不同矢状骨面型患者后牙颊舌向倾斜度及Wilson曲线曲度的CBCT测量研究.pdf

口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/【摘要】目的研究不同矢状骨面型患者的后牙颊舌向倾斜度及Wilson曲线曲度，探讨不同矢状骨面型患者的后牙水平向倾斜代偿机制，为骨性错畸形治疗中后牙倾斜度控制提供参考依据。方法本研究已通过单位伦理委员会审查批准，并获得患者知情同意。选取90例青少年及90例成人正畸治疗前的CBCT资料作为研究对象，两组样本中各包括矢状骨面型类、类、类各30例。分别测量每一侧由第一前磨牙至第二磨牙的所有后牙颊舌向倾斜度、第一磨牙及第二磨牙的Wilson曲线曲度，比较不同矢状骨面型的青少年及成人间的差异。结果与类骨面型成人相比，类骨面型成人的上颌后牙倾斜度减小，下颌后牙倾斜度增大，差异有统计学意义；类骨面型成人上颌后牙倾斜度增大，下颌后牙倾斜度减小，差异有统计学意义；类骨面型成人第二磨牙的Wilson曲线曲度显著性增大，差异有统计学意义。与类骨面型青少年相比，类骨面型青少年的上颌后牙倾斜度增大，差异有统计学意义。不同矢状骨面型青少年下颌后牙倾斜度差异无统计学意义。对比青少年与成人，类骨面型成人上后牙更偏舌倾，除下颌第一磨牙外下颌后牙更偏直立；类骨面型成人下颌后牙除下颌第二磨牙外更偏舌倾，差异有统计学意义，上颌后牙无明显变化，差异无统计学意义。结论上下后牙的颊舌向倾斜度及Wilson曲线曲度在不同矢状骨面型人群间存在差异，类骨面型人群以上后牙代偿性舌倾、下后牙代偿性直立为主。类骨面型人群以下后牙代偿性舌倾为主，上后牙维持原有的代偿性颊倾。【关键词】青少年；成人；正畸；后牙；颊舌向倾斜度；Wilson曲线曲度；矢状骨面型；锥形束CT；骨性错；代偿机制【中图分类号】R78【文献标志码】A【文章编号】20961456（2023）12086308【引用著录格式】姚宇,谢嘉欣,熊国平,等.不同矢状骨面型患者后牙颊舌向倾斜度及Wilson 曲线曲度的CBCT测量研究J.口腔疾病防治,2023,31(12):863870.doi:10.12016/j.issn.20961456.2023.12.004.Measurement of buccolingual inclination of posterior teeth and the curve of Wilson in patients with differentsagittal skeletal patterns using conebeam computed tomographyYAO Yu,XIE Jiaxin,XIONG Guoping,ZHENG Yuyan,WENG Junquan,WEI Xiaoxia.Department of Stomatology,Shenzhen Peoples Hospital(The SecondClinical Medical College,Jinan University;The First Affiliated Hospital,Southern University of Science and Technology),Shenzhen 518020,ChinaCorresponding author:WEI Xiaoxia,Email:X,Tel:[phone]【Abstract】ObjectiveTo study the buccolingual inclination of posterior premolars and molars and the curve of Wilson in patients with different sagittal skeletal patterns,to explore the compensation mechanism of horizontal inclinationof posterior teeth in patients with different sagittal skeletal patterns and to provide a reference for the control of posterior tooth inclination in the treatment of bone malocclusion.MethodsThis study was reviewed and approved by the Ethics Committee,and informed consent was obtained from the patients.Ninety CBCT scans of adults and ninety scans ofadolescents before orthodontic treatment were evaluated in this crosssectional study.There were 30 skeletal Class I,微信公众号【收稿日期】20230204；【修回日期】20230531【基金项目】国家自然科学基金项目（81900972）；深圳市科技计划项目（JCYJ20180228164315116）【作者简介】姚宇，主治医师，博士，Email：【通信作者】卫晓霞，主任医师，博士，Email：X，Tel：[phone]DOI 10.12016/j.issn.20961456.2023.12.004临床研究不同矢状骨面型患者后牙颊舌向倾斜度及Wilson曲线曲度的CBCT测量研究姚宇，谢嘉欣，熊国平，郑雨燕，翁军权，卫晓霞深圳市人民医院（暨南大学第二临床医学院，南方科技大学第一附属医院）口腔医学中心，广东 