1、1高角和低角病例的診斷、臨床特征及高角和低角病例的診斷、臨床特征及正畸治療特點正畸治療特點High angle and low angle cases, diagnosis, clinical features and orthodontic treatment2 由于以往的診斷是以安氏由于以往的診斷是以安氏分類為主分類為主, 正畸醫(yī)生常常正畸醫(yī)生常常只注意到矢狀向錯牙合而只注意到矢狀向錯牙合而忽略了垂直向不調(diào)。忽略了垂直向不調(diào)。 近年來近年來, 學(xué)者們逐漸認(rèn)識學(xué)者們逐漸認(rèn)識到垂直面型在錯畸形診斷到垂直面型在錯畸形診斷和治療中的重要性和治療中的重要性: 它不它不僅為顱面復(fù)合體的生長方僅為顱面復(fù)

2、合體的生長方向提供了線索向提供了線索, 而且直接而且直接影響治療的成功與否。影響治療的成功與否。Previous diagnosis was based on Angles classification so orthodontists often only noticed the sagittal malocclusion while ignoring the vertical dimension.In recent years, scholars have come to realize the importance of the vertical dimensions in the di

3、agnosis and treatment of malocclusion it not only provides clues to the direction of growth of the craniofacial complex, but also directly affects the success of treatment.3 垂直向異常有高角和低角兩種類型垂直向異常有高角和低角兩種類型, 在在類類安氏錯牙合中約有安氏錯牙合中約有50%左右的患者存在不同程度左右的患者存在不同程度的垂直向異常。的垂直向異常。Vertical anomaly are of two types o

4、f high-angle and low angle, about 50%of patients with angle class III malocclusion have varying degrees of abnormal vertical dimensionhigh-angle and low angle cases, diagnosis, clinical features, and orthodontic treatment 4一、一、高角病例和低角病例的診斷和形成機制高角病例和低角病例的診斷和形成機制High angle and low angle cases diagnosi

5、s and form 文獻(xiàn)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( backward rotation ) 、垂直生長型(vertical type) 、長面型( dolichocephalic ) 、高角型( high -angle face ) , 均指垂直向異常以發(fā)育過度( vertical excessive ) 為主, 而聚合面型( hypodivergent ) 、向前旋轉(zhuǎn)型( forward rotation) 、水平生長型( horizontal type) 、短面型( brachypechalic) 、低角型( lo

6、w -angle face) 則是指垂直發(fā)育不足( vertical deficiency ) 。 由于診斷標(biāo)準(zhǔn)和側(cè)重點不同, 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經(jīng)常通用。Diagnostic criteria and a different focus, in the strict sense, these concepts there is a difference, but often common in the clinical description of vertical type.5高角病例和低角病例的診斷和形成機制高角病例和低角病例的診斷和形成

7、機制High angle and low angle cases diagnosis and form 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(biāo)準(zhǔn)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(yīng)結(jié)合其他指標(biāo)。 Referred to article as high-angle and low angle, should not be confuse with the mandibular plane angle, if it is high, called high

8、 angle case, and if small than low angle case. Because the mandibular angle and mandibular margin changes with growth,so simple mandibular plane angle as the diagnostic criteria may mask the true mandibular rotation and direction of the vertical growth.The correct diagnosis should be combined with o

9、ther indicators6目前常用的診斷標(biāo)準(zhǔn)是目前常用的診斷標(biāo)準(zhǔn)是: The commonly used diagnostic criteria are: ( 1) 下頜平面角Mandibular plane angle: 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anterior to the posterior facial height ratio ( S- Go/ N- Me) : 高角病例大于68%; 低角病例小于62% 。 (

10、3) 下前面高與前面高比值lower to the upper facial height ratio( ANS- Me/ N - Me) : 高角病例大于58% ; 低角病例小于55%。7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(guān)。 high-angle or low angle cases with a high level of growth and development before and after facial disorders后面部高度生長不足( 升支短小、關(guān)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)

