高角和低角病例的診斷臨床特征及正畸治療特點

高角和低角病例的診斷、臨床特征及正畸治療特點

Highangleandlowanglecases,diagnosis,clinicalfeaturesandorthodontictreatment1整理ppt由于以往的診斷是以安氏分類為主,正畸醫(yī)生常常只注意到矢狀向錯牙合而忽略了垂直向不調(diào)。近年來,學者們逐漸認識到垂直面型在錯畸形診斷和治療中的重要性:它不僅為顱面復合體的生長方向提供了線索,而且直接影響治療的成功與否。PreviousdiagnosiswasbasedonAngle'sclassificationsoorthodontistsoftenonlynoticedthesagittalmalocclusionwhileignoringtheverticaldimension.Inrecentyears,scholarshavecometorealizetheimportanceoftheverticaldimensionsinthediagnosisandtreatmentofmalocclusionitnotonlyprovidescluestothedirectionofgrowthofthecraniofacialcomplex,butalsodirectlyaffectsthesuccessoftreatment.2整理ppt垂直向異常有高角和低角兩種類型,在Ⅲ類安氏錯牙合中約有50%左右的患者存在不同程度的垂直向異常。Verticalanomalyareoftwotypes

of

high-angleand

low

angle,

about

50%of

patientswithangleclassIIImalocclusionhave

varyingdegreesofabnormal

verticaldimensionhigh-angle

and

low

anglecases,

diagnosis,clinicalfeatures,

andorthodontictreatment3整理ppt一、高角病例和低角病例的診斷和形成機制

Highangleandlowanglecasesdiagnosisandform文獻中用來描述垂直向異常的說法很多,常用的有開張面型(hyperdivergent)、向后旋轉(zhuǎn)型(backwardrotation)、垂直生長型(verticaltype)、長面型(dolichocephalic)、高角型(high-angleface),均指垂直向異常以發(fā)育過度(verticalexcessive)為主,而聚合面型(hypodivergent)、向前旋轉(zhuǎn)型(forwardrotation)、水平生長型(horizontaltype)、短面型(brachypechalic)、低角型(low-angleface)則是指垂直發(fā)育不足(verticaldeficiency)。由于診斷標準和側重點不同,從嚴格意義上講,這些概念之間是有差異的,但在臨床中描述垂直面型時經(jīng)常通用。Diagnosticcriteriaandadifferentfocus,inthestrictsense,theseconceptsthereisadifference,butoftencommonintheclinicaldescriptionofverticaltype.4整理ppt高角病例和低角病例的診斷和形成機制Highangleandlowanglecasesdiagnosisandform本文中統(tǒng)稱為高角和低角,但不能誤解為下頜平面角大者即為高角型、小者即為低角型,這是因為下頜角和下頜下緣在生長改建過程中變化較大,所以單純以下頜平面角作為診斷標準可能掩蓋了下頜真實的旋轉(zhuǎn)方向,對垂直面型的正確診斷還應結合其他指標。

Referredtoarticleas

high-angle

andlow

angle,shouldnotbeconfusewiththemandibular

planeangle,ifitishigh,called

highanglecase,andifsmallthanlowanglecase.Because

themandibularangleandmandibularmarginchangeswithgrowth,sosimple

mandibularplaneangle

as

the

diagnosticcriteria

maymaskthe

true

mandibular

rotationanddirectionofthe

vertical

growth.Thecorrect

diagnosis

shouldbe

combinedwith

otherindicators5整理ppt目前常用的診斷標準是:

Thecommonlyuseddiagnosticcriteriaare:(1)下頜平面角Mandibularplaneangle:高角病例前顱底—下頜平面角(SN-MP)大于40°,FH平面—下頜平面角(FH-MP)大于32°;低角病例SN-MP小于29°,FH-MP小于22°。(2)后面高與前面高比值anteriortotheposteriorfacialheightratio(S-Go/N-Me):高角病例大于68%;低角病例小于62%。(3)下前面高與前面高比值lowertotheupperfacialheightratio(ANS-Me/N-Me):高角病例大于58%;低角病例小于55%。6整理ppt高角病例或低角病例的形成主要與前后面部高度的生長發(fā)育失調(diào)有關。

