（医学课件）高角和低角病例的诊断、临床特征及正畸治疗特点

高角和低角病例的诊断 临床特征及正畸治疗特点Highangleandlowanglecases diagnosis clinicalfeaturesandorthodontictreatment 1 由于以往的诊断是以安氏分类为主 正畸医生常常只注意到矢状向错牙合而忽略了垂直向不调 近年来 学者们逐渐认识到垂直面型在错畸形诊断和治疗中的重要性 它不仅为颅面复合体的生长方向提供了线索 而且直接影响治疗的成功与否 PreviousdiagnosiswasbasedonAngle sclassificationsoorthodontistsoftenonlynoticedthesagittalmalocclusionwhileignoringtheverticaldimension Inrecentyears scholarshavecometorealizetheimportanceoftheverticaldimensionsinthediagnosisandtreatmentofmalocclusionitnotonlyprovidescluestothedirectionofgrowthofthecraniofacialcomplex butalsodirectlyaffectsthesuccessoftreatment 2 垂直向异常有高角和低角两种类型 在 类安氏错牙合中约有50 左右的患者存在不同程度的垂直向异常 Verticalanomalyareoftwotypesofhigh angleandlowangle about50 ofpatientswithangleclassIIImalocclusionhavevaryingdegreesofabnormalverticaldimensionhigh angleandlowanglecases diagnosis clinicalfeatures andorthodontictreatment 3 一 高角病例和低角病例的诊断和形成机制Highangleandlowanglecasesdiagnosisandform 文献中用来描述垂直向异常的说法很多 常用的有开张面型 hyperdivergent 向后旋转型 backwardrotation 垂直生长型 verticaltype 长面型 dolichocephalic 高角型 high angleface 均指垂直向异常以发育过度 verticalexcessive 为主 而聚合面型 hypodivergent 向前旋转型 forwardrotation 水平生长型 horizontaltype 短面型 brachypechalic 低角型 low angleface 则是指垂直发育不足 verticaldeficiency 由于诊断标准和侧重点不同 从严格意义上讲 这些概念之间是有差异的 但在临床中描述垂直面型时经常通用 Diagnosticcriteriaandadifferentfocus inthestrictsense theseconceptsthereisadifference butoftencommonintheclinicaldescriptionofverticaltype 4 高角病例和低角病例的诊断和形成机制Highangleandlowanglecasesdiagnosisandform 本文中统称为高角和低角 但不能误解为下颌平面角大者即为高角型 小者即为低角型 这是因为下颌角和下颌下缘在生长改建过程中变化较大 所以单纯以下颌平面角作为诊断标准可能掩盖了下颌真实的旋转方向 对垂直面型的正确诊断还应结合其他指标 Referredtoarticleashigh angleandlowangle shouldnotbeconfusewiththemandibularplaneangle ifitishigh calledhighanglecase andifsmallthanlowanglecase Becausethemandibularangleandmandibularmarginchangeswithgrowth sosimplemandibularplaneangleasthediagnosticcriteriamaymaskthetruemandibularrotationanddirectionoftheverticalgrowth Thecorrectdiagnosisshouldbecombinedwithotherindicators 5 目前常用的诊断标准是 Thecommonlyuseddiagnosticcriteriaare 1 下颌平面角Mandibularplaneangle 高角病例前颅底 下颌平面角 SN MP 大于40 FH平面 下颌平面角 FH MP 大于32 低角病例SN MP小于29 FH MP小于22 2 后面高与前面高比值anteriortotheposteriorfacialheightratio S Go N Me 高角病例大于68 低角病例小于62 3 下前面高与前面高比值lowertotheupperfacialheightratio ANS Me N Me 高角病例大于58 低角病例小于55 6 高角病例或低角病例的形成主要与前后面部高度的生长发育失调有关 high angleorlowanglecaseswithahighlevelofgrowthanddevelopmentbeforeandafterfacialdisorders后面部高度生长不足 