功能因素對(duì)正畸長(zhǎng)期穩(wěn)定性影響的相關(guān)研究進(jìn)展

于 航,胡 敏,張 祎,王六一,劉 楠,馮 旭

(吉林大學(xué)口腔醫(yī)學(xué)院 口腔正畸科,吉林 長(zhǎng)春130041)

1 咬合

1.1 前牙前導(dǎo)運(yùn)動(dòng)

1.2 咬合干擾

2 TMJ與正畸穩(wěn)定性

顱頜面系統(tǒng)是一個(gè)整體,只有各部分協(xié)調(diào)統(tǒng)一,整個(gè)系統(tǒng)才能最好的行使功能,咀嚼肌和髁突作為下頜行使運(yùn)動(dòng)時(shí)不可或缺的部分,當(dāng)發(fā)生功能障礙時(shí),將會(huì)影響口頜系統(tǒng)的平衡,但目前關(guān)于咀嚼肌及髁突位置與TMD的相關(guān)性尚存爭(zhēng)議。

2.1 咀嚼肌

咀嚼運(yùn)動(dòng)是由中樞神經(jīng)誘發(fā),外周神經(jīng)根據(jù)食物質(zhì)地、形狀及咬合穩(wěn)定性等影響因素而調(diào)節(jié)的肌肉節(jié)律性收縮形成的下頜運(yùn)動(dòng)。正畸治療產(chǎn)生的咬合重建,是需要口頜系統(tǒng)神經(jīng)肌肉平衡來實(shí)現(xiàn)的,但對(duì)于這點(diǎn)往往沒有給予足夠的重視。臨床中,我們常常可以觀察到,當(dāng)咬合關(guān)系改變后,咀嚼肌的垂直距離也會(huì)發(fā)生改變[15,16]。當(dāng)咀嚼肌的垂直距離改變后,初始的肌纖維的長(zhǎng)度也發(fā)生永久性改變,進(jìn)而導(dǎo)致肌張力降低[17,18]。有學(xué)者對(duì)大鼠進(jìn)行咬合干擾實(shí)驗(yàn),發(fā)現(xiàn)單側(cè)咬合干擾會(huì)引起雙側(cè)咀嚼肌發(fā)生病理性變化[19]。但這種動(dòng)物實(shí)驗(yàn)所造成的干擾都是急性的,并不能完全與臨床相符。另一方面也有研究發(fā)現(xiàn),當(dāng)顳下頜關(guān)節(jié)和上下頜間運(yùn)動(dòng)發(fā)生功能障礙時(shí),口頜肌肉將引起相應(yīng)的代償反應(yīng)。為了適應(yīng)新的垂直距離,肌纖維兩端會(huì)產(chǎn)生新的肌小節(jié),從而達(dá)到新的工作長(zhǎng)度,同時(shí)其他附著于骨骼區(qū)域的肌肉結(jié)締組織也會(huì)發(fā)生相應(yīng)的變化,以維持咀嚼肌正常的功能[20,21]。因此整齊的牙列并不代表咀嚼肌功能的平衡,當(dāng)存在咬合干擾時(shí)肌肉會(huì)發(fā)生一系列病理生理性及形態(tài)學(xué)變化,當(dāng)代償反應(yīng)超出極限時(shí)肌肉的功能將不能達(dá)到平衡,進(jìn)而影響整個(gè)顱頜面系統(tǒng),正畸的長(zhǎng)期穩(wěn)定性將受到影響。

