Doctor 1/2018 by Infodent srl

1-2018 Visit us at Dental South China Hall 14.1 Booth K09

DOCTOR牙医 Infodent International •1 2018

ImplantBook 2018 Dealers e Dentists: Download your copy from www.implant-book.com to discover new brands and products

Manufacturers: Learn more about ImplantBook on www.implant-book.com to reach your next partner

The ultimate global guide 2017

The ultimate global guide 2018 DENTAL IMPLANTS

Iris View

OSSEOINTEGRATION &BIOMATERIALS

Polaris

AROUND IMPLANTOLOGY

Nuvolina

3D PRINTERS

The best lights, for the best implants.

EQUIPMENT PIEZOSURGERY

www.gcomm-online.com

SOFTWARE RADIOLOGY CONGRESSES

Gcomm Cover DEF.indd 1

Topic: Dental Implants pag. 9 - 65

Topic: Equipment & Supplies for Dental Implants pag. 81 - 98

Topic: Software pag. 117 - 125

21/12/16 11:45

COMPANY LIST

implant-book.com

代理商，牙医:下载ImplantBook 2018完整版免费从 www.implant-book.com, 以便找到新品牌和产品

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The Chapters: Dental Implants, Osseointegration & Biomaterials, Around Implantology, Congresses, Company List For more, please write to prc@infodent.com | 如需了解更多信息，请发送电子邮件到 prc@infodent.com

Technology that innovates Skema 6 combines the best of Castellini technology with the practicality and effectiveness of multiple integrated systems. Ample scope for personalisation ensures the achievement of outstanding clinical and specialist performance via a precise, interactive control panel, available as a Full Touch version with a 5.7” glass display. Cutting-edge configuration is completed via the availability of highly advanced dynamic instruments, an innovative multimedia system, all the main certified hygiene devices and the latest exclusive functions from Castellini.

卡斯特里尼

CONTENTS 目录

Editorial

学术文章

Scientific Update

China, still a land of opportunity 中国，依然是那片充满了机会的土地

Highlights

10 Silfradent Regenerative medicine 再生医学 16 Treatment of “white spot lesions” after removal of fixed orthodontic appliances 固定式正畸器械拆除后的“病变白斑”治疗

7 迈锐(MYRAY) - 性能卓越、用户友好的解决方案 MyRay, solutions which bring you performance and user-friendliness.

20 Interceptive Treatment for the Class III Malocclusion III类错牙合畸形的阻断性治疗

与卡斯特里尼(CASTELLINI) 一同触摸未来 Touch the future with Castellini

28 New Therapeutic Management of TMDs, Through the Immediate Re-educational Device: “Lingual Ring Ri.P.A.Ra.” 颞下颌关节紊乱综合症（TMDs）的新疗法，运用“Lingual RingRi.P.A.Ra.”即刻恢复训练纠治器

8 安福士 (ANTHOS) -向全世界牙医提供无限解决方案的品牌。ANTHOS.The brand with limitless solutions for dentists all around the world

42 SIA Orthodontics - Trial of “Leonardo” a new rapid palatal expansion screw “Leonardo”新快速颚扩张器的临床试验

赛特伟邦 STERN S320TR STERN WEBER Stern S320TR 9 公理福V286 – 一生好伙伴 Victor V286 a lifetime partner

日历

Calendar

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• CEO: Baldo Pipitone baldo.pipitone@infodent.com • General Manager: Paola Uvini paola@infodent.com • Editorial Director: Silvia Borriello infodent@infodent.com • Marketing Consulting Manager: Riccardo Bonati riccardo.bonati@infodent.com • Exhibition Manager: Alessia Murano alessia.murano@infodent.com • Newsroom: Nadia Coletta nadia@infodent.com Claudia Ragonesi pressoffice@infodent.com • Social: Ilaria Ceccariglia ilaria.ceccariglia@infodent.com • Graphic Dept.: Silvia Cruciani silvia.cruciani@infodent.com Lorenzo Burla lorenzo.burla@infodent.com • Account Dept.: Alessandra Mercuri alessandra.mercuri@infodent.com

• Translator: Zhuoling Xiong 熊卓玲 renmei1@126.com - Tel: +39 331 2507669 Publishing House: Infodent S.r.l. Str. Cassia Nord Km 86,300 01100 Viterbo - Italy Tel: +39 0761 352 198 Fax: +39 0761 352 133 VAT 01612570562 Printer: 宁波市镇海印颂电子商务有限公司 No.1 Qiujing Road, Shiqi town, Yinzhou District, Ningbo, Zhejiang, China. +86 0574 8658 2081 n°1/2018 - aut. trib. VT n°528 del 21-07-2004 Doctor by Infodent International is the title of this magazine as well as an applied for trademark. Any use there of without the publisher’s authorization is to be deemed illegal and shall be prosecuted.