深圳（518020）863口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/Class,and Class patients in the adult group and adolescent group.The inclination angles of posterior teeth andthe curve of Wilson of first and second molars were measured,and data were analyzed between adolescents and adultswith different sagittal skeletal patterns.ResultsCompared with skeletal Class adult patients,the upper posteriormolar inclination of skeletal Class patients was significantly lower,and the lower posterior molar inclination was significantly higher.Compared with skeletal Class adult patients,the upper posterior molar inclination of skeletal Class adult patients was higher,and the lower posterior molar inclination was significantly lower.The Wilson curve of thesecond molar in skeletal Class adult patients was significantly higher than that in the other groups.Compared withskeletal Class adolescent patients,skeletal Class adolescent patients had a significantly higher upper posterior molar inclination;however,no difference was found between the inclination of the posterior teeth between skeletal Class,Class and Class adolescent patients.Comparing adolescent and adult samples,in skeletal Class patients,adults showed more lingual inclination than adolescents in the upper posterior teeth and less lingual inclination in thelower posterior teeth except for the mandibular first molar.Comparing adolescent and adult samples,in skeletal Class patients,adults showed more lingual inclination than adolescents in the lower posterior teeth except for the mandibular second molars and showed no difference in the upper posterior teeth.ConclusionsThe inclination of the posteriorteeth and the curve of Wilson show significant differences between the three sagittal skeletal patterns.Compared withthose of skeletal Class patients,the posterior teeth of skeletal Class patients show more lingual inclination in theupper arch and less lingual inclination in the lower arch.Meanwhile,posterior teeth of skeletal Class patients showmore lingual inclination in the lower arch and maintain the inclination in the upper arch.【Key words】adolescents;adults;orthodontics;posterior teeth;buccolingual inclination;curve of Wilson;sagittal skeletal pattern;conebeam computer tomography;skeletal malocclusion;mechanism of compensationJ Prev Treat Stomatol Dis,2023,31(12):863870.【Competing interests】The authors declare no competing interests.This study was supported by the grants from National Natural Science Foundation of China(No.81900972);the Shenzhen Science and Technology Project(No.JCYJ20180228164315116).