儿童早期矫治与咬合管理

儿童生长发育期的咬合管理是儿童口腔健康管理的重要组成部分,对儿童口腔临床工作具有重要的指导作用。咬合管理中的早期矫治,也一直是口腔医学关注和研究的热点。早期矫治通过预防、诱导和矫治等手段,引导颅颌面各时期的正常发育,阻断错牙合畸形的发生发展,最终降低儿童错牙合畸形的发生率与严重程度,促进儿童身心健康发展。结合儿童口腔发育特点、儿童错牙合畸形成因以及早期预防矫治方法,文章对儿童早期矫治与咬合管理进行探讨,希望进一步完善咬合管理的临床技术体系与理论基础,促进儿童口腔医学的发展。     

儿童早期肌功能训练与错（牙合）畸形预防矫治

现代儿童错(牙合)畸形的矫治更强调早期预防与阻断,矫正理念是“咬合发育管理”,治疗儿童从出生后到恒牙替换萌出结束整个过程的咬合发育不良。儿童早期肌功能训练及错(牙合)畸形预防矫治应用“Muscle?Win”理论,早期预防与阻断错(牙合)畸形的发生,以期最终降低儿童错(牙合)畸形的发生率与严重程度。早期肌功能训练及错(牙合)畸形预防矫治器是一种功能矫治器,其特点是：1）其重建了上下咬合关系,控制上下颌骨的位置及生长;2）矫治器功能结构能训练舌肌、唇颊肌及颏肌的功能和矫正口呼吸习惯;3）恒牙萌出诱导槽能引导排列新萌出的恒牙;4）矫治器能恢复上下牙弓的形态与宽度。临床佩戴矫治器,能训练儿童口腔功能,去除口腔不良习惯,引导恒牙萌出,并对Ⅱ/Ⅲ类错(牙合)畸形和轻中度牙弓发育不良有矫治效果。儿童早期肌功能训练及错(牙合)畸形预防矫治有局限性,正确选择临床适应证及使用时机是保证疗效、防止临床过度治疗的关键。作为儿童错(牙合)畸形早期功能矫治的有益探索,早期肌功能训练及错(牙合)畸形预防矫治器正成为“咬合发育管理”临床技术体系的有机组成,并得到儿童口腔医学及口腔正畸学医生越来越多的重视。     

咬合诱导与功能矫治在儿童早期错牙合畸形矫治中的应用

近年来儿童口腔医学早期矫治得到了飞速发展,通过预防错牙合畸形的发生、阻断错牙合畸形的进展等措施,诱导儿童建立正常的咬合关系,降低后期综合正畸治疗的难度,促进儿童身心健康发展已成为儿童错牙合畸形早期矫治的公认方法。本文结合儿童错牙合畸形的形成原因、儿童生长发育的特点、咬合诱导、肌功能训练及其应用和功能矫治的发生发展、临床应用等方面进行综述,以期为儿童错牙合畸形的早期矫治提供理论依据。     

牙弓/牙槽骨弓的塑形矫治——基于牙弓形态发育不良的儿童错牙合畸形诊断与阻断治疗

错畸形是颅面颌系统生长发育的异常,其产生是遗传、环境及特殊病因共同作用的结果。儿童错畸形的早期矫治是去除造成错畸形的病因,维持、恢复及矫正异常发育的颅面颌结构,矫正咬合关系异常;其主要目的就是要利用个体生长潜力,用较小的代价达到有效的稳定的矫治效果。错畸形早期矫治的范围很宽,包括口腔功能的早期矫治（口腔不良习惯早期矫治）、口周肌肉功能训练、牙替换的维护、牙发育不良的矫治、上下颌骨关系异常的矫治等等。从正畸学角度上看,牙错位的矫正称为“正牙”（orthodontics）,上下颌骨发育关系异常的矫治称为“矫形”（orthopedics）;而在牙弓/牙槽骨弓形态大小异常上的矫治,临床仍有进一步梳理和发展的空间。四川大学华西口腔医院儿童与口腔正畸科·儿童早期矫治专科在大量的临床实践中,总结了牙弓/牙槽骨弓发育的特点与规律,探索早期矫治异常牙弓发育的正畸临床思路与技术,在国内首次提出“牙弓/牙槽骨弓发育不良的塑形矫治”理论。把牙弓/牙槽骨弓发育不良的早期阻断矫治定义为“塑形”（remodeling）,丰富除“正牙”与“矫形”等正畸治疗理论与技术外的错治疗方法,并用于指导错畸形早期矫治的临床工作,以期达到早期预防、阻断错畸形的发生发展,简化错复杂程度、降低错治疗难度的效果。本文从临床矫治的基础及儿童生长发育的角度,全面归纳分析“牙弓/牙槽骨弓发育不良的塑形矫治”的理论基础和临床思路,阐述该理论的可能性及必要性,希望借此促进儿童错畸形的早期预防与阻断矫治的理论与技术的发展。     