2.2 髁突的位置

髁突的位置與TMD的相關(guān)性一直以來都是臨床醫(yī)生關(guān)注和討論的熱點(diǎn),但目前尚有爭(zhēng)議。有學(xué)者認(rèn)為,正常成年人的髁突基本位于關(guān)節(jié)窩中央,左右基本對(duì)稱,關(guān)節(jié)后間隙稍大于前間隙[22,23]。黃鵬程等[24]對(duì)伴有TMD癥狀和體征的15例患者和正常的成人患者進(jìn)行髁突位置的測(cè)量分析,發(fā)現(xiàn)TMD患者髁突位置明顯后移。Girardot[25]應(yīng)用MPI發(fā)現(xiàn)TMD患者髁突在關(guān)節(jié)窩中位置下移,并且在髁突回到關(guān)節(jié)窩中央位置時(shí)癥狀得到緩解。因此,支持者們認(rèn)為正畸治療應(yīng)在髁突位于關(guān)節(jié)窩中央位置的基礎(chǔ)上建立新的咬合,這樣更利于避免TMD發(fā)生,維持治療效果長(zhǎng)久穩(wěn)定,減少?gòu)?fù)發(fā)的可能性。但也有研究者認(rèn)為髁突位置與TMD關(guān)系不大,他們認(rèn)為正常人群中髁突的位置存在較大的變異。Ren等[26]對(duì)正常人群進(jìn)行關(guān)節(jié)造影研究,發(fā)現(xiàn)正常關(guān)節(jié)只有41%的髁突居中,32%髁突發(fā)生后移,27%前移。這說明髁突的中性位置并不能反映正常髁突的真實(shí)位置。同時(shí)關(guān)于矯治結(jié)束時(shí)髁突是否一定要達(dá)到中央位置也存有爭(zhēng)議。有學(xué)者認(rèn)為,TMJ的組成部分就像其他任何關(guān)節(jié)一樣,即使到達(dá)成年后,在應(yīng)對(duì)環(huán)境變化時(shí),仍會(huì)產(chǎn)生重構(gòu)現(xiàn)象,以維持形狀和功能之間的平衡[27]。為了適應(yīng)應(yīng)力變化,髁突與關(guān)節(jié)結(jié)節(jié)的關(guān)節(jié)層成纖維細(xì)胞會(huì)顯著地轉(zhuǎn)化為軟骨細(xì)胞,此外,髁突及關(guān)節(jié)窩表面的細(xì)胞增殖層有產(chǎn)生骨細(xì)胞和軟骨細(xì)胞的能力[28]。因此,通過影像學(xué)觀察,可見髁突、關(guān)節(jié)結(jié)節(jié)以及這些結(jié)構(gòu)之間的空間關(guān)系都在不斷地進(jìn)行適應(yīng)性變化。這些發(fā)現(xiàn)提示,顳下頜關(guān)節(jié)同其他關(guān)節(jié)類似,具有一定的自身調(diào)節(jié)能力。

3 Roth功能及其穩(wěn)定性

3.1 Roth功能

3.2 Roth功能的爭(zhēng)議

參考文獻(xiàn)：

[1]Angle EH.Treatment of malocclusion of the teeth and fractures of the maxillae.6th ed.Philadelphia:SS White;1900.

[2]Andrews LF.The six keys to normal occlusion[J].Am J Orthod,1972,62:296.

[3]Andrews LF.The six element of orofacial harmony[J].Andrews J Orthod Oroface Harmony,2000,1(1):13.

[4]Andrews LF.Straight wire:the concept and appliance[M].San Diego:L.A.Wells Co,1989:35.

[5]Kattner PF,Schneider BJ.Conparison of Roth appliance and standard edgewise appliance treatment results[J].Am J Orthod Dentofacial Orthop,1993,103(1):24.

[6]Andrews LF.The straight-wire appliance,origin,controoversy,commentary[J].J Clin Orthod,1976,10(2):99.

[9]王新知.口腔固定修復(fù)中的美學(xué)重建[M].第1卷.北京：人民軍醫(yī)出版社,2009：220-223.

[10]李雨軒,翟 桐,譚文宏，等.實(shí)驗(yàn)性前導(dǎo)斜度改變的大鼠模型的建立及其顳下頜關(guān)節(jié)滑膜組織病理學(xué)觀察[J].華西口腔醫(yī)學(xué)雜志,2017,35(3):253.

[11]kerstein RB,Farrell S.Treatment of myofascial pain-dysfunction syndrome with occlusal equilibration[J].J Prosthet Dent,1990,63(6):695.

[12]楊建軍,趙文科,王守彪,等.定量咬合干擾對(duì)顳下頜關(guān)節(jié)早期損傷的實(shí)驗(yàn)研究[J].現(xiàn)代口腔醫(yī)學(xué)雜志,2001，6:418，482.

[13]Kvinnsland S,Kvinnsland I,Kristiansen A．Effect of experimentaltraumatic occlusion on blood flow in the temporomandibular joint of the rat[J]．Acta Odontol Scand,1993,51(5):293．

[14]Ruben M,Mafla E．Effects of traumatic occlusion on the tem-poromandibular joint of Rhesus monkeys[J].J Periodontol,1971,42(2):79.