牙结构的平衡和稳定是正畸治疗追求的目标。全口咬合的支撑依赖于正确的后牙颊舌向倾斜度。Wilson1率先报道了正常天然磨牙的正常倾斜角度，即上磨牙颊倾、下磨牙舌倾。在冠状面上，倾斜的上下后牙咬合面形成一条凸向下凹向上的曲线，称之为 Wilson 曲线。Andrews2在正常的六个关键中也提出，上下后牙牙冠长轴应具有一定的倾斜度，才能建立正常的后牙咬合关系。因此，充分了解后牙颊舌向倾斜度可为正畸治疗提供必要的参考。不同的上下颌骨位置关系引导牙列在萌出建中发生必要代偿，不仅包括三维空间上位置的代偿，更包括倾斜度的代偿34，如类人群的下前牙代偿性唇倾及类人群的下前牙代偿性舌倾5。单一维度的上下颌骨矢状向差异在三维方向上对牙结构产生影响。水平向上，后牙往往发生位置与倾斜度的变化6，但针对此问题，少有相关文献报道。因此，本研究旨在测量不同矢状骨面型青少年与成人的后牙颊舌向倾斜度，以骨性类患者作为标准，探讨不同矢状骨面型患者后牙在颊舌向倾斜度上的代偿机制，为正畸治疗解决上下牙弓宽度不调提供必要的参考。1资料和方法本研究已获得深圳市人民医院伦理委员审批通过（批号：2022071），已获得患者知情同意。1.1临床资料选取2013年7月至2022年10月于深圳市人民医院口腔医学中心就诊的青少年（1317岁）及成人患者（1830岁）各90例，拍摄头颅定位侧位片及锥形束CT。根据ANB角度测量值分为骨性I类（0.7ANB 4.7）、骨性类（ANB4.7）、骨性类（ANB 0.7），各30例，共180例样本。纳入标准：垂直骨面型为均角型，否认相关正畸治疗史；无明显后牙段拥挤不齐（拥挤度2 mm）；无后牙锁、反；无明显腭盖高拱；后牙段牙体结构健康，无明显龋坏，牙冠及牙根完整，无明显牙周组织破坏；后牙段牙齿数量正常，无缺牙（不含第三磨牙缺失）。排除标准：上下颌骨基骨宽度差异大于5 mm；864口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/a:in the maxilla,theline across the centralpoint of the buccolingual width of the occlusal surface of the molartooth and the cervicalpart of the anatomicalcrown as the tooth longaxis were used to measure the angle betweenthe tooth axis and baseline.b:in the mandible,the line across the central point of the buccolingual width of the occlusal surface of the molar tooth and the cervicalpart of the anatomical crown as the tooth long axis were used to measure the angle between the tooth axis and baseline.baseline:connect the inferior border of the orbital rims which was parallel to the floorFigure 1Measurement of the inclination of the maxillary posterior teeth and mandibular posterior teeth in patients withdifferent sagittal skeletal patterns图1不同矢状骨面型患者上颌和下颌后牙颊舌向倾斜度的测量ab曾有正颌外科史、颅面综合征（如唇腭裂）、面部不对称、下颌骨肥大、上呼吸道病变、上呼吸道感染、慢性口呼吸、永久性打鼾、外伤史、腺样体及扁桃体肥大等呼吸系统疾病。1.2测量方法所有 CBCT 影像均使用 NewTom VGI CBCT 系统（维罗纳，意大利）扫描采集。扫描设置要求患者采用自然头位，牙尖交错位咬合。拍摄视野为15 cm15 cm。所有CT 图像的空间分辨率分别为300 m、110 kV 和 78.59 mAs。CBCT 数 据 使 用NNT Viewer 软件测量。在轴位、矢状位和冠状位对 CBCT 图像进行评估。在轴位及矢状位调整截面位置，在冠状位平面测量牙齿倾斜度和 Wilson曲线角度。测量前重定位图像，以使眼耳平面（FH平面）和眼眶间线（连接眼眶边缘下点的线）平行于水平线。作眼眶间线平行线，并以此作为基线，所有角度测量以此为参考。经过后牙牙冠咬合面颊舌向中心点与牙冠颈部颊舌向中心点作被测牙的牙体长轴，测量牙体长轴与基线间夹角（图1），得到以下测量值：上颌第一前磨牙倾斜度（U4I）、上颌第二前磨牙倾斜度（U5I）、上颌第一磨牙倾斜度（U6I）、上颌第二磨牙倾斜度（U7I）、下颌第一前磨牙倾斜度（L4I）、下颌第二前磨牙倾斜度（L5I）、下颌第一磨牙倾斜度（L6I）、下颌第二磨牙倾斜度（L7I）。经过上颌磨牙的近中颊尖与近中舌尖作直线，左右两侧直线相交所形成夹角角度作为Wilson曲线角度，得到第一磨牙Wilson曲线曲度（Wilson6）和第二磨牙 Wilson 曲线曲度（Wilson7）7。2 周后，随机抽取其中20例样本再次测量，组内相关系数最低为0.958，提示测量结果可靠，可排除测量者误差。