FAS定位系统与颞下颌关节紊乱病的治疗-动脉网

The FAS Aligner System and the treatment of temporomandibular disorders

Dental Tribune 等信源发布 2024-07-22 19:09

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Dr Domingo Martín

多明戈·马丁博士

Mon. 22. July 2024

周一。2024年7月22日

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When there is alteration of any of the internal structures that make up the temporomandibular joint (TMJ), it can be said that we are facing possible temporomandibular disorder (TMD). It should be noted that, according to Wu et al., only 17% of the population is free of TMJ problems, and 83% present with mild to severe manifestations of dysfunction.1.

当构成颞下颌关节（TMJ）的任何内部结构发生改变时，可以说我们面临着可能的颞下颌关节紊乱病（TMD）。值得注意的是，根据Wu等人的说法，只有17%的人口没有颞下颌关节问题，83%的人出现轻度至严重的功能障碍表现。

The literature on the aetiology of TMD describes it as multifactorial, involving biological, environmental, social, emotional and cognitive factors.2–6 The relationship between malocclusion and the development of TMD is still a matter of debate. There is currently a great deal of controversy regarding the link between TMD and occlusal factors.

关于TMD病因的文献将其描述为多因素，涉及生物，环境，社会，情绪和认知因素。2-6错牙合与TMD发展之间的关系仍存在争议。。

Authors such as Serrat,7 Bottino,8 Barker,9 Taboada et al.,10 Cooper and Kleinberg,11 and Selaimen et al.12 relate malocclusion to mandibular instability and therefore joint instability. In contrast, authors such as Martínez et al.,13 Kahn et al.,14 Gesch et al.,15 Seligman and Pullinger,16 and Lipp17 suggest that occlusal factors do not play an important role in the aetiology of TMD..

。相比之下，Martínez等人，13 Kahn等人，14 Gesch等人，15 Seligman和Pullinger，16和Lipp17等作者认为咬合因素在TMD的病因中不起重要作用。。

As the philosopher Karl Popper rightly said, scientific knowledge is the best and most important type of knowledge we have, although it is far from being the only source of knowledge.18 In our daily practice, in addition to considering the scientific literature, we must consider our clinical experience and clinical results.

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Okeson says, “Although orthodontics cannot be linked to prevention or causing TMD, it is difficult to imagine a specialty that changes interocclusal relationships so much and does not impact masticatory structures and function.19.

Okeson说，“虽然正畸学不能与预防或引起TMD联系起来，但很难想象有一种专业可以改变如此多的舌间关系，并且不会影响咀嚼结构和功能。

All the articles written that do not find a relationship between occlusion and TMD define occlusion from a static point of view.20, 21 Okeson keenly observes this and writes, “The literature finds a minor relationship between occlusal factors and TMD. It should be noted, however, that these studies report on the static relationship of the teeth as well as the contact pattern of the teeth during various eccentric movements.

所有没有发现咬合与TMD之间关系的文章都从静态的角度定义了咬合。20,21 Okeson敏锐地观察到这一点，并写道：“文献发现咬合因素与TMD之间存在微小关系。然而，应该注意的是，这些研究报告了牙齿的静态关系以及各种偏心运动期间牙齿的接触模式。

This represents the traditional approach to evaluating occlusion. Perhaps these static relationships can provide only limited insight into the role of occlusion and TMD.”.

这代表了评估遮挡的传统方法。也许这些静态关系只能对闭塞和TMD的作用提供有限的见解。”。

Undoubtedly, if we look at occlusion from a dynamic functional aspect as it relates to joint position, it is likely to provide more information regarding the relative risk of developing TMD. As McKee mentions in a guest editorial in Cranio,22 “Much of the confusion about occlusion could be resolved if we redefined the definition of ‘occlusion’.” The problem when defining occlusion solely by the position of the teeth is that the mandible is made up not only of teeth at the anterior end but also of condyles and discs at the posterior end.

毫无疑问，如果我们从与关节位置相关的动态功能方面来看闭塞，它可能会提供更多关于发展TMD相对风险的信息。正如McKee在《Crano》杂志的一篇客座社论中提到的那样，22“如果我们重新定义“咬合”的定义，那么关于咬合的许多困惑都可以得到解决。”当仅通过牙齿的位置来定义咬合时，问题是下颌骨不仅由前端的牙齿组成，而且由后端的髁突和椎间盘组成。

If we redefine occlusion as the position in which the mandible fits into the maxilla, an occlusal analysis would then consist of evaluating not only how the teeth in the mandible fit with the maxillary teeth but also how the unit of the condyle head and articular disc fits into the glenoid fossa. By evaluating occlusion at both the posterior end and the anterior end of the system, it becomes clear that changes at the TMJ level can explain many of the tooth-based malocclusions that have confounded our profession..

如果我们将咬合重新定义为下颌骨适合上颌骨的位置，那么咬合分析将不仅包括评估下颌骨中的牙齿如何与上颌牙齿匹配，还包括髁突头部和关节盘的单位如何适合关节盂窝。通过评估系统后端和前端的咬合情况，可以清楚地看出，颞下颌关节水平的变化可以解释许多困扰我们职业的基于牙齿的错牙合。。

Condyles become displaced for three main reasons (regardless of trauma): Class II Division 2 molar relationship, fulcrums and progressive condylar resorption.

髁突移位有三个主要原因（无论创伤如何）：II类2级磨牙关系，支点和进行性髁突吸收。

Class II Division 2 molar relationship. In a recent doctoral thesis [Spanish] carried out at the University of Seville in Spain, a study of CBCT images observed a more posterior position of the condyle within the glenoid fossa in patients who presented with the aforementioned malocclusion compared with patients with normal occlusion.23 The displacements were mainly downward and backward condylar displacements, producing compression of the synovial membranes, the posterior ligament and the bilaminar zone.

II类2级摩尔关系。在西班牙塞维利亚大学最近进行的一篇博士论文[西班牙语]中，对CBCT图像的研究观察到，与正常咬合患者相比，上述错牙合患者的髁突在关节盂窝内的位置更靠后.23位移主要是向下和向后的髁突移位，产生滑膜，后韧带和双侧区的压缩。

These patients were thus symptomatic..

因此，这些患者有症状。。

Fulcrum (posterior interference). Authors such as Čimić et al.,24 Palla25 and Isberg26 have observed that occlusal interferences, also known as fulcrums, can lead to an immediate change in condylar position within the TMJ. Most of these fulcrums are caused by the palatal cusps of the maxillary second molars.

。Čimić等[24]Palla25和Isberg26]的作者观察到，咬合干扰（也称为支点）可导致颞下颌关节内髁突位置的立即改变。大多数这些支点是由上颌第二磨牙的腭尖引起的。

These fulcrums will take the condyles out of the fossae, since the occlusion determines the condylefossa relationship, regulated by periodontal receptors that in turn activate the muscles. These fulcrums will interfere with the patient’s arc of closure and will not allow the condyles to sit correctly within the fossae with the discs correctly positioned.

这些支点将髁突从窝中取出，因为闭塞决定了髁突之间的关系，这种关系受牙周受体的调节，牙周受体反过来激活肌肉。这些支点会干扰患者的闭合弧，并且不允许髁突正确地位于椎间盘正确定位的窝内。

Therefore, as Padala et al. conclude, the condylar position will play a significant role in the aetio-pathogenesis of TMD.27.

