伴颞下颌关节病错[牙合]畸形的正畸治疗原则与方案

The orthodontic therapeutic principles for malocclusions concurring with temporomandibular joint disorders

颞下颌关节(TMJ)的生物学特征是适应性改建,主要表现为髁突在咬合状态与下颌位置改变时会引发吸收、增生或修复。错[牙合]畸形类型与颞下颌关节病(TMD)易感性之间存在关联。总体上,错[牙合]畸形与TMD易感性从高到低依次为:突面、偏颌、直面、凹面错[牙合]畸形。在突面畸形中,骨源性与混合Ⅱ型的TMD易感性最高,常表现为突吸退(突面畸形-髁突吸收-下颌骨后退)、突吸偏(突面畸形-髁突不对称吸收-下颌骨偏斜);在凹面畸形中,骨源性凹面伴偏颌的TMD易感性最高,常表现为凹增偏(凹面畸形-髁突不对称增生-下颌骨偏斜)等。伴TMD错[牙合]畸形,或称病理性错[牙合]畸形,是指伴有已经确诊的TMD或有TMD影像学表现的错[牙合]畸形,特别是对TMD高易感性的错[牙合]畸形。对正畸首诊患者,正畸医师要进行生理性与病理性错[牙合]畸形的鉴别诊断。伴TMD错[牙合]畸形正畸治疗的总体原则是治疗前发现TMD迹象并告知患者,治疗中监测TMD动态并设置预案,治疗后追踪TMD变化并进行颌位保持。对于TMD已造成较严重咬合紊乱及颌位改变的正畸患者(如突吸退、突吸偏、凹增偏),正畸治疗是手术之外的一个保守治疗选项,其治疗目标从主到次分别是改善咬合状态、缓解TMD发展、提升面形美观;治疗策略是纠正因TMJ病理变化而导致的颌位因素,通过颌位重建诱发TMJ改建,最终达到咬合重建;治疗方法包括S8-SGTB、S8-SGHB、S9、S10等正畸矫形技术。

The biological nature of temporomandibular joint(TMJ) featuring adaptive remodeling allows for TMJ structural changes in response to external stimuli, including alterations in occlusion and in mandibular posture. Correlative susceptibility exists between malocclusions and TMJ disorders(TMD), evidenced by high incidence of TMD coinciding with skeletal originated malocclusion with facial prognathsim(Angle Class Ⅰ skeletal Ⅱ high angle). Clinical manifestations include markedly retruded mandible together with increased overjet, or mandibular transverse deviation, due to condylar pathological resorption. It is critically imperative to execute differential diagnosis between the routine malocclusions and those infringed with TMD. The prime stipulations governing the orthodontic procedures include the patient’s notification of the existential TMD conditions prior to any orthodontic interventions, close inspections of TMD developments during the treatment, and a specially designed retention protocol aftermath. For the cases where severe overjet and mandibular displacement occur as a result of TMD, some specific orthopedic modalities can be implemented to improve the occlusion by restoring the shifted mandible. TMD conditions are also expected to be relieved with mandibular repositioning, which encourages new bone formation in the degraded condyles. The newly developed clear version of orthopedic appliances,namely, S8-SGTB, S8-SGHB, S9 and S10 are of promising efficacy in treating this category of patients.