Trade Shows and Conferences for Dental Practitioners 牙科技术会议及展览会

Cover page: My Ray (Cefla Group) Via Bicocca, 14/C I-40026 Imola (BO) - Italy imaging@my-ray.com +39 0542 653441 AIO Congress 2019.....................................................................................p. 50 Anthos....................................................................................................................p. 19 Arianto - Post Graduate Management & Marketing.......p. 55 Castellini................................................................................................................p. 2 DenTech China 2018..........................................................................II Cover Expodental Meeting 2018....................................................................p. 49 FDI World Dental Congress 2018....................................................p. 41 IDEA 2018.................................................................................................III Cover ImplantBook.......................................................................................................p. 1 Maco International.......................................................................Back Cover SIA Orthodontics.............................................................................................p. 48 Silfradent...............................................................................................................p. 10 Stern Weber.......................................................................................................p. 27 Suzhou Victor Medical Equipment...................................................p. 14 Vanmax..................................................................................................................p. 6

The ultimate global guide 2017

DOCTOR牙医 Infodent International •1 2018

DITORIAL

China, still a land of opportunity After two successful years, “Doctor by Infodent International” magazine – our highly scientific publication, in English and Chinese, dedicated to a selected target of Chinese dentists, professors and scientific boards - keeps on helping all dental businesses compete in today’s Chinese dynamic market, allowing them to create wealth and increase revenue. As living standards continue to improve and the awareness of oral health grows, consumers’ demand for dental services has kept increasing and the dental industry in China has witnessed robust development in recent years, primarily reflected in the following four aspects: • Scale of dental equipment industry expanded steadily: there were 54 dental equipment enterprises with total annual revenue of RMB4.61 billion in China by the end of 2016. The figures are expected to reach 75 and RMB6.55 billion in 2021. • Number of stomatological hospitals and dentists rose rapidly: the number of stomatological hospitals and dentists in China has grown steadily at a CAGR of 10.2% during 2010-2016, compared with a CAGR of 17.7% for private hospitals and a CAGR of 10.4% for medical personnel in stomatological hospitals. In 2016, there were about 542 stomatological hospitals (including 373 private ones) and 48,053 medical staff (including 16,348 medical practitioners). • Chain operation has become a main model for oral medical institutions: major typical private dental institutions include BYBO Dental, TC Medical, ARRAIL Group, Keen Dental, Dazhong Dental, Huamei Dental, U-dental, Jiamei Dental, Yafei Dental, and C.K.J Stomatological Hospital, all adopting the model of chain operation and achieving good results. A high and full chain operation will be the main pattern adopted by dental institutions so as to grow bigger and stronger.

• Huge potential attracts inrush of capital: featuring high growth and high gross margin, the oral medical industry has attracted a large amount of money. 12 dental enterprises obtained financing in 2016 alone. Inflow of capital helps fuel rapid development of the industry. China is the great economic success story of the past 30 years, the world’s second-largest economy. Since the “reform and opening-up” policy was introduced in 1978, China has changed beyond recognition. A Soviet-styled planned economy has transformed into a vibrant market orientated economy and 600 million people have been lifted out of poverty. Between 1985 and 2010, 70% of the world population who had been lifted out of poverty was Chinese. The first and most important thing anyone hoping to set up a business should do is find a local partner. A local partner will most often be an established Chinese-owned company, or a businessperson with good contacts in the country who can navigate the complicated regulations and legal processes and, most importantly, deal with China’s government directly. A good partner is an incorporated company that is about the same size as your firm, at least partly Chinese-owned, and well-connected in the Chinese market. China is no longer the Wild West of business that it once was. While the rise of China is easy to acknowledge, businesses constantly need to catch up with the speed and depth of change and development in China’s large and complex market space. With this latest “Doctor by Infodent International” issue, focused on orthodontic research articles, we really hope to help fulfil the needs of what the dental industry is looking for.