因此，正如Padala等人所总结的那样，髁突位置将在TMD的发病机制中发挥重要作用。

Considering that occlusion is proprioceptive and always avoids interferences, the occlusal contacts of the teeth significantly influence the stability of the masticatory system. That is why Okeson asserts so widely that a functionally healthy masticatory system depends entirely on an orthopedically stable condylar position, and the condyles’ most stable musculoskeletal position coincides with maximum intercuspation.19, 28, 29 Therefore, orthopaedic stability should be the goal of treatment for any orthodontist.

考虑到咬合是本体感受的并且总是避免干扰，牙齿的咬合接触显着影响咀嚼系统的稳定性。这就是为什么Okeson如此广泛地断言，一个功能健康的咀嚼系统完全取决于骨科稳定的髁突位置，而髁突最稳定的肌肉骨骼位置与最大的内插相吻合.19,28,29因此，骨科稳定性应该是任何正畸医生治疗的目标。

He et al. show that, in most patients with signs and symptoms of TMD, there is a discrepancy between maximum intercuspation of the teeth and stable condylar position.30.

他等人表明，在大多数有TMD体征和症状的患者中，牙齿的最大尖牙间插和稳定的髁突位置之间存在差异。

A functional physiological occlusion is one in which the following characteristics are present:

功能性生理闭塞是指具有以下特征的闭塞：

Maximum intercuspation with no interferences occurs in a musculoskeletally stable position of the system.

在系统的肌肉骨骼稳定位置发生无干扰的最大插入。

Teeth have normal anatomy; cusps, pits and grooves allow vertical mastication without interferences.

；牙尖，凹坑和凹槽允许垂直咀嚼而不受干扰。

The condyles guide repetitive mandibular movements without parafunctional compensation.

。

The agonistic and antagonistic muscles work in coordination and act synergistically.

激动肌和拮抗肌协同工作，协同作用。

In a parafunctional occlusion, the following alterations can be observed:

在功能异常闭塞中，可以观察到以下变化：

Occlusal interferences in the arc of closure cause the mandibular movement to adapt to avoid these interferences.

。

The interferences often produce wear facets that alter dental anatomy, and patients lose their vertical masticatory pattern. Patients become horizontal chewers, further increasing tooth wear. Some authors have related wear facets to TMD.31–39 Large discrepancies between maximum intercuspation and stable condylar position frequently contribute to tooth wear and changes in masticatory patterns.34, 37, 39–42.

干扰通常产生磨损面，改变牙齿解剖结构，患者失去垂直咀嚼模式。患者变成水平咀嚼者，进一步增加牙齿磨损。一些作者将磨损面与TMD联系起来[31-39]。最大内插和稳定髁突位置之间的巨大差异经常导致牙齿磨损和咀嚼模式的改变[34,37,39-42]。

The patient may have pain, muscular spasm and other signs of TMD.32, 37

患者可能有疼痛、肌肉痉挛和其他TMD症状

Progressive condylar resorption (PCR), also called idiopathic condylar resorption. It is an aggressive form of degenerative disease of the TMJ. It is more frequent in adolescent females, although it has also been observed in males. Pathognomonic features of this condition include a loss of condylar mass, loss of condylar morphology, and reduction in size and height of the condyle.

进行性髁突吸收（PCR），也称为特发性髁突吸收。它是颞下颌关节退行性疾病的一种侵袭性形式。它在青春期女性中更为常见，尽管在男性中也有观察到。这种情况的病理特征包括髁突质量的丧失，髁突形态的丧失以及髁突的大小和高度的减小。

There is also a decrease in ramus height and mandibular length, producing postero-rotation of the mandible and a corresponding Class II molar relationship and open bite..

下颌支高度和下颌长度也有所减少，从而产生下颌骨的后旋转以及相应的II类磨牙关系和开放咬合。。

Changes occur in the soft tissue first; advanced cases involve hard tissue. Involvement of hard tissue is often preceded by disc displacement without reduction, which in turn contributes to the destruction of joint tissue and occurs when functional demands have surpassed the adaptive capacity of the tissue.

首先在软组织中发生变化；晚期病例涉及硬组织。硬组织受累之前通常会出现椎间盘移位而不复位，这反过来会导致关节组织的破坏，并且当功能需求超过组织的适应能力时就会发生。

In 67% of cases, PCR is unilateral.43 PCR is often related to unstable occlusion, leading to dysfunctional remodelling and morphological changes to the TMJ.44 Although some cases will be asymptomatic, according to Kristensen et al., most patients will develop signs and symptoms of TMD.45.

在67%的病例中，PCR是单侧的[43]。PCR通常与不稳定的闭塞有关，导致功能失调的重塑和TMJ的形态学改变[44]。根据Kristensen等人的研究，尽管有些病例无症状，但大多数患者会出现症状和体征。TMD.45。

Colonna et al. observed that individuals with TMJ pain have a smaller condylar volume and a tendency to hyperdivergent growth.46 Manfredini et al. in a systematic review of the literature suggest that individuals with a Class II skeletal pattern and hyper-divergent growth pattern have a higher frequency of disc displacement and degenerative changes.47.

Colonna等人观察到，患有颞下颌关节疼痛的个体髁突体积较小，并且有过度发散生长的趋势.46 Manfredini等人在对文献的系统综述中表明，具有II类骨骼模式和过度发散生长模式的个体椎间盘移位和退行性改变的频率较高。

Oh et al. also observed that facial asymmetry and deviated chins are associated with PCR.48 In these cases, we can also observe smaller condyles on the side of the deviation, reduced length of the condylar neck, or reduced volume of the neck and condylar head directly related to the resorption process.

Oh等人还观察到面部不对称和下巴偏斜与PCR有关.48在这些情况下，我们还可以观察到偏斜一侧的较小髁突，髁突颈部长度减少，或颈部和髁突头部体积减少与吸收过程直接相关。

However, when these changes occur in one or both TMJs, it is unlikely that the teeth at the other end of the jaw will not be affected..

但是，当一个或两个颞下颌关节发生这些变化时，下颌另一端的牙齿不太可能不受影响。。

Thus, there are many manifestations of PCR:

因此，PCR有许多表现形式：

open bite with only posterior contacts;

只有后部接触的开放咬合；

loss of overbite;

覆牙合缺失；

deviation from the midline;

偏离中线；

inclination of the occlusal plane to the affected side;

咬合平面向受影响侧的倾斜；

flat and worn teeth;

牙齿扁平磨损；

cervical enamel erosion;

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widening of the periodontal ligament space;

牙周膜间隙扩大；

dentine hypersensitivity;

牙本质过敏症；

acceleration of the progression of periodontal disease; and

加速牙周病的进展；和

worsening of endodontic lesions.

牙髓病变恶化。

When the articular tissue changes in volume, shape and morphology to achieve the necessary characteristics to maintain function (to restore congruency of the surfaces), the muscles pull the condyles upwards and forwards, the condyle seats upwards and forwards, and the mandibular plane rotates clockwise so that only the posterior teeth are in contact.

当关节组织在体积，形状和形态上发生变化以达到维持功能（恢复表面一致性）的必要特征时，肌肉将髁向上和向前拉动，髁向上和向前移动，下颌平面顺时针旋转，只有后牙接触。

When patients want to reach maximum intercuspation, they do so at the expense of the condylar position. The posterior teeth become the fulcrum, where the occlusal plane pivots, pushing the condyles downwards and backwards..

