骨性Ⅲ类下颌偏斜患者颞下颌...位置及上颌骨特征的三维评估_唐汝萍.pdf

收稿日期 2020-11-06；修回日期 2021-01-13作者简介唐汝萍（1992-），女，硕士，医师，E-mail：通信作者赵震锦，E-mail：c2023年版权归上海口腔医学编辑部所有骨性类下颌偏斜患者颞下颌关节形态位置及上颌骨特征的三维评估唐汝萍1，刘帅2，赵震锦3，汪俊妍31.南方医科大学口腔医院（口腔医学院）海珠广场院区儿童口腔科，广东广州510000；2.邯郸市中心医院口腔科，河北邯郸056000；3.中国医科大学附属口腔医院第一门诊部口腔正畸科，辽宁沈阳110000摘要目的：研究双侧下颌角点垂直向不调的骨性类下颌偏斜患者颞下颌关节的形态、位置及上颌骨特征。方法：对79例成人骨性类错畸形患者进行颅面部螺旋CT扫描，采用ProPlan CMF3.0三维分析软件对颞下颌关节进行三维重建，根据颏点偏斜程度分为对称组（S组：n=24）和偏斜组（n=55）。偏斜组中，根据双侧下颌角点有无垂直向不调分为2组，ASV组双侧下颌角点存在垂直向差异（n=27），ASNV组双侧下颌角点不存在垂直向差异（n=28）。测量7项髁突形态、位置指标以及9项上颌骨相关指标，采用SPSS 22.0软件包对数据进行统计学分析。结果：偏斜组的偏斜侧髁突长度均短于偏斜对侧，两侧差值均大于对称组，上颌骨均存在自身不对称以及不同程度的三维方向不调。ASV组中，偏斜侧髁突轴与水平面的角度更小，髁突前后径更小。ASNV组中，偏斜侧髁突内外径更小。方差分析和多重比较显示，ASV组和ASNV组两侧髁突长度的差值均比对称组大。ASV组和ASNV组上颌骨存在自身不对称，偏斜侧上颌骨宽度大于非偏斜侧。ASNV组更有可能存在上颌骨横向不调。ASV组上颌骨左右侧垂直向不调大于ASNV组和S组，且偏斜侧小于偏斜对侧。结论：双侧下颌角点垂直向不调的骨性类下颌偏斜患者，颞下颌关节的形态、位置以及上颌骨三维方向上存在不对称，在正畸、正颌的诊断和方案设计中应予以关注。关键词骨性类错；面部偏斜；颞下颌关节；三维重建；上颌骨特征中图分类号 R782.2文献标志码 ADOI:10.19439/j.sjos.2023.01.017Three-dimensional assessment and study on temporomandibular joint and the maxillary characteristics of skeletalClass mandibular deviation patientsTANG Ru-ping1,LIU Shuai2,ZHAO Zhen-jin3,WANG Jun-yan3.(1.De-partment of Pediatric Stomatology,Haizhu Square Branch,Stomatological Hospital&College of Stomatology,SouthernMedical University.Guangzhou 510000,Guangdong Province;2.Department of Stomatology,Handan Central Hospital.Handan 056000,Hebei Province;3.Department of Orthodontics,The First Outpatient Department,Stomatological Hospi-tal,China Medical University.Shenyang 110000,Liaoning Province,China)Abstract PURPOSE:To study the temporomandibular joint morphology and position and the maxillary characteristics ofskeletal Class mandibular deviation patients with vertical disproportion in bilateral gonions.METHODS:Overall 79adult patients with skeletal Class malocclusions were selected.Craniofacial spiral CT scanning was performed,andthree-dimensional reconstruction of the temporomandibular joint(TMJ)was carried out by using ProPlan CMF3.0 three-di-mensional analysis software.The patients were divided into two groups according to the deviation degree of the mentum:symmetric group(the S group:n=24)and deviation group(n=55).The deviation group was divided into two subgroups ac-cording to whether there was vertical disproportion in bilateral gonions,i.e.,ASV group:there were vertical differences inbilateral gonions(n=27),and ASNV group:there was no vertical difference in bilateral gonions(n=28).Seven condylar mor-phological and position indicators and nine