摘要
根管治疗术是临床上治疗各型牙髓病和根尖周病的基本方法。根管治疗术的成功与否很大程度上取决于根管预备的质量及根管充填的密合度。根管治疗术通过根管预备、根管消毒和根管充填等步骤，消除根管内的病源刺激，利用尖周组织血运丰富，修复和再生力强的特点，治愈牙髓坏死或根尖周病。根管预备和充填是根管治疗术的重要步骤，预备的主要目的在于清理根管、根管成形，以利于根管充填；根管充填是将已经去除牙髓并经过预备的根管充填起来，隔绝根管和根尖周组织的交通，防止再感染，促进根尖周病变的愈合。
近年来，国内外对Profile技术预备根管及高温热塑牙胶充填根管的研究较多，但将不同预备方法及充填材料相结合的效果比较研究较少。本研究拟采用体视显微镜、扫描电镜技术及临床病例，观察不同根管预备方法对高温热塑牙胶充填根管效果的影响及中短期临床疗效。实验共分三个部分：
一、高温热塑牙胶充填根管的微渗漏研究
选取60个新鲜拔除的人单根管牙，在釉牙骨质界处切除牙冠。将所有牙根随机分为3组，每组20个。均采用Profile技术预备根管。A组用高温热塑牙胶充填；B组用氧化锌丁香油糊剂+牙胶尖充填；C组根管预备后不充填。用印度墨水染色法对比两种根管充填材料对离体人牙根管的密封性能。结果显示：高温热塑牙胶组的染色线长度为1.370mm，氧化锌丁香油糊
第四军医大学硕士学位论文
剂+牙胶尖组染色线长度为4.155~，两组之间差异显著伊切.001)，两组与
空白对照组之间差异亦显著(P<0.001)。该结果说明，高温热塑牙胶充填
法充填根管时，其微渗漏明显小于临床上最常应用的氧化锌丁香油糊剂+
牙胶尖充填根管;牙胶与根管壁间、根尖孔扫描电镜结果显示A组微渗漏
1一3um，B组3礴um，亦证明高温热塑牙胶根管密封性优于氧化锌丁香油糊
剂+牙胶尖充填组。
二、不同方法预备根管商温热塑牙胶充填的微渗漏研究
40个因正畸拔除的下领前磨牙，室温下保存于含有0.2%叠氮钠的生理盐
水中。随机分为4组，每组ro个:A组采用常规法预备根管:选用K型根管
锉，自巧.器械开始，逐号进行，均预备至根尖止点，主尖锉扩大至40.。B
组采用逐步深人法预备根管:根据ROfile根管预备系统的操作要求，以逐步
深人法预备根管至06125。c组采用超声法预备根管:分别使用15.、25#、
4护超声扩大锉扩大成形根管。D组采用 ROfile结合超声技术预备根管。各
组预备过程中，交替使用3%双氧水、生理盐水冲洗根管。预备完毕后，按
照实验一所述方法，用Obturan系统进行根管充填。对所有牙齿进行体视
显微镜观察根管的微渗漏并采集数据，所得实验结果用5 PSS统计软件进行
方差分析。结果显示:不同根管预备组微渗漏染色不同，A组染色线长度为
6.941~，B组为4.700幻nrn，C组为5.494mln，D组为1.534m们n，说明常规
法预备根管高温热塑牙胶充填组微渗漏最大，ROfile+超声预备热塑牙胶充
填组微渗漏最小，密封性能最好，对高温热塑牙胶充填适充性好。
三、高温热塑牙胶充填根管的临床研究
观察高温热塑牙胶充填根管的中短期疗效。选择160个患牙随机分为两
组，以ROfile机用根管器械采用逐步深人法进行根管预备。开髓、切冠髓、
拔除根髓、初步预测根管长度，预备根管至06/25。根管预备过程中，以
5 .25%次氯酸钠液反复冲洗根管，两组根管预备完毕后用纸捻吸干并封人FC
棉球一周。A组按照obturan使用说明充填热塑牙胶，B组常规充填氧化锌
丁香油糊剂+牙胶尖。通过摄X线片了解根管充填情况并进行调整，保证
根管恰填。治疗完成后于l周、3个月、6个月进行复查。统计学比较两组
第四军医大学硕士学位论文
差异。结果:A组术后1周、3个月、6个月的治疗成功率分别为95 .1%、
96.3%、98.8%，B组为88.5%、91.0%、93.6%，两组疗效无显著差异。但
高温热塑牙胶充填根管术后反应少，临床操作时间短，故该方法是比较理想
的根管充填技术。
Root canal therapy(RCT) is an essential method for treating various endodontic and periapical diseases. The success of the treatment depends majorly on the quality of canal preparation and the strictness of the canal filling. Root canal therapy for treating dental pulp necrosis and periapical diseases consists of root canal preparation, disinfection and filling in order to eliminate the stimulus source derived of the root canal. The canal preparation is an important step of RCT whose purpose lies in clearing the canal and taking shape to benefit the filling. The prepared canal where the dental pulp has been removed is filled in order to cut off the communication of the canal and periapical tissues, to prevent reinfection and to promote the healing of periapical lesions.