当患者想要达到最大的内插时，他们会以髁突位置为代价。后牙成为支点，咬合面在这里旋转，将髁向下和向后推。。

When there is orthopaedic instability and the teeth are not in occlusion, the condyles are held in their stable musculoskeletal position by the elevator muscles, resulting in a very unstable occlusion. However, when the teeth are brought into occlusion, maximum intercuspation cannot be achieved with the condyles in a stable position.

当骨科不稳定且牙齿不咬合时，髁突被提升肌保持在稳定的肌肉骨骼位置，导致咬合非常不稳定。然而，当牙齿被咬合时，髁突处于稳定位置时无法实现最大的内插。

Therefore, the individual has to choose either to maintain a stable condylar position and occlude on a few teeth or to make the teeth contact in a more stable occlusal position, which would compromise joint stability..

因此，个体必须选择保持稳定的髁突位置并咬合几颗牙齿，或者使牙齿接触到更稳定的咬合位置，这会损害关节的稳定性。。

Therefore, in diagnosing and planning any orthodontic treatment, a complete vision of the patient’s problems is necessary to determine the ideal solution for each case. Diagnosis is a fundamental part of our specialty if we want to achieve all our goals, especially stability and longevity. Our main goals are orthopaedic stability, TMJ health, dental and facial aesthetics, increased airway, optimal jaw dynamics with a vertical masticatory pattern, periodontal health, dental stability and longevity and of course patient satisfaction..

因此，在诊断和计划任何正畸治疗时，必须全面了解患者的问题，以确定每种情况下的理想解决方案。如果我们想实现所有目标，尤其是稳定性和寿命，诊断是我们专业的基本组成部分。我们的主要目标是骨科稳定性、颞下颌关节健康、牙齿和面部美学、增加气道、具有垂直咀嚼模式的最佳下颌动力学、牙周健康、牙齿稳定性和寿命，当然还有患者满意度。。

In the case of orthopaedically unstable patients, a stable arc of closure must be achieved before starting any orthodontic treatment. Stabilisation is achieved with an occlusal splint, and once stabilised, this position must be maintained until the end of treatment to attain orthopaedic stability. Splints must be worn 24 hours a day, seven days a week.

对于骨科不稳定的患者，在开始任何正畸治疗之前必须达到稳定的闭合弧。稳定是通过咬合夹板实现的，一旦稳定，这个位置必须保持到治疗结束，以达到骨科的稳定性。夹板必须每周七天，每天24小时佩戴。

We use a two-piece splint, and both parts are constructed at the same vertical dimension of occlusion. The anterior splint covers the six anterior teeth (incisors and canines), and the posterior splint is united by a palatal bridge and covers the premolars and molars..

我们使用两片夹板，两部分都在相同的垂直咬合维度上构建。前夹板覆盖六颗前牙（门牙和犬齿），后夹板通过腭桥连接，覆盖前磨牙和磨牙。。

The anterior splint opens the bite and avoids posterior contacts, diminishing the muscular activity and restoring symmetrical function. By increasing the vertical dimension, we obtain relaxation of the elevator and depressor muscles. Patients wear it during sleep, ideally for at least eight hours. This splint allows repositioning of the condyles upwards and forwards and harmonising of the neuromuscular system by eliminating clenching and parafunction.

前夹板打开咬合并避免后部接触，减少肌肉活动并恢复对称功能。通过增加垂直尺寸，我们可以放松升降肌和减压肌。患者在睡眠期间佩戴它，最好至少八小时。这种夹板允许髁突向上和向前重新定位，并通过消除握紧和副功能来协调神经肌肉系统。

During the day, patients wear the posterior splint, allowing seating of the condyles, stabilisation of dental contacts and recovery of the true arc of closure. The two-piece splint is much better accepted by patients since it produces no aesthetic problems and thus encourages greater compliance.49.

白天，患者佩戴后夹板，使髁突就位，稳定牙齿接触并恢复真正的闭合弧。两片式夹板更容易被患者接受，因为它不会产生美学问题，因此可以鼓励更大的依从性。

Fig. 1: FACE treatment goals. TMJ = temporomandibular joint.

图1：面部治疗目标。TMJ=颞下颌关节。

According to the literature, the main reason for using splints in our profession is to deprogramme the muscles, modify sensory input and reduce the electromyographic activity of the mandibular and cervical elevator muscles. Our splints also reduce hyperactivity and muscle pain to achieve occlusal stability and to stabilise the mandibular position, supporting the healing and remodelling process of the TMJ.

根据文献，在我们的专业中使用夹板的主要原因是对肌肉进行编程，改变感觉输入并减少下颌和颈部提升肌的肌电图活动。我们的夹板还可以减少活动过度和肌肉疼痛，以实现咬合稳定并稳定下颌位置，从而支持颞下颌关节的愈合和重塑过程。

Sletten et al. analysed the effect of deprogramming splints in relieving 12 symptoms related to TMD (e.g. noises, locking of the mandible, clenching and grinding of the teeth, headaches and neck pain, earaches and tinnitus) and observed statistically significant improvements in 11 of the symptoms analysed.50.

Sletten等人分析了脱编程夹板在缓解与TMD相关的12种症状（例如噪音，下颌骨锁定，牙齿紧咬和磨牙，头痛和颈部疼痛，耳痛和耳鸣）中的作用，并观察到11种症状的统计学显着改善。

Nemes et al. concluded that treatment with occlusal splints followed by molar intrusion to eliminate the discrepancy between maximum intercuspation and stable condylar position (centric relation) seems to be an effective method in the treatment of patients with TMD.51 They also saw improvements in the condylar morphology in comparing the CBCT scans pre- and post-treatment.

Nemes等人得出结论，用咬合夹板治疗，然后进行磨牙侵入，以消除最大内插和稳定髁突位置（中心关系）之间的差异，似乎是治疗TMD患者的有效方法.51他们还发现，在比较治疗前后CBCT扫描时，髁突形态有所改善。

On the basis of CBCT scans, Ok et al. also observed that treatment of TMJ osteoarthritis with stabilisation splints induced favourable bone remodelling on the anterior surface of condylar heads with degenerative condylar changes.52.

在CBCT扫描的基础上，Ok等人还观察到，用稳定夹板治疗TMJ骨关节炎可在髁突头前表面诱导有利的骨重塑，并伴有退行性髁突改变。

Because treatment with splints seats the condyles upwards and forwards within the glenoid fossae and the mandible rotates clockwise, in most cases, only the posterior teeth will come into contact. It is at this time that we must change the occlusal plane with orthodontics to achieve orthopaedic stability, that is, coincidence of maximum intercuspation and stable condylar position..

因为用夹板治疗可以使髁突在关节盂内向上和向前移动，并且下颌骨顺时针旋转，所以在大多数情况下，只有后牙会接触。正是在这个时候，我们必须通过正畸改变咬合平面，以实现骨科的稳定性，即最大内插和稳定髁突位置的一致性。。

Two clinical cases of patients with TMD are presented in this article. Their condylar positions were first stabilised with splints, and they were then treated with the FAS Aligner System (FORESTADENT) using the true arc of closure, allowing us to achieve good aesthetics and occlusal function, which are the FACE treatment objectives (Fig.

