發(fā)布時(shí)間：2018-08-13 11:20

【摘要】：Angle在1860年首次提出利用擴(kuò)大腭中縫進(jìn)行上頜擴(kuò)展來解決牙弓橫向發(fā)育不足、牙弓狹窄、牙列擁擠、后牙反合等錯(cuò)合畸形問題,至今,上頜擴(kuò)弓技術(shù)已經(jīng)在臨床應(yīng)用了一個(gè)多世紀(jì)并發(fā)展的極為成熟。但單純的上頜擴(kuò)弓不能解決下頜牙列擁擠等問題,并使下頜牙弓與擴(kuò)大的上頜難以匹配。下頜骨由于解剖結(jié)構(gòu)的特殊性導(dǎo)致其擴(kuò)弓的可行性一直備受學(xué)者們的質(zhì)疑。直到1962年,Walter通過臨床觀察提出下頜擴(kuò)展的可行性,1982年Sandstorm發(fā)表了第一篇有關(guān)下頜擴(kuò)弓的臨床報(bào)道。目前國內(nèi)外對下頜擴(kuò)弓進(jìn)行了大量的研究,但鮮少有關(guān)于上下頜聯(lián)合擴(kuò)弓矯治牙列擁擠的臨床報(bào)道,我院正畸科教授針對下頜骨特殊的解剖結(jié)構(gòu),將改良制作的下頜鋼網(wǎng)式螺旋擴(kuò)大器應(yīng)用于臨床,至今已成功矯治百余例。通常認(rèn)為上頜快速擴(kuò)弓產(chǎn)生的矯形力作用于牙齒和骨組織,打開腭中縫的同時(shí)導(dǎo)致支抗牙的輕度頰向傾斜和牙槽骨板的傾斜彎曲,同時(shí)伴隨骨改建。關(guān)于下頜擴(kuò)弓,目前主要觀點(diǎn)認(rèn)為主要是由于牙齒的頰傾帶來寬度的增加。國內(nèi)目前對上下頜聯(lián)合擴(kuò)弓的臨床報(bào)道較少,且多為個(gè)案報(bào)道,對于擴(kuò)弓前后,牙頜、牙齒與牙槽骨變化的系統(tǒng)研究也較少。相較于X線片檢查,近年來錐體束CT的應(yīng)用使測量內(nèi)容更加全面,測量更加精確可靠,為我們評(píng)價(jià)上下頜聯(lián)合擴(kuò)弓產(chǎn)生牙齒及頜骨的變化提供了有效手段。以往研究一般基于模型測量及X線片研究,本實(shí)驗(yàn)通過擴(kuò)弓前后牙合模型的測量,分析上下頜聯(lián)合擴(kuò)弓對上下頜牙列擁擠度及牙弓周長變化的影響,通過對截取的擴(kuò)弓前后正中矢狀面進(jìn)行定點(diǎn)測量,觀察擴(kuò)弓前后軟硬組織變化,通過MIMICS17.0軟件對擴(kuò)弓前后的CBCT影像進(jìn)行定點(diǎn)測量,評(píng)估青少年安氏Ⅰ類患者經(jīng)過上下頜聯(lián)合擴(kuò)弓后牙頜及側(cè)貌變化、牙弓形態(tài)、支抗磨牙及其牙槽骨的變化,為臨床應(yīng)用上下頜聯(lián)合擴(kuò)弓技術(shù)提供一定參考。研究目的本實(shí)驗(yàn)以應(yīng)用上下頜聯(lián)合擴(kuò)弓矯治牙列擁擠的25名青少年安氏Ⅰ類患者為研究對象,對其擴(kuò)弓前及保持三個(gè)月后拆除擴(kuò)弓器時(shí)的牙合模型及CBCT影像進(jìn)行測量,對比其前后測量結(jié)果,探討上下頜聯(lián)合擴(kuò)弓對牙列擁擠度及牙弓周長的影響,以及擴(kuò)弓過程中軟硬組織與牙弓形態(tài)的改變、支抗磨牙及相應(yīng)牙槽骨的傾斜變化和寬度變化,為上下頜聯(lián)合擴(kuò)弓的臨床應(yīng)用提供參考。研究方法對納入研究的25例青少年安氏Ⅰ類錯(cuò)合畸形患者,在其擴(kuò)弓前,擴(kuò)弓后保持三個(gè)月拆除擴(kuò)弓器時(shí)分別取牙頜模型,拍攝CBCT影像。在牙頜模型上測量上下頜牙列擁擠度及牙弓周長,截取CBCT正中矢狀面影像的測量內(nèi)容包括反應(yīng)硬組織變化和唇部軟組織變化的指標(biāo),運(yùn)用MIMICS17.0軟件對所有CBCT影像進(jìn)行同名牙牙冠和牙根寬度的測量,對上頜兩側(cè)第一磨牙及其牙槽骨的角度變化、下頜兩側(cè)第一磨牙的角度變化進(jìn)行測量,對上頜鼻底平面、硬腭平面、頰腭側(cè)牙槽嵴頂對應(yīng)的上頜骨寬度,下頜兩側(cè)第一磨牙的CEJ、頰舌側(cè)牙槽骨的對應(yīng)寬度進(jìn)行測量。所有測量工作均由作者本人完成,每項(xiàng)數(shù)據(jù)分別測量三次,每次測量間隔一周,三次測量結(jié)果取平均值,應(yīng)用SPSS19.0統(tǒng)計(jì)軟件對擴(kuò)弓前后的數(shù)據(jù)進(jìn)行配對t檢驗(yàn)等相關(guān)統(tǒng)計(jì)學(xué)分析。結(jié)果擴(kuò)弓前后各測量結(jié)果對比統(tǒng)計(jì)顯示1.上下頜牙列擁擠度明顯減小且變化具有統(tǒng)計(jì)學(xué)意義(P0.05),上下頜牙弓周長增加,變化具有統(tǒng)計(jì)學(xué)意義(P0.05)。2.CBCT正中矢狀面影像軟硬組織測量結(jié)果顯示,下頜平面角稍增大,上下切牙稍有唇傾,但變化均無統(tǒng)計(jì)學(xué)意義(P0.05),上下唇凸點(diǎn)至審美平面距離均有減小,但變化也無統(tǒng)計(jì)學(xué)意義(P0.05)。3.上下頜牙冠及牙根寬度均有增加,且變化具有統(tǒng)計(jì)學(xué)差異(P0.05),牙冠寬度增加量稍大于牙根寬度增加量,且寬度增加呈現(xiàn)前磨牙區(qū)最大,磨牙區(qū)次之,尖牙區(qū)最小的趨勢。4.上頜第一磨牙的傾斜角度變化無統(tǒng)計(jì)學(xué)意義(P0.05),但上頜牙槽骨傾斜角度和下頜第一磨牙傾斜角度的變化有統(tǒng)計(jì)學(xué)意義(P0.05),說明上下頜聯(lián)合擴(kuò)弓時(shí),上頜支抗磨牙基本未發(fā)生傾斜,而上頜左右側(cè)牙槽骨傾斜角度分別增加約10.75°和8.61°,下頜左右側(cè)第一磨牙分別頰向傾斜約7.74°和7.18°。5.上頜第一磨牙牙槽骨各線距均有增加,變化有統(tǒng)計(jì)學(xué)意義(P0.05)。鼻底平面對應(yīng)寬度增加約3.95mm,硬腭平面對應(yīng)寬度增加約5.90mm,頰舌側(cè)牙槽嵴頂對應(yīng)寬度分別增加約6.37mm和5.09mm,總體趨勢與牙槽骨傾斜變化一致。6.下頜第一磨牙區(qū)域的頰舌側(cè)牙槽骨寬度均得到增加,變化具有統(tǒng)計(jì)學(xué)意義(P0.05),釉牙骨質(zhì)界寬度增加(約4.39mm)較牙冠寬度增加(約5.98mm)較小,但從牙槽骨頰舌側(cè)寬度增加幅度看來,釉牙骨質(zhì)界下2mm處與7mm處,頰舌側(cè)骨板增加量基本一致。結(jié)論1.上下頜聯(lián)合擴(kuò)弓可有效開辟間隙,增加牙弓周長,解決青少年橫向發(fā)育不足和牙列擁擠等問題。2.擴(kuò)弓前后面部軟硬組織并未發(fā)生明顯變化。3.上頜擴(kuò)弓時(shí),上頜支抗磨牙基本未發(fā)生傾斜,可視為整體移動(dòng),主要為上頜腭中縫的開展及牙槽骨的傾斜。4.改良鋼網(wǎng)式擴(kuò)弓器對下頜的擴(kuò)弓作用不單單是牙齒的頰傾,而是牙齒頰向移動(dòng)的同時(shí)伴隨牙根的移動(dòng)和牙槽骨的改建。