At present, studies in this field mainly focus on Profile technique applied in root canal preparation and thermoplasticized gutta-percha technique applied in root canal filling. Up to date, however, little is studied about the combination of those two kinds of techniques. Therefore, this study aimed at getting a better understanding on the filling effect affected by different preparation methods and the medium and short-term clinical effect. The main contents and results of the study are presented as follows:
1 The microleakage study on thermoplasticized gutta-percha technique applied in root canal filling
60 freshly pulled out teeth were selected and resected at cemento-enamel junction. All specimens were divided randomly into 3 groups that each contained 20 teeth. The specimens in Group A were filled with thermoplasticized gutta-percha; The ones in Group B were filled with zinc oxide clove oil paste
with gutta-percha point and the ones in Group C were left unfilled. The lutation quality of the two root canal filling materials was contrasted after India Ink staining. The results showed that the length of staining line of the teeth in Group A was significantly shorter than that in Group B (P<0.001). The difference between those two groups and the control group was significant (P<0.001). These results suggested that the microleakage in the specimens in Group A filled with heated Gutta-percha by high temperature thermoplasticized injectable obturation was significantly smaller than that filled with zinc oxide clove oil paste with gutta-percha. In addition, the lutation quality of the former was superior to the latter.
2 The microleakage study on thermoplasticized gutta-percha technique applied in root canal filling prepared with different methods
40 lower first premolars after being pulled out and preserved were divided randomly into 4 groups which each contained 10 teeth. The root canals of specimens in Group A were prepared with routine method, the ones in Group B prepared with step by step method, the ones in Group C prepared with ultrasound technique and the ones in Group D prepared with Profile and ultrasound technique. During root canal preparation every canal was rinsed with 3% hydrogen peroxide solution and saline alternatively. The canals were filled by Obtura II system when prepared. The microleakage in every specimen was obtained by observation under stereomicroscope and the data were collected and analyzed with SPSS software. The results showed that the length of staining line of the teeth in Group D; was significantly shorter than those in the other groups. These results suggested that the microleakage was the smallest and the lutation quality was best in the specimens which prepared with Profile and ultrasound technique and filled with injectable obturation with thermoplasticized gutta-percha.
3 Short-term curative effect of filling with thermoplasticized gutta-percha
In order to observe the short-term curative effect of heated gutta-percha of the Obtura n system, 160 teeth were divided into 2 groups. After they were all prepared with Profile system, Group A was filled with heated Gutta-percha by injectable obturation and Group B was filled with zinc oxide-eugenol paste with
gutta-percha. The patients were
引文
1. Ingle JL., Bakland LK. Endodontics. 4th ed. Baltimore. 1994: 233.
2. K(?)bota K, Golden BE, Penugonda B. Root canal filling materials for primary teeth: a review of the literature. ASDC J Dent Child. 1992;59(3):225.
3. Pantera EA Jr, Pantera CT. Trends in endodontic instruments and materials. N Y State Dent J. 1996;62(5):22
4. AliGhamdi A, Wennberg A. Testing of sealing ability of endodontie filling materials. Endod Dent Traumatol. 1994; 10(6):249.
5．史俊南．现代口腔内科学．高等教育出版社．2000：348．
6．陈治清．口腔材料学(第三版)。北京：人民卫生出版社，2002：81
7. Torabinejad M, Hong CU, Pitt Ford TR, et al. Antibacterial effects of some root end filling materials. J Endod. 1995 ;21 (8):403.
8. Hashieh IA, Pommel L, Camps J. Concentration of eugenol apically released from zinc oxide-eugenol-based sealers.J Endod. 1999;25(11):713.
