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,維持治療效果長久穩(wěn)定,減少復(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功能的爭議

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