maxilla-related indicators were measured.SPSS 22.0 software package wasused for statistical analysis.RESULTS:In deviation group,the condylar length on the deviated side was shorter than theopposite side,the difference value between the two sides was greater than the symmetric group,and there were asymmetry上海口腔医学2023年2月 第32卷第1期Shanghai Journal of Stomatology Vol32 No1 February,202391and different degrees of disproportion in the three-dimensional direction in the maxilla.In ASV group,the angle of thecondylar axis to the horizontal plane on the deviated side was smaller and the anteroposterior diameter of the condyle wassmaller.In ASV group,the mediolateral dimension of condyle on the deviated side were smaller.From variance analysisand multiple comparisons,the difference of condylar length on both sides in ASV group and ASNV group was greater thanthat in the symmetric group.There were asymmetries in the maxillae in ASV group and ASNV group,and the maxillarywidth on the deviated side was greater than that on non-deviated side.Transverse maxillary disproportion was more likelyto occur in the ASNV group.The vertical maxillary disproportion on both sides in ASV group was larger than that in AS-NV group and S group,and the deviated side was smaller than the opposite side.CONCLUSIONS:The TMJ morphologyand position of skeletal Class mandibular deviation patients with vertical disproportion in bilateral gonions and themaxillary asymmetry in the three-dimensional direction require attention in the diagnosis and conceptual design of surgi-cal-orthodontic treatment.Key words Skeletal Class malocclusion;Facial deviation;Temporomandibular joint;Three-dimensional reconstruc-tion;Maxillary featuresShanghai J Stomatol,2023,32(1):91-96.面部偏斜是临床上常见的错畸形，随着人们对面部美学要求的提高，面部偏斜是患者最常见的主诉之一。面部偏斜以面下1/3最明显，因此以往对面部偏斜的研究多关注于下颌骨的不对称。目前，面部偏斜的分类众多1-6，但是多数分类在偏斜的精准治疗方面的临床实际应用价值尚未得到验证，同时复杂的分类系统也使得临床应用变得困难。对于患者而言，他们更容易关注横向不调，而偏斜常常存在三维方向的差异。许多偏斜患者也存在颞下颌关节不对称7-8，目前尚无关于下颌骨垂直方向不调与颞下颌关节大小、形态、位置关系的研究。在颅颌面生长发育过程中，上颌骨的发育早于下颌骨，上颌骨不调也会影响下颌偏斜。有学者报道一些面部偏斜患者同时存在上颌骨不调7，但是相关研究较少。对于类偏斜的成人患者，大多需要正畸-正颌联合治疗，如果不纠正上颌骨不调，则无法有效纠正面部偏斜。因此，明确上颌骨三维向的不调对于正畸术前去代偿以及正颌手术方案的选择至关重要。本研究通过对成年骨性类偏斜患者有、无垂直向不调进行分类，并对颞下颌关节进行CT三维模型重建，探讨不同类型的下颌偏斜患者颞下颌关节和上颌骨的特征，为这类患者的临床诊断和治疗提供指导。1对象与方法1.1研究对象本研究获得中国医科大学附属口腔医院医学伦理委员会批准，在患者知情同意下，选择2016年3月2019年3月在中国医科大学附属口腔医院正畸二科就诊的骨性类错畸形患者，临床和影像资料完整。纳入标准如下：年龄1835岁；颏点相对于面部正中矢状面偏斜4 mm；头影测量ANB角0；恒牙完全萌出，无缺牙，无明显拥挤或异位。排除标准如下：可引起颅面部不对称的综合征、遗传性疾病、肿瘤等病史；颌面部重大创伤史；颞下颌关节紊乱病及关节区外伤史；正畸-正颌治疗史。共纳入79例患者，以颏下点偏向侧为偏斜侧，分为偏斜侧和偏斜对侧。根据颏下点偏斜程度，即颏下点距面部正中矢状面