[15]Akagawa Y,Nikai H,Tsuru H.histologic changes in ratmasticatory muscles subsequent to experimental increase of the occlusal vertical dimension[J].J Pros Dent,1983,50:725.

[16]Carlsson GE,Ingerval B,Kocak G.Effect of increasing verticaldimension on the masticatory system in patients with naturalteeth[J].J Pros Dent，1979,41:284.

[17]Kovaleski WC,De Boever J.Influence of occlusal splints on jawposition and musculature in patients with temporomandibularjoint dysfunction[J].J Pros Dent，1975，33:321.

[18]Carr AB,Christensen LV,Donegan SJ,et al.Posturalcontractile activities of human jaw muscles following use of anocclusal splint[J].J Oral Rehabil,1991,18:185.

[19]Muller J,Vayssiere N,Muller A,et al.Bilateral effect of a unilateral occlusal spint on the expression of myosin heavychain isoforms in rat deep masseter muscle[J].Arch Oral Biol,2000,45(12):1017.

[20]Goldspink G.Malleability of the motor system:a comparativeapproach[J].J Exp Biol,1985,115:375.

[21]Herring SW,Muhl ZF,Obrez A.Bone growth and periostealmigration control masseter muscle orientation in pigs (Susscrofa)[J].Anat Rec,1993,235:215.

[22]張震康,趙福運(yùn),孫廣熙,等.正常成年人顳頜關(guān)節(jié)100例X線分析[J].中華醫(yī)學(xué)雜志,1975,55(2):130.

[23]王瑞永,馬緒臣,張萬林,等.健康成年人顳下頜關(guān)節(jié)間隙錐形束計(jì)算機(jī)體層攝影術(shù)測(cè)量分析[J].北京大學(xué)學(xué)報(bào)(醫(yī)學(xué)版),2007,39(5)：503.

[24]黃鵬程,張端強(qiáng).顳下頜關(guān)節(jié)紊亂綜合征患者的髁突位置及對(duì)稱性[J].上海口腔醫(yī)學(xué),2012,21(6):663.

[25]Girardot RA.Condylar displacement in patients with TMJ dysfunction[J].CDS Rev,1989,89:49.

[26]Ren YF,Isberg A,Westesson PL.Condyle position in the temporomandibular joint.Comparison between asymptomatic volunteers with normal disk position and patients with disk displacement[J].Oral Surg Oral Med Oral Pathol Oral Radiol Endod,1995,80(1):101.

[27]Hansson TL.Pathologic aspects of arthritides and derangements.In:Sarnat BG,Laskin DM,eds.The Temporomandibular Joint:A Biological Basis for Clinical Practice[M].4th ed.Philadelphia,PA:Saunders;1992:165-182.

[28]Greene CS,Obrez A.Treating temporomandibular disorders with permanent mandibular repositioning:is it medically necessary[J].Oral Surg Oral Med Oral Pathol Oral Radiol,2015,119(5):489.

[29]Roth RH.Functonal occlusion for the orthodontist[J].J Clin Orthod,1981,15(1) 32,44.

[30]Roth RH.Functional occlusion for the orthodontist.II[J].Clin Orthod,1981,25:100.

[31]Roth RH.Temporomandibular pain-dysfunction and occlusal relationship[J].Angle Orthod,1973,43:136.

[32]Dawson PE.New definition for relating occlusion to varying conditions of the temporomandibular joint[J].J prosthet dent,1995,74(6):619.

[33]Wyatt WE.Preventing adverse effects on the temporomandibular joint through orthodontic treatment[J].Am J Orthod Dentofacial Orthop,1987,91(6):493.

[34]Klar NA,Kulbersh R,Freeland T,et al.Maximum intercuspation-centric relation disharmony in 200 consecutively finished cases in a gnathologically oriented proactively finished cases in a gnathologically oriented practice[J].Semin Orthod,2003,9(2):109.

[35]Utt TW,Meyers CE Jr,Wierzbr TF,et al.A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator[J].Am J Orthod Dentofacial Orthop,1995,107(3):298.

[36]丁 寅.正畸治療中咬合、頜位及顳下頜關(guān)節(jié)相關(guān)問題的探討[J].中華口腔醫(yī)學(xué)雜志,2015,50(5):275.