Successful treatment of vertical root fracture through intentional replantation and root fragment bonding with 4-META/MMA-TBB resin 通过意图性再植和 4-META/MMA-TBB 树脂粘接根部碎片成功治疗垂直根裂
\author{ \作者{
Morio Okaguchi , Tienchun Kuo , Yi-Ching Ho Morio Okaguchi ，Tienchun Kuo ，Yi-Ching Ho Okaguchi Dental Clinic, Tokyo, Japan 日本东京冈口牙科诊所 Elite Dental Clinic, Taipei, Taiwan 台湾台北精英牙科诊所
c School of Dentistry, National Taiwan University, Taipei, Taiwan 台湾台北国立台湾大学牙科学院
University, Taipei, Taiwan 台湾台北大学
e Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan 台湾台北台北榮民總醫院口腔科 Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei, Taiwan 台湾台北国立阳明大学牙科学院牙科部
}
Received 28 July 2018; accepted 3 August 2018 收稿日期：2018 年 7 月 28 日；接受日期：2018 年 8 月 3 日
Vertical root fracture; Clinical outcome 垂直根裂; 临床结果
Background/Purpose: Vertical root fracture (VRF) is a complication in endodontically treated teeth. This study aimed to assess the clinical outcomes of treatment of 6 VRF teeth with intentional replantation and root fragment bonding with 4 -methacryloxyethyl trimellitate anhy dride/methyl methacrylate-tri-n-butyl borane (4-META/MMA-TBB) resin. 背景/目的：垂直根裂（VRF）是根管治疗后牙齿的并发症。本研究旨在评估采用意向性再植和使用 4-甲基丙烯酰氧乙基三甲酸酐/甲基丙烯酸三正丁基硼（4-META/MMA-TBB）树脂对 6 颗 VRF 牙齿进行治疗的临床结果。
Methods: A series of 6 complete VRF teeth (one incisor, one canine, one premolar, and 3 M ) were treated through intentional replantation and root fragment bonding with 4 -META/MMA TBB resin. 方法：通过有意义的再植和使用 4-META/MMA TBB 树脂对一组 6 颗完整的 VRF 牙齿（一个门牙，一个犬齿，一个前磨牙和 3 颗 M 牙）进行处理。
Results: This study included 6 VRF teeth in 6 patients (one man and 5 women; mean age, years). All 6 teeth had VRF in the bucco-lingual direction and one tooth had concomitant VRF in the mesio-distal direction. The root thickness was classified as thick in all 6 teeth. O the 6 VRF teeth, 4 had biting, percussion, or palpation pain, 4 had gingival swelling, 3 had sinus tracts, 3 had discomfort, and one had tooth mobility. Radiographically, 5 of the 6 teeth had periradicular radiolucent lesions, 4 of which exhibited complete regression and one of which exhibited nearly complete regression after root fragment bonding therapy. Because all 6 treated teeth exhibited sound function in the oral cavity after a follow-up period ranging from 33 to 74 (mean, ) months, the clinical outcomes were all considered to be successful. 结果：本研究纳入了 6 名患者的 6 颗 VRF 牙齿（1 名男性和 5 名女性；平均年龄 岁）。所有 6 颗牙齿在颊舌方向上均存在 VRF，其中 1 颗牙齿同时在前后方向上存在 VRF。所有 6 颗牙齿的根部厚度被分类为厚。在这 6 颗 VRF 牙齿中，有 4 颗出现咬合、叩击或触诊疼痛，4 颗有牙龈肿胀，3 颗有窦道，3 颗有不适感，1 颗有牙齿松动。在 X 线片上，6 颗牙齿中有 5 颗出现根尖周放射状透亮病变，其中 4 颗在根部碎片粘合治疗后完全消退，1 颗在治疗后几乎完全消退。因为在随访期间范围从 33 到 74 个月（平均 个月）内，所有 6 颗治疗过的牙齿在口腔中表现出良好功能，临床结果被认为是成功的。
Conclusion: For a VRF tooth, in addition to tooth extraction, intentional replantation combined with root fragment bonding with 4-META/MMA-TBB resin is a successful treatment modality that can be used to preserve a complete VRF tooth. 结论：对于 VRF 牙齿，除了拔牙外，意向性再植结合 4-META/MMA-TBB 树脂粘合根碎片是一种成功的治疗方式，可用于保留完整的 VRF 牙齿。
Vertical root fracture (VRF) is a major complication in endodontically treated teeth. The prevalence of VRF in extracted endodontically treated teeth has been reported to be The 4 -methacryloxyethyl trimellitate anhydride/methyl methacrylate-tri-n-butyl borane (4-META) MMA-TBB) dental adhesive resin (Super Bond , Sun Medical Co., Kyoto, Japan) has been used for bonding VRF teeth with excellent clinical outcomes. Intracanal bonding with 4-META/MMA-TBB resin for VRF teeth can reduce the probing depth, gingival bleeding score, and tooth mobility, and increase the alveolar bone level. Moreover, in a study by Masaka, 5 of 6 VRF teeth treated using this technique remained functional for more than 10 years. In addition, VRF teeth treated using intentional replantation and extraoral bonding with 4-META/MMA-TBB resin can achieve a high 5year tooth retention rate of 垂直根裂（VRF）是根管治疗后牙齿的主要并发症。已报道在拔除的根管治疗后牙齿中 VRF 的患病率为 。4-甲基丙烯酸氧乙基三甲酸酐/甲基丙烯酸三正丁硼酯（4-META）MMA-TBB）牙科粘合树脂（Super Bond ，日本京都 Sun Medical Co.）已用于与 VRF 牙齿结合，临床效果优异。 使用 4-META/MMA-TBB 树脂对 VRF 牙齿进行根管内粘合可减少探诊深度、牙龈出血评分和牙齿松动，并增加牙槽骨水平。 此外，在 Masaka 的研究中，使用这种技术治疗的 6 颗 VRF 牙齿中有 5 颗在 10 年以上保持功能。 此外，使用有意义的再植术和体外粘合 4-META/MMA-TBB 树脂治疗的 VRF 牙齿可以实现高达 的 5 年牙齿保留率。