中国，依然是那片充满了机会的土地《Doctor by Infodent International》牙科杂志 - 我们的中英文高科技出版物，以致力于服务中国牙医，牙科教授以及各类牙科科学委员会为使命。经过连续两年的成功发行之后，它还在继续帮助着牙科企业在当今中国动态市场上展开有力的竞争，并促进其继续增加收入创造出更多的财富。随着生活水平的不断提高和口腔健康意识的增强，消费者对牙科服务的需求不断增加，近年来中国牙科行业发展强劲，主要表现在以下四个方面： • 牙科设备产业规模稳步扩大：截至2016年底，全国共有54家牙科设备企业年收入达46.1 亿元，预计到2021年将达到75家牙科设备企业，届时年收入将达到65.5亿元。 • 口腔医院和牙医的数量也在迅速增加：2010 - 2016年期间，中国口腔医院和牙医的数量稳步增长，复合年增长率为10.2％，相比之下，私立口腔医院的复合年增长率为17.7％，从事口腔医院医务人员的复合年增长率为10.4％。 2016年，约有542家口腔医院（包括373家私立医院）和48053名牙科医务人员（包括16348 名牙医）。 • 巨大的市场潜力吸引着资本的不断涌入：高增长高毛利率的口腔医疗行业吸引了大量

的资金，仅2016年就有12家牙科企业获得融资，资本的流入大大推动了行业的快速发展。中国成了过去30年来最大的经济成功案例，当今世界的第二大经济体。自1978年实行“改革开放”政策以来，中国的状况已是今非昔比。苏联式的计划经济已经转变为充满活力的市场导向型经济，6亿人摆脱了贫困。在1985年至2010年间，70％脱离贫困的世界人口为中国人。任何希望在当地建立企业的人都应该首先找到当地的合作伙伴。一个当地的合伙人通常可以是一家老牌的中国公司，或者是在国内有良好关系的商人，他们可以驾驭复杂的法律法规程序，最重要的是可以直接与中国政府打交道。一个理想的合作伙伴应该是一家合并公司，其规模应与贵公司的规模大致相同，至少部分所有权应由中方合伙人拥有，并且能够在中国市场上建立良好的关系。中国不再是曾经的商业界的狂野西部。我们在轻易地识别到中国崛起的同时，企业也需要不断赶上中国庞大而复杂的市场空间变化以及其发展的速度和深度。有了这个最新的《Doctor by Infodent International》牙科杂志，主要发表正畸研究领域的文章，我们真的希望可以满足所有牙科行业正在寻找的需求。

DOCTOR牙医 Infodent International •1 2018

作者投稿指南

迈锐(MYRAY) - 性能卓越、用户友好的解决方案。迈锐Hyperion X9 体现了一种模块化概念，覆盖了从 2D 全景成像、头影测量到具有真正的全颌弓容积扫描范围的3D 锥形束立体断层的所有拍摄功能。迈锐Hyperion X9 通过全局的360°扫描进行容积采集，可以有效消除所得图像中的伪影。它可以在极低的X-射线剂量下实现高分辨率成像，从而提供超凡的图像质量、精致的细节呈现以及即时的诊断结果。迈锐Hyperion X9 的扫描视野宽度为Ø 11厘米，它可以配备大号图像传感器器提供检测区高度8厘米（可扩展到13厘米）的视野；也可提供较小版本的传感器器，提供检测区高度5厘米（可扩展到8厘米）的视野。其软件可在不到1分钟内处理所有采集数据并完成重建，包括3D数据。X9所提供图像信息的数量、质量以及管理这些数据的便捷方式有助于进行更高效的诊断，并为达到有效治疗进行有效的规划。 www.my-ray.com

MyRay, solutions which bring you performance and user-friendliness. Hyperion X9 is a modular concept which covers all aspects from 2D panoramic imaging, through cephalometric exams up to cone beam 3D with true full arch volumetric scan capability. Hyperion X9 performs a volumetric acquisition with a full 360° scan capable of eliminating the artefacts of the resulting image. High resolution at extremely low X-ray doses: excellent quality, finest details, immediate diagnosis. Hyperion X9 scans with a Ø

