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1高角和低角病例的诊断、临床特征及正畸治疗特点Highangleandlowanglecases,diagnosis,clinicalfeaturesandorthodontictreatment2•由于以往的诊断是以安氏分类为主,正畸医生常常只注意到矢状向错牙合而忽略了垂直向不调。•近年来,学者们逐渐认识到垂直面型在错畸形诊断和治疗中的重要性:它不仅为颅面复合体的生长方向提供了线索,而且直接影响治疗的成功与否。PreviousdiagnosiswasbasedonAngle'sclassificationsoorthodontistsoftenonlynoticedthesagittalmalocclusionwhileignoringtheverticaldimension.Inrecentyears,scholarshavecometorealizetheimportanceoftheverticaldimensionsinthediagnosisandtreatmentofmalocclusionitnotonlyprovidescluestothedirectionofgrowthofthecraniofacialcomplex,butalsodirectlyaffectsthesuccessoftreatment.3•垂直向异常有高角和低角两种类型,在Ⅲ类安氏错牙合中约有50%左右的患者存在不同程度的垂直向异常。•Verticalanomalyareoftwotypesofhigh-angleandlowangle,about50%ofpatientswithangleclassIIImalocclusionhavevaryingdegreesofabnormalverticaldimension•high-angleandlowanglecases,diagnosis,clinicalfeatures,andorthodontictreatment4一、高角病例和低角病例的诊断和形成机制Highangleandlowanglecasesdiagnosisandform•文献中用来描述垂直向异常的说法很多,常用的有开张面型(hyperdivergent)、向后旋转型(backwardrotation)、垂直生长型(verticaltype)、长面型(dolichocephalic)、高角型(high-angleface),均指垂直向异常以发育过度(verticalexcessive)为主,而聚合面型(hypodivergent)、向前旋转型(forwardrotation)、水平生长型(horizontaltype)、短面型(brachypechalic)、低角型(low-angleface)则是指垂直发育不足(verticaldeficiency)。•由于诊断标准和侧重点不同,从严格意义上讲,这些概念之间是有差异的,但在临床中描述垂直面型时经常通用。Diagnosticcriteriaandadifferentfocus,inthestrictsense,theseconceptsthereisadifference,butoftencommonintheclinicaldescriptionofverticaltype.5高角病例和低角病例的诊断和形成机制Highangleandlowanglecasesdiagnosisandform•本文中统称为高角和低角,但不能误解为下颌平面角大者即为高角型、小者即为低角型,这是因为下颌角和下颌下缘在生长改建过程中变化较大,所以单纯以下颌平面角作为诊断标准可能掩盖了下颌真实的旋转方向,对垂直面型的正确诊断还应结合其他指标。•Referredtoarticleashigh-angleandlowangle,shouldnotbeconfusewiththemandibularplaneangle,ifitishigh,calledhighanglecase,andifsmallthanlowanglecase.Becausethemandibularangleandmandibularmarginchangeswithgrowth,sosimplemandibularplaneangleasthediagnosticcriteriamaymaskthetruemandibularrotationanddirectionoftheverticalgrowth.Thecorrectdiagnosisshouldbecombinedwithotherindicators6目前常用的诊断标准是:Thecommonlyuseddiagnosticcriteriaare:•(1)下颌平面角Mandibularplaneangle:高角病例前颅底—下颌平面角(SN-MP)大于40°,FH平面—下颌平面角(FH-MP)大于32°;低角病例SN-MP小于29°,FH-MP小于22°。•(2)后面高与前面高比值anteriortotheposteriorfacialheightratio(S-Go/N-Me):高角病例大于68%;低角病例小于62%。•(3)下前面高与前面高比值lowertotheupperfacialheightratio(ANS-Me/N-Me):高角病例大于58%;低角病例小于55%。7•高角病例或低角病例的形成主要与前后面部高度的生长发育失调有关。high-angleorlowanglecaseswithahighlevelofgrowthanddevelopmentbeforeandafterfacialdisorders•后面部高度生长不足(升支短小、关节窝靠前靠上)和/或前面部高度生长过度(髁突向后生长、上颌骨垂直发育过度、后牙垂直萌出过度)形成了高角型。