[Abstract]:Angle first proposed in 1860 to expand the maxillary arch by enlarging the middle palatal suture to solve the problems of malocclusion, such as underdevelopment, narrow arch, crowded dentition, occlusion of posterior teeth, etc. Up to now, maxillary arch expansion technology has been used in clinical practice for more than a century and developed very mature. But simple maxillary arch expansion can not solve the problem of mandibular dentition. The feasibility of mandibular arch expansion was questioned by scholars because of the anatomical structure of the mandible. Until 1962, Walter proposed the feasibility of mandibular expansion through clinical observation. Sandstorm published the first clinical report on mandibular arch expansion in 1982. At present, a large number of studies have been done on mandibular expansion, but few reports have been reported on the treatment of crowded dentition with combined maxillary and mandibular expansion. In view of the special anatomical structure of the mandible, our orthodontic professor has applied the modified mandibular steel mesh spiral expander to the clinic. Up to now, more than 100 cases have been corrected successfully. The orthodontic force produced by rapid expansion of the arch acts on the teeth and bone tissues, opening the middle palatal seam and leading to a slight buccal inclination of the anchorage teeth and an oblique bending of the alveolar bone plate, accompanied by bone remodeling. Compared with X-ray examination, the application of cone-beam CT in recent years makes the measurement more comprehensive, more accurate and reliable, and provides a basis for evaluating the changes of teeth and jaws caused by combined maxillary and mandibular expansion. Previous studies were generally based on model measurements and X-ray studies. In this study, the effects of combined maxillary and mandibular arch expansion on crowding degree and periodontal length of maxillary and mandibular dentition were analyzed by measuring occlusal models before and after arch expansion. Objective To evaluate the changes of maxillary and lateral appearance, arch shape, anchorage molars and alveolar bones of the juvenile Angle class I patients after combined maxillary and mandibular arch expansion by measuring CBCT images before and after the expansion with MIMICS 17.0 software. The occlusal models and CBCT images of 25 adolescents with Class I dentition crowding treated with maxillary and mandibular combined arch expansion were measured before and three months after the arch expansion. The effects of maxillary and mandibular combined arch expansion on the crowding degree and periodontal length of dental arch were compared. The changes of the morphology of the soft and hard tissues and arch, the inclination and width of the anchorage molars and the corresponding alveolar bones during the course of the arch expansion can provide reference for the clinical application of combined maxillary and mandibular arch expansion. The crowding degree of maxillary and mandibular dentition and the circumference of dental arch were measured on the dental model. The measurement contents of CBCT median sagittal plane included the indexes reflecting the changes of hard tissue and lip soft tissue. The width of crown and root of all CBCT images were