11 cm FOV, but it can also be equipped with a large image detector, 8 cm high and extendable to 13 cm, or a small version that limits the height of the examined region to 5 cm, extendable to 8 cm. The software processes all types of acquired data, including 3D data, in less than a minute. The quantity and quality of the information X9 provides and the simple way you can manage that data makes for a clearer diagnosis and helps effective planning, ready for efficient treatment. www.my-ray.com

与卡斯特里尼(CASTELLINI) 一同触摸未来将公司80年的历史、创新精神及丰富的临床专业经验熔于一体创造出一流的口腔综合治疗台Skema 6。

Touch the future with Castellini Eighty years of experience, innovation and clinical expertise concentrated into a high-class unit: Skema 6. Skema 6 by Castellini, with its high-tech instruments, touchscreen controls and integrated systems, offers dental professionals the ideal tool for high-performance treatment including conservative dentistry, endodontics and implantology. The advanced hygiene devices, fully certified by leading Italian universities, together with a design which ensures functionally ergonomic solutions, enables the dentist to work comfort-

ably, enjoying total peace of mind. Skema 6 is equipped with Implantor LED, an extremely lightweight induction micromotor with electronic torque control up to 5.3 Ncm, fully autoclavable and suitable for integrated endodontics and implantology. Full Touch consolle, available as an optional, features a tempered glass display and 5.7” touchscreen interface. Skema 6 brings dentistry a step closer to the future, with a host of innovative solutions enabling excellent hygiene, total control and enviable comfort, both for patients and medical staff.

卡斯特里尼Skema 6，集高科技器械、触摸屏控制界面和整合式的内建系统，可满足从牙体牙髓到种植等各专业口腔医生高品质临床需求的理想工具。它还可以提供高端卫生消毒设备，经意大利大学测试认证有效，为医生提供舒适的符合人体工学的感控解决方案，使他们可以平静专注地对待患者。 Skema 6 装备的LED光纤种植电马达，其具有超轻的重量，高达5.3Ncm的扭矩，可耐全面高温高压灭菌，可用于包括根管及种植等临床应用。本机还可以选配具有坚固的5.7英寸触摸屏用户界面的全触摸屏控制器。凭借高效的卫生学解决方案、全面操控体验以及令人羡慕的舒适度，无论医生及护士团队均可轻松体会Skema6带领牙科界更进一步迈入未来。

castellini.com

DOCTOR牙医 Infodent International •1 2018 Doctor Os 牙医 Infodent International •3/2017

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highlights

赛特伟邦（STERN WEBER） STERN S320TR

安福士 (ANTHOS) -向全世界牙医提供无限解决方案的品牌。 A级系列完整的A级系列口腔综合治疗台的设计宗旨是尽可能提供最大的灵活性，使牙医可以选择最适合其操作风格和专业需求的人体工学和功能设置。 A5级可提供6种不同的配置。适合各种操作风格的人体工学，整合的安福士品牌器械，脚控和手术灯的扩展性选择，不同的卫生学系统、可选配置和颜色主题，从每个方面讲都具有多样的变化。选择 A7 +级的牙医知道他们可以根据当前和未来的特殊需求对其口腔综合治疗台进行个性化定制，无论他们的专业领域属于常规牙科还是种植科。鉴于搭载了向所有的可整合安福士设备开放的基础技术配置接口，这款高端的治疗台可以在现场或在未来与超高性能器械仪器、X-射线装置、多媒体系统以及先进的卫生学设备相匹配，达到扩展功能的目的。

