目的探討肌激動(dòng)器對(duì)不同骨面型的安氏Ⅱ類1分類患者矯治前后軟硬組織變化的影響。方法納入22 例骨性安氏II類1分類患者[(男12 例，女10 例，平均年齡(11.5±0.67) 歲]，根據(jù)其骨面型分為低角組(n=15)和均角組(n=7)。肌激動(dòng)器矯治前后拍攝頭顱側(cè)位定位片，頭影測(cè)量分析治療前后軟硬組織的變化。用SPSS 13.0軟件，t檢驗(yàn)分析治療結(jié)果差異。結(jié)果所有患者治療前后Co-Pg、ANB、Wits、NA-Pg、L1-APg和L6-MP值差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。骨組織項(xiàng)目中低角組和均角組治療前后Wits值變化分別為1.34°±1.82°和3.50°±1.77°，NA-Pg值變化分別為(3.06±2.00) mm和(5.80±3.17) mm，牙齒項(xiàng)目中L1-APg變化值分別為(-1.16±1.74) mm和(-2.83±1.48) mm，組間差異均具有顯著統(tǒng)計(jì)學(xué)意義(P<0.05)。低角與均角組軟組織測(cè)量項(xiàng)目比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論肌激動(dòng)器矯治低角和均角骨性安氏II類1分類患者均能取得較理想的治療效果，均角患者對(duì)矯治器的反映效果好于低角患者。

垂直骨面型； 肌激動(dòng)器； 功能矯治器； 頭影測(cè)量； 安氏Ⅱ1

1 材料與方法

1.1 研究對(duì)象

1.2 矯治方法

1.3 X線頭影測(cè)量項(xiàng)目

1.3.4 軟組織測(cè)量項(xiàng)目 UL-Eline，上唇突點(diǎn)到審美平面的距離；LL-Eline，下唇突點(diǎn)到審美平面的距離；∠N'-A'-FH，軟組織鼻根點(diǎn)和上唇凹點(diǎn)的連線與眶耳平面之交角；∠N'-Pg'-FH，軟組織鼻根點(diǎn)和軟組織頦前點(diǎn)連線與眶耳平面之交角；∠N'-Sn-Pg'，軟組織鼻根點(diǎn)，軟組織頦前點(diǎn)分別與鼻底點(diǎn)連線，兩線相交成角；ZAngle，軟組織頦前點(diǎn)和相對(duì)位置靠前的上下唇突點(diǎn)的連線的延長線與FH平面的后下之交角。

圖 1 測(cè)量標(biāo)志點(diǎn)及參考平面

1.4 統(tǒng)計(jì)學(xué)分析

采用SPSS 13.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析，對(duì)所有測(cè)量數(shù)據(jù)進(jìn)行t檢驗(yàn)，P<0.05具有顯著統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

另外，SNB 2 組治療后比治療前均有所增大，均角組增大值多于低角組，但低角組治療前后比較差異有統(tǒng)計(jì)學(xué)意義。ANS-Ptm均有所增大，但均角組治療前后比較差異有統(tǒng)計(jì)學(xué)意義。U6-PP 2 組治療前后比較均有所增大，其中低角組治療前后比較差異有統(tǒng)計(jì)學(xué)意義。∠L1-NB值2 組治療后比治療前均稍有增大，其中均角組治療前后比較差異有統(tǒng)計(jì)學(xué)意義。

3 討 論

表 1 骨組織測(cè)量項(xiàng)目

表 2 牙齒測(cè)量項(xiàng)目

表 3 軟組織測(cè)量項(xiàng)目

3.1 上、下頜骨變化情況

結(jié)果顯示2 組SNA和OP/FH治療后均略有減少，但變化不明顯；均角患者治療后上頜骨長度增加，治療前后差異有統(tǒng)計(jì)學(xué)意義，可能是生長發(fā)育的原因；2 組SNA、ANS-Ptm和OP/FH比較無明顯差別。對(duì)于肌激動(dòng)器是否能抑制上頜骨的生長,學(xué)者們有不同的看法。Cozza等[4]用肌激動(dòng)器矯治了40 例替牙列患者，發(fā)現(xiàn)治療后SNA減少了0.5°；Maran等[5]用肌激動(dòng)器聯(lián)合頭帽治療了28 例混合牙列患者治療后SNA減少了2°，而Lerst?l 等[6]發(fā)現(xiàn)肌激動(dòng)器聯(lián)合頭帽治療后SNA變化不大。Van[7]認(rèn)為單純的肌激動(dòng)器對(duì)上頜復(fù)合體的作用并不明確,但它與口外牽引聯(lián)合使用時(shí),可以抑制上頜骨的向前與向下生長,并阻止腭部下降。