Because teeth treated using intentional replantation have a high tooth retention rate of and 4 -META/ MMA-TBB resin has a high tensile and dentin-bonding strength and favorable biocompatibility, in this study, we used intentional replantation and root fragment bonding with 4-META/MMA-TBB resin to successfully treat a series of 6 complete VRF teeth. Furthermore, cone-beam computed tomography (CBCT, 3D Accuitomo 170, Morita, Kyoto, Japan) was used after the treatment to monitor 3-dimensional changes in the periradicular radiolucent lesions present in 4 of the 6 VRF teeth. We believe that this is a reliable treatment modality that can be used to preserve a complete VRF natural tooth, as an alternative to tooth extraction and subsequent restoration of a dental implant. 由于采用有意移植治疗的牙齿具有高 的牙齿保留率，而 4-META/MMA-TBB 树脂具有高拉伸和牙本质结合强度 以及良好的生物相容性 ，在本研究中，我们使用有意移植和 4-META/MMA-TBB 树脂粘接根片成功治疗了一系列 6 颗完整的 VRF 牙齿。此外，治疗后使用锥形束计算机断层扫描（CBCT，3D Accuitomo 170，日本京都的森田公司）监测 6 颗 VRF 牙齿中 4 颗存在的根尖周放射透亮病变的三维变化。我们认为这是一种可靠的治疗方式，可用于保留完整的 VRF 天然牙齿，作为拔牙和随后种植牙修复的替代方法。
Materials and methods 材料和方法
Six VRF teeth (one incisor, one canine, one premolar, and 3 M ) in 6 patients (one man and 5 women; mean age, years; age range, years) were included in this study. All 6 VRF teeth were treated at the private dental clinic of one of the authors (OM) from July 2006 to January 2014. VRF was classified as either bucco-lingual or mesio-distal, according to the direction of the fracture line. VRF fracture lines are either complete or incomplete, where complete VRF lines extend from the cervical third to the apical third of the root, and the extension of incomplete VRF lines involves only part of the root. According to these definitions, all 6 teeth had complete VRF in the bucco-lingual direction, and one tooth had concomitant incomplete VRF in the mesio-distal direction, according to visual inspection as well as stereomicroscopic and radiographic examinations (Table 1). The thickness of the fractured root was evaluated through visual inspection or radiographic examination and characterized as thick when the fractured root retained more than half the thickness of the original root, and characterized as thin when the fractured root retained less than half the thickness of the original root because of preparation for root canal filling or post-core restoration. 本研究纳入了 6 名患者（1 名男性和 5 名女性；平均年龄 岁；年龄范围 岁）的 6 颗 VRF 牙齿（1 颗门牙、1 颗犬齿、1 颗前磨牙和 3 颗 M）。所有 6 颗 VRF 牙齿在 2006 年 7 月至 2014 年 1 月期间由其中一位作者（OM）的私人牙科诊所治疗。VRF 被分类为颊舌向或前后向，根据骨折线的方向。VRF 骨折线可以是完全的或不完全的，完全的 VRF 线延伸从根部的颈部到尖端的第三部分，而不完全的 VRF 线的延伸仅涉及部分根部。根据这些定义，所有 6 颗牙齿在颊舌向方向上均有完全的 VRF，其中 1 颗牙齿在前后向方向上同时有不完全的 VRF，根据视觉检查以及立体显微镜和放射学检查（表 1）。 骨折根的厚度是通过视觉检查或放射学检查进行评估的，当骨折根保留了原始根的一半以上厚度时，被描述为厚，当骨折根由于根管充填或核心修复而保留了原始根厚度的一半以下时，被描述为薄。
Informed consent was obtained from each patient before treatment after a thorough explanation of the entire treatment procedure and follow-up schedule, as well as any possible risks and benefits of this particular root fragment bonding therapy. All 6 VRF teeth were treated with intentional replantation and root fragment bonding with 4META/MMA-TBB resin. The size, location, and boundary of the periradicular radiolucency were recorded at the baseline and at several specific follow-up time points. Periradicular lesion response was evaluated using periapical radiography (in all 6 cases) and CBCT (Cases 1-4 in Table 1) after treatment and characterized as follows: complete response, indicating complete regression of the radiolucent lesion; partial response, indicating reduction of the radiolucent lesion by at least ; no response, indicating reduction of the radiolucent lesion by less than ; and progression of the disease, indicating an increase in the size of the radiolucent lesion after treatment. 在对每位患者进行全面解释整个治疗程序和随访计划以及此特定根残片粘接疗法的任何可能风险和益处后，获得了知情同意。所有 6 颗 VRF 牙齿均采用有意义的再植和 4META/MMA-TBB 树脂根残片粘接进行治疗。在基线和几个特定随访时间点记录了根尖周透光性的大小、位置和边界。使用根尖 X 线摄影（所有 6 例）和 CBCT（表 1 中的 1-4 例）评估根尖周病变反应，并在治疗后进行以下特征描述：完全反应，表示透光病变完全消退；部分反应，表示透光病变至少减少 ；无反应，表示透光病变减少少于 ；疾病进展，表示治疗后透光病变增大。
In this study, all clinical procedures were performed by one of the authors (OM), using local anesthesia. The detailed clinical procedures of the intentional replantation and root fragment bonding with 4-META/MMA-TBB resin have been described previously. In brief, the operation field was sterilized by swabbing with hydrogen peroxide, followed by chlorhexidine. The pulp chamber was accessed, and caries or contaminated dentin were removed by hand instrumentation, using a spoon excavator and then a lowspeed handpiece with a round bur (No. 1,008 , Kerr Co, Orange, CA, USA) or a high-speed handpiece with a 0.8mm round carbide bur (No. 1, 0001/008, Mani, Tochigi, Japan) with