咬合治疗二双语

正畸和正颌治疗中的牙合学问题Occlusion study in orthodontics and orthognathic treatment,咬合治疗(二),Two upper first premolars were extracted to correct open bite , but after the treatment TMD appeared.,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。,A young female with open bite+ tongue thrust.Extracted two upper first premolars to correct her open bite ,and after the treatment, the patients occlusal relationship became normal.After the treatment, the patients lower third molars were pulled out by a surgeon, then she presented with TMD, and the symptom was aggravated after retainment.,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。,The patient prosecuted the surgeon to compensate for $2500 .The judge finally considered that TMD was caused by the orthodontist , who moved anterior teeth palatally and then led to the retrognathism of mandible , and sentenced him to pay $1,000,000.,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。The occlusion depends on the muscle,joint and teeth, anyone in wrong will lead to the system broken.,与TMD的发生有明显关系的特征性错牙合Characteristic malocclusions,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,Malposition in individual teethDeep overjet and overbiteAnterior teeth crossbiteUnilateral crossbite,深覆牙合Deep Overbite,深覆盖Deep Overjet,反牙合 Crossbite,正畸中的牙合学The occlusion during orthodontic treatment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。Orthodontic treatment is tooth movement, as you know, is also a rebuilding progress of mastication systemtherefore, pay attention to any possible reaseson.,初诊First visit,牙列拥挤 前牙对刃Dentition crowdingAnterior teeth edge to edge,通过X线检查颞下颌关节Examining TMJ through X-ray,排齐和整平 Alignment and leveling,a.拉尖牙向远中Pulling canine distally,b.关闭前牙间隙 Closing space at anterior region,上切牙内收Upper incisors moving palatally,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。,If upper and lower anterior teeth move posteriorly proportioned, the normal TMJ will be maintained.If upper anterior teeth moving too palatally forcing mandibular setback, the relative setback of condyle, pain and TMJ sounds.,颌间牵引Intermaxillary traction,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。,Class II traction condyle moving forward displacement of disk. Class III traction condyle moving backward putting pressure on posterior region of disk. Orthodontist should examine not only the teeth but also the TMJ during further consultations.,颌间高度的控制Control of intermaxillary height,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。,Mandibular rotation, backward or forward, will lead to the relative alteration of TMJ.Intermaxillary height reducing madibular counterclockwise rotation condyle moving backward TMJ sounds.,3.精细调整fine adjustment,治疗后 Post-treatment,牙合的六项标准,Six keys to normal occlusion,治疗中以下情况需注意Following situations should be paid attention during treatment,1. 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,Occlusal curveAdduction of the upper incisors Intermaxillary tractionControl of the intermaxillary heightOcclusal trauma,治疗中处理Managements,牙合干扰 处理：调牙合症状处理：暂停治疗、消除症状,Occlusal interferencesManagement: adjusting occlusionTMD symptomsManagement: postponing or discontinuing treatment, eliminating symptoms,对咀嚼系统功能影响较大的正畸治疗因素Major factors,矫治时机 施加力量 牙合的改变 后牙咬合,Treatment timeForceOcclusal changesPosterior occlusion,1. 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。If skeletal discrepancy is shown and the functional treatment is wanted, making sure to examine the patients growth and development.,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。 Force ClassIII Intermaxillary traction force is too heavy mandible move posteriorly too much , pain of the joint. ClassII intermaxillary traction force is too heavy secondary posterior displacement of condyle joint symptoms. Force of partial teeth is inappropriate occlusal trauma.,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。 Occlusal changes:There maybe premature contacts when moving teeth during treatment. Patients dont follow the doctors advice.Utilizing overhigh occlusal splint for a long time anterior condyle displacement with compensatory.Severe malposed tooth, severe occlusal interference.Premature contacts by inappropriate treatment.,4. 后牙咬合Posterior occlusion 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。Posterior occlusal trauma or occlusal interference may appear if only paying attention to anterior aesthetic but ignoring posterior occlusion.,5. 