升支短小 关节窝靠前靠上 和 或前面部高度生长过度 髁突向后生长 上颌骨垂直发育过度 后牙垂直萌出过度 形成了高角型 Lackofposteriorfacialgrowth ascendingbranchoftheglenoidfossasmall and oranteriorfacialheightovergrowth condylarbackwardgrowth excessiveeruptionofthemaxillaryposteriorteeth isresponsibleforahigh anglecase 后面部高度生长过度 升支较长 关节窝靠后靠下 和 或前面部高度生长不足 髁突向上向前生长 上颌骨垂直发育不足 后牙萌出不足 形成了低角型 posteriorheightovergrowth theascendingbranchofaglenoidfossalong and orinlackofposteriorfacialgrowth upwardandforwardrotationofcondyle lackoferuptionofmaxillaryposteriorteeth isresposibleforlow anglecase 7 二 高角病例和低角病例的临床特征Thecaseofhigh angleandlowangleoftheclinicalfeatures 1 面型 正面观高角病例多为窄长脸型 两侧下颌角不明显 鼻根部较窄 常伴有唇功能不足 开唇露齿 低角病例则多为宽短脸型 两侧下颌角呈方形 鼻根部较宽 唇闭合十分自然 8 9 clinicalfeaturesofhigh angleandlowanglecases Aface frontview High angle longandnarrowface bothsidesofthemandibularangleisnotdistinct thenasionisnarrow oftenaccompaniedwithincompetentlip Low anglecasesaremuchmorewideandshortface Bothsidesofthemandibularanglewasasquare nasioniswide lipclosureisnormal 9 侧面观Lateralview 高角病例呈开张面型 面下1 3长 凹面型多见 上唇较厚 颏部和颏唇沟均不明显 头位略前伸 Highanglecases lengthofthelower1 3ofthefaceislong theconcavetypeprofilemorecommon thickupperlip chinandchinlipgroovearenotprominent 低角病例呈聚合面型 面下1 3段短 凸面型多见 上唇较薄 颏部和颏唇沟明显 low anglecasesthelower1 3ofthefacegenerallyshorterconvexfacialprofile thinupperlip chinandchinlipgrooveareprominent 10 二 高角病例和低角病例的临床特征Thecaseofhigh angleandlowangleoftheclinicalfeatures 2 牙Tooth 高角病例常见上牙弓狭窄 腭盖高拱 由于切牙多唇向倾斜前牙拥挤较少见 前牙覆浅甚至呈现开或开倾向 后牙的临床冠高度较大 曲线平坦甚或反向 上下颌之间的息止间隙较小 Highanglecases narrowupperarchwithdeeperhardpalate anteriorproclinationisrarelyseen theheightofclinicalcrownlarger thecurveofspeeisflatandtheanglebetweenthefacialaxisofupperandlowerincisorisless 11 clinicalfeaturesofhigh angleandlowanglecases Teeth 低角病例上牙弓较宽阔 切牙位置较直立故前牙拥挤多见 前牙覆较深甚至呈闭锁 后牙的临床冠较短 Spee曲线深 曲度较大 息止间隙较大 伴有吐舌习惯的高度病例根尖片常可见恒中切牙牙根明显变短 Lowanglecases broadupperarchwithshallowhardpalate theincisorpositionismoreuprightsoanteriorteethcrowdingiscommon clinicalcrownissmaller Curveofspeeisdeep anglebetweenlongaxisofupperandlowerincisorishigh 12 12 牙弓狭窄 腭盖高拱 高角病例 低角病例 上牙弓较宽阔 13 二 高角病例和低角病例的临床特征Thecaseofhigh angleandlowangleoftheclinicalfeatures 3 硬组织颅面形态 高角病例的腭平面 牙合平面和下颌平面向下倾斜 下颌角钝 下颌下缘弯曲 磨牙与平面角度倾斜 上下前牙唇向倾斜 上下中切牙角较小high anglecase thepalatalplane occlusalplaneandmandibularplaneislow angleofmandibleislarge curvedmandibularlowermargin slightlyproclinedupperandloweranteriorteeth