Lackofposteriorfacialgrowth(ascendingbranchoftheglenoidfossasmall)and/oranteriorfacialheightovergrowth(condylarbackwardgrowth,excessiveeruptionofthemaxillaryposteriorteeth)isresponsibleforahigh-anglecase.•后面部高度生长过度(升支较长、关节窝靠后靠下)和/或前面部高度生长不足(髁突向上向前生长、上颌骨垂直发育不足、后牙萌出不足)形成了低角型。posteriorheightovergrowth(theascendingbranchofaglenoidfossalong)and/orinlackofposteriorfacialgrowth(upwardandforwardrotationofcondyle,lackoferuptionofmaxillaryposteriorteeth)isresposibleforlow-anglecase.8二、高角病例和低角病例的临床特征Thecaseofhigh-angleandlowangleoftheclinicalfeatures1、面型:正面观高角病例多为窄长脸型,两侧下颌角不明显,鼻根部较窄,常伴有唇功能不足、开唇露齿;低角病例则多为宽短脸型,两侧下颌角呈方形,鼻根部较宽,唇闭合十分自然。99clinicalfeaturesofhigh-angleandlowanglecasesAface:frontview:High-angle:longandnarrowface,bothsidesofthemandibularangleisnotdistinct,thenasionisnarrow,oftenaccompaniedwithincompetentlip.Low-anglecasesaremuchmorewideandshortface.Bothsidesofthemandibularanglewasasquare,nasioniswide,lipclosureisnormal10•侧面观Lateralview:高角病例呈开张面型,面下1/3长,凹面型多见,上唇较厚,颏部和颏唇沟均不明显,头位略前伸;Highanglecases,lengthofthelower1/3ofthefaceislong,theconcavetypeprofilemorecommon,thickupperlip,chinandchinlipgroovearenotprominent.低角病例呈聚合面型,面下1/3段短,凸面型多见,上唇较薄,颏部和颏唇沟明显。low-anglecasesthelower1/3ofthefacegenerallyshorterconvexfacialprofile,thinupperlip,chinandchinlipgrooveareprominent.11二、高角病例和低角病例的临床特征Thecaseofhigh-angleandlowangleoftheclinicalfeatures2、牙Tooth:高角病例常见上牙弓狭窄、腭盖高拱,由于切牙多唇向倾斜前牙拥挤较少见,前牙覆浅甚至呈现开或开倾向,后牙的临床冠高度较大,曲线平坦甚或反向,上下颌之间的息止间隙较小;Highanglecases:-narrowupperarchwithdeeperhardpalate,anteriorproclinationisrarelyseen.theheightofclinicalcrownlarger,thecurveofspeeisflatandtheanglebetweenthefacialaxisofupperandlowerincisorisless.12clinicalfeaturesofhigh-angleandlowanglecasesTeeth:低角病例上牙弓较宽阔,切牙位置较直立故前牙拥挤多见,前牙覆较深甚至呈闭锁,后牙的临床冠较短,Spee曲线深、曲度较大,息止间隙较大。伴有吐舌习惯的高度病例根尖片常可见恒中切牙牙根明显变短。Lowanglecases:-broadupperarchwithshallowhardpalate,theincisorpositionismoreuprightsoanteriorteethcrowdingiscommon.clinicalcrownissmaller.Curveofspeeisdeep.anglebetweenlongaxisofupperandlowerincisorishigh1213牙弓狭窄、腭盖高拱高角病例低角病例上牙弓较宽阔14二、高角病例和低角病例的临床特征Thecaseofhigh-angleandlowangleoftheclinicalfeatures•3、硬组织颅面形态:高角病例的腭平面、牙合平面和下颌平面向下倾斜,下颌角钝,下颌下缘弯曲,磨牙与平面角度倾斜,上下前牙唇向倾斜,上下中切牙角较小high-anglecase:-thepalatalplane,occlusalplaneandmandibularplaneislow,angleofmandibleislarge,curvedmandibularlowermargin,slightlyproclinedupperandloweranteriorteeth.Anglebeteenlongaxisofupperandlowerincisorissmall.15•低角病例腭平面、牙合平面和下颌平面接近平行,下颌角呈直角,下颌下缘平缓,下颌管弯曲,前牙直立,上下中切牙角较大•thepalatalplane,occlusalplaneandmandibularplanenearlyparalleltotheangleofmandibularperpendiculartotheflatedgeunderthelowerj