copious water spraying. If the VRF was complicated by both bucco-lingual and mesio-distal fracture lines (as in Case 1), the fracture lines were prepared and sealed with 4-META/MMA-TBB resin with the VRF tooth in situ, the apical third of the root canal was filled with mineral trioxide aggregate (MTA) if needed, and the other residual root canal and the pulp chamber spaces were filled with a light-curing composite resin to reinforce the crown and root strength before tooth extraction. For VRF teeth with a marked separation of the root into 2 parts, the 2 fragments were extracted carefully, the surfaces were cleaned, and the contaminated dentin and cementum were removed using either a highspeed handpiece with a round bur or an ultrasonic device with copious water spraying under a stereomicroscope. Subsequently, 4-META/MMA-TBB resin was adhered to the clean root fragments, and the apical root end was also prepared 在这项研究中，所有临床程序均由其中一位作者（OM）使用局部麻醉进行。先前已描述了有意移植和使用 4-META/MMA-TBB 树脂粘合根碎片的详细临床程序。简而言之，手术区域通过用双氧水擦拭，然后用氯己定消毒。打开牙髓室，用手工器械（勺子刨）清除龋齿或受污染的牙本质，然后使用带有圆形钻头的低速手柄（No. 1,008，Kerr Co, Orange, CA, USA）或带有 0.8mm 圆形碳化硼钻头的高速手柄（No. 1,0001/008，Mani, Tochigi, Japan）进行大量水喷洒。如果 VRF 同时伴有颊舌和前后方向的断裂线（如案例 1），则在 VRF 牙齿原位的情况下，准备并用 4-META/MMA-TBB 树脂密封断裂线，如有需要，根管的尖端三分之一填充矿物三氧化二铝（MTA），其余残留的根管和牙髓室空间填充光固化复合树脂以加强牙冠和根的强度，然后进行拔牙前牙齿。 对于根分为两部分的 VRF 牙齿，仔细提取了两个碎片，清洁表面，并使用高速手柄和圆形钻头或超声波设备，在立体显微镜下大量喷水清洗，去除受污染的牙本质和牙骨。随后，4-META/MMA-TBB 树脂粘附在清洁的根部碎片上，并且顶端根部也被准备好
and covered with 4-META/MMA-TBB resin. The fused tooth was held with a saline-wetted gauge for at least 5 min after adhesion. Any overflowing resin was removed cautiously using a hand scaler under a stereomicroscope or using a high-speed handpiece with a fissure bur. The socket was gently curetted to remove any periradicular granulation tissues present Inflamed tissue on the surface of the fractured root was removed using fine scissors under a stereomicroscope. The bonded tooth was then cleaned with saline and replanted into the original socket using gentle finger pressure. The patient was instructed to close his or her jaw to produce centric occlusion and ensure complete repositioning. Finally, the replanted tooth was splinted to adjacent teeth with 4-META/ MMA-TBB resin for 4 wk . The occlusion was checked and any premature contact points on the replanted tooth in centric occlusion were removed. Moreover, the replanted tooth was prevented from contacting other teeth when lateral and protrusive movements were performed to avoid excessive occlusal force. Analgesics and antibiotics were routinely prescribed to each patient after treatment. 覆盖 4-META/MMA-TBB 树脂。粘合后，将熔合牙用浸湿盐水的纱布固定至少 5 分钟。使用手持放大镜下的手工刮削器或带有裂纹钻头的高速手柄小心地去除任何溢出的树脂。轻轻刮除龈槽，清除任何周根周围肉芽组织。使用手持放大镜下的细剪刀去除断裂根表面的炎症组织。然后用盐水清洁粘合的牙齿，并用轻轻的手指压力重新植入原牙槽。指导患者闭合下颌，使中心咬合，确保完全复位。最后，用 4-META/MMA-TBB 树脂将重新植入的牙齿固定到相邻牙齿上 4 周。检查咬合，去除中心咬合时重新植入牙齿上的任何早期接触点。此外，在进行侧向和前伸运动时，避免重新植入的牙齿与其他牙齿接触，以避免过度咬合力。治疗后，每位患者常规处方镇痛药和抗生素。
The patients were followed up once per week in the first month after the operation, once per month from the second to third month, once every 2 months from the fourth to eighth month, and once every 3 months thereafter. At each follow-up visit, clinical photographs were taken, but periapical radiography or CBCT was performed if necessary. The clinical evaluation included the presence or absence of spontaneous percussion or biting pain, gingival swelling sinus tracts, and tooth mobility. The radiographic evaluation included the healing of periradicular radiolucency, the occurrence of root resorption, and refracture of the root. 患者手术后第一个月每周随访一次，第二至第三个月每月一次，第四至第八个月每两个月一次，之后每三个月一次。每次随访时拍摄临床照片，必要时进行根尖 X 线摄影或 CBCT 检查。临床评估包括自发性叩击或咬痛、牙龈肿胀窦道和牙齿松动的有无。放射学评估包括根尖周放射透亮区的愈合、根吸收的发生和根再骨折。
Results 结果
Clinical and radiographic information for the 6 VRF teeth treated using intentional replantation and root fragment bonding with 4-META/MMA-TBB resin is shown in Table 1. The clinical and stereomicroscopic photographs, periapical radiographs, and CBCT images of the first 4 VRF teeth in Table 1 before and after treatment are shown in Figs. 1-4. All 6 teeth had complete VRF in the bucco-lingual direction (Table 1). In addition, one left mandibular second molar (Case 1) had concomitant incomplete VRF in the mesiodistal direction (Fig. 1D). The root thickness was classified as thick in all 6 teeth (Table 1). Of the 6 VRF teeth, 4 had biting, percussion, or palpation pain, 4 had gingival swelling, 3 had sinus tracts, 3 had discomfort, and one had tooth mobility (Table 1). Radiographically, 5 VRF teeth had periradicular radiolucent lesions, 4 of which exhibited complete response (Cases 1-4) and one of which exhibited partial but nearly complete response (Case 5) after root fragment bonding therapy (Table 1). Because all 6 treated teeth had sound function and no additional clinical symptoms or signs in the oral cavity after a follow-up period ranging from 33 to 74 (mean, ) months, the clinical outcomes were all considered to be successful (Table 1). 