1.3统计学分析所有数据均采用SPSS18.0（SPSS公司，伊利诺伊州，美国）进行分析，数据的正态分布使用 KolmogorovSmirnov 检验进行评估。若数据呈正态分布，组间比较采用方差分析，Tukey 检验用于两两比较，显著性水平为0.05。2结果共采集180例样本，其中青少年90例（男52例，女 38 例），平均年龄（14.72.3）岁，成人 90 例（男44 例，女 46 例），平均年龄（25.35.2）岁。根据以往研究，矢状骨面型的性别差异并无统计学意义7，因此将男女数据合并统计。KolmogorovSmirnov 检验表明所有定量变量均呈正态分布（P 0.05）。2.1不同矢状骨面型人群的后牙颊舌向倾斜度比较90例成人患者的后牙颊舌向倾斜度见表1，不同矢状骨面型成人后牙倾斜度差异具有统计学意义。与类骨面型成人比较，类骨面型成人的 865口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/上颌后牙倾斜度减小，下颌后牙倾斜度增大，差异均具有统计学意义（P0.05）；类骨面型成人的上颌后牙倾斜度增大，下颌后牙倾斜度减小，差异均具有统计学意义（P0.05）。不同矢状骨面型成人的第一磨牙的 Wilson 曲线曲度无明显差异，第二磨牙的 Wilson 曲线曲度差异具有统计学意义（P0.05）。表1不同矢状骨面型成人后牙颊舌向倾斜度及Wilson曲线曲度Table 1The buccoligual inclination of posterior teeth and thecurve of Wilson in adults with different sagittalskeletal patterns,x sU4IU5IU6IU7IL4IL5IL6IL7IWilson6Wilson7Skeletal Clas(n=30)89.2 4.9a90.7 4.5b93.8 5.6b103.6 3.8b82.7 6.6a78.4 5.6b75.3 4.8b73.1 6.1b157.7 6.2143.8 9.2bSkeletal Clas(n=30)85.0 4.3a87.4 4.9a91.9 4.9a97.1 4.5a86.3 6.6b81.0 4.9c77.9 5.7c74.3 7.6b160.7 8.0149.5 9.7cSkeletal Class(n=30)91.1 6.6b94.3 7.6c98.4 4.6c107.3 6.1c81.5 7.8a75.3 6.6a73.1 5.2a69.5 6.7a157.1 8.4140.3 12.1aF20.1420.8126.3867.077.5014.6912.148.011.945.97P0.0010.0010.0010.0010.0010.0010.0010.0010.1490.003abc was found in pairwise comparison.Significanct difference wasfound between a and b,b and c,a and c.U4IU5IU6IU7I:inclinationof upper first premolar,second premolar,first molar and second molar.L4IL5IL6IL7I:inclination of lower first premolar,second premolar,first molar and second molar.Wilson6Wilson7:the wilson curve offirst molar and second molar.Skeletal Class I:0.7ANB 4.7.Skeletal Class II:ANB4.7.Skeletal Class:ANB 0.7.The curve ofWilson:the tips of mesiobuccal and mesiolingual cusps of maxillaryfirst and second molars along the buccal groove were connected and theformed angles were measured90例青少年患者的后牙颊舌向倾斜度见表2，不同矢状骨面型青少年的后牙倾斜度差异亦具有统计学意义，且差异只表现在上颌，而在下颌后牙区，颊舌向倾斜度差异无统计学意义。在上颌后牙区，仅表现为类骨面型青少年的上颌后牙倾斜度较类明显增大，差异具有统计学意义（P0.05）；而类骨面型青少年的上颌后牙倾斜度与类差异无统计学意义。第一磨牙与第二磨牙的Wilson曲线曲度在三种矢状骨面型间的差异无统计学意义。2.2青少年及成人后牙颊舌向倾斜度的比较各类矢状骨面型青少年与成人上下颌后牙的颊舌向倾斜度见表 3表 5。在类骨面型人群中，除下颌第一前磨牙外，成人上下颌后牙倾斜度与青少年的差异无统计学意义。在类骨面型人群中，成人上颌后牙倾斜度较青少年减小，差异有统计学意义。下颌后牙除第一前磨牙外，其余后牙均表现为成人倾斜度较青少年增加，且差异具有统计学意义。成人下颌第一磨牙的 Wilson 曲线曲度也较青少年增大，差异具有统计学意义。第二磨牙Wilson曲线曲度在两者间的差异无统计学意义。在类骨面型人群中，成人上颌后牙的颊舌向倾斜度虽然较青少年倾斜度减小，除上颌第二磨牙外，其余上颌后牙间差异均无统计学意义。在下颌后牙区，除下颌第二磨牙外的所有下颌后牙均表现为成人患者的倾斜度较青少年减小，差异具有统计学意义。成人下颌第一磨牙的Wilson曲线曲度也较青少年增大，差异具有统计学意义。第二磨牙的Wilson曲线曲度在两者间的差异无统计学意义。