所有患者SNB治療后均有所增加，低角組治療前后有差異；下頜平面角(FMA)和Y軸角治療前后沒有明顯變化；2 組患者下頜骨長度(Co-Pg)治療后比治療前均有明顯增加；測(cè)量的4 個(gè)下頜指標(biāo)2 組之間比較無明顯差別。以上說明肌激動(dòng)器治療后，B點(diǎn)前移，下頜長度有所增加。曹凌[8]以未做功能矯治的下頜后縮Ⅱ類患者為對(duì)照，發(fā)現(xiàn)對(duì)照組治療后SNB角增大了0.2°,下頜長度增加1.3 mm，而肌激動(dòng)器治療組SNB增大1.8°，下頜長度增加了2.2 mm, 明顯多于對(duì)照組，因此認(rèn)為肌激動(dòng)器可以促進(jìn)下頜的生長發(fā)育。下頜前伸對(duì)下頜骨的生長及改建是否產(chǎn)生實(shí)質(zhì)性的影響尚存在爭論。McNamara[9]認(rèn)為下頜前伸能刺激髁突的改建,從而能刺激整個(gè)下頜骨的生長；Ma等[10]發(fā)現(xiàn)肌激動(dòng)器治療后關(guān)節(jié)窩變淺，髁突高度增加，矢狀向髁突輕微前移，關(guān)節(jié)盤明顯后移，關(guān)節(jié)盤沒有改建。Luder[11]則把下頜前伸引起的下頜骨位置變化歸于牙槽骨及下切牙位置的補(bǔ)償性改變,否定有任何實(shí)質(zhì)性的骨改建。Jakobsson等[12]指出用肌激動(dòng)器治療后下頜平面角與治療前比較有顯著性差異，他認(rèn)為下頜平面角的增長是治療中下頜骨的向前下旋轉(zhuǎn)所致,而與下后牙的萌出無關(guān)；在正常生長發(fā)育的兒童中，隨著下面高的增長，頦點(diǎn)順時(shí)針向后旋轉(zhuǎn)，但由于下頜長度的增長,使頦部相對(duì)于頭顱位置以每年1 mm的速度向前生長。本研究中2 組患者治療后下頜平面角沒有顯著變化，表明由于下頜功能性后縮的消除，抵消了下面高增加所致的不利影響,使下頜平面角保持不變，與曹凌[8]的研究基本一致。

3.2 牙齒變化情況

3.3 軟組織變化情況

各項(xiàng)指標(biāo)治療前后無明顯差別，2 組之間也無差別，可能與樣本量小有關(guān)系。但從側(cè)貌上看治療后比治療前還是有明顯改善的。軟組織形態(tài)是人們?cè)u(píng)價(jià)顏面外形的最直接指標(biāo), 是正畸患者就診的主要原因之一，要達(dá)到良好的正畸療效,必然要考慮到患者的軟組織形態(tài)。Türkkahraman等[16]觀察到肌激動(dòng)器治療后下唇的突出，認(rèn)為肌激動(dòng)器能成功的改變下唇位置，改善軟組織凸度。Mara等[5]發(fā)現(xiàn)治療后軟組織面角(G'-Sn-Pg' )增大了2.3°，頦唇溝深度減少了0.8 mm；曹凌[8]發(fā)現(xiàn)與未治療的對(duì)照組相比,實(shí)驗(yàn)組的G'-Sn-Pg'增大1.9°；本實(shí)驗(yàn)中低角和均角組G'-Sn-Pg' 分別增大了1.87°±3.84°和2.43°±2.26°。Varlik等[17]認(rèn)為安氏Ⅱ類錯(cuò)患者經(jīng)過肌激動(dòng)器矯治后,額突角和下唇基角都有增大,使得下領(lǐng)后縮面型得到改善?；诂F(xiàn)在的文獻(xiàn)，肌激動(dòng)器等功能矯治器對(duì)軟組織的改變還是存在爭議的，需要長期的雙盲的前瞻型的隨機(jī)研究證實(shí)，三維定量測(cè)量可以幫助我們解決頭顱側(cè)位定位片分析帶來的局限[18-19]。

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Theeffectsofactivatortreatmentonthehardandsofttissueprofileofdifferentskeletalpatterns

ZHANGYanxiao,CHENYing,XUQing.

214001,DepartmentofOrthodontics,WuxiStomatologyHospital,China

Objective: To evaluate skeletal, dentoalveolar and soft tissue profile changes by activator therapy in patients with different skeletal patterns of Class II 1 malocclusions.Methods22 subjects(10 girls, 12 boys, mean age 11.5±0.67 years) in the mixed or early permanent dentition , were included and divided into low angle(n=15) and average angle(n=7) groups on the basis of skeletal pattern. All patients were treated with a traditional activator. The skeletal, dentoalveolar and soft tissue profile changes were compared on lateral cephalograms before and after treatment. Statistical analysis was performed witht-test of SPSS 13.0 at a level of significance ofP<0.05.ResultsActivator treatment in these growing patients resulted in a correction of the skeletal Class II relationship(decrease of ANB , Wits and NA-Pg), an advancement of the mandibular structures(increase of Co-Pg and L1-APg), and changes of the teeth(increase of L6-MP). The changes of Wits, NA-Pg and L1-APg value of low and average angle groups were 1.34°±1.82° and 3.50°±1.77°,( 3.06±2.00) mm and (5.80±3.17) mm,(-1.16±1.74) mm and (-2.83±1.48) mm respectively(P<0.05). No statistical significance was found in the soft tissue profile changes whether intra-class or inter-group comparison.ConclusionThe activator appliance is effective in treating growing patients with mandibular deficiency, and mandibular reconstruction, in patients with average angle it is more effective than in those with low angle.

Verticalskeletalpattern;Activator;Functionalappliance;Cephalometricmeasurement;AngleⅡ1

214001， 無錫牙病防治所

陳瑛 E-mail： chenyin234@126.com

R783.5

A

10.3969/j.issn.1001-3733.2017.05.025

(收稿： 2017-03-22 修回： 2017-04-25)