表 1 显示了使用意向性再植和 4-META/MMA-TBB 树脂进行根部碎片粘接治疗的 6 颗 VRF 牙齿的临床和放射学信息。表 1 中第 1-4 颗 VRF 牙齿的临床和立体显微镜照片、根尖 X 线片和 CBCT 图像在治疗前后的显示在图 1-4 中。所有 6 颗牙齿在颊舌方向上均有完全的 VRF（表 1）。此外，左下第二磨牙（Case 1）在近远中方向上伴有不完全的 VRF（图 1D）。所有 6 颗牙齿的根部厚度被分类为厚（表 1）。在这 6 颗 VRF 牙齿中，有 4 颗出现咬合、叩击或触诊疼痛，4 颗有牙龈肿胀，3 颗有窦道，3 颗有不适感，1 颗有牙齿松动（表 1）。放射学上，5 颗 VRF 牙齿有根尖周放射透亮病变，其中 4 颗在根部碎片粘接治疗后表现出完全缓解（Case 1-4），1 颗表现出部分但几乎完全缓解（Case 5）（表 1）。 因为在随访期间（范围为 33 至 74 个月，平均 个月），所有 6 颗接受治疗的牙齿功能正常，在口腔内没有额外的临床症状或体征，因此所有临床结果被认为是成功的（表 1）。
Discussion 讨论
In this study, 6 complete VRF teeth, treated with intentional replantation and root fragment bonding with 在这项研究中，6 颗完整的 VRF 牙齿经过有意的再植治疗，并进行了根部碎片粘接
Figure 1 Clinical and microscopic photographs, periapical radiographs, and CBCT images of Case 1 from Table 1. (A) Prepared and composite resin-filled crown of the left mandibular second molar in a 43 -year-old female patient. (B and C) CBCT images of the left mandibular second molar, exhibiting a completely filled distal root canal and a partially filled mesial root canal with extrusion of filling materials into the periradicular radiolucent lesion. (D) Microscopic photograph showing the fractured tooth with complete bucco-lingual and incomplete mesio-distal fracture lines at the crown dentinal wall and pulp chamber floor. The intracrown fracture lines were first prepared and sealed with 4-META/MMA-TBB resin. The residual cavity was filled with lightcuring composite resin (not shown) and the tooth was then carefully extracted. (E-H) Extracted tooth exhibiting longitudinal fracture lines on both mesio-buccal and disto-lingual root trunks. The fracture lines and the two root ends were prepared and sealed with 4-META/MMA-TBB resin. (I) The replanted tooth was splinted to the adjacent mandibular first molar with 4-META/ MMA-TBB resin. (J) Periapical radiograph taken immediately after the replantation, showing the treated tooth in the right position. (K) The 45 -month follow-up CBCT image, showing a porcelain fused to zirconia crown on the replanted tooth, as well as complete regression of the radiolucent lesion at the periradicular area of the mesial root of the left mandibular second molar. 图 1 表 1 中病例 1 的临床和显微镜照片、根尖 X 线片和 CBCT 图像。(A) 43 岁女性患者左下第二磨牙制备和复合树脂充填冠。 (B 和 C) 左下第二磨牙的 CBCT 图像，显示完全填充的远中根管和部分填充的近中根管，填充物外溢至根尖周围放射透亮病变。 (D) 显微镜照片显示断裂的牙齿，冠牙本质壁和牙髓室底部有完全的颊舌和不完全的近远断裂线。冠内断裂线首先用 4-META/MMA-TBB 树脂处理和封闭。剩余腔被光固化复合树脂填充（未显示），然后小心拔除牙齿。 (E-H) 拔除的牙齿显示近颊和远舌根干上的纵向断裂线。断裂线和两个根尖被用 4-META/MMA-TBB 树脂处理和封闭。 (I) 移植的牙齿用 4-META/MMA-TBB 树脂固定到相邻的下颌第一磨牙上。 (J) 拔牙后立即拍摄的根尖 X 光片，显示右侧位置的治疗牙齿。(K) 45 个月随访 CBCT 图像显示，重新植牙上有瓷贴合氧化锆冠，左下第二磨牙近根尖区的放射透亮病变完全消退。
4-META/MMA-TBB resin had successful clinical outcomes. All 6 treated teeth remained functional without clinical symptoms or signs after a mean follow-up period of months. Of the 5 VRF teeth with periradicular radiolucent lesions, 4 showed complete response and one exhibited nearly complete response after treatment. These findings indicate that root fragment bonding therapy is a reliable alternative treatment option for complete VRF teeth. 4-META/MMA-TBB 树脂在临床上取得了成功的治疗效果。在平均随访 个月后，所有 6 颗接受治疗的牙齿保持功能正常，没有临床症状或体征。在 5 颗有根尖周放射透亮病变的 VRF 牙齿中，4 颗在治疗后显示完全缓解，1 颗显示几乎完全缓解。这些发现表明，根片粘接疗法是完全 VRF 牙齿的可靠替代治疗选择。
At least 6 factors could explain the successful clinical outcomes for the treated VRF teeth. First, all 6 treated teeth had thick root fragments, which provided sufficient bonding surfaces and structures to prevent subsequent 至少有 6 个因素可以解释治疗 VRF 牙齿取得成功临床结果。首先，所有 6 颗治疗过的牙齿都有厚根残片，提供了足够的结合表面和结构，以防止随后的情况。