high-angle

or

low

angle

cases

with

ahighlevelof

growthanddevelopmentbeforeandafterfacialdisorders后面部高度生長不足(升支短小、關節(jié)窩靠前靠上)和/或前面部高度生長過度(髁突向后生長、上頜骨垂直發(fā)育過度、后牙垂直萌出過度)形成了高角型。Lackofposteriorfacial

growth(ascendingbranchof

the

glenoidfossasmall

)and/or

anteriorfacialheightovergrowth(condylarbackwardgrowth,excessiveeruptionofthemaxillaryposteriorteeth)isresponsibleforahigh-anglecase.后面部高度生長過度(升支較長、關節(jié)窩靠后靠下)和/或前面部高度生長不足(髁突向上向前生長、上頜骨垂直發(fā)育不足、后牙萌出不足)形成了低角型。posteriorheight

overgrowth(theascendingbranchof

a

glenoidfossa

long)

and/or

inlackofposterior

facialgrowth

(upwardandforwardrotationofcondyle,lackoferuptionofmaxillaryposteriorteeth)isresposibleforlow-anglecase.7整理ppt二、高角病例和低角病例的臨床特征

Thecaseofhigh-angleandlowangleoftheclinicalfeatures1、面型:正面觀高角病例多為窄長臉型,兩側下頜角不明顯,鼻根部較窄,常伴有唇功能不足、開唇露齒;

低角病例則多為寬短臉型,兩側下頜角呈方形,鼻根部較寬,唇閉合十分自然。8整理ppt9clinicalfeaturesofhigh-angleandlowanglecases

A

face:

frontview:

High-angle:

longandnarrow

face,bothsidesof

themandibularangle

isnotdistinct,

the

nasionis

narrow,

oftenaccompaniedwithincompetentlip.

Low-anglecases

aremuchmore

wide

and

short

face.

Bothsidesofthe

mandibularangle

wasasquare,

nasion

iswide,lipclosureisnormal9整理ppt側面觀Lateralview:

高角病例呈開張面型,面下1/3長,凹面型多見,上唇較厚,頦部和頦唇溝均不明顯,頭位略前伸;Highanglecases,lengthofthelower1/3ofthefaceislong,theconcavetypeprofilemorecommon,thickupperlip,chinandchinlipgroovearenotprominent.

低角病例呈聚合面型,面下1/3段短,凸面型多見,上唇較薄,頦部和頦唇溝明顯。low-anglecasesthelower1/3ofthefacegenerallyshorterconvexfacialprofile,thinupperlip,chinandchinlipgrooveareprominent.10整理ppt二、高角病例和低角病例的臨床特征

Thecaseofhigh-angleandlowangleoftheclinicalfeatures2、牙Tooth:高角病例常見上牙弓狹窄、腭蓋高拱,由于切牙多唇向傾斜前牙擁擠較少見,前牙覆淺甚至呈現(xiàn)開或開傾向,后牙的臨床冠高度較大,曲線平坦甚或反向,上下頜之間的息止間隙較小;

Highanglecases:-narrowupperarch

withdeeperhardpalate,

anteriorproclinationisrarelyseen.

theheightofclinicalcrownlarger,

thecurveofspee

is

flat

andtheanglebetweenthefacialaxisofupperandlowerincisorisless.11整理pptclinicalfeaturesofhigh-angleandlowanglecases

Teeth:低角病例上牙弓較寬闊,切牙位置較直立故前牙擁擠多見,前牙覆較深甚至呈閉鎖,后牙的臨床冠較短,Spee曲線深、曲度較大,息止間隙較大。伴有吐舌習慣的高度病例根尖片常可見恒中切牙牙根明顯變短。Lowanglecases:-broadupperarchwithshallowhardpalate,the

incisor

position

is

moreupright

soanteriorteeth

crowdingiscommon.clinicalcrownissmaller.Curveofspeeisdeep.anglebetweenlongaxisofupperandlowerincisorishigh

1212整理ppt牙弓狹窄、腭蓋高拱高角病例低角病例上牙弓較寬闊13整理ppt二、高角病例和低角病例的臨床特征

Thecaseofhigh-angleandlowangleoftheclinicalfeatures3、硬組織顱面形態(tài):