9. Schmalz G, Hoffmann M, Weis K, et al. Influence of albumin and collagen on the cell mortality evoked by zinc oxide-eugenol in vitro. J Endod. 2000;26(5):284.
10. Huumonen S, Lenander-Lumikari M, Sigurdsson A, et al. Healing of apical periodontitis after endodontic treatment: a comparison between a silicone-based and a zinc oxide-eugenol-based sealer. Int Endod J. 2003; 36(4):296.
11. Hosoya N, Kurayama H, Iino F, et al. Effects of calcium hydroxide on physical and sealing properties of canal sealers. Int Endod J. 2004;37(3): 178.
12. Pawinska M, Skrzydlewska E. Release of hydroxyl ions from calcium hydroxide preparations used in endodontic treatment. Rocz Akad Med Bialymst. 2003;48:145.
13. Tanomaru JM, Leonardo MR, Tanomaru Filho M, et al. Effect of differentirrigation solutions and calcium hydroxide on bacterial LPS. Int Endod J.2003 ;36(11):733.
14. Estrela C, Pimenta FC, Ito IY, et al. Antimicrobial evaluation of calcium
hydroxide in infected dentinal tubules. J Ended. 1999;25(6):416.
15. Siqueira Junior JF, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. Int Ended J. 1999 ;32(5):361.
16. De Moor R. Calcium hydroxide-based pastes used in endodontics Rev Belge Meal Dent. 2003;58(1):34-48.
17. Dian Garcia-Godoy E Evaluation of an iodoform paste in root canal therapy for infected primary teeth. ASDC J Dent Child. 1987 ;54(1):30.
18. Saggar V, Chandra S, Jaiswal JN, et al. Antimicrobial efficacy of iodoformized zinc oxide-eugenol sealer on micro-organisms of root canal. J Pedod Prev Dent. 1991;9(1): 1.
19. Holland R, de Souza V, Nery MJ, et al. Root canal treatment of pulpless teeth with Calvital or zinc oxide-eugenol, in one or two sittings. Histological study in dog. Rev Fac Odontol Aracatuba. 1988;7(1):47.
20. Mochizuki K, Fujii H, Machida Y. Dentin bridge formation following direct pulp capping in dog's. Bull Tokyo Dent Coll. 1998;39(1):31.
21. Matsuzaki K, Fujii H, Machida Y. Experimental study of pulpotomy with calcium hydroxide-iodoform paste in dogs' immature permanent teeth. Bull Tokyo Dent Coll. 1990;31 (1):9.
22. Nurko C, Garcia-Godoy F. Evaluation of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth. J Clin Pediatr Dent. 1999;23(4):289.
23. Nurko C, Ranly DM, Garcia-Godoy F, et al. Resorption of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth: a case report. Pediatr Dent. 2000;22(6):517.
24. Hosoya N, Kurayama H, Iino F, Arai T. Effects of calcium hydroxide on physical and sealing properties of canal sealers. Int Endod J. 2004;37(3): 178.
25．吕海鹏 三种根管充填材料的临床与基础研究[学位论文]。西安：第四军医大学 2003年．
26. De Bruyne MA, De Moor RJ. The use of glass ionomer cements in both conventional and surgical endodontics, lnt Endod J. 2004;37(2):91.
27. Dalat DM, Onal B. Apical leakage of a new glass ionomer root canal sealer. J Endod. 1998;24(3): 161.
28．谢欣梅，肖明振，陈礼森．复方羟磷灰石钛尖根管充填材料的临床研究．牙体牙髓牙周病学研究，1997；7(4)：256．
29．刘国勤，宋培止，徐逸敏．磁性固定根充材料临床应用分析．牙体牙髓牙周病学杂志，1995；5(3)：158．
30. Koch MJ. Formaldehyde release from root-canal sealers: influence of method. Int Endod J. 1999;32(1): 10.
31. Cohen BI, Pagnillo MK, Musikant BL, Deutseh AS. Formaldehyde evaluation from endodontic materials. Oral Health. 1998;88(12):37.
32．凌均启．新型药物控释根尖用于牙髓尖周病的可行性研究．牙体牙髓牙周病杂志，1995；5(4)：195．
33．刘国勤；宋培智；徐逸敏；刘琪．磁性固体根充材料临床应用分析．牙体牙髓牙周病学杂志 1995．09．30；5(3)：158-159．
34. Hulsmann M, Herbst U, Schafers F. Comparative study of root-canal preparation using Lightspeed and Quantec SC rotary NiTi instruments.Int Endod J. 2003 Nov;36(11):748-56.
