正畸和正颌治疗中的牙合学问题

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.
正畸治疗
Orthodontic treatment
颞下颌关节紊乱症
TMD
100万美元
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,

If skeletal discrepancy is shown and the functional treatment is wanted, making sure to examine the patient’s 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
咬合治疗(二)
正畸和正颌治疗中的牙合学问题 Occlusion study in orthodontics and orthognathic treatment
Two upper first premolars were extracted to correct open bite , but after the treatment TMD appeared.

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.
初诊First visit
牙列拥挤 前牙对刃 Dentition crowding Anterior 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
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。


Lots of studies incline to accept that there is no significant differences in TMD symptom between the treatment group and tne non-treatment one.

青春期的正畸治疗不会 增加或减少日后产生 TMD的机率。


3.精细调整 fine adjustment
治疗后 to normal occlusion
治疗中以下情况需注意
Following situations should be paid attention during treatment
治疗中处理 Managements

牙合干扰 处理：调牙合 ＴＭＤ症状 处理：暂停治疗、消 除症状


Occlusal interferences
Management: adjusting occlusion



TMD symptoms
Management: postponing or discontinuing treatment, eliminating symptoms

Mandibular rotation, backward or forward, will lead to the relative alteration of TMJ.
Intermaxillary height reducing madibular counterclockwise rotation condyle moving backward TMJ sounds.
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 curve
Adduction of the upper Intermaxillary traction Control of the intermaxillary height incisors
Occlusal trauma
颌间牵引 Intermaxillary traction


II类牵引: 髁突向前下方 关节盘随之移位。

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.

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。


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。
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 system therefore, pay attention to any possible reaseson.
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
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.
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. 2. 3. 4.
个别牙错位 深覆牙合，深覆盖 前牙反牙合 单侧后牙反牙合
Malposition in individual teeth
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。
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
Treatment time Force Occlusal changes Posterior occlusion
牙合的改变
后牙咬合
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。
ClassIII Intermaxillary traction force is too heavy posteriorly too much , pain of the joint. mandible move
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 don’t follow the doctor’s 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.
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 patient’s occlusal relationship became normal. After the treatment, the patient’s lower third molars were pulled out by a surgeon, then she presented with TMD, and the symptom was aggravated after retainment.
Deep overjet and overbite
Anterior teeth crossbite Unilateral 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