一例混合牙列牙弓发育不足患儿的早期口腔健康管理

儿童口腔健康管理（Oral health management for children,OHMC）包含儿童牙病的预防、治疗和咬合发育管理两部分,进行早期OHMC可以保护儿童口腔软硬组织、养成良好的口腔卫生保健意识、预防及阻断错畸形的发生发展,目的是使儿童牙、牙合、颜面正常发育,达到颅颌面的功能完善与美观协调。本文报道一例混合牙列早期个别前牙反牙合患儿的口腔健康管理。     

固定义齿与正畸联合治疗伴错(牙合)畸形的牙列缺损

临床上常见伴发错[牙合]畸形的牙列缺损病例，用常规的修复方法，虽然能够修复缺失牙余留的间隙，但很难达到美观、功能、稳定兼顾的效果。作者对12例伴发错[牙合]畸形的牙列缺损患者，采用正畸与固定修复联合治疗的方法，先正畸矫治错[牙合]畸形，调整咬合关系，调整余留牙与缺失牙在牙弓中的位置，以获得固定修复的适应症，然后对牙列缺损进行固定修复，取得了良好的治疗效果。     

基于牙弓形态大小发育的青少年隐形矫治

青少年牙弓形态大小的发育具有特定的规律，正常的牙弓形态大小是正常咬合发育的基础之一。全面深入地分析颅颌面的形态和结构，可完善青少年错牙合畸形的临床矫治方案。文章就牙弓形态大小对咬合关系影响的临床理论在错牙合畸形矫治中的应用，探讨青少年隐形矫治技术的特点，总结其应用的发展规律，拟更有效地开展青少年错牙合畸形的隐形矫治工作，推动青少年错牙合畸形早期阻断及综合矫治的发展，提高青少年错牙合畸形隐形矫治技术的水平。     

上颌尖牙错(牙合)的正畸治疗

目的探讨上颌尖牙错[牙合]畸形诊断和治疗的相关问题。方法对217例有上颌尖牙错[牙合]的患者根据其年龄和发育阶段以及错[牙合]畸形的不同情况采取了不同的矫治方法。结果上颌尖牙唇向低位的184例患者通过扩弓、前方牵引、邻面去釉及减数拔牙的方法，1例异位牙和3例尖牙位于侧切牙唇侧的通过正畸和修复的方法，29例埋伏阻生的通过手术及开窗导萌等外科和正畸的方法，均达到了牙列整齐，咬合关系良好的目标。结论对于复杂的上颌尖牙错位萌出，只要及早发现并且采取积极有效的预防及治疗方法，都会在美观和功能上得到较好的效果。     

预成型肌功能矫治器早期肌功能矫治研究进展

儿童在生长发育期存在的不良习惯,可能导致其颌面部肌群的不平衡,增加了(牙合)系统发生错(牙合)畸形的风险。儿童的早期矫治与肌功能训练是为了去除能够造成错(牙合)畸形的病因和进行早期的肌功能训练,从而达到恢复正常颅颌面结构和咬合关系的目的。预成型肌功能矫治器是一类通过改变口面肌肉功能,促进(牙合)发育和颅颌面生长的矫治器,可以对患者的不良习惯及颅颌面畸形的危险因素进行早期的阻断治疗。预成型肌功能矫治器由于其预成型、疗效快、舒适等优点,近年来被广泛使用,该文对预成型肌功能矫治器进行综述。     