Figure 2 Clinical photographs, periapical radiographs, and CBCT images of Case 2 from Table 1. (A) Clinical photograph showing a separated crown with a labio-palatal fracture at the distal portion of the left maxillary central incisor in a 31-yearold female patient. (B) Periapical radiograph showing the left maxillary central incisor with a labio-palatal fracture line at the disto-cervical area of the crown and a periapical radiolucent lesion. (C) Distal portion of the fractured crown was first restored with a light-curing composite resin. (D) The two tooth fragments were extracted with caution. (E) The fractured root surfaces were prepared and cleaned using an ultrasonic device. (F) The two root fragments were adhered with the radiolucent 4-META/MMA-TBB resin after ultrasonic cleaning. (G) Periapical radiograph taken immediately after the replantation, showing the treated tooth in the right position. The 74 -month follow-up CBCT image, showing the complete healing of the periapical lesion of the replanted left maxillary central incisor. 图 2 案例 2 的临床照片、根尖 X 线片和 CBCT 图像，详见表 1。 (A) 临床照片显示一名 31 岁女性患者左上颌中切牙远端部位出现分离的冠部，伴有唇腭面骨折。 (B) 根尖 X 线片显示左上颌中切牙冠部远近颈区域出现唇腭面骨折线和根尖周围透亮病变。 (C) 首先用光固化复合树脂修复了骨折冠部的远端部位。 (D) 小心地取出了两块牙齿碎片。 (E) 使用超声波设备准备和清洁了骨折根面。 (F) 在超声波清洁后，用透亮 4-META/MMA-TBB 树脂粘合了两块根片。 (G) 重新植入后立即拍摄的根尖 X 线片显示治疗后牙齿处于正确位置。 74 个月后的随访 CBCT 图像显示重新植入的左上颌中切牙根尖周围病变完全愈合。
refracture. Second, the extracted tooth fragments were treated extraorally and the entire root fragment cleaning procedure was performed under a stereomicroscope; thus, the contaminated dentin, cementum, and periodontal ligament tissue could be thoroughly removed and the bacteria inside the root could be eliminated. Third, all the apical root ends of the 6 treated teeth were prepared and sealed 再次骨折。其次，提取的牙齿碎片在体外处理，并在立体显微镜下进行整个根部碎片清洁程序；因此，可以彻底去除受污染的牙本质、牙骨质和牙周韧带组织，并消灭根内的细菌。第三，对 6 颗处理过的牙齿的所有根尖进行了准备和封闭。
residual bacteria to the periradicular tissue. Fourth, 4with 4-META/MMA-TBB resin to prevent the leakage of any META/MMA-TBB resin has high dentin-bonding and tensile strength as well as favorable biocompatibility. Fifth, to avoid heavy occlusal loading, all of the treated VRF teeth were prevented from contacting other teeth during lateral and protrusive movements, with the preservation of centric contact only. Sixth, the treatment procedure for each VRF tooth was completed within 10 or 15 min , with the tooth being kept in a wet condition using a saline spray during the entire treatment procedure. 残留细菌到根尖周组织。第四，使用 4-META/MMA-TBB 树脂防止任何 META/MMA-TBB 树脂泄漏，该树脂具有高牙本质结合力和拉伸强度以及良好的生物相容性。第五，为了避免过重的咬合负荷，所有接受治疗的 VRF 牙齿在侧向和前伸运动期间都不与其他牙齿接触，仅保留中性接触。第六，每颗 VRF 牙齿的治疗程序在 10 或 15 分钟内完成，整个治疗过程中用生理盐水喷雾保持牙齿湿润。
VRF teeth can be treated from the inside (through the root canal) with the tooth in situ, from the outside after flap reflection to expose the fracture line, from the outside after tooth extraction, or from the inside with the tooth in situ and then from the outside after tooth extraction. First, when a VRF tooth was treated from the inside with the tooth in the socket, intracrown and intracanal fracture lines were carefully prepared using an ultrasonic device and then sealed with 4-META/MMA-TBB resin. Because of the limitation of the anatomical structure, the entire fracture line could not be reached and the full depth of the fracture line could not be prepared and adhered with 4-META/MMA-TBB resin. Therefore, some of the bacteria could have remained in the fracture gap and in turn could have led to treatment failure. To avoid the bacterial factor influencing the clinical outcome, intracanal bonding is particularly effective for fresh VRF teeth and for VRF teeth with little associated periodontal inflammation and bacterial contamination. Sugaya et al. treated 11 VRF teeth with 4-META/MMA-TBB resin bonding through the root canal. Nine of the 11 treated teeth remained functional over a mean follow-up period of 33 months. In another study, Sugaya et al. treated 83 VRF teeth with intracanal 4-META/MMA-TBB resin bonding and discovered more favorable clinical outcomes in the fracture line preparation group than in the non-preparation group. Masaka found that 5 out of 6 VRF teeth treated with intracanal 4-META/ resin bonding remained functional for more than 10 years. The aforementioned findings suggest that bonding VRF teeth with 4-META/MMA-TBB resin through the root canal is a viable alternative treatment modality for VRF teeth. This technique can achieve a favorable clinical outcome if the VRF is detected at a very early stage. VRF 牙齿可以从内部（通过根管）在牙齿原位时进行治疗，也可以在瓣膜反折后暴露断裂线的外部进行治疗，或者在拔牙后的外部进行治疗，或者在牙齿原位时从内部开始，然后在拔牙后从外部进行治疗。 首先，当 VRF 牙齿在牙槽内部进行治疗时，使用超声波设备仔细准备牙冠内部和根管内的断裂线，然后用 4-META/MMA-TBB 树脂密封。由于解剖结构的限制，无法到达整个断裂线，也无法准备并粘合整个断裂线的深度与 4-META/MMA-TBB 树脂。因此，一些细菌可能会残留在断裂间隙中，从而导致治疗失败。为避免细菌因素影响临床结果，根管内粘接对于新鲜的 VRF 牙齿以及伴有少量牙周炎炎症和细菌污染的 VRF 牙齿尤为有效。 Sugaya 等人 用 4-META/MMA-TBB 树脂通过根管对 11 颗 VRF 牙齿进行了治疗。 在平均 33 个月的随访期内，11 颗治疗过的牙齿中有 9 颗保持功能。在另一项研究中，Sugaya 等人治疗了 83 颗 VRF 牙齿，使用根管内 4-META/MMA-TBB 树脂粘结，并发现在裂纹处理组中的临床结果比非处理组更有利。Masaka 发现，使用根管内 4-META/MMA 树脂粘结治疗的 6 颗 VRF 牙齿中有 5 颗在 10 年以上保持功能。上述研究结果表明，通过根管用 4-META/MMA-TBB 树脂粘结 VRF 牙齿是一种可行的替代治疗方式。如果在非常早期发现 VRF，这种技术可以实现有利的临床结果。
