characteristics that the root canal retreated instruments should have. A rare report on the effect of root canal filling material on the retreatment of root canal in TF has been rare. The purpose of this study is to evaluate the effect of the root canal retreatment in vitro, to evaluate the removal effect of the retreated root canal filling materials for the root canal nickel titanium rotating apparatus at different rotational speeds, and to calculate the debris quality of the spillover root tip and the ratio of the residual filling materials in the root canal, and to record the operation time and evaluate the retreatment of the retreatment. The performance of the therapy provides a theoretical basis and data support for the enhancement of root canal retreatment, thus establishing the future research direction of the root canal retreatment technology. Materials and methods: 48 of the first molar of the mandibular first molar extracted with the curved lateral buccal lateral root canal because of periodontitis are used as the experimental teeth. The shape of the tooth is required to be complete, Ya Genfa The bending degree of the proximal and middle buccal root canal in the first molar of the mandible was evaluated by Schneider and Schafer. The bending angle was expressed by R and the bending radius was expressed by R. The root canal of 25 = < < < < 35 degrees and R < 10mm was selected as the experimental object. The application of the 10 K type expansion file was unobstructed. The root canal to the root tip, remove the soft tissue, stone and pigment attached to the tooth surface, and reserve it in 0.09% of the normal saline. The ProTaper machine is used with a nickel titanium file to prepare the crown down method. After the initial preparation of the sample root canal, the hot tooth glue continuous wave filling technique is used to fill the root canal and the crown is closed in 37 centigrade water bath for 2 weeks. The samples were randomly divided into four groups. The rotating speed of 500rpm, 1000rpm, and 1500 rpm was used by TF Ni Ti file to prepare two times for A, B, C group, and the root canal filling material was removed. The manual instruments were used to prepare the D group for two times. The fragments of the spillover root holes were collected with the pre weighing centrifuge tube, and the quality of the centrifuge tube before and after retreatment was compared and calculated. In addition, the amount of debris was obtained. In addition, micro CT was used to scan the samples before and after two preparation, to evaluate the percentage of the residual root canal filling materials in each part of root canal, and to compare the working time of each group. The results of each group were statistically analyzed by single factor analysis of variance. Results: 1. root spillover fragments. All the retreatment techniques in the experiment could produce root apex fragments. The amount of debris (0.69 + 0.04mg) produced by the manual apparatus group (group D) was significantly more than that of other rotating instruments (A:0.54 + 0.05mg; B:0.48 + 0.04 mg; C:0.42 + 0.03 mg; all P0.001). The amount of spillover fragments produced by the.C group was the least. The faster the rotation speed, the less the amount of spillover fragments is.A, B, C three groups of data differences between the three groups are statistically significant (Avs.B:P=0.006; Bvs.C:P0.001; A vs.C:P0.001).2. root canal residual filling material results show that all the application of retreatment technology can not completely remove the root charge material. The proportion of residual material is between 4%-8%. The residual filling material ratio (4.01 + 0.68) of the C group was significantly less than that of each group (A:5.78 0.93; B:5.28 + 0.53; D:5.03 + 0.60; all P0.01), especially in the root tip 5mm (A:7.72 + 0.76; B:6.95 + 0.78; C:6.04 + 0.79; D:6.90). There was no statistical significance between the.3. working hours and the time (T1) for the first time to reach the work length (T1): the C group took the least time, and the data difference between the groups was statistically significant (Avs.B:P0.001; B vs.C:P0.001; A vs.C:P0.001; A vs.D:P=0.036). The operation time of the apparatus group (group D) (19.70 + 0.30) was significantly more than that of other rotating instruments (A:8.08 + 0.23min; B:5.80 + 0.26min; C:3.53 + 0.33min).4 group had statistical difference (P0.01). Conclusion: This study provides an important reference for reducing the production of root tip spillovers and the removal of the high root canal, as well as the removal of the high root canal. The following conclusions are drawn: 1. in the first part of the experiment, each group has spillover of root apex, the faster the rotation speed of TF, the less the crumbs produced in the root tip, the higher rotation speed and the low speed and the manual apparatus, which can significantly reduce the production of the root tip fragments, and the rotation speed is positively related to the amount of debris production in the second part of the experiment. All the groups have residual filling materials. When the rotation speed of TF is 1500rpm, the residual root canal filling material has the least proportion, and there is no significant difference between the remaining materials. In the severe curved root canal, when the rotation speed reaches a certain requirement, the higher rotation speed is better than the low speed and the manual equipment. Retreatment effect. At a lower rotational speed of l000rmp, the faster the rotation speed of.3.TF is not reached, the less operation time required. At 1500rpm, the operation time is the least. In summary, the rotation speed of the nickel titanium instrument may be an important factor affecting the effect of root canal retreatment. In a certain range of speed, the same rotation speed does not fully agree with the effect of the generation of the apical debris and the proportion of the residual root charge material. In the future, we need to further improve the experiment design in vitro, simulate the internal environment as much as possible, the speed of the apparatus and the various factors that affect the curative effect of the root canal retreatment. In order to find the most suitable working speed and mode of work in one step, we can achieve the ideal effect in reducing the production of the root tip debris and reducing the residual filling material and improving the working efficiency, and establish the standardized operation process of the root canal retreatment.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R781.05

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本文編號(hào)：2020597