表2不同矢状骨面型青少年后牙颊舌向倾斜度及Wilson曲线曲度Table 2The buccoligual inclination of posterior teeth and thecurve of Wilson in adolescents with different sagittalskeletal patterns,x sU4IU5IU6IU7IL4IL5IL6IL7IWilson6Wilson7Skeletal Clas(n=30)89.7 5.4a91.2 5.3a94.6 4.9a101.9 7.0a86.3 7.280.0 5.576.7 4.671.7 6.0157.0 8.4143.7 10.7Skeletal Clas(n=30)89.6 4.8a90.5 4.9a94.2 3.5a101.9 5.0a87.4 5.479.0 4.575.0 6.071.3 7.6155.0 6.5145.8 8.9Skeletal Class(n=30)92.6 4.5b96.3 5.4b99.9 4.7b109.9 6.3b85.0 5.680.2 5.077.4 6.270.8 6.6154.7 7.8139.8 9.2F5.3616.8824.5126.091.930.892.700.242.402.31P0.0050.0010.0010.0010.1480.4110.0700.7860.0990.106abc was found in pairwise comparison.Significanct difference wasfound between a and b,b and c,a and c.U4IU5IU6IU7I:inclinationof upper first premolar,second premolar,first molar and second molar.L4IL5IL6IL7I:inclination of lower first premolar,second premolar,first molar and second molar.Wilson6Wilson7:the wilson curve offirst molar and second molar.Skeletal Class I:0.7ANB 4.7.Skeletal Class II:ANB4.7.Skeletal Class:ANB 0.7.The curve ofWilson:the tips of mesiobuccal and mesiolingual cusps of maxillaryfirst and second molars along the buccal groove were connected and theformed angles were measured 866口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/3讨论影响后牙颊舌向倾斜度的因素包括年龄、矢状骨面型、垂直骨面型、基骨弓宽度、腭穹隆高度及后牙段拥挤度等810。合理的颊舌向倾斜度是建立稳定后牙咬合的重要因素，因此区分不同骨面型及发育阶段的研究可提示后牙倾斜度在不同人群间的差异和增龄性变化下的代偿机制，为正畸治疗中协调后牙宽度不调提供参考。锥形束CT引入颌面结构形态研究之后，基于CBCT 三维重建技术的扫描测量为后牙倾斜度提供了更为精确的测量手段1115。Kasai等16定义后牙牙体长轴为牙冠1/2中点及牙根尖1/3中点的连线。本研究参考Alkhatib等17的研究方法，采用临床冠咬合面中心点及牙颈部中心点的连线作为目标牙的牙体长轴，可有效避免牙冠形态及牙根畸形变异所产生的测量误差。既往研究中，并未发现人种差异对后牙倾斜的影响，因此本研究未对纳入对象的人种来源作严格限定1112,1718。本研究纳入标准限定垂直骨面型为均角型，排除了上颌骨垂直向发育差异及腭盖深度差异，降低了腭盖深度对后牙颊舌向倾斜表3类骨面型青少年与成人后牙倾斜度及Wilson曲线曲度的比较Table 3The comparison of buccoligual inclination of posteriorteeth and the curve of Wilson in skeletal Class adolescents and adults,x sU4IU5IU6IU7IL4IL5IL6IL7IWilson6Wilson7Adults(n=30)89.2 4.990.7 4.593.8 5.6103.6 3.882.7 6.678.4 5.675.3 4.873.1 6.1157.7 6.2143.8 9.2Adolescents(n=30)89.7 5.491.2 5.394.6 4.9101.9 7.086.3 7.280.0 5.576.7 4.671.7 6.0157.0 8.4143.7 10.7t-0.53-0.61-0.831.70-2.79-1.56-1.641.220.320.01P0.5980.5360.4070.0910.0060.1210.1010.2240.7460.985U4IU5IU6IU7I:inclination of upper first premolar,second premolar,first molar and second molar.L4IL5IL6IL7I:inclination of lower firstpremolar,second premolar,first molar and second molar.Wilson6Wilson7:the wilson curve of first molar and second molar.Skeletal