本文介绍了两例TMD患者的临床病例。他们的髁突位置首先用夹板稳定，然后用FAS对准器系统（FORESTADENT）使用真正的闭合弧进行治疗，使我们能够实现良好的美学和咬合功能，这是面部治疗的目标（图）。

1).53.

Case 1

案例1

A 30-year-old female patient presented with the chief complaints of severe muscle and joint pain, open bite and tooth wear. She was treated orthodontically as a teenager with fixed appliances. Extra-orally, we observed slight mandibular asymmetry with deviation of the chin to the right, as well as lip incompetence, insufficient chin projection and a long face typical of a dolichofacial skeletal pattern (Fig.

一名30岁的女性患者主诉严重的肌肉和关节疼痛，咬合开放和牙齿磨损。她在青少年时期接受了固定矫治器的正畸治疗。口外，我们观察到轻微的下颌不对称，下巴向右偏移，以及嘴唇功能不全，下巴投影不足和典型的面部骨骼模式的长脸（图）。

2). Intra-orally, she had an anterior open bite, retroclined maxillary incisors, moderate crowding in both arches, an asymmetrical arch form uneven gingival margins, a mandibular midline shifted to the right, abfractions, gingival recession and wear facets (Fig. 3). The joint and muscle examination revealed pain on palpation of the masseter, temporalis, and superior right and left lateral pterygoid muscles.

2）。在口腔内，她的前牙开咬，上颌门牙后倾，两个牙弓中度拥挤，不对称的牙弓形成不均匀的牙龈边缘，下颌中线向右移动，脱落，牙龈退缩和磨损面（图3）。关节和肌肉检查显示咬肌，颞肌以及右上和左上翼外肌触诊时疼痛。

She also exhibited pain in the bilaminar zone and both lateral poles of the condyles. Clinically, she had early clicking during mandibular opening and closing owing to anterior displacement of the articular disc in both joints. In the dental panoramic tomogram, she was missing all four third molars, but had no other noteworthy pathology (Fig.

她还表现出双侧区域和髁突两侧的疼痛。临床上，由于两个关节的关节盘前移，她在下颌骨打开和关闭过程中都有早期的咔哒声。在牙科全景断层扫描中，她缺失了所有四个第三磨牙，但没有其他值得注意的病理（图）。

4). Cephalometrically, she had a dolichofacial skeletal pattern and proclination of the mandibular incisors (Fig. 5)..

4）。头影测量显示，她的面部骨骼模式和下颌门牙的前倾角（图5）。。

We performed a visual treatment objective, and our goals were to lingualise the mandibular incisors, decrease the vertical dimension through intrusion of the posterior teeth and produce anticlockwise rotation of the mandibular plane. This would improve the patient’s facial profile, lip competence and articular function.

我们进行了视觉治疗目标，我们的目标是使下颌切牙舌化，通过侵入后牙减少垂直尺寸，并产生下颌平面的逆时针旋转。这将改善患者的面部轮廓，嘴唇能力和关节功能。

The CBCT images of the joints showed that both condyles were improperly located within the fossae (Fig. 6). The joint spaces were increased and the condyles descended. The airway area on the CBCT scan showed compression (Fig. 7). The patient was referred for a polysomnographic study to rule out compromised respiratory function..

关节的CBCT图像显示，两个髁突都不正确地位于窝内（图6）。关节间隙增加，髁下降。CBCT扫描的气道区域显示压缩（图7）。。。

Figs. 2a–g: Pretreatment extra-oral photographs.

图2a–g：预处理口外照片。

Figs. 3a–f: Pretreatment intra-oral photographs.

图3a–f：预处理口内照片。

Fig. 4: Pretreatment dental panoramic tomogram.

图4：预处理牙科全景断层扫描图。

Figs. 5a–c: (a) Cephalometric radiograph. (b) Cephalometric tracing. (c) Visual treatment objective.

图5a–c：（a）头影测量X光片。（b）头影测量追踪。（c）视觉治疗目标。

Figs. 6a–d: CBCT images showing the instability of both temporomandibular joints. Right, (a) sagittal and (b) coronal views. Left, (c) coronal and (d) sagittal views.

图6a–d:CBCT图像显示了两个颞下颌关节的不稳定性。右，（a）矢状面和（b）冠状面。左，（c）冠状面和（d）矢状面。

Figs. 7a–f: Pretreatment airway volume.

图7a–f：预处理气道容积。

When measuring the size of her teeth and conducting a Bolton analysis, we identified an anterior Bolton discrepancy due to mandibular excess (Fig. 8). In maximum intercuspation, there were bilateral contacts only on the posterior teeth (Fig. 9). In her arc of closure (Fig. 10), a unilateral posterior fulcrum was observed.

当测量她的牙齿大小并进行Bolton分析时，我们发现由于下颌骨过多导致了前Bolton差异（图8）。在最大的插入中，只有后牙有双侧接触（图9）。在她的闭合弧中（图10），观察到单侧后支点。

It was due to premature contact on the maxillary left second molars..

这是由于上颌左第二磨牙过早接触所致。。

Based on the complete clinical situation, the patient was diagnosed with orthopaedic instability with muscular and joint symptoms, tooth wear, recession, a dental fulcrum, altered joint spaces and anterior articular disc displacement. Therefore, it was paramount to establish condylar stability and achieve a stable arc of closure before starting any orthodontic treatment..

根据完整的临床情况，该患者被诊断为骨科不稳定，伴有肌肉和关节症状，牙齿磨损，退缩，牙齿支点，关节间隙改变和前关节盘移位。因此，在开始任何正畸治疗之前，建立髁突稳定性并实现稳定的闭合弧至关重要。。

Figs. 8a & b: Measurement of the (a) maxillary and (b) mandibular anterior teeth and calculation of a Bolton discrepancy.

图8a和b：（a）上颌和（b）下颌前牙的测量以及博尔顿差异的计算。

Figs. 9a–f: (a) Frontal view. (b) Overjet view. (c) Left lateral view. (d) Upper oclussal view. (e) Right lateral view. (f) Lower oclussal view.

。（b） Overjet视图。（c）左侧视图。（d）上眼眶视图。（e）右侧视图。（f）下眼眶视图。

Figs. 10a–f: Relationship at the first contact in the arc of closure.

图10a–f：闭合弧中第一次接触时的关系。

Fig. 11: Posterior splint.

图11：后夹板。

The stabilisation phase was carried out with a full-time two-piece splint. The patient wore the posterior part during the day in order to achieve stable contacts with the antagonist teeth (Fig. 11). The anterior part, worn during the night, helped to eliminate clenching and parafunction (Fig. 12). Regular adjustments were made until we achieved stable occlusal contacts, allowing the condyles to seat, first recovering and then maintaining the arc of closure during the process..

稳定阶段是用全职两片式夹板进行的。患者白天佩戴后部，以实现与拮抗牙齿的稳定接触（图11）。夜间佩戴的前部有助于消除握紧和副功能（图12）。定期进行调整，直到我们实现稳定的咬合接触，使髁突就位，首先恢复，然后在此过程中保持闭合弧。。

The objectives of splint therapy are to achieve a stable condylar position, obtain the patient’s true arc of closure and achieve muscular coordination and, consequently, remission of symptoms. However, the final and most important aspect of splint therapy is to obtain the correct maxillomandibular relationship in order to diagnose and plan treatment in a more predictable manner..