Second, when a fractured tooth is treated from the outside after flap reflection, sometimes not all of the fracture lines can be accessed, and this leads to retention of bacteria in the unreached fracture gaps. Furthermore, some of the sound alveolar bone might need to be removed to expose the fracture lines. Thus, in addition to the problem of residual bacteria, the unnecessary removal of healthy periodontal soft and hard tissue might endanger the supporting structure of the VRF tooth, finally resulting in treatment failure. 其次，在瓣膜反射后从外部治疗断裂牙齿时，有时无法接触到所有的裂纹，这导致细菌滞留在未到达的裂纹间隙中。此外，可能需要去除一些健康的牙槽骨以暴露裂纹。因此，除了残留细菌的问题外，不必要地去除健康的牙周软组织和硬组织可能会危及 VRF 牙齿的支持结构，最终导致治疗失败。
Third, when a fractured tooth is treated from the outside after tooth extraction, contaminated dentin and cementum can be thoroughly removed, the entire fracture surfaces can be cleaned and then adhered with 4-META MMA-TBB resin, and the apical root end can also be sealed with 4-META/MMA-TBB resin. The elimination of bacteria, hermetic sealing of the fracture gap and the root end, and the wide surface bonding of the root fragments eventually results in successful clinical outcomes. The 第三，当一颗断裂的牙齿在拔牙后从外部治疗时，可以彻底清除受污染的牙本质和牙骨质，清洁整个断裂表面，然后用 4-META MMA-TBB 树脂粘合，还可以用 4-META/MMA-TBB 树脂封闭根尖。消灭细菌，密封断裂间隙和根尖，以及根部碎片的广泛表面粘合最终导致成功的临床结果。
Figure 3 Clinical and microscopic photographs, periapical radiographs, and CBCT images of Case 3 from Table 1. (A) CBCT image showing the left maxillary second molar with filling material in the apical third of the root canal and a large radiolucent lesion at the periapical area of the first and second molars of a 55 -year-old female patient. (B) After the tooth was accessed, a bucco-palatal fracture line was found. (C) Endodontic treatment was performed for the left maxillary first molar and the fractured second molar. CBCT imaging demonstrated the placement of MTA filling material at the apical third of the root canals of the left maxillary first and second molars. (D-G) The left maxillary second molar was extracted cautiously. The extracted tooth showed discolored MTA at the apical root end. The discolored MTA was removed and the root end was prepared. The prepared apical cavity and the fracture line gap were filled with radiolucent 4-META/MMA-TBB resin. (H) The periapical radiolucent lesion was enucleated and the treated tooth was replanted into the original socket and fixed to the left maxillary first molar, using 4-META/MMA-TBB resin. (I) Periapical radiograph showing the treated tooth in the right position. (J and K) The 35 -month follow-up CBCT image and periapical radiograph, showing the healing of the radiolucent lesion at the periradicular area of the left maxillary first and second molars. 图 3 表 1 中病例 3 的临床和显微镜照片、根尖 X 线片和 CBCT 图像。(A) CBCT 图像显示左侧上颌第二磨牙根管尖端填充物及 55 岁女性患者第一和第二磨牙根尖区大片影。 (B) 打开牙齿后发现颊舌裂纹。 (C) 对左侧上颌第一磨牙和断裂的第二磨牙进行了根管治疗。CBCT 成像显示左侧上颌第一和第二磨牙根管尖端填充 MTA。 (D-G) 小心地拔除左侧上颌第二磨牙。拔除的牙齿显示根尖处变色的 MTA。移除变色的 MTA 并准备根尖。准备的根尖腔和裂纹间隙填充放射透明的 4-META/MMA-TBB 树脂。 (H) 切除根尖区大片影，治疗后的牙齿重新植入原牙槽并用 4-META/MMA-TBB 树脂固定到左侧上颌第一磨牙。 (I) 显示右侧位置处置牙的根尖 X 光片。(J 和 K) 35 个月随访 CBCT 图像和根尖 X 光片，显示左侧上颌第一和第二磨牙根尖区放射透亮病变的愈合。
short-term evaluation of 20 treated VRF teeth in a study using this root fragment bonding therapy revealed a tooth retention rate of after one year and after 2 years. Moreover, a long-term clinical observation study of 26 treated VRF teeth revealed a tooth retention rate of after 3 years and after 5 years. Sugaya et al. found that 9 of 12 VRF teeth treated with this technique remained functional over a mean follow-up period of 22 months. Masaka reported that 24 of 28 VRF teeth treated with this technique were functional for 5 years. All these 使用根部碎片粘接疗法治疗的 20 颗 VRF 牙的短期评估显示，1 年后 的牙齿保留率，2 年后 。此外，对 26 颗接受治疗的 VRF 牙进行的长期临床观察研究显示，3 年后 的牙齿保留率，5 年后 。Sugaya 等人发现，在平均随访期为 22 个月的情况下，使用该技术治疗的 12 颗 VRF 牙中有 9 颗保持功能。Masaka 报告称，使用该技术治疗的 28 颗 VRF 牙中有 24 颗在 5 年内保持功能。