治疗目标,和谐的功能统一。不但是正中，还有侧位和前伸。The best target is harmony in three situation.,6. 调牙合,调牙合是最后的抉择。The adjusting of occlusion is final step.,常见问题,一、正畸治疗与TMD的关系Post-Treatment and TMD,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。,Lots of studies incline to accept that there is no significant differences in TMD symptom between the treatment group and tne non-treatment one.The adolescent orthodontic treatment will not increase or decrease the possibility of TMD.,二、拔牙治疗与TMD的关系Teeth-extracted and TMD,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: After premolars are extracted, anterior teeth will move too palatally, which consequently causing the setback of mandible and the post-displacement of condyle.Investigations: the prevalence rates of TMD sounds both declined in extracted group and non-extracted one.Conclusion: TMD sounds have nothing to do with teeth-extracted or not.,三、正畸治疗对髁突位置的影响Treatment and position of condyle,正畸治疗后髁突的位置有一定改变，但不一定会导致TMD。,The position of condyle will change to some extent after treatment, but whether TMD will appear is not for sure.,四、不同矫治技术的影响Influence of different techniques,多数人认为矫治技术的类型与TMD的发生无明显关系。,Most experts suggest that there is no significant relationship between the techniques and the incidence of TMD.,正颌外科治疗错牙合畸形Orthognatic surgery treat malocclusion,正颌手术基本步骤： Basic procedures in orthognathic surgery（一）术前正畸（二）手术 （三）术后正畸与康复治疗Orthodontic treatment before surgeryOperationOrthodontic treatment after surgery, recovering treatment,初诊First visit,三类错牙合、开牙合Class III open bite,8976,骨性三类Skeletal Class III,术前正畸Orthodontic treatment before surgery,术前正畸 Orthodontic treatment before surgery目的：矫正错位牙，调整不协调的牙弓与牙牙合关系，排 除牙牙合干扰，排齐牙列，消除牙的代偿性倾斜。Objective: correcting malposed teeth,adjusting the inconsistent dental arch and occlusion, eliminating teeth interference ,aligning the dentition, eliminating the compensatory lean of teeth.,术前正畸结束The end of Pre-surgeryOrthodontic Treatment,手术 Operation,手术后 Post-treatment,术后正畸Orthodontic Treatment After surgery,术后正畸 Orthodontic treatment after surgery原因： 即使是成功的外科手术，一般在术后都会存在上 下牙的尖窝关系不协调，咬合不平衡等问题。Reason: even the operation is successful , there are still some problems such as: disharmony between the upper and lower teeth , imbalance in occlusion and so on.,完成Accomplishment,8976,坚强内固定Rigid internal fixation (RIF),8976,897603-22-2001,正颌外科治疗中的牙合学问题The occlusion problems in orthognathic surgery,与颞下颌关节关系密切的正颌外科术式The most relative surgery methods,1.上颌Le FortI型截骨术Maxillary LeFortI osteotomy,2. 下颌升支切开术 Mandibular ramus osteotomy(1)双侧下颌升支矢状劈开术(BSSO)Bilateral sagital split osteotomy(2)下颌升支斜行或垂直骨切开术Oblique or vertical ramus osteotomy,下颌升支切开术 Mandibular ramus osteotomy,正颌手术与TMD之间的相互作用 Interaction between operation and TMD,两种观点 1.手术有时会加重关节症状，造成髁突移位与吸收。2.手术对TMD的治疗作用：建立适宜的上下颌关系。,Two opinions TMD symptom will be aggravated after operation because of the pre-positioned and absorbtion of condyle. TMD symptom will be improved by the operation: establishing appropriate relationship of the upper and lower jaws.,正颌外科治疗对髁突位置的影响Influences on TMJ,髁突位置改变 (1) 全麻状态 (2) 手术方式 (3) 固定方式,The altered location of condyleGeneral anesthesiaOperation modeFixed mode,牙合关系改变 Occlusal relationship changes手术创伤 Surgery trauma,TMJ 对手术的影响Effects on the operation,手术对关节造成的改变反过来又能影响手术效果导致复发。通过影响髁突的位置或髁突吸收及骨段间移动导致复发。,The TMJ alterations can effect the operation as well and finally cause recurrence .Recurrence is caused by the alterations or the absorbtion of condyle.,正畸治疗TMDTMD cured by orthodontic treatment,颞下颌关节紊乱的病因Etiology,牙合因素： 磨牙、紧咬牙肌肉因素精神心理因素,Occlusal factors: grinding, clenchingMasticatory muscles factors Emotional factors,1. 掌握适应证 必须是由错牙合畸形引起的颞颌关节问题。Mastering indications The TMD must be caused by malocclusion.,正畸治疗TMD的特点,2. 明确针对病因及机制进行治疗Treatment according to pathogenies and mechanisms,颞下颌关节紊乱病患者 去除病因。内倾型深覆牙合型 解除锁结。个别牙错位 解除 牙合干扰。 肌功能紊乱患者 配合理疗等手段。,TMD patients eliminating pathogeny.Palatal inclination and deep overbite Eliminating locked occlusion. Individual malposed tooth eliminating occlusal interference.Myofunctional disorder patients applying with physical therapy and so on.,3. 美观与功能统一 The unity of esthetics and function 若有冲突，应以功能为主。 If there is a conflict, function should be considered first.,4. 重视对颞下颌关节的定期检查 Attach importance to TMJ regularly examination 正畸治疗的前、中、后都应对关节进行检查。 TMJ should be examined before