夹板治疗的目标是实现稳定的髁突位置，获得患者真正的闭合弧，实现肌肉协调，从而缓解症状。然而，夹板治疗的最后也是最重要的方面是获得正确的上颌骨关系，以便以更可预测的方式诊断和计划治疗。。

After four months of wearing the splint, the patient’s condylar position was stable (Fig. 13). This position was maintained during treatment in order to retain the true arc of closure by placing occlusal build-ups on the posterior teeth (Figs. 14 & 15). These occlusal build-ups also have an intrusion effect, favouring the correction of patients who require vertical control.

佩戴夹板四个月后，患者的髁突位置稳定（图13）。在治疗期间保持该位置，以便通过在后牙上放置咬合累积来保持真正的闭合弧（图14和15）。这些咬合累积也具有侵入效应，有利于矫正需要垂直控制的患者。

Only when the patient is stable do we have a predictable situation for planning and starting orthodontic treatment. In treatment with aligners, planning based on the patient’s true arc of closure allows us to achieve successful results in less treatment time and with fewer aligners and fewer refinements while protecting the TMJ..

只有当患者病情稳定时，我们才能有一个可预测的情况来计划和开始正畸治疗。在使用对准器进行治疗时，基于患者真实闭合弧的计划使我们能够在保护颞下颌关节的同时，以更少的治疗时间，更少的对准器和更少的改进取得成功。。

Figs. 12a & b: Diagram of ideal contacts on the splint. (a) Posterior contact. (b) Anterior contact and guidance.

图12a和b：夹板上理想触点的示意图。（a）后接触。（b）前接触和指导。

Figs. 13a–f: (a–d) Posterior splint placed in the mouth for stable occlusal contacts. (e & f) Posterior splint.

图13a–f：（a–d）将后夹板置于口腔中以稳定咬合接触。（e＆f）后夹板。

Figs. 14a–c: (a) Wax registration material. (b) Bite registration of the arc of closure for the placement of occlusal stops. (c) Envelope of motion A = occlusion in the arc of closure; B = maximum opening in rotation only; C = maximum total opening, a combination of rotation and translation of the condyles; D = maximum protrusion with tooth contacts; E = habitual occlusion (compensation of the jaw when teeth don´t match the arc of closure).

图14a–c：（a）蜡注册材料。（b）咬合登记闭合弧以放置咬合停止。（c）运动包络A=闭合弧中的遮挡；B=仅旋转时的最大开口；；D=齿接触的最大突出量；E=习惯性咬合（当牙齿与闭合弧不匹配时下颌的补偿）。

R = resting position of the lower jaw..

R=下颌的静止位置。。

Figs. 15a–f: Occlusal stops placed in the mouth.

图15a–f：咬合停止放置在口腔中。

Figs. 16a–h: Pretreatment situation (purple) and expected post-treatment situation (white) in FAS OcclusalDesign.

图16a–h:FAS咬合设计中的预处理情况（紫色）和预期的治疗后情况（白色）。

Figs. 17a–f: Visualisation of bone volume in FAS OcclusalDesign. Planned relationship of the teeth post-treatment (white) with the vestibular cortex of the alveolar bone (blue).

图17a–f:FAS咬合设计中骨量的可视化。牙齿治疗后（白色）与牙槽骨前庭皮质（蓝色）的计划关系。

Figs. 18a–f: Pretreatment with the FAS Aligner System. Placement of attachments and skeletal anchorage.

图18a–f:FAS对准器系统的预处理。附件和骨骼锚定的放置。

Figs. 19a–f: Situation after seven months of treatment.

图19a–f：治疗七个月后的情况。

Figs. 20a–f: Final planned occlusion after the second phase of aligner treatment in FAS OcclusalDesign.

图20a–f:FAS OcclusalDesign中对准器治疗第二阶段后的最终计划闭塞。

Figs. 21a–f: Comparison of the evolution between the position before the second phase of aligner treatment (purple) and the expected final position (white) in FAS OcclusalDesign.

图21a–f:FAS咬合设计中对准器治疗第二阶段之前的位置（紫色）与预期最终位置（白色）之间的演变比较。

Figs. 22a–f: Situation at the start of the second phase of aligner treatment.

。

Figs. 23a–l: Situation at the end of the second phase of aligner treatment. Stable occlusion and correct excursive movements. (a–f) Orthopaedic stability. (g & h) Right lateral excursion. (i & j) Protrusion (k & l) Left lateral excursion.

图23a–l：对准器处理第二阶段结束时的情况。稳定的闭塞和正确的偏移运动。（a–f）骨科稳定性。（g＆h）右侧偏移。（i＆j）突出（k＆l）左侧偏移。

Figs. 24a–f: Post-treatment models.

图24a–f：后处理模型。

Figs. 25a–h: Post-treatment extra-oral photographs.

图25a–h：治疗后口外照片。

Treatment with the FAS Aligner System, as shown in the FAS OcclusalDesign tool (Fig. 16), was used, aiming at decreasing the vertical dimension through intrusion of the maxillary molars, correcting the arch form, centring the mandibular midline and levelling the maxillary and mandibular occlusal planes.

如FAS咬合设计工具（图16）所示，使用FAS Aligner系统进行治疗，旨在通过侵入上颌磨牙来减小垂直尺寸，纠正弓形，使下颌中线居中并调平上颌和下颌咬合平面。

The Bolton discrepancy would be resolved with inferior interproximal reduction. The planned movement was compatible with periodontal health, being within the biological limits of the patient’s alveolar bone (Fig. 17)..

博尔顿差异将通过较差的邻间复位来解决。计划的运动符合牙周健康，在患者牙槽骨的生物学范围内（图17）。。

Fig. 26: Post-treatment dental panoramic tomogram.

图26：治疗后牙科全景断层扫描图。

Initial treatment in 29 stages was planned, by which point the final occlusal results would have been obtained. We began with the placement of attachments and micro-screws in the maxillary arch for posterior intrusion (Fig. 18). After seven months of treatment and in the 20th stage, we introduced the FAS STOP and GO concept and took new records to prepare for the second phase of aligner treatment (Fig.

计划在29个阶段进行初步治疗，届时将获得最终的咬合结果。我们首先在上颌弓中放置附件和微型螺钉以进行后侵（图18）。经过七个月的治疗，在第20阶段，我们引入了FAS停止和前进的概念，并取得了新的记录，为对准器治疗的第二阶段做准备（图）。

19). Thanks to STOP and GO, it is possible to achieve better tracking so that aligners fit properly and shorter treatment times using fewer aligners. This is the advantage of planning in different stages. It helps us achieve all our treatment goals on a consistent basis, and treatment efficiency is much higher..

19）。多亏了走走停停，才有可能实现更好的跟踪，从而使对准器正确匹配，并使用更少的对准器缩短治疗时间。这是在不同阶段进行规划的优势。它有助于我们在一致的基础上实现所有治疗目标，并且治疗效率要高得多。。

The second phase of treatment began with the placement of new attachments (Figs. 20–22) and consisted of 12 stages, during which we continued to intrude the maxillary molars, centre the mandibular midline and level the occlusal planes. This phase lasted for four months. The total treatment involved 32 stages over 11 months, and all the treatment goals were achieved (Figs.