35. Zuckerman O, Katz A, Pilo R, Tamse A, Fuss Z. Residual dentin thickness in mesial roots of mandibular molars prepared with Lightspeed rotary instruments and Gates-Glidden reamers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Sep;96(3):351-5.
36．樊明文．现代根管概述．中国当代医学，2001；7(8)：38．
37. Gettleman BH, Aguirre R. Endodontic cleaning and shaping: current concepts. Endod Rep. 1993;8(1): 19.
38. Obtura Ⅰ、 Obtura Ⅱ [Tani-Ishii N, Teranaka T. Clinical and radiographic evaluation of root-canal obturation with obtura Ⅱ. J Endod. 2003 Nov;29(11):739-42.
39. Cathro PR, Love RM. Comparison of MicroSeal and System B/Obtura Ⅱ obturation techniques. Int Endod J. 2003 Dec;36(12):876-82.
40. 40. Gilhooly RM, Hayes S , Bryant ST, et al. Comparison of lateral condensation and thermomechanieally compacted warm alpha-phase gutta-percha with a single cone for obturating curved root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(1):89.
41. Cohen BD, Combe ED, Lilley JD. Effect of thermal placement techniques on some physical properties of gutta-percha. Int Endod J. 1992 ;25(6):292.
42. Marciano J, Michailesco P, Charpentier E, et al. Thermomechanical analysis of dental gutta-percha. J Endod. 1992; 18(6):263.
43. Beatty RG, Vertucci FJ, Hojjatie B. Thermomechanical compaction of gutta-percha: effect of speed and duration. Int Endod J. 1988;21(6):367.
44. Saunders EM. The effect of variation in thermomechanical compaction techniques upon the quality of the apical seal. Int Endod J. 1989;22(4): 163.
45. Gencoglu N. Comparison of 6 different gutta-percha techniques (part Ⅱ): Thermafil, JS Quick-Fill, Soft Core, Microseal, System B, and lateral condensation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96(1):91.
46. Weller RN, Kimbrough WF, Anderson RW. A comparison of thermoplastic obturation techniques: adaptation to the canal walls. J Endod. 1997; 23(11):703.
47. Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. J Endod. 2001;27(7):449.
48. Vizgirda PJ, Liewehr FR, Patton WR, et al. A comparison of laterally condensed gutta-percha, thermoplastieized gutta-percha, and mineral trioxide aggregate as root canal filling materials. J Endod. 2004;30(2): 103.
49. Oliver CM, Abbott PV. An in vitro study of apical and coronal microleakage of laterally condensed gutta percha with Ketac-Endo and AH-26. Aust Dent J. 1998;43(4):262.
50. Kardon BP, Kuttler S, Hardigan P, et al. J Endod. An in vitro evaluation of the sealing ability of a new root-canal-obturation system. 2003;29(10):658.
51. Saunders EM. In vivo findings associated with heat generation during thermomechanical compaction of gutta-percha. 1. Temperature levels at the external surface of the root. Int Endod J. 1990;23(5):263.
52. Figdor D, Beech DR, Waterson J. Factors affecting heat generation in the McSpadden compaction technique. J Dent Res 1983;132:664.
53. Silver GK, Love RM, Purton DG. Comparison of two vertical condensation obturation techniques: Touch 'n Heat modified and System B. Int Endod J.
1999;32(4):287.
54. Smith RS, Weller RN, Loushine RJ,et al. Effect of varying the depth of heat application on the adaptability of gutta-percha during warm vertical compaction. J Endod. 2000;26(11):668.
55. Sweatman TL, Baumgartner JC, Sakaguchi RL. Radicular temperatures associated with thermoplasticized gutta-percha. J Endod. 2001 ;27(8):512.
56. Blanas N, Kienle F, Sandor GK. Injury to the inferior alveolar nerve due to thermoplastic gutta percha. J Oral Maxillofac Surg. 2002;60(5):574.