11、 形成了高角型。Lack of posterior facial growth ( ascending branch of the glenoid fossa small ) and/or anterior facial height overgrowth(condylar backward growth, excessive eruption of the maxillary posterior teeth) is responsible for a high-angle case.后面部高度生長過度( 升支較長、關(guān)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)

12、育不足、后牙萌出不足) 形成了低角型。 posterior height overgrowth (the ascending branch of a glenoid fossa long) and/or in lack of posterior facial growth (upward and forward rotation of condyle,lack of eruption of maxillary posterior teeth) is resposible for low-angle case.8二、高角病例和低角病例的臨床特征二、高角病例和低角病例的臨床特征The case o

13、f high-angle and low angle of the clinical features 1、面型、面型: 正面觀正面觀 高角病例多為窄長臉高角病例多為窄長臉型型,兩側(cè)下頜角不明顯兩側(cè)下頜角不明顯, 鼻鼻根部較窄根部較窄, 常伴有唇功能常伴有唇功能不足、開唇露齒不足、開唇露齒; 低角病例則多為寬短臉型低角病例則多為寬短臉型,兩側(cè)下頜角呈方形兩側(cè)下頜角呈方形, 鼻根部鼻根部較寬較寬, 唇閉合十分自然。唇閉合十分自然。9 9clinical features of high-angle and low angle cases A face: front view: High-angl

14、e: long and narrow face, both sides of the mandibular angle is not distinct, the nasion is narrow, often accompanied with incompetent lip. Low-angle cases are much more wide and short face.Both sides of the mandibular angle was a square, nasion is wide, lip closure is normal 10 側(cè)面觀Lateral view : 高角病

15、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; High angle cases, length of the lower 1/3 of the face is long, the concave type profile more common, thick upper lip, chin and chin lip groove are not prominent. 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-angle cases the lower 1/3 of the face gen

16、erally shorter convex facial profile, thin upper lip, chin and chin lip groove are prominent.11二、高角病例和低角病例的臨床特征The case of high-angle and low angle of the clinical features2、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; High angle cases:- narrow uppe

17、r arch with deeper hard palate, anterior proclination is rarely seen. the height of clinical crown larger, the curve of spee is flat and the angle between the facial axis of upper and lower incisor is less.12clinical features of high-angle and low angle cases 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

18、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恒中切牙牙根明顯變短。 Low angle cases:- broad upper arch with shallow hard palate, the incisor position is more upright so anterior teeth crowding is common.clinical crown is smaller. Curve of spee is deep.angle between long axis of upper and lower incis

19、or is high 1213牙弓狹窄、腭蓋高拱高角病例低角病例上牙弓較寬闊14二、高角病例和低角病例的臨床特征二、高角病例和低角病例的臨床特征The case of high-angle and low angle of the clinical features 3、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-angle case:- the palatal plane, occlusal plane and mandibular plane is low, angle

20、of mandible is large, curved mandibular lower margin, slightly proclined upper and lower anterior teeth. Angle beteen long axis of upper and lower incisor is small.15 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the palatal plane, occlusal plane and mandibular plane nearly parallel to

21、 the angle of mandibular perpendicular to the flat edge under the lower jaw. Angle between long axis of upper and lower incisor is large.16二、高角病例和低角病例的臨床特征二、高角病例和低角病例的臨床特征The case of high-angle and low angle of the clinical features 4、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。Soft tissue and airway: Low-a

22、ngle cases face is convex, soft tissue thin to alleviate and jaw shape is easily palpated.17 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-angle cases, lower lip length is greater than the low-angle cases, adverse to compensate for lip closure. Cases of high-angle position of the to

23、ngue back down, soft palate, tilted back, the airway in the nasopharynx and oropharynx narrow.18二、高角病例和低角病例的臨床特征二、高角病例和低角病例的臨床特征The case of high-angle and low angle of the clinical features 5、口頜系統(tǒng)功能Stomatognathic system function: 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, 下頜的運動以水平向為主;