治疗的第二阶段始于放置新的附着体（图20-22），分为12个阶段，在此期间，我们继续侵入上颌磨牙，使下颌中线居中并使咬合面水平。这一阶段持续了四个月。总治疗涉及11个月内的32个阶段，所有治疗目标均已实现（图）。

23–25)..

The final dental panoramic tomogram showed the correct levelling of the occlusal planes and root positions (Fig. 26). The final cephalometric tracing showed closure of the facial angle thanks to the posterior intrusion and mandibular auto-rotation (Figs. 27 & 28). Mandibular antero-rotation shortens the lower facial third, improving lip competence and ultimately the facial profile.

。最终的头影测量追踪显示，由于后部侵入和下颌自动旋转，面部角度闭合（图27和28）。下颌前旋缩短了面部下三分之一，改善了嘴唇能力，最终改善了面部轮廓。

The CBCT images of the TMJs showed the correct position of the condyles within the glenoid fossae (Fig. 29). When looking at the airway on the CBCT scan, we also saw an improvement of the patient’s airway (Fig. 30)..

颞下颌关节的CBCT图像显示髁突在关节盂内的正确位置（图29）。在CBCT扫描中观察气道时，我们还看到患者的气道有所改善（图30）。。

Figs. 27a & b: (a) Post-treatment cephalometric radiograph and (b) tracing.

图27a和b：（a）治疗后头影测量X光片和（b）追踪。

Figs. 28a–e: Superimposition of the pretreatment (black) and post-treatment cephalometric tracings (red) showing the evolution of the treatment.

图28a–e：治疗前（黑色）和治疗后头影测量（红色）的叠加显示了治疗的进展。

Figs. 29a–d: Pretreatment CBCT images showing the stability of both temporomandibular joints. Right, (a) sagittal and (b) coronal views. Left, (c) coronal and (d) sagittal views.

图29a–d：显示两个颞下颌关节稳定性的预处理CBCT图像。右，（a）矢状面和（b）冠状面。左，（c）冠状面和（d）矢状面。

Figs. 30a–e: (a–c) Post-treatment airway volume. Comparison between the (d) pretreatment and (e) post-treatment volume obtained from the CBCT scan.

图30a–e：（a–c）治疗后气道容积。从CBCT扫描获得的（d）预处理和（e）后处理体积之间的比较。

Figs. 31a–f: Pretreatment extra-oral photographs.

图31a–f：预处理口外照片。

Case 2

案例2

A 36-year-old female patient was referred by her osteopath because of neck, shoulder and back pain and also presented with severe dental wear. The patient had undergone orthodontic treatment in the past with fixed multi-bracket appliances, and this was her motivation to be treated with aligners.

一名36岁的女性患者因颈部，肩部和背部疼痛而被她的骨科医生转诊，并出现严重的牙齿磨损。该患者过去曾接受过固定多托槽矫治器的正畸治疗，这是她接受对准器治疗的动机。

Extra-orally, we observed a dolichofacial skeletal pattern, a long lower facial third, a slightly gummy smile, lip incompetence, maxillary compression and a mandibular deviation to the right (Fig. 31). We also perceived a maxillary and mandibular retrusive profile with an obtuse nasolabial angle and lack of support of the upper lip when smiling.

口外，我们观察到了面部骨骼模式，面部下三分之一长，略带牙龈微笑，嘴唇机能不全，上颌骨受压和下颌向右偏移（图31）。我们还感觉到上颌骨和下颌骨的后缩轮廓，鼻唇沟角钝，微笑时上唇缺乏支撑。

Intra-orally, we confirmed the maxillary compression and noted negative torques of the lateral segments, maxillary and mandibular crowding, and deviated midlines (Fig. 32). Dental wear, gingival recession and hypoplastic lateral incisors were also present. Occlusally, she presented with Class I molar and canine relationships, retroclination of the maxillary incisors, lack of overjet and overbite, and an increased curve of Wilson due to the palatal cusps of the maxillary second molars..

在口腔内，我们证实了上颌骨受压，并注意到侧节段的负扭矩，上颌骨和下颌拥挤以及中线偏斜（图32）。还存在牙齿磨损，牙龈退缩和侧切牙发育不良。闭塞，她表现出I类磨牙和犬齿的关系，上颌门牙的后倾，缺乏过度喷射和覆牙，以及由于上颌第二磨牙的腭尖而导致的威尔逊曲线增加。。

The panoramic radiograph showed slight bone loss, the presence of the maxillary third molars and mandibular left third molar and correct root morphology (Fig. 33). In the cephalometric radiograph and tracing, a Class II skeletal pattern and a marked negative torque of the maxillary incisors were observed (Fig.

全景X光片显示轻微的骨质流失，上颌第三磨牙和下颌左第三磨牙的存在以及正确的牙根形态（图33）。在头影测量X线片和追踪中，观察到上颌切牙的II类骨骼模式和明显的负扭矩（图）。

34). The CBCT scan of the condyles showed that both condyles were well corticated, although the right condyle had undergone a process of PCR with reparation, evident from the good corticalisation and osteophyte (Fig. 35). This resorption process had affected the ramus, the right mandibular ramus being shorter than the left.

34）。髁突的CBCT扫描显示，两个髁突都有良好的皮质，尽管右髁经历了修复的PCR过程，这从良好的皮质化和骨赘中可以明显看出（图35）。这种再吸收过程影响了下颌支，右下颌支比左下颌支短。

This perfectly explained the reason for the patient’s mandibular deviation. We also observed a lack of functional space around the right condylar head, which was a clear sign that there was probably no disc present..

这完美地解释了患者下颌偏斜的原因。我们还观察到右髁头周围缺乏功能空间，这是一个明显的迹象，表明可能没有椎间盘存在。。

Clinically, she had TMJ sounds, hyper-laxity with mouth opening of 54 mm and pain on palpation of both joints. The patient also suffered from masseter, temporalis and occipitalis muscle pain. In addition, the patient reported frequent headaches, neck and shoulder pain, nocturnal bruxism and episodes of closed lock.

临床上，她有颞下颌关节声音，过度松弛，张口54毫米，两个关节触诊疼痛。患者还患有咬肌，颞肌和枕肌疼痛。此外，该患者报告经常头痛，颈肩痛，夜间磨牙症和闭锁发作。

Upon manipulation, we observed an important discrepancy between maximum intercuspation and first contact on the arc of closure..

在操纵时，我们观察到闭合弧上的最大插入和第一次接触之间存在重要差异。。

Figs. 32a–f: Pretreatment intra-oral photographs.

图32a–f：预处理口内照片。

Fig. 33: Pretreatment dental panoramic tomogram.

图33：预处理牙科全景断层扫描图。

Figs. 34a & b: (a) Cephalometric radiograph and (b) tracing.

图34a和b：（a）头影测量X光片和（b）追踪。

Figs. 35a–h: Pretreatment CBCT images of both temporomandibular joints (sagittal views). (a–d) Right. (e–h) Left.

图35a–h：两个颞下颌关节的预处理CBCT图像（矢状视图）。（a–d）正确。（e–h）左。

Figs. 36a–f: Pretreatment virtual mounting.