高角病例的腭平面、牙合平面和下頜平面向下傾斜,下頜角鈍,下頜下緣彎曲,磨牙與平面角度傾斜,上下前牙唇向傾斜,上下中切牙角較小

high-anglecase:-thepalatalplane,occlusalplaneandmandibularplaneislow,angleofmandibleislarge,curvedmandibularlowermargin,slightlyproclinedupperandloweranteriorteeth.Anglebeteenlongaxisofupperandlowerincisorissmall.14整理ppt低角病例腭平面、牙合平面和下頜平面接近平行,下頜角呈直角,下頜下緣平緩,下頜管彎曲,前牙直立,上下中切牙角較大thepalatalplane,occlusalplaneandmandibularplanenearlyparalleltotheangleofmandibularperpendiculartotheflatedgeunderthelowerjaw.Anglebetweenlongaxisofupperandlowerincisorislarge.15整理ppt二、高角病例和低角病例的臨床特征

Thecaseofhigh-angleandlowangleoftheclinicalfeatures4、軟組織和氣道:低角病例面型較凸,軟組織較薄以緩解側貌中下頜外形明顯。Softtissueandairway:

Low-anglecasesfaceisconvex,softtissuethintoalleviateandjawshapeiseasilypalpated.16整理ppt高角病例上下唇長度大于低角病例,以補償唇閉合不良。高角病例舌位向下向后,軟腭向后傾斜,氣道在鼻咽和口咽處較窄。High-anglecases,lowerliplengthisgreaterthanthelow-anglecases,adversetocompensateforlipclosure.Casesofhigh-anglepositionofthetonguebackdown,softpalate,tiltedback,theairwayinthenasopharynxandoropharynxnarrow.17整理ppt二、高角病例和低角病例的臨床特征

Thecaseofhigh-angleandlowangleoftheclinicalfeatures5、口頜系統(tǒng)功能Stomatognathicsystemfunction:高角病例口頜功能較弱,主要表現(xiàn)在咀嚼肌肌力小、口周肌張力低下,力較小,由于正中位和正中關系位之間前后距離較大,下頜的運動以水平向為主;Highanglecasesstomatognathicfunctionisweak,mainlyinthemasticatorymusclestrengthissmall,perioralhypotonia,asmallerforce.thedifferencebetweencentricocclusionandcentricrelationislarger,lowerjawmovementmainlyonhorizontaldirection.低角病例口頜功能較強,咀嚼肌肌力大,力亦大,正中自由度小,下頜以垂直運動為主。

Low-anglecasesStomatognathicpowerfulchewingmusclestrength,force,themiddleofdegreesoffreedomissmall,lowerjawmovementmainlyonverticaldirection18整理ppt三、正畸治療特點

Orthodontictreatmentcharacteristics高角病例和低角病例不僅在形態(tài)和功能上存在差異,對正畸治療的反應也截然不同,這可能與二者下頜骨骨密度不同有關high-angleandlowanglecases,therearedifferencesnotonlyintheformandfunction,butlasoinresponsetoorthodontictreatment,theremaybedifferentinmineralcontentofthetwomandibularbone.

高角病例下頜骨骨密度低,對施加于牙齒上的力量更敏感,牙齒移動速度較快High-anglecasesofmandibularbonemineraldensityislow,theforceimposedontheteethmoresensitive,fastertoothmovement;

低角病例下頜骨密度較高,對矯治力不敏感Thecasesofjawbonedensityoflow-anglehigh,isnotsensitivetotheorthodonticforce。

19整理ppt1、正畸治療的時機

Thetimingoforthodontictreatment:

由于高角病例比低角病例青春迸發(fā)期出現(xiàn)早,所以高角病例的矯治年齡較低角病例小。在青春迸發(fā)期開始之前對高角病例進行垂直向控制,可以減緩或抑制下頜的向下向后旋轉(zhuǎn),應提倡早期治療,最好是在頜骨和牙槽骨垂直生長活躍期。Duetothehighincidenceofhigh-anglecasesthanthelow-anglecase,highanglecasesaretreatedearlierthanlowanglecases.verticalgrowthshouldbecontrolbeforetheincidenceincaseofhighanglecase.highanglecaserequiredearlytreatment,preferablyintheactiveperiodoftheverticalgrowthofthemandibleandalveolarbone

