第9章咬合治疗(二)(双语)

正畸和正颌治疗中的牙合学问题Occlusionstudyinorthodonticsandorthognathictreatment咬合治疗(二)Twoupperfirstpremolarswereextractedtocorrectopenbite,butafterthetreatmentTMDappeared.CASE患者为年轻女性，开牙合伴有吐舌习惯。拔除上颌两个第一双尖牙后，术后良好矫正结束后，外科拔除了下颌第三磨牙，之后出现关节症状，保持期后，症状加重。Ayoungfemalewithopenbite+tonguethrust.Extractedtwoupperfirstpremolarstocorrectheropenbite,andafterthetreatment,thepatient’socclusalrelationshipbecamenormal.Afterthetreatment,thepatient’slowerthirdmolarswerepulledoutbyasurgeon,thenshepresentedwithTMD,andthesymptomwasaggravatedafterretainment.病人起诉外科医生，要求赔偿2500美元。法官最终认为是正畸医生内收上前牙迫使下颌后退造成关节病，判决赔偿一百万美元。Thepatientprosecutedthesurgeontocompensatefor$2500.ThejudgefinallyconsideredthatTMDwascausedbytheorthodontist,whomovedanteriorteethpalatallyandthenledtotheretrognathismofmandible,andsentencedhimtopay$1,000,000.颞下颌关节紊乱症TMD100万美元正畸治疗Orthodontictreatment错牙合畸形的致病机制牙合的稳定依赖于肌肉，关节，牙齿三者的平衡，任何打破这一平衡，都有可能导致咀嚼系统问题的发生。Theocclusiondependsonthemuscle,jointandteeth,anyoneinwrongwillleadtothesystembroken.与TMD的发生有明显关系的特征性错牙合Characteristicmalocclusions1.个别牙错位2.深覆牙合，深覆盖3.前牙反牙合4.单侧后牙反牙合MalpositioninindividualteethDeepoverjetandoverbiteAnteriorteethcrossbiteUnilateralcrossbite深覆牙合DeepOverbite深覆盖DeepOverjet反牙合Crossbite正畸中的牙合学Theocclusionduringorthodontictreatment正畸治疗是牙位置的改变，也是咀嚼系统的重建过程，因此，需注意任何可能的诱因。Orthodontictreatmentistoothmovement,asyouknow,isalsoarebuildingprogressofmasticationsystemtherefore,payattentiontoanypossiblereaseson.初诊Firstvisit牙列拥挤前牙对刃DentitioncrowdingAnteriorteethedgetoedge通过X线检查颞下颌关节ExaminingTMJthroughX-ray排齐和整平Alignmentandlevelinga.拉尖牙向远中Pullingcaninedistallyb.关闭前牙间隙Closingspaceatanteriorregion上切牙内收Upperincisorsmovingpalatally若上下前牙成比例后移，基本可以维持正常的盘突关系。但若上切牙内收过度下颌强迫后退,髁突相对的后退,疼痛、弹响。Ifupperandloweranteriorteethmoveposteriorlyproportioned,thenormalTMJwillbemaintained.Ifupperanteriorteethmovingtoopalatallyforcingmandibularsetback,therelativesetbackofcondyle,painandTMJsounds.颌间牵引IntermaxillarytractionII类牵引:髁突向前下方关节盘随之移位。III类牵引:髁突向后上方压迫盘后区。医生对颌间牵引的患者，在每次复查时应当检查关节，不应只关注牙齿。ClassIItractioncondylemovingforwarddisplacementofdisk.ClassIIItractioncondylemovingbackwardputtingpressureonposteriorregionofdisk.OrthodontistshouldexaminenotonlytheteethbutalsotheTMJduringfurtherconsultations.颌间高度的控制Controlofintermaxillaryheight下颌向前向后旋转都会引起盘突关系的相对改变。颌间高度减小下颌逆时针旋转髁突相对关节盘后移,弹响。Mandibularrotation,backwardorforward,willleadtotherelativealterationofTMJ.IntermaxillaryheightreducingmadibularcounterclockwiserotationcondylemovingbackwardTMJsounds.3.