图36a–f：预处理虚拟安装。

We performed a virtual mounting of the case using the Tech in Motion device (MODJAW; Fig. 36), and the severe occlusal discrepancy was confirmed. In addition, the MODJAW condylar graphs showed unstable condylar movements, especially of the left condyle during opening and closing, as it deviated to the right (Fig.

我们使用Tech in Motion设备（MODJAW；图36）对病例进行了虚拟安装，并确认了严重的咬合差异。此外，MODJAW髁突图显示不稳定的髁突运动，特别是在打开和关闭期间左侧髁突的运动，因为它偏向右侧（图）。

37). In the recording of the arc of closure, we observed the inability of the condyles to rotate, moving purely horizontally within the joint spaces (Fig. 38)..

37）。。。

Considering the joint instability, our initial treatment began with a splint (Fig. 39). After four months of treatment with the splint, the condylar position was stable, the condyles rotated and the patient was completely asymptomatic. However, her occlusion had changed to more of a Class II malocclusion, and she had developed a larger open bite owing to the mandibular clockwise rotation (Fig.

。用夹板治疗四个月后，髁突位置稳定，髁突旋转，患者完全无症状。然而，她的咬合已经改变为更多的II类错牙合，并且由于下颌顺时针旋转，她已经形成了更大的开放咬合（图）。

40)..

The CBCT scan of the condyles after splint therapy showed a more normal position of the condyles54 with respect to the fossae, as well as greater corticalisation of the right condyle (Fig. 41). In addition, the condylar graphs of the 4D images showed a significant improvement of the condylar movement, having a more uniform and anatomical trajectory during opening and closing and achieving condylar rotation (Figs.

夹板治疗后髁突的CBCT扫描显示髁突54相对于窝的位置更正常，右髁的皮质化程度更高（图41）。此外，4D图像的髁突图显示髁突运动显着改善，在打开和关闭期间具有更均匀和解剖的轨迹，并实现髁突旋转（图）。

42 & 43)..

Using the post-splint cephalometric radiograph, a visual treatment objective was done (Fig. 44). To achieve our goals, we needed to correct the Class II malocclusion, close the open bite and correct the incisor positions. We wished to increase the torque of the maxillary incisors by 15°, reduce the torque of the mandibular incisors by 2° and intrude the maxillary molars by 3.4 mm to produce anticlockwise rotation of the mandible to close the open bite and improve the facial and dental aesthetics..

使用夹板后头影测量X光片，完成了视觉治疗目标（图44）。为了实现我们的目标，我们需要纠正II类错牙合，闭合开放咬合并纠正门牙位置。我们希望将上颌切牙的扭矩增加15°，将下颌切牙的扭矩减少2°，并将上颌磨牙侵入3.4 mm，以产生下颌骨的逆时针旋转，以闭合开口咬合并改善面部和牙齿美学。。

Fig. 37: Pretreatment condylar and incisor graph recordings during opening and closing.

图37：在打开和关闭期间预处理髁突和切牙图形记录。

Fig. 38: Pretreatment condylar and incisor graph recordings of the arc of closure.

图38：闭合弧的预处理髁突和切牙图形记录。

Figs. 39a & b: Two-piece splint.

图39a和b：两片式夹板。

Figs. 40a–d: Occlusion after splint therapy.

图40a–d：夹板治疗后的闭塞。

Figs. 41a–d: CBCT images of both temporomandibular joints after splint therapy (sagittal views). (a & b) Right. (c & d) Left.

图41a–d：夹板治疗后两个颞下颌关节的CBCT图像（矢状视图）。（a和b）正确。（c＆d）左。

Fig. 42: Condylar and incisor graph recordings during opening and closing after splint therapy.

图42：夹板治疗后打开和关闭期间的髁突和切牙图形记录。

Fig. 43: Condylar and incisor graph recordings of the arc of closure after splint therapy.

图43：夹板治疗后闭合弧的髁突和切牙图形记录。

Fig. 44: Visual treatment objective.

图44：视觉治疗目标。

Figs. 45a–d: Pretreatment situation (purple) and expected post-treatment situation (white) in FAS OcclusalDesign.

图45a–d:FAS咬合设计中的预处理情况（紫色）和预期的治疗后情况（白色）。

The treatment plan with FAS consisted of aligning and levelling both arches, recovering arch forms and introducing positive torque to the entire maxillary arch, intruding the maxillary posterior teeth with the help of skeletal anchorage (vertical control) to correct the Class II malocclusion and opening space for the lateral incisors for their restoration (Figs.

FAS的治疗计划包括对齐和调平两个牙弓，恢复牙弓形态并向整个上颌牙弓引入正扭矩，借助骨骼支抗（垂直对照）侵入上颌后牙，以纠正II类错牙合和侧切牙的开放空间以进行修复（图2和图2）。

45 & 46)..

The first phase consisted of 26 maxillary and mandibular aligners. After the attachments had been cemented, six micro-screws were placed (four buccal screws between the maxillary first and second molars and between the maxillary first and second premolars and two palatal screws between the maxillary second premolar and first molar), and the patient was instructed to use 5⁄16 in.

第一阶段由26个上颌和下颌对准器组成。附着物粘合后，放置六个微型螺钉（上颌第一和第二磨牙之间以及上颌第一和第二前磨牙之间的四个颊侧螺钉和上颌第二前磨牙和第一磨牙之间的两个腭侧螺钉），并指示患者使用5/16英寸。

and 8 oz elastics to help in the intrusion of the posterior teeth (Fig. 47). At the 16th pair of aligners, we introduced the STOP and GO concept. After STOP and GO at the 17th pair of aligners, we decided to continue, since the treatment was progressing correctly..

和8盎司的松紧带有助于后牙的侵入（图47）。在第16对校准器上，我们引入了停止和前进的概念。在第17对对准器停止后，我们决定继续，因为治疗进展正确。。

Because the treatment had distributed the spaces between the maxillary incisors, it was decided to provisionally restore the lateral incisors (Fig. 48). After the incisors had been restored with provisional composite, we scanned the patient for new aligners to initiate the second phase. In this phase, we expanded the maxillary and mandibular arches, continued the postero-superior intrusion to close the open bite by mandibular auto-rotation and finalised the alignment (Fig.

由于治疗分配了上颌切牙之间的空间，因此决定暂时恢复侧切牙（图48）。门牙用临时复合材料修复后，我们扫描患者以寻找新的对准器以启动第二阶段。在这个阶段，我们扩大了上颌和下颌弓，继续进行后上侵，通过下颌自动旋转关闭开放咬合，并完成对齐（图）。

49). This stage consisted of 20 pairs of aligners (Fig. 50). We finished the case with a third phase of ten pairs of aligners and incorporated inter-maxillary elastics (Fig. 51)..

49）。该阶段由20对对准器组成（图50）。我们用十对对准器的第三阶段完成了案例，并纳入了上颌间弹性（图51）。。

Figs. 46a–c: 3D superimpositions of the planned torque movements on to the CBCT images. (a) Maxillary first premolars. (b) Central incisor. (c) Maxillary second premolars.

。（a）上颌第一前磨牙。（b）中切牙。（c）上颌第二前磨牙。

Figs. 47a–f: Attachments and micro-screws placed.

图47a–f：放置的附件和微型螺钉。

Figs. 48a–e: (a–c) Lateral incisors before and (d & e) after provisional composite restoration.

图48a–e：（a–c）临时复合修复前后的侧切牙。

Figs. 49a–f: Final planned occlusion after the second phase of aligner treatment in FAS OcclusalDesign.