57．刘剑，Donald C．Yu，沈丽佳，等．热牙胶垂直挤压术充填侧支根管的探讨．广东牙病防治 2002；10(4)：284．
58．刘颖婷，吴恩格，欧炯光．热侧压牙胶根管充填法的实验研究．昆明医学院学报，1998；19(03)：23．
59．李梅，张颂农．热塑载体牙胶尖在根管治疗术中的临床应用．牙体牙髓牙周病学杂志，2000；10(2)：38．
60. Aktener BO, Bilkay U. Smear layer removal with different concentrations of EDTA-ethylenediamine mixtures.J Endod. 1993 May;19(5):228-31.
61. Hulsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: mode of action and indications for their use. Int Endod J. 2003 Dec;36(12):810-30.
62. Cheung GS. Survival of fitrst-time nonsurgical root canal treatment performed in a dental teaching hospital. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 May;93(5):596-604.
63. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990 Oct; 16(10): 498-504.
64. Waltimo TM, Boiesen J, Eriksen HM, Orstavik D. Clinical performance of 3 endodontic sealers.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Jul;92(1):89-92.
65. de Deus GA, Martins F, Lima AC, Analysis of the film thickness of a root canal sealer following three obturation techniques. Pesqui Odontol Bras. 2003 Apr-Jun; 17(2): 119-25. Epub 2003 Oct 10.
66. Gomes BE Sato E, Ferraz CC, Evaluation of time required for
recontamination of coronally sealed canals medicated with calcium hydroxide and chlorhexidine. Int Endod J. 2003 Sep;36(9):604-9.
67. Staribratova-Reister K, Reister JP, Attin T, Apical leakage in maxillary type Ⅳ premolars with three different endodontic treatments. Clin Oral Investig. 2003 Sep;7(3): 148-53. Epub 2003 Aug 26.
68. Britto LR, Grimaudo NJ, Vertucci FJ. Coronal microleakage assessed by polymicrobial markers. 51: J Contemp Dent Pract. 2003 Aug 15;4(3):1-10.
69. Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part Ⅰ. Time periods.J Endod. 1987 Feb; 13(2):56-9.
70. Sousa-Neto MD, Passarinho-Neto JG, Carvalho-Junior JR, Cruz-Filho AM, Pecora JD, Saquy PC. Evaluation of the effect of EDTA, EGTA and CDTA on dentin adhesiveness and microleakage with different root canal sealers. Braz Dent J. 2002; 13(2): 123-8.
71. Roux D, Domejean-Orliaguet S, Saade M. Leakage associated with intermediate restorative material and glass-ionomer cement retrograde fillings: a human and sheep teeth comparison with 2 different aging procedures.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Jan; 93(1):81-7.
72. Economides N, Kokorikos I, Gogos C, Kolokouris I, Staurianos C. Comparative study of sealing ability of two root-end-filling materials with and without the use of dentin-bonding agents. J Endod. 2004 Jan; 30(1):35-7.
73. Roulet JF, Reich T, Blunck U, Noack M. Quantitative margin analysis in the scanning electron microscope.Scanning Microsc. 1989 Mar;3(1): 147-5.
74. Hannig M, Grafe A, Atalay S, Bott B. Microleakage and SEM evaluation of fissure sealants placed by use of self-etching priming agents.J Dent. 2004 Jan; 32(1):75-81.
75. Chevitarese AB, Chevitarese O, de Souza IP, Viarma RB. Influence of prophylaxis on the microleakage of sealants: in vitro study. J Clin Pediatr Dent. 2002 Summer;26(4):371-5.
76. Taylor MJ, Lynch E. Microleakage. J Dent. 1992 Feb;20(1):3-10.
77. Kazemi R.B, Spangberg LS. Effect of reduced air pressure on dye penetration in standardized voids.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Dec;80(6):720-5.
78. Douglas WH, Fields RP, Fundingsland J. A comparisonbetween the microleakage of direct and indirect composite restorative systems.J Dent. 1989 Aug;17(4): 184-8.
79. Lim KC. The microleakage of a glass ionomer cement using two methods of moisture protection. Quintessence Int. 1987 Dec; 18( 12): 835-9.
80. Marques JLL,Eduardo CP, Matsumoto K. Astudy on morphological changes of the root canal,walls lased by pulsed Nd;YAG laser, J Jpn Endod Asso,1995,16:64-9.
81．沙鑫家，吴补领，林媛．两种根管预备器械根管清洁能力的扫描电镜观察．牙体牙髓牙周病学杂志，2003，13(6)：295．
82．王晓仪主编．现代根管治疗学．北京：人民卫生出版社；2002；8．