24、High angle cases stomatognathic function is weak, mainly in the masticatory muscle strength is small, perioral hypotonia, a smaller force.the difference between centric occlusion and centric relation is larger, lower jaw movement mainly on horizontal direction. 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

25、運動為主。 Low-angle cases Stomatognathic powerful chewing muscle strength, force, the middle of degrees of freedom is small, lower jaw movement mainly on vertical direction19三、正畸治療特點Orthodontic treatment characteristics 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(yīng)也截然不同, 這可能與二者下頜骨骨密度不同有關(guān)high-angle and low angle case

26、s, there are differences not only in the form and function, but laso in response to orthodontic treatment, there may be different in mineral content of the two mandibular bone. 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-angle cases of mandibular bone mineral density is low, the force imposed on the tee

27、th more sensitive, faster tooth movement; 低角病例下頜骨密度較高,對矯治力不敏感The cases of jaw bone density of low-angle high, is not sensitive to the orthodontic force。 201、正畸治療的時機The timing of orthodontic treatment: 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(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

28、骨垂直生長活躍期。Due to the high incidence of high-angle cases than the low-angle case, high angle cases are treated earlier than low angle cases. vertical growth should be control before the incidence in case of high angle case. high angle case required early treatment, preferably in the active period of t

29、he vertical growth of the mandible and alveolar bone 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(yán)重, 通過生長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)等到生長發(fā)育基本停止后進(jìn)行治療。 On the contrary, low-angle cases can wait until the cessation of growth spurt. If skeletal deformities more serious, the correction can not be achieved through th

30、e growth alterations and teeth eruption. surgical treatment should wait until the required adult growth and development basically stopped.21 2、早期矯治Early treatment: 對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。 Should be combination of removal of the cause muscle function training 替牙期存在嚴(yán)重?fù)頂D時, 高角病例不宜草率實施序列拔牙, 因為牙

31、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(yīng)拖延至活躍生長減速后裝置固定矯治器時再拔牙 During mixed Dentition period, existence of severe crowding, the high-angle cases should not be hasty implementation serial extraction, because the earlier removal of teeth is not conducive to masseter muscle function. Serial extraction sh

32、ould be delayed until active growth deceleration; 22 低角病例則可適當(dāng)進(jìn)行序列拔牙, 利用牙齒自然生長的力量關(guān)閉間隙、解除擁擠, 矯治高角病例的功能矯治器應(yīng)是抑制后牙伸長的后牙牙合墊、口外唇弓或FRIV 型矯治器; 而多數(shù)能促進(jìn)后牙伸長的功能矯治器, 如Activator , 適用于低角病例。Low-angle cases can be appropriate for the serial extraction, teeth has the natural growth power to close the gap, and relieve

33、congestion. For the correction of high-angle cases, functional appliance which inhibit tooth eruption is used like extraoral lip bow or FR-IV the type of appliance; functional appliance which promote tooth eruption,such as the Activator, apply to low-angle cases.FRIV 型矯治器23 擴(kuò)弓矯治器使A 點向前向下移動、上頜位置改變, 肯

34、定會導(dǎo)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。Expansion arch appliance allows maxilla to move forward and downward that will certainly lead to the lower jaw backward and downward rotation, reducing the effective length of the lower jaw, increasing the vertical dimension. it does not apply to high-

35、angle cases.24 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(dá), 適用于高角病例。 The use of the face bow to prevent the point A to move forward, palatal plane to inclined downward, the direction of extra oral force can

36、affect the direction of rotation of the mandible, such as backward and downward extraoral force (cervical traction),may prevent tooth elongation, mandibular clockwise rotation;i.e.High traction prevent teeth eruption, reduce the clockwise rotation, or even to increase counter-clockwise rotation due

37、to the growth of the molar area to reduce the condoyle growth to be expressed, for high-angle cases.25 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(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針旋轉(zhuǎn)的高角病例。 Low-angle cases cervical traction to stimulate alveolar sudden vertical growth is conducive to the improvement of the face. The use of vertical traction chin cup can maintain the position of the chin or vertical height of the lower face, but also the role of hydraulic conductivity