图49a–f:FAS OcclusalDesign中对准器治疗第二阶段后的最终计划闭塞。

Figs. 50a–f: Situation after the second phase of aligner treatment.

图50a–f：对准器处理第二阶段后的情况。

Figs. 51a–d: Third phase of aligner treatment and inter-maxillary elastics.

图51a–d：对准器治疗的第三阶段和上颌间弹性。

After treatment, the patient had bilateral Class I molar and canine relationships, correct overjet and overbite, centred midlines and improved arch forms (Fig. 52). Extra-orally, she had improved arch forms, a wider smile, an improved smile line and less gingival exposure (Fig. 53). The lower facial third had been shortened thanks to mandibular antero-rotation, and there was improvement of the upper lip support thanks to the positive torque of the maxillary incisors.

治疗后，患者有双侧I类磨牙和犬齿关系，正确的覆盖和覆牙，中线居中，弓形得到改善（图52）。除口腔外，她的牙弓形态得到改善，笑容更宽，笑容线得到改善，牙龈暴露减少（图53）。由于下颌前旋，面部下三分之一缩短了，由于上颌门牙的正扭矩，上唇支撑得到了改善。

In the post-treatment panoramic radiograph, we observed excellent periodontal status, no resorption of the roots and extraction of the maxillary third molars (Fig. 54). In the post-treatment cephalometric tracing, we saw a decrease of the ANB angle, a reduction in the anterior face height, an increase of the facial axis angle, and a decrease in the distance between the soft pogonion and the true vertical line thanks to the anticlockwise rotation of the mandible (Fig.

在治疗后的全景X光片中，我们观察到良好的牙周状态，没有牙根吸收和上颌第三磨牙拔除（图54）。在治疗后的头影测量追踪中，我们看到ANB角度减小，前面部高度减小，面轴角度增加，并且由于下颌骨的逆时针旋转，软角和真实垂直线之间的距离减小（图）。

54). We also found an increase in the inclination of the maxillary incisors and an improvement in the final inter-incisal angle. Concerning her TMJs, the patient remained totally asymptomatic and had a vertical masticatory pattern and a stable arc of closure. The CBCT scan showed well-corticated condyles in the same position as that obtained after the splint therapy (Fig.

54）。我们还发现上颌切牙的倾斜度增加，最终切牙间角度改善。关于她的颞下颌关节，患者仍然完全无症状，具有垂直咀嚼模式和稳定的闭合弧。CBCT扫描显示皮质良好的髁突与夹板治疗后获得的位置相同（图）。

56)..

Figs. 52a–f: Post-treatment intra-oral photographs.

图52a–f：治疗后口腔内照片。

Figs. 53a–f: Post-treatment extra-oral photographs.

图53a–f：治疗后口外照片。

Fig. 54: Post-treatment dental panoramic tomogram.

图54：治疗后牙科全景断层扫描图。

Figs. 55a & b: (a) Cephalometric radiograph and (b) tracing.

图55a和b：（a）头影测量X光片和（b）追踪。

Figs. 56a–d: Post-treatment CBCT images of both temporomandibular joints (sagittal views). (a & b) Right. (c & d) Left.

图56a–d：两个颞下颌关节的治疗后CBCT图像（矢状视图）。（a和b）正确。（c＆d）左。

Conclusion

结论

The stabilisation phase with a splint in patients with unstable condylar positions is necessary in many cases before starting orthodontic treatment. Thanks to the splint, we can resolve symptoms, but more importantly, we can achieve the patient’s true arc of closure, which is of the utmost importance for correct diagnosis and treatment planning..

在许多情况下，在开始正畸治疗之前，髁突位置不稳定的患者需要使用夹板进行稳定阶段。由于夹板，我们可以解决症状，但更重要的是，我们可以实现患者真正的闭合弧，这对于正确的诊断和治疗计划至关重要。。

Working on the arc of closure is without any doubt the main reason for our success, not only with aligners but with our TMD patients. When you diagnose and plan treatment on the true arc of closure of the patient, this allows you to know exactly where the problem lies and helps in finding the correct solution.

毫无疑问，闭合弧的工作是我们成功的主要原因，不仅是对准器，而且是TMD患者。当您在患者真正的闭合弧上进行诊断和计划治疗时，这可以让您准确地知道问题所在，并有助于找到正确的解决方案。

When you capture the true arc of closure and when you see where the first contact is, you can see exactly why the patient has a centric occlusion–maximum intercuspation slide, why and where the mandible is shifting, why the patient’s teeth are wearing, why there is recession, why the patient has muscular symptoms, why there is abfraction and why the patient has TMD.

当你捕捉到真正的闭合弧线，当你看到第一次接触的位置时，你可以确切地看到为什么患者有一个中心咬合-最大的咬合滑动，为什么下颌骨在移动，为什么下颌骨在移动，为什么牙齿在磨损，为什么会出现衰退，为什么患者会出现肌肉症状，为什么会出现abfraction，为什么患者会出现TMD。

Knowing all of this informs what needs to be done to resolve the discrepancy. We know what needs to be done to obtain the correct vertical dimension, and in the case of a transverse discrepancy, we know whether it can be resolved with orthodontics alone or whether we need miniscrew-assisted rapid maxillary expansion, surgically assisted rapid maxillary expansion or corticotomy.

了解了所有这些，就可以知道需要做什么来解决差异。我们知道需要做什么才能获得正确的垂直尺寸，并且在横向差异的情况下，我们知道是否可以仅通过正畸来解决，或者我们是否需要微型螺钉辅助的快速上颌扩张，手术辅助的快速上颌扩张或皮质切开术。

We also know what needs to be done with the sagittal discrepancies. Once we capture the arc of closure, we know exactly whether the sagittal problem is vertical or truly sagittal, and this of course will also lead us to the exact solution..

我们也知道需要对矢状面差异做些什么。一旦我们捕捉到闭合弧，我们就可以确切地知道矢状问题是垂直的还是真正的矢状的，这当然也会引导我们找到确切的解决方案。。

Working on the true arc of closure helps us to achieve predictable and stable results and, when using aligners, to utilise fewer aligners, reduce the treatment time and finally achieve orthopaedic stability in 100% of our patients. Luckily, the FAS Aligner System allows us to work on the patient’s arc of closure before, during and after orthodontic treatment, and this is what supports predictability in all our decisions..

研究真正的闭合弧有助于我们获得可预测和稳定的结果，并且在使用对准器时，使用更少的对准器，减少治疗时间，最终在100%的患者中实现骨科稳定性。幸运的是，FAS Aligner系统允许我们在正畸治疗之前，期间和之后处理患者的闭合弧，这就是支持我们所有决定的可预测性的原因。。

Editorial note:

编辑注释：

This article was published in aligners—international magazine of aligner orthodontics vol. 2, issue 2/2023.

这篇文章发表在aligner国际杂志的aligner orthodontics vol。2023年2月2日。

Topics:

主题：

Orthodontics

正畸学

Tags:

标签：

Bolton analysis

博尔顿分析

CBCT

Clear aligners

清除对齐器

Malocclusion

错牙合

MODJAW

模型

Occlusal splint

咬合夹板

Temporomandibular disorder

颞下颌关节紊乱病

Temporomandibular joint

颞下颌关节

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