安氏Ⅲ类错畸形矫治对髁突影响的研究现状

安氏Ⅲ类错[牙合]畸形对患者口腔功能、颜面美观和心理健康均有较严重影响,临床上常对此类患者进行早期矫治。在早期矫治该类错[牙合]畸形中常使用矫形力抑制下颌骨的生长。髁突作为面部重要的生长发育区,其生长改建直接影响下颌的形态和功能。安氏Ⅲ类错[牙合]畸形矫治的矫形力对髁突的影响近年来逐渐受到学者们的关注,本文就近年来国内外安氏Ⅲ类错[牙合]畸形矫治对髁突影响的研究现状作一综述。     

中国儿童错𬌗畸形早期矫治专家共识

错𬌗畸形是世界卫生组织公布的口腔三大疾病之一,其发病率在我国有升高的趋势,严重影响我国近2.6亿儿童牙颌面功能、颜面美观及生长发育,甚至影响儿童全身及心理健康发育。错𬌗畸形发生涉及遗传及环境因素,早期矫治创建良好的牙颌面生长环境,纠正异常牙颌面生长、控制异常遗传因素,能有效地降低儿童错𬌗畸形的发病率,维护我国儿童身心健康,这是我国社会经济发展的迫切需要,具有重大的现实和社会意义。中国国家卫生健康委医院管理研究所“儿童早期矫治规范化诊疗项目”专家组撰写“中国儿童错𬌗畸形早期矫治专家共识”,旨在引导和普及我国儿童早期矫治临床治疗,促进我国儿童早期矫治理论与临床水平的提高,加速我国儿童早期矫治专业发展。共识阐述了错𬌗畸形的危害性及早期矫治的必要性,提出了儿童早期矫治的原则和基本内容。在遵循牙颌面发展规律的基础上,提出从孕期到恒牙列初期儿童牙颌面生长发育不同时期分阶段的预防与阻断治疗的指导性建议。错𬌗畸形早期矫治的推广和规范是一个系统工程,通过科学的、全面的分级医疗及专业培训将最终完善我国儿童早期矫治临床体系,达到全面呵护我国儿童牙颌面健康,提高我国儿童口腔健康及全身健康水平的目的。     

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儿童口腔临床治疗的根本目的在于使儿童保持完整的乳牙列,进而建立正常的恒牙列.儿童期的咬合紊乱不仅可影响儿童的口腔功能,妨碍牙齿及牙周组织的健康,还可影响口腔颌面软硬组织正常发育、颜面美观和心理健康.因此,目前对儿童时期咬合异常的早期矫治越来越受到国内外学者及儿童牙医的重视,本文就儿童期常见的乳牙列前牙反(牙合)、乳牙列后牙反(牙合)及混合牙列期的个别恒牙反(牙合)早期矫治的临床应用做一介绍.     

口腔颌面创伤后的早期心理测评及心理干预

目的：探讨性格因素对口腔颌面创伤患者心理干预临床效果的影响。方法：采用暴露疗法、催眠等方式,对72例不同程度口腔颌面创伤住院患者进行心理干预．通过SCL-90症状自评清单对患者干预前后的心理状态进行评估,采用SPSS18．0软件包对数据进行统计学分析。结果：干预前,口腔颌面创伤患者SCL-90因子得分普遍高于常模（P〈O．001）．干预后创伤患者的心理健康水平与常模无显著差异。不同创伤严重等级患者心理干预效果差异显著（P〈0．001）,性格因素对干预效果的影响在强迫、人际关系、抑郁和偏执4个因子上差异显著。结论：心理干预的效果与性格因素有关,早期心理干预对内向性格类型的口腔颌面创伤患者的治疗效果优于外向性格类型的患者：创伤严重程度对心理干预的影响与性格因素有关。     

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??Severe skeletal malocclusion is not only an existing dental problems??which is associated with upper and lower arch size discrepancy?? Morphology??Position??Symmetry and other significant abnormalities??but also it affects the patient's oral cavity??the physiological function of maxillofacial and even the whole body??patient's social status??furthermore it may also cause a different Psychological effects to the patient. The combination of orthodontic treatment and orthognathic surgery can treat severe skeletal malocclusion problems which cannot be treated by orthodontic treatment alone. As a result??the patient can have an ideal improvement by a combination of both therapies in order to maintain healthy aligned teeth??stable occlusal relationship??improved oralfunctionand facial aesthetics. These will improve the patient's life quality??enhance patient′s selfconfidence??as well as a happy life.     