Anglebeteenlongaxisofupperandlowerincisorissmall 14 低角病例腭平面 牙合平面和下颌平面接近平行 下颌角呈直角 下颌下缘平缓 下颌管弯曲 前牙直立 上下中切牙角较大thepalatalplane occlusalplaneandmandibularplanenearlyparalleltotheangleofmandibularperpendiculartotheflatedgeunderthelowerjaw Anglebetweenlongaxisofupperandlowerincisorislarge 15 二 高角病例和低角病例的临床特征Thecaseofhigh angleandlowangleoftheclinicalfeatures 4 软组织和气道 低角病例面型较凸 软组织较薄以缓解侧貌中下颌外形明显 Softtissueandairway Low anglecasesfaceisconvex softtissuethintoalleviateandjawshapeiseasilypalpated 16 高角病例上下唇长度大于低角病例 以补偿唇闭合不良 高角病例舌位向下向后 软腭向后倾斜 气道在鼻咽和口咽处较窄 High anglecases lowerliplengthisgreaterthanthelow anglecases adversetocompensateforlipclosure Casesofhigh anglepositionofthetonguebackdown softpalate tiltedback theairwayinthenasopharynxandoropharynxnarrow 17 二 高角病例和低角病例的临床特征Thecaseofhigh angleandlowangleoftheclinicalfeatures 5 口颌系统功能Stomatognathicsystemfunction 高角病例口颌功能较弱 主要表现在咀嚼肌肌力小 口周肌张力低下 力较小 由于正中位和正中关系位之间前后距离较大 下颌的运动以水平向为主 Highanglecasesstomatognathicfunctionisweak mainlyinthemasticatorymusclestrengthissmall perioralhypotonia asmallerforce thedifferencebetweencentricocclusionandcentricrelationislarger lowerjawmovementmainlyonhorizontaldirection 低角病例口颌功能较强 咀嚼肌肌力大 力亦大 正中自由度小 下颌以垂直运动为主 Low anglecasesStomatognathicpowerfulchewingmusclestrength force themiddleofdegreesoffreedomissmall lowerjawmovementmainlyonverticaldirection 18 三 正畸治疗特点Orthodontictreatmentcharacteristics 高角病例和低角病例不仅在形态和功能上存在差异 对正畸治疗的反应也截然不同 这可能与二者下颌骨骨密度不同有关high angleandlowanglecases therearedifferencesnotonlyintheformandfunction butlasoinresponsetoorthodontictreatment theremaybedifferentinmineralcontentofthetwomandibularbone 高角病例下颌骨骨密度低 对施加于牙齿上的力量更敏感 牙齿移动速度较快High anglecasesofmandibularbonemineraldensityislow theforceimposedontheteethmoresensitive fastertoothmovement 低角病例下颌骨密度较高 对矫治力不敏感Thecasesofjawbonedensityoflow anglehigh isnotsensitivetotheorthodonticforce 19 1 正畸治疗的时机Thetimingoforthodontictreatment 由于高角病例比低角病例青春迸发期出现早 所以高角病例的矫治年龄较低角病例小 在青春迸发期开始之前对高角病例进行垂直向控制 可以减缓或抑制下颌的向下向后旋转 应提倡早期治疗 最好是在颌骨和牙槽骨垂直生长活跃期 Duetothehighincidenceofhigh anglecasesthanthelow anglecase highanglecasesaretreatedearlierthanlowanglecases verticalgrowthshouldbecontrolbeforetheincidenceincaseofhighanglecase highanglecaserequiredearlytreatment preferablyintheactiveperiodoftheverticalgrowthofthemandibleandalveolarbone而低角病例相反 可等到生长快速期末开始治疗 但如果骨骼畸形比较严重 通过生长改建及牙齿代偿不能达到矫治目的 需成年后手术治疗者则应等到生长发育基本停止后进行治疗 Onthecontrary low