精细调整fineadjustment治疗后Post-treatment牙合的六项标准Sixkeystonormalocclusion治疗中以下情况需注意Followingsituationsshouldbepaidattentionduringtreatment1.牙合平面2.上切牙内收3.颌间牵引4.颌间高度的控制5.牙合创伤OcclusalcurveAdductionoftheupperincisorsIntermaxillarytractionControloftheintermaxillaryheightOcclusaltrauma治疗中处理Managements牙合干扰处理：调牙合ＴＭＤ症状处理：暂停治疗、消除症状OcclusalinterferencesManagement:adjustingocclusionTMDsymptomsManagement:postponingordiscontinuingtreatment,eliminatingsymptoms对咀嚼系统功能影响较大的正畸治疗因素Majorfactors矫治时机施加力量牙合的改变后牙咬合TreatmenttimeForceOcclusalchangesPosteriorocclusion1.矫治时机上下颌骨存在骨性不调,希望进行功能矫形治疗时,一定要检测患者的生长发育情况。Ifskeletaldiscrepancyisshownandthefunctionaltreatmentiswanted,makingsuretoexaminethepatient’sgrowthanddevelopment.2.施加力量III类颌间牵引力过大下颌后移过多关节区疼痛。II类颌间牵引力过大继发下颌髁突后移位关节症状。局部牙齿用力不当牙合创伤。ForceClassIIIIntermaxillarytractionforceistooheavymandiblemoveposteriorlytoomuch,painofthejoint.ClassIIintermaxillarytractionforceistooheavysecondaryposteriordisplacementofcondylejointsymptoms.Forceofpartialteethisinappropriateocclusaltrauma.3.牙合的改变：正畸治疗牙移动过程中可能有早接触。病人配合不好。长期使用过高合垫髁突发生代偿性前移。重度错位牙，严重的牙合干扰。矫治不当，形成早接触。Occlusalchanges:Theremaybeprematurecontactswhenmovingteethduringtreatment.Patientsdon’tfollowthedoctor’sadvice.Utilizingoverhighocclusalsplintforalongtimeanteriorcondyledisplacementwithcompensatory.Severemalposedtooth,severeocclusalinterference.Prematurecontactsbyinappropriatetreatment.4.后牙咬合Posteriorocclusion只重前牙美观，忽略后牙咬合，可能会出现后牙区合创伤或干扰。Posteriorocclusaltraumaorocclusalinterferencemayappearifonlypayingattentiontoanterioraestheticbutignoringposteriorocclusion.5.治疗目标和谐的功能统一。不但是正中，还有侧位和前伸。Thebesttargetisharmonyinthreesituation.6.调牙合调牙合是最后的抉择。Theadjustingofocclusionisfinalstep.常见问题一、正畸治疗与TMD的关系Post-TreatmentandTMD大量研究趋向于：接受正畸治疗与未接受群体比较，TMD症状与体征无明显差别。青春期的正畸治疗不会增加或减少日后产生TMD的机率。LotsofstudiesinclinetoacceptthatthereisnosignificantdifferencesinTMDsymptombetweenthetreatmentgroupandtnenon-treatmentone.TheadolescentorthodontictreatmentwillnotincreaseordecreasethepossibilityofTMD.二、拔牙治疗与TMD的关系Teeth-extractedandTMD焦点：担心前磨牙拔除后，前牙内收过度，造成下颌后移，以致髁突后移。调查研究：拔牙组与不拔牙组，弹响发生率均下降。认为：弹响的发生与拔牙发生与否无关。Focus:Afterpremolarsareextracted,anteriorteethwillmovetoopalatally,whichconsequentlycausingthesetbackofmandibleandthepost-displacementofcondyle.Investigations:theprevalenceratesofTMDsoundsbothdeclinedinextractedgroupandnon-extractedone.Conclusion:TMDsoundshavenothingtodowithteeth-extractedornot.三、正畸治疗对髁突位置的影响Treatmentandpositionofcondyle正畸治疗后髁突的位置有一定改变，但不一定会导致TMD。Thepositionofcondylewillchangetosomeextentaftertreatment,butwhetherT