基于分体落地式的主体特征，S320TR在保证患者椅运行的独立性同时，依然具备极高的稳定性和充分的治疗操作空间。作为来自意大利的最新型号款式，牙医在诊断上能够获得崭新的操作体验。赛特伟邦（Stern Weber）以持续开发先进的牙科设备为基本指导原则（秉持-坚固、紧凑、操作友好方便、符合人体工程学结构以及自身出色的性能），TR系列最大限度的为您提供前所未有的丰富的新的机遇。医生位的良好机动性保证了此种操作风格的完美定位性和移动操作的优化流畅性。医生位采用铸铝支架臂，具备出色的稳定性，再加上通过按键操作进行高度调节，可以让牙科医生从容而安心的工作。由于采用了最新的数码电子科技，使得S320TR给牙科医生们带来了最好的操作体验。

www.anthos.com

sternweber.com

ANTHOS. THE BRAND WITH LIMITLESS SOLUTIONS FOR DENTISTS ALL AROUND THE WORLD. The Classe A range Developed to provide as much flexibility as possible, the full Classe A range of units enables dentists to select the ergonomic and functional set-up best suited to their operating style and professional needs. Classe A5 can be supplied in 6 different configurations. Ergonomics to suit every operating style, integrated Anthos brand instruments, an extensive choice of foot controls and operating

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lights, various hygiene systems, options and colour schemes: versatility in every sense of the word. Dentists who choose Classe A7 Plus know they can personalise their dental unit according to the specific needs of today and tomorrow, whatever their field of specialization, from conservative dentistry to implantology. Thanks to the underlying technological configuration, open to all integrated Anthos systems, this premium treatment centre can be expanded, immediately or at a later date, with ultra-high performance instruments, X-ray and multimedia systems, and advanced hygiene devices.

DOCTOR牙医 Infodent International •1 2018 Doctor Os 牙医 Infodent International •3/2017

STERN WEBER Stern S320TR Characterised by a floor-mounted unit body, which remains independent from the patient chair and its movements, the S320TR models provide stability and extensive operating space. This latest model from the Italian brand lets dentists explore new capabilities within the diagnostic field. By taking the guiding principles behind Stern Weber’s advanced dental unit development program – sturdiness, compactness, user-friendliness, ergonomics and performance – the TR Series maximises them as never before

so as to provide you with a wealth of new opportunities. Excellent manoeuvrability of the dentist’s module ensures perfect positioning and optimises fluidity of the movements associated with this operating style. The outstanding stability of the dentist’s module and its cast aluminium support arm, coupled with a telescopic height adjustment function operated via the keypad, allows the dentist to work calmly and confidently. Thanks to the latest digital electronics, the S320TR brings out the dentist’s very best. sternweber.com

作者投稿指南

Victor V286 a lifetime partner

精心挑选优质材料保证持久运行及超凡的可靠性，V286采用铸铝结构部件来增加稳定性，和注塑塑料工艺来提供出色的表面处理。作为最新款的公理福口腔综合治疗台，结合了美观设计与最新人体工学及空间利用理念的V286在欧洲开发并完成工程学测试。高级的电子电路允许最多5 位不同操作者的个性化设置。最新的具有同步功能的病人椅（最大可以提升190公斤的重量）可确保患者的最佳舒适度，也有柔软的沙发皮垫可供选配，体现奢华。治疗台可以配备4组可动器械，包括意大利原装进口的高性能无碳刷电动马达。口腔医生可以通过带有新款三位液晶数字屏幕的控制面板调整及观察参数和设置。液晶面板可以显示操作状态的细节，并进行自我诊断。

Built with premium quality materials for lasting service and superb reliability, the V286 boasts cast aluminium structural elements for increased stability and injection moulded plastics to provide an excellent surface finish. Developed and engineered in Europe, the latest treatment centre in the Victor range not only seduces from a design point of view, but can also count on the latest solutions in terms of ergonomics and space-efficiency. Advanced electronics allow extensive personalisation for up to 5 different operators. Synchronised patient chair movements (lift capacity can reach up to 190 kg) enable maximum comfort and soft upholstery is an attractive option. The unit can be fitted with up to 4 dynamic instruments, including the high-performance brushless micromotor manufactured in Italy. Dentists can select operating parameters and visualise key settings on the new, large 3-digit LCD control panel. The LCD display provides details of operating status and includes a selfdiagnostic system.

更多信息请详见www.victordentalequipment.com

More details on www.victordentalequipment.com

公理福V286 – 一生好伙伴

DOCTOR牙医 Infodent International •1 2018 Doctor Os 牙医 Infodent International •3/2017

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Silfradent

Regenerative medicine The CGF (Concentrated Growth Factors) initial popularity grew from its promise as a safe and natural alternative to surgery. The CGF promoters supported the procedure as an organism-based therapy that allowed healing thanks to its own natural growth factors.