anglecasescanwaituntilthecessationofgrowthspurt Ifskeletaldeformitiesmoreserious thecorrectioncannotbeachievedthroughthegrowthalterationsandteetheruption surgicaltreatmentshouldwaituntiltherequiredadultgrowthanddevelopmentbasicallystopped 20 2 早期矫治Earlytreatment 对存在功能因素的高角病例或低角病例 应结合病因治疗及肌功能训练 Shouldbecombinationofremovalofthecausemusclefunctiontraining替牙期存在严重拥挤时 高角病例不宜草率实施序列拔牙 因为牙齿较早拔除 不利于嚼肌功能 使咀嚼肌得不到充分的锻炼 后牙更易伸长 应拖延至活跃生长减速后装置固定矫治器时再拔牙DuringmixedDentitionperiod existenceofseverecrowding thehigh anglecasesshouldnotbehastyimplementationserialextraction becausetheearlierremovalofteethisnotconducivetomassetermusclefunction Serialextractionshouldbedelayeduntilactivegrowthdeceleration 21 低角病例则可适当进行序列拔牙 利用牙齿自然生长的力量关闭间隙 解除拥挤 矫治高角病例的功能矫治器应是抑制后牙伸长的后牙牙合垫 口外唇弓或FR IV型矫治器 而多数能促进后牙伸长的功能矫治器 如Activator 适用于低角病例 Low anglecasescanbeappropriatefortheserialextraction teethhasthenaturalgrowthpowertoclosethegap andrelievecongestion Forthecorrectionofhigh anglecases functionalappliancewhichinhibittootheruptionisusedlikeextraorallipboworFR IVthetypeofappliance functionalappliancewhichpromotetootheruption suchastheActivator applytolow anglecases FR IV型矫治器 22 扩弓矫治器使A点向前向下移动 上颌位置改变 肯定会导致下颌向后向下旋转 减小了下颌的有效长度 增加下面部的垂直高度 故不适用于高角病例 Expansionarchapplianceallowsmaxillatomoveforwardanddownwardthatwillcertainlyleadtothelowerjawbackwardanddownwardrotation reducingtheeffectivelengthofthelowerjaw increasingtheverticaldimension itdoesnotapplytohigh anglecases 23 口外弓的使用可阻止A点前移 使腭平面向下倾斜 口外力的方向可影响下颌的旋转方向 如口外力向下向后 颈牵引 可使牙齿伸长 下颌顺时针旋转 方向向上向后 即高位牵引 牙齿压低 减小顺时针旋转 甚至增加逆时针旋转 由于磨牙区生长减小使髁突生长得以表达 适用于高角病例 TheuseofthefacebowtopreventthepointAtomoveforward palatalplanetoinclineddownward thedirectionofextraoralforcecanaffectthedirectionofrotationofthemandible suchasbackwardanddownwardextraoralforce cervicaltraction maypreventtoothelongation mandibularclockwiserotation i e Hightractionpreventteetheruption reducetheclockwiserotation oreventoincreasecounter clockwiserotationduetothegrowthofthemolarareatoreducethecondoylegrowthtobeexpressed forhigh anglecases 24 低角病例使用颈牵引以刺激齿槽突的垂直向生长 有利于面型的改善 垂直牵引颏兜的使用可以通过保持颏的位置或使颏向上影响面下部的垂直高度 还可使力传导作用于牙周膜 延缓后牙的萌出 所以适合不希望下颌顺时针旋转的高角病例 Low anglecasescervicaltractiontostimulatealveolarsuddenverticalgrowthisconducivetotheimprovementoftheface Theuseofverticaltractionchincupcanmaintainthepositionofthechinorverticalheightofthelowerface butalsotheroleofhydraulicconductivityintheperiodontalligament delayingtheerupt