Figure 4 Clinical photographs, periapical radiographs, and CBCT images of Case 4 from Table 1. (A) Clinical photograph showing a sinus tract in the swollen palatal mucosa of the left maxillary second premolar of a 48 -year-old male patient. (B) Initial periapical radiograph showing radiopaque filling material in the apical two-thirds of the root canal, a metal post in the cervical third of the root canal, a suspected bucco-palatal root fracture, and a periradicular radiolucent lesion involving the apical third of the root of the left maxillary second premolar. (C) The tooth was extracted, and two separated tooth fragments with black contaminated dentin at the root canal wall and the gutta-percha points in the root canal were found. (D) The black contaminated dentin at the root canal wall, the gutta-percha points, and part of the metal post were removed. The fractured root fragments were adhered with radiolucent 4META/MMA-TBB resin. The bonded tooth was then inserted back into the original socket. A periapical radiograph taken immediately after replantation showed the treated tooth in the correct position. (E) The treated left maxillary second premolar was covered by a porcelain full jacket crown. (F-H) The 56 -month follow-up periapical radiograph and CBCT images, showing complete remission of the radiolucent lesion at the periapical area of the left maxillary second premolar. 图 4 表 1 中案例 4 的临床照片、根尖 X 线片和 CBCT 图像。(A)临床照片显示 48 岁男性患者左侧上颌第二前磨牙肿胀的腭粘膜中有窦道。 (B)初始根尖 X 线片显示根管尖端两三分之一处有放射性不透明充填物，根管颈部有金属柱，可疑颊腭根部骨折，以及涉及左侧上颌第二前磨牙根尖三分之一处的根尖周放射透亮病变。 (C)拔除牙齿后，在根管壁发现两个分离的牙齿碎片，带有黑色污染的牙本质和根管内的橡胶点。 (D)去除根管壁上的黑色污染牙本质、橡胶点和部分金属柱。断裂的根部碎片用放射透亮的 4META/MMA-TBB 树脂粘合。粘合的牙齿然后插入原牙槽。重新植入后立即拍摄的根尖 X 线片显示治疗后的牙齿位置正确。 （E）治疗过的左侧上颌第二前磨牙覆盖着全瓷冠。 （F-H）56 个月随访期尖牙周围 X 线片和 CBCT 图像显示左侧上颌第二前磨牙根尖区放射透亮病变完全缓解。
findings indicate that this root fragment bonding therapy is a reliable treatment modality for VRF teeth. 研究结果表明，这种根部碎片粘合疗法是治疗 VRF 牙齿的可靠方法。
Fourth, if a tooth has a complicated fracture or further tooth damage may occur during tooth extraction, accessible fracture lines can be prepared and sealed with 4META/MMA-TBB resin through the root canal system, and the remaining tooth space is filled with light-curing composite resin before tooth extraction. After tooth extraction, the untreated fracture lines can be further prepared and sealed with 4-META/MMA-TBB resin and the bonded tooth is then replanted into the original socket. 第四，如果一颗牙齿有复杂的断裂或在拔牙过程中可能会进一步损坏，可以通过根管系统准备和封闭可达的断裂线，并在拔牙前用 4META/MMA-TBB 树脂封闭，剩余的牙齿空间用光固化复合树脂填充。拔牙后，未处理的断裂线可以进一步准备和用 4-META/MMA-TBB 树脂封闭，然后将粘合的牙齿重新植入原始插座。
All four of these treatment modalities have indications and contraindications. are convinced that teeth with fresh VRF and VRF teeth with thick root fragments but without marked root caries and severe periodontal destruction are indications for root fragment bonding therapy. Conversely, VRF teeth with divergent or curved roots that are difficult to extract, VRF teeth in patients with heavy occlusal force or with severe systemic diseases (e.g., diabetes mellitus), and long-term VRF teeth with severe periodontal destruction are contraindications for root fragment bonding therapy. Therefore, application of the most appropriate technique for a precisely selected VRF tooth can lead to a successful clinical outcome. 所有这四种治疗方式都有适应症和禁忌症。 认为，具有新鲜 VRF 和有厚根碎片但没有明显根龋和严重牙周破坏的牙齿适合进行根碎片粘接疗法。相反，VRF 牙齿具有分叉或弯曲根、难以拔除、患有重度咬合力或严重全身性疾病（例如糖尿病）的患者、以及长期 VRF 牙齿伴有严重牙周破坏的情况则不适合进行根碎片粘接疗法。因此，对于精确选择的 VRF 牙齿应用最适当的技术可以带来成功的临床结果。
A meta-analysis study of the role of CBCT in VRF diagnosis revealed that CBCT can achieve higher sensitivity and specificity than periapical radiography in the detection of VRF in unfilled teeth. However, a systematic review performed by Chang et al. demonstrated that there is insufficient evidence to suggest that CBCT is a reliable tool for detecting VRFs in endodontically treated teeth. This study used mainly CBCT for monitoring the 3-dimensional changes in periradicular radiolucency before and after treatment. Compared to periapical radiography, 3-dimensional information on periradicular bone destruction after VRF and on periradicular bone healing around the bonded root can be obtained using CBCT. These data help to elucidate the entire periradicular alveolar bone destruction process after VRF and the periradicular alveolar bone healing process after root fragment bonding therapy. CBCT 在 VRF 诊断中的作用的荟萃分析研究表明，CBCT 可以比根尖 X 线摄影更准确地检测未填充牙齿中的 VRF，具有更高的敏感性和特异性。 然而，Chang 等人进行的系统性回顾 表明，目前没有足够的证据表明 CBCT 是一种可靠的工具，用于检测根管治疗过的牙齿中的 VRF。该研究主要使用 CBCT 来监测治疗前后根尖周围放射透亮度的三维变化。与根尖 X 线摄影相比，CBCT 可以提供有关 VRF 后根尖周围骨质破坏和根部结合治疗后根尖周围骨质愈合的三维信息。这些数据有助于阐明 VRF 后整个根尖周围牙槽骨破坏过程以及根部碎片结合治疗后根尖周围牙槽骨愈合过程。