Class:0.7ANB 4.7.Skeletal Class II:ANB4.7.Skeletal Class:ANB 0.7.The curve of Wilson:the tips of mesiobuccal and mesiolingual cusps of maxillary first and second molars along the buccalgroove were connected and the formed angles were measured表4类骨面型青少年与成人后牙倾斜度及Wilson曲线曲度的比较Table 4The comparison of buccoligual inclination of posteriorteeth and the curve of Wilson in skeletal Class adolescents and adults,x sU4IU5IU6IU7IL4IL5IL6IL7IWilson6Wilson7Adults(n=30)85.0 4.387.4 4.991.9 4.997.1 4.586.3 6.681.0 4.977.9 5.774.3 7.6160.7 8.0149.5 9.7Adolescents(n=30)89.6 4.890.5 4.994.2 3.5101.9 5.087.4 5.479.0 4.575.0 6.071.3 7.6155.0 6.5145.8 8.9t-5.43-3.44-3.04-5.51-1.022.332.692.192.051.55P0.0010.0010.0020.0010.3080.0210.0080.0290.0360.124U4IU5IU6IU7I:inclination of upper first premolar,second premolar,first molar and second molar.L4IL5IL6IL7I:inclination of lower firstpremolar,second premolar,first molar and second molar.Wilson6Wilson7:the wilson curve of first molar and second molar.Skeletal Class:0.7ANB 4.7.Skeletal Class II:ANB4.7.Skeletal Class:ANB 0.7.The curve of Wilson:the tips of mesiobuccal and mesiolingual cusps of maxillary first and second molars along the buccalgroove were connected and the formed angles were measured表5类骨面型青少年与成人后牙倾斜度及Wilson曲线曲度的比较Table 5The comparison of buccoligual inclination of posteriorteeth and the curve of Wilson in skeletal Class adolescents and adults,x sU4IU5IU6IU7IL4IL5IL6IL7IWilson6Wilson7Adults(n=30)91.1 6.694.3 7.698.4 4.6107.3 6.181.5 7.875.3 6.673.1 5.269.5 6.7157.1 8.4140.3 12.1Adolescents(n=30)92.6 4.596.3 5.499.9 4.7109.9 6.385.0 5.680.2 5.077.4 6.270.8 6.6154.7 7.8139.8 9.2t-1.34-1.53-1.62-2.02-2.61-4.24-3.69-0.952.800.15P0.1810.1290.1090.0470.0110.0010.0010.3440.0070.878U4IU5IU6IU7I:inclination of upper first premolar,second premolar,first molar and second molar.L4IL5IL6IL7I:inclination of lower firstpremolar,second premolar,first molar and second molar.Wilson6Wilson7:the wilson curve of first molar and second molar.Skeletal Class:0.7ANB 4.7.Skeletal Class II:ANB4.7.Skeletal Class:ANB 0.7.The curve of Wilson:the tips of mesiobuccal and mesiolingual cusps of maxillary first and second molars along the buccalgroove were connected and the formed angles were measured 867口腔疾病防治2023年12月第31卷第12期Journal of Prevention and Treatment for Stomatological Diseases,Dec.2023,Vol.31 No.12http:/度测量的干扰误差19。回顾以往研究，仅 Golshah 等7的研究对不同矢状骨面型进行区分。其研究样本量较少，仅为66例成人，不包含青少年样本，且未对纳入样本的后牙段拥挤度作明确限制。后牙段拥挤常表现为磨牙