高角和低角病例的診斷臨床特征及正畸治療特點(diǎn)

高角和低角病例的診斷、臨床特征及正畸治療特點(diǎn)

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(cuò)牙合而忽略了垂直向不調(diào)。近年來(lái),學(xué)者們逐漸認(rèn)識(shí)到垂直面型在錯(cuò)畸形診斷和治療中的重要性:它不僅為顱面復(fù)合體的生長(zhǎng)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(cuò)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(jī)制

Highangleandlowanglecasesdiagnosisandform文獻(xiàn)中用來(lái)描述垂直向異常的說(shuō)法很多,常用的有開張面型(hyperdivergent)、向后旋轉(zhuǎn)型(backwardrotation)、垂直生長(zhǎng)型(verticaltype)、長(zhǎng)面型(dolichocephalic)、高角型(high-angleface),均指垂直向異常以發(fā)育過(guò)度(verticalexcessive)為主,而聚合面型(hypodivergent)、向前旋轉(zhuǎn)型(forwardrotation)、水平生長(zhǎng)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(biāo)準(zhǔn)和側(cè)重點(diǎn)不同,從嚴(yán)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(shí)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(jī)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?yàn)橄骂M角和下頜下緣在生長(zhǎng)改建過(guò)程中變化較大,所以單純以下頜平面角作為診斷標(biāo)準(zhǔn)可能掩蓋了下頜真實(shí)的旋轉(zhuǎn)方向,對(duì)垂直面型的正確診斷還應(yīng)結(jié)合其他指標(biāo)。

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(biāo)準(zhǔn)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(zhǎng)發(fā)育失調(diào)有關(guān)。

high-angle

or

low

angle

cases

with

ahighlevelof

growthanddevelopmentbeforeandafterfacialdisorders后面部高度生長(zhǎng)不足(升支短小、關(guān)節(jié)窩靠前靠上)和/或前面部高度生長(zhǎng)過(guò)度(髁突向后生長(zhǎng)、上頜骨垂直發(fā)育過(guò)度、后牙垂直萌出過(guò)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(zhǎng)過(guò)度(升支較長(zhǎng)、關(guān)節(jié)窩靠后靠下)和/或前面部高度生長(zhǎng)不足(髁突向上向前生長(zhǎng)、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(zhǎng)臉型,兩側(cè)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(cè)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(cè)面觀Lateralview:

高角病例呈開張面型,面下1/3長(zhǎng),凹面型多見(jiàn),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(jiàn),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(jiàn)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(jiàn),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(jiàn),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(xí)慣的高度病例根尖片常可見(jiàn)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(cè)貌中下頜外形明顯。Softtissueandairway:

Low-anglecasesfaceisconvex,softtissuethintoalleviateandjawshapeiseasilypalpated.16整理ppt高角病例上下唇長(zhǎng)度大于低角病例,以補(bǔ)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(guān)系位之間前后距離較大,下頜的運(yùn)動(dòng)以水平向?yàn)橹?Highanglecasesstomatognathicfunctionisweak,mainlyinthemasticatorymusclestrengthissmall,perioralhypotonia,asmallerforce.thedifferencebetweencentricocclusionandcentricrelationislarger,lowerjawmovementmainlyonhorizontaldirection.低角病例口頜功能較強(qiáng),咀嚼肌肌力大,力亦大,正中自由度小,下頜以垂直運(yùn)動(dòng)為主。

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

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(duì)正畸治療的反應(yīng)也截然不同,這可能與二者下頜骨骨密度不同有關(guān)high-angleandlowanglecases,therearedifferencesnotonlyintheformandfunction,butlasoinresponsetoorthodontictreatment,theremaybedifferentinmineralcontentofthetwomandibularbone.

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

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

19整理ppt1、正畸治療的時(shí)機(jī)

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(duì)高角病例進(jìn)行垂直向控制,可以減緩或抑制下頜的向下向后旋轉(zhuǎn),應(yīng)提倡早期治療,最好是在頜骨和牙槽骨垂直生長(zhǎng)活躍期。Duetothehighincidenceofhigh-anglecasesthanthelow-anglecase,highanglecasesaretreatedearlierthanlowanglecases.verticalgrowthshouldbecontrolbeforetheincidenceincaseofhighanglecase.highanglecaserequiredearlytreatment,preferablyintheactiveperiodoftheverticalgrowthofthemandibleandalveolarbone

而低角病例相反,可等到生長(zhǎng)快速期末開始治療。但如果骨骼畸形比較嚴(yán)重,通過(guò)生長(zhǎng)改建及牙齒代償不能達(dá)到矯治目的,需成年后手術(shù)治療者則應(yīng)等到生長(zhǎng)發(fā)育基本停止后進(jìn)行治療。

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

對(duì)存在功能因素的高角病例或低角病例,應(yīng)結(jié)合病因治療及肌功能訓(xùn)練。Shouldbecombinationofremovalofthecausemusclefunctiontraining

替牙期存在嚴(yán)重?fù)頂D時(shí),高角病例不宜草率實(shí)施序列拔牙,因?yàn)檠例X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(zhǎng),應(yīng)拖延至活躍生長(zhǎng)減速后裝置固定矯治器時(shí)再拔牙

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

21整理ppt

低角病例則可適當(dāng)進(jìn)行序列拔牙,利用牙齒自然生長(zhǎng)的力量關(guān)閉間隙、解除擁擠,矯治高角病例的功能矯治器應(yīng)是抑制后牙伸長(zhǎng)的后牙牙合墊、口外唇弓或FR—IV型矯治器;而多數(shù)能促進(jìn)后牙伸長(zhǎng)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(kuò)弓矯治器使A點(diǎn)向前向下移動(dòng)、上頜位置改變,肯定會(huì)導(dǎo)致下頜向后向下旋轉(zhuǎn),減小了下頜的有效長(zhǎng)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(diǎn)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(zhǎng),下頜順時(shí)針旋轉(zhuǎn);方向向上向后,即高位牽引,牙齒壓低,減小順時(shí)針旋轉(zhuǎn),甚至增加逆時(shí)針旋轉(zhuǎn),由于磨牙區(qū)生長(zhǎng)減小使髁突生長(zhǎng)得以表達(dá),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(zhǎng),有利于面型的改善。垂直牽引頦兜的使用可以通過(guò)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(dǎo)作用于牙周膜、延緩后牙的萌出,所以適合不希望下頜順時(shí)針旋轉(zhuǎn)的高角病例。

Low-anglecasescervicaltractiontostimulatealveolarsuddenverticalgrowthisconducivetotheimprovementoftheface.Theuseofverticaltractionchincupcanmaintainthepositionofthechinorverticalheightofthelowerface,butalsotheroleofhydraulicconductivityintheperiodontalligament,delayingtheerupti