而低角病例相反,可等到生長快速期末開始治療。但如果骨骼畸形比較嚴重,通過生長改建及牙齒代償不能達到矯治目的,需成年后手術治療者則應等到生長發(fā)育基本停止后進行治療。

Onthecontrary,low-anglecasescanwaituntilthecessationofgrowthspurt.Ifskeletaldeformitiesmoreserious,thecorrectioncannotbeachievedthroughthegrowthalterationsandteetheruption.surgicaltreatmentshouldwaituntiltherequiredadultgrowthanddevelopmentbasicallystopped.20整理ppt2、早期矯治Earlytreatment:

對存在功能因素的高角病例或低角病例,應結合病因治療及肌功能訓練。Shouldbecombinationofremovalofthecausemusclefunctiontraining

替牙期存在嚴重擁擠時,高角病例不宜草率實施序列拔牙,因為牙齒較早拔除,不利于嚼肌功能,使咀嚼肌得不到充分的鍛煉,后牙更易伸長,應拖延至活躍生長減速后裝置固定矯治器時再拔牙

DuringmixedDentitionperiod,existenceofseverecrowding,thehigh-anglecasesshouldnotbehastyimplementationserialextraction,becausetheearlierremovalofteethisnotconducivetomassetermusclefunction.Serialextractionshouldbedelayeduntilactivegrowthdeceleration;

21整理ppt

低角病例則可適當進行序列拔牙,利用牙齒自然生長的力量關閉間隙、解除擁擠,矯治高角病例的功能矯治器應是抑制后牙伸長的后牙牙合墊、口外唇弓或FR—IV型矯治器;而多數(shù)能促進后牙伸長的功能矯治器,如Activator,適用于低角病例。Low-anglecasescanbeappropriatefortheserialextraction,teethhasthenaturalgrowthpowertoclosethegap,andrelievecongestion.Forthecorrectionofhigh-anglecases,functionalappliancewhichinhibittootheruptionisusedlikeextraorallipboworFR-IVthetypeofappliance;functionalappliancewhichpromotetootheruption,suchastheActivator,applytolow-anglecases.FR—IV型矯治器22整理ppt

擴弓矯治器使A點向前向下移動、上頜位置改變,肯定會導致下頜向后向下旋轉(zhuǎn),減小了下頜的有效長度,增加下面部的垂直高度,故不適用于高角病例。Expansionarchapplianceallowsmaxillatomoveforwardanddownwardthatwillcertainlyleadtothelowerjawbackwardanddownwardrotation,reducingtheeffectivelengthofthelowerjaw,increasingtheverticaldimension.itdoesnotapplytohigh-anglecases..23整理ppt口外弓的使用可阻止A點前移,使腭平面向下傾斜,口外力的方向可影響下頜的旋轉(zhuǎn)方向,如口外力向下向后(頸牽引),可使牙齒伸長,下頜順時針旋轉(zhuǎn);方向向上向后,即高位牽引,牙齒壓低,減小順時針旋轉(zhuǎn),甚至增加逆時針旋轉(zhuǎn),由于磨牙區(qū)生長減小使髁突生長得以表達,適用于高角病例。TheuseofthefacebowtopreventthepointAtomoveforward,palatalplanetoinclineddownward,thedirectionofextraoralforcecanaffectthedirectionofrotationofthemandible,suchasbackwardanddownwardextraoralforce(cervicaltraction),maypreventtoothelongation,mandibularclockwiserotation;i.e.Hightractionpreventteetheruption,reducetheclockwiserotation,oreventoincreasecounter-clockwiserotationduetothegrowthofthemolarareatoreducethecondoylegrowthtobeexpressed,forhigh-anglecases.24整理ppt

低角病例使用頸牽引以刺激齒槽突的垂直向生長,有利于面型的改善。垂直牽引頦兜的使用可以通過保持頦的位置或使頦向上影響面下部的垂直高度,還可使力傳導作用于牙周膜、延緩后牙的萌出,所以適合不希望下頜順時針旋轉(zhuǎn)的高角病例。

Low-anglecasescervicaltractiontostimulatealveolarsuddenverticalgrowthisconducivetotheimprovementoftheface.Theuseofverticaltractionchincupcanmaintainthepositionofthechinorverticalheightofthelowerface,butalsotheroleofhydraulicconductivityintheperiodontalligament,delayingtheerupti