measured by MIMICS 17.0 software. The angles of the first molars on both sides of the jaw and their alveolar bones, the angles of the first molars on both sides of the jaw were measured. The maxillary width corresponding to the maxillary floor, hard palate, buccal and palatal alveolar crest, the CEJ of the first molars on both sides of the jaw, and the corresponding width of the alveolar bone on the buccal and lingual sides were measured. Completed, each data were measured three times, one week interval between each measurement, three measurements were taken to average, the data before and after the expansion of the paired t-test and other statistical analysis. Significance (P 0.05), maxillary and mandibular arch circumference increased, the change was statistically significant (P 0.05). 2. CBCT median sagittal imaging soft and hard tissue measurement results showed that the mandibular plane angle slightly increased, the upper and lower incisors slightly inclined lip, but the change was not statistically significant (P 0.05), the upper and lower lip bump to the aesthetic plane distance were reduced, but the change was not statistically significant. Significance (P 0.05). 3. The crown and root widths of maxillary and mandibular teeth increased significantly (P 0.05). The increase of crown width was slightly larger than that of root width. The increase of crown width showed the largest in premolar area, the second in molar area, and the smallest in canine area. 4. There was no significant difference in the inclination angle of maxillary first molar (P 0.05). However, the maxillary alveolar inclination angle and the mandibular first molar inclination angle were significantly different (P 0.05), indicating that the maxillary anchorage molars did not incline, the maxillary alveolar inclination angle increased by 10.75 degrees and 8.61 degrees respectively, and the mandibular first molars inclined by 7.74 degrees and 7.61 degrees respectively. Alveolar bone spacing of maxillary first molars increased significantly (P 0.05). The corresponding width of nasal floor increased by 3.95 mm, that of hard palate increased by 5.90 mm, and that of buccolingual alveolar ridge increased by 6.37 mm and 5.09 mm, respectively. The overall trend was consistent with that of alveolar bone inclination. The width of the alveolar bone on the buccal-lingual side of the alveolar bone increased significantly (P 0.05). The width of the enamel-cementum boundary increased slightly (about 4.39 mm) than that of the crown (about 5.98 mm). However, the increase of the alveolar bone width on the buccal-lingual side of the alveolar bone was similar to that on the buccal-lingual side at the 2 mm and 7 mm below the enamel-cementum boundary. The expansion of the maxillary arch can effectively open the space, increase the perimeter of the arch, and solve the problems of underdevelopment and crowded dentition in adolescents. 4. The effect of modified steel mesh expander on mandibular expansion is not only the buccal inclination of teeth, but also the buccal movement of teeth accompanied by root movement and alveolar bone remodeling.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R783.5

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