A recent animal study revealed no cementum-like tissue formation on the 4-META/MMA-TBB resin surface of replanted VRF beagle incisors, with the fracture gap being sealed with 4-META/MMA-TBB resin. Sugaya et al. studied the influence of an enamel matrix derivative (Emdogain, Straumann, MA, USA) on the healing of vertically fractured root surfaces of beagle maxillary premolars treated using intentional replantation and root fragment bonding with 4 META/MMA-TBB resin. They found that the application of the enamel matrix derivative on the bonded root surface was effective in regenerating new cementum and in reducing the incidence of root resorption. Newly generated cementum can help the attachment of periodontal ligament tissue to the root surface, which in turn reduces the depth of the periodontal pocket of the replanted tooth. Inoue et al. reported that bone morphogenetic proteincontaining 4-META/MMA-TBB resin may accelerate the wound healing of damaged pulp tissue. Furthermore, 4 META/MMA-TBB resin is biocompatible with cultured periodontal ligament cells. Thus, Hayashi et al. suggested that bone morphogenetic protein-containing 4-META/MMA TBB resin may also accelerate the regeneration of damaged periodontal tissue when it is used for root fragment bonding therapy for VRF teeth. These findings suggest that the application of an enamel matrix derivative on the bonded root surface or using bone morphogenetic protein- 最近的动物研究显示，再植 VRF 犬门牙 4-META/MMA-TBB 树脂表面上没有类似水泥质组织的形成，骨折间隙被 4-META/MMA-TBB 树脂密封。 Sugaya 等人研究了携带牙本质基质衍生物（Emdogain，Straumann，MA，美国）对经过有意再植和使用 4 META/MMA-TBB 树脂粘接根残片处理的犬上颌前磨牙垂直骨折根面愈合的影响。他们发现，在粘接根面上应用牙本质基质衍生物有助于再生新的水泥质并减少根吸收的发生率。新生成的水泥质可以帮助牙周膜组织附着到根面，从而减少再植牙的牙周袋深度。井上等人报告说，含骨形成蛋白的 4-META/MMA-TBB 树脂可能加速受损牙髓组织的伤口愈合。此外，4 META/MMA-TBB 树脂与培养的牙周膜细胞具有生物相容性。因此，Hayashi 等人。 建议，当用于 VRF 牙的根片粘接治疗时，含有骨形态发生蛋白的 4-META/MMA TBB 树脂也可能加速受损牙周组织的再生。这些发现表明，在粘结根面上应用搪瓷基质衍生物或使用骨形态发生蛋白-
containing 4-META/MMA-TBB resin as an adhesive material for root fragment bonding may have strong potential for improving the prognosis of VRF teeth after root fragment bonding therapy. 含有 4-META/MMA-TBB 树脂作为根片粘接材料的材料可能对改善根片粘接治疗后 VRF 牙的预后具有强大潜力。
This study presented the successful clinical outcomes of 6 complete VRF teeth treated using intentional replantation and root fragment bonding with 4-META/MMA-TBB resin. In addition to periapical radiography, we also used CBCT to observe the periradicular alveolar bone destruction around the fractured root and to monitor the periradicular alveolar bone regeneration after root fragment bonding therapy. Furthermore, the entire root fragment cleaning procedure was performed under a stereomicroscope; thus, the contaminated dentin, cementum, and periodontal ligament tissue could be thoroughly removed. Application of this new cementum-formation-inducing agent on the bonded root surface may be an effective approach to improve the prognosis of VRF teeth treated using root fragment bonding therapy. However, a largescale clinical study is necessary to further verify the efficacy of this new therapeutic approach. We hope to provide a reliable and alternative treatment option for dental practitioners to manage complete VRF teeth because natural teeth are invaluable even if they have VRF. 本研究展示了使用有意移植和 4-META/MMA-TBB 树脂对 6 颗完全 VRF 牙进行治疗的成功临床结果。除了根尖 X 线摄影外，我们还使用 CBCT 观察断裂根周围的根尖周围牙槽骨破坏，并监测根片粘接治疗后的根尖周围牙槽骨再生。此外，整个根片清洁程序是在立体显微镜下进行的；因此，受污染的牙本质、水泥质和牙周韧带组织可以被彻底清除。在粘接根表面上应用这种新的水泥质形成诱导剂可能是改善使用根片粘接治疗的 VRF 牙预后的有效方法。 然而，需要进行大规模临床研究以进一步验证这种新治疗方法的有效性。我们希望为牙科医生提供可靠和替代的治疗选择，以管理完全 VRF 牙，因为即使有 VRF，天然牙也是无价的。
We conclude that for a VRF tooth, in addition to tooth extraction and subsequent restoration of a dental implant, intentional replantation combined with root fragment bonding with 4-META/MMA-TBB resin is a successful treatment modality that can be used to preserve a complete VRF tooth. 我们得出结论，对于 VRF 牙齿，除了拔牙和随后种植牙植入物的修复外，意向性再植结合 4-META/MMA-TBB 树脂粘合根碎片是一种成功的治疗方式，可用于保留完整的 VRF 牙齿。
Conflicts of interest 利益冲突
The authors have no conflicts of interest relevant to this article. 作者在本文中没有相关利益冲突。
Acknowledgements 致谢
This research was partially funded by the Ministry of Science and Technology (MOST), Taiwan, R.O.C (MOST 1072314-B-075-044-). 本研究部分资金支持来自中华民国台湾地区科技部（MOST 1072314-B-075-044-）。
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Corresponding author. Department of Stomatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei, 11217, Taiwan. 通讯作者。台湾台北市北投区石牌路二段 201 号台北榮民總醫院口腔科。