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随着口腔正畸学的发展与成熟,口腔正畸医生和颌面外科医生通过良好的合作,有效地将口腔正畸学与颌面外科学紧密地结合起来,形成口腔正畸-正颌外科联合治疗骨性错耠畸形的治疗手段。正颌外科对于颌面部和牙弓形态学的改善已经得到学术界的普遍认可,并且获得越来越多患者的接受。正颌手术治疗后,患者颌骨和牙齿均有移动,打破了原有的口颌系统,重建咬合平衡。近些年来,关于患者正颌手术治疗后口颌系统功能改变的研究一直受到广泛关注并存在很多争议。本文就近年来正颌手术治疗后口腔生理功能变化的相关研究进展做一综述。     

Treatment of mandibular asymmetry by distraction osteogenesis and orthodontics: a report of four cases

Distraction osteogenesis devices followed by hybrid functional appliance therapy and fixed orthodontic appliance therapy were used to correct a variety of maxillofacial skeletal and dental deformities in 4 patients. The patients underwent procedures to lengthen the mandibular ramus and body. Transcutaneous pins were used to activate the distraction devices. After achieving the desired skeletal position, the distraction devices were maintained for 2 to 3 months to allow ossification. Following distraction, functional orthodontic appliance therapy was initiated during growth to correct the cant of the occlusal plane by extrusion of teeth on the affected side for improved facial symmetry. Fixed orthodontic therapy was used for final occlusal adjustments. All patients achieved lengthening of their jaws and substantial improvement in facial symmetry and occlusion. The follow-up period for this group of 4 patients ranged from 18 to 36 months.     

Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic patients.

Pretreatment cephalometric radiographs may contain important incidental findings that require attention before orthodontic therapy. A review of the cephalometric and dental radiographs of 325 consecutive healthy orthodontic patients revealed 431 notable findings of the skull, cervical spine, and maxillofacial complex. Most of these findings were nonpathologic anomalies or normal variants. If recognized as such by the orthodontist, no further evaluation would be required, thus avoiding unnecessary costs and patient anxiety. However, there were 15 findings (3.5%) that required additional evaluation by physicians or oral and maxillofacial surgeons before or concurrent with the initiation of orthodontic therapy. Familiarity with the appearance and prevalence of skeletal and dental anomalies and normal variants seen in cephalometric radiographs, and the ability to separate those that require follow-up from those that do not, is an important facet of orthodontic practice.     

Role of interceptive orthodontics in early mixed dentition

Early orthodontic interventions are often initiated in the developing dentition to promote favourable developmental changes and remove or suppress those that are unfavourable. Early interceptive orthodontics can eliminate or reduce the severity of a developing malocclusion, the complexity of orthodontic treatment, overall treatment time and cost. It also improves self-esteem in the subjects and parental satisfaction. Early detection and appropriate referral of cases requiring interceptive orthodontics are important. However, lack of awareness among school children, parents and primary-care personnel (dental nurses and dental officers) may result in patients not being referred for timely interceptive intervention. This article presents a general view of the scope of interceptive orthodontics that can be carried out in early mixed dentition, i.e. when the permanent incisors and molars are erupting into the oral cavity.     

Early orthodontic treatment: what are the imperatives?

BACKGROUND: Then authors provide a critical review of the issues involved in determining the appropriate timing of orthodontic treatment. Both single- and two-phase treatments are discussed and guidelines are offered to assist in formulating treatment plans. OVERVIEW: In providing orthodontic care for pediatric patients, clinicians often question whether to begin treatment early--during the primary or early-transitional dentition--or wait until all or most of the permanent teeth are present. The authors review the most current literature (from 1991 to 1999), including several recently completed and ongoing randomized clinical trials, to critically evaluate the effectiveness of each approach. PRACTICAL IMPLICATIONS: The controversy surrounding early vs. late orthodontic treatment is often confusing to the dental community. This article reviews both sides of the issue for orthodontic treatment of Class II and III malocclusions, as well as for the management of Class I crowding and problems in the transverse dimension. Early orthodontic treatment is effective and desirable in specific situations. However, the evidence is equally compelling that such an approach is not indicated in many cases for which later, single-phase treatment is more effective. Therefore, clinicians must decide, on a case-by-case basis, when to provide orthodontic treatment. For many patients, delaying treatment until later in their dental and skeletal development may be advisable.