再生医学

CGF（浓缩生长因子）最初的受欢迎程度来自于其可作为安全和自然的手术替代品.CGF推广者们把它当作是一个由有机体自然生长因子促成愈合的疗法.

Author

Dott.ssa Paola Pederzoli specialist in dentistry, dental prosthetics and aesthetic medicine

“APAG” DENATURATION DEVICE - A.P.A.G. Activated Plasma Albumin Gel - I.C.F. Induces Collagen Formation Built with anti-static and anti-magnetic materials. Operations with heating pulse and thermal equilibrium temperature

“APAG” DENATURATION DEVICE 离心机-A.PA.G.A 活性血浆白蛋白凝胶 - I.C.F. 诱导胶原蛋白形成用抗静电和抗磁性材料制成. 加热脉冲和热量温度自动平衡的操作系统

In recent years, scientific research and technology provided a new perspective on platelets. Studies suggest that platelets contain abundance of growth factors and cytokines which can affect the inflammation, the post-operative blood loss, the infection, the osseogenesis, the wound, the muscle laceration and the soft tissue healing.

近年来，科学的研究和技术为血小板提供了新的视角。研究表明，血小板含有丰富的生长因子和细胞因子，它们可以影响炎症、术后失血、感染、骨形成，伤口，肌肉裂伤和软组织愈合。. 现在的研究表明，血小板释放出许多负责吸引巨噬细胞、间质干细胞和成骨细胞的生物活性蛋白质，这不仅促进了退化和坏死组织的移除，并且改善了组织再生和愈合.

Research now shows that platelets release also numerous bioactive proteins responsible for the attraction of macrophages, mesenchymal stem cells and osteoblasts that not only promote the removal of degenerated and necrotic tissues, but also improve tissues regeneration and healing. In regenerative medicine, three factors are important to optimize the regenerative process: the scaffold (biological, natural or synthetic), growth factors and autologous cells. All the above is present in CGF. CGF is obtained following a process of blood separation collected in vacuum tubes, using a special medical device (Medifuge, Silfradent Srl, Italy). The CGF technology has an interesting characteristic: the centrifugation simplicity and speed, allow a more elastic matrix of fibrin glue rich in growth factors. Using SEM analysis (Electron Scanning Electron Microscopy), Rodella and associates (University of Brescia) showed the presence of a fibrin network formed by thin and thick elements with numerous platelets trapped in the network itself, representing an optimal autologous scaffold. In addition to the growth factors released after the platelets activation and degranulation, we also count the vascular endothelial growth factor (VEGF), the insulin growth factor (IGF), the transforming growth factor (TGF), the tumour necrosis factor (TNF), the brain-derived neurotrophic factor (BDNF) and the presence of TGF-β1 and VEGF.

在再生医学中，有三种因素对于优化再生过程至关重要：支架（生物性、自然性和合成性）、生长因子和自体细胞。使用专业的医疗设备在真空管中将所收集血浆分离即可获得CGF浓缩因子（MEDIFGE 血清分离机由意大利的Silfradent公司研制）。

DOCTOR牙医 Infodent International •1 2018

CGF技术有个有趣的特点：离心简单和速度快，允许富含生长因子的纤维蛋白胶更富有弹性。意大利Brescia大学的Rodella及其同事，使用SEM的分析（电子扫描电子显微镜）发现由薄厚不一的元件形成纤维蛋白网络的存在，无数血小板被捕获在网络当中，说明这是最佳的自体支架。除了血小板激活和脱粒后释放的生长因子外，我们还统计血管内皮生长因子（VEGF）、胰岛素生长因子（IGF）、转化生长因子（TGF）、肿瘤坏死因子（TNF）、脑源性神经营养因子（BDNF）和 TGF-β1和VEGF的存在。在CGF中已经发现了自体细胞如血小板和白细胞（包括CD34 +细胞）的存在。他的组织化学证据表明了CD34 +在细胞血管循环中的作用：血管的更新和生成。这些细胞在PRP中的存在有利于组织再生.CGF具有良好的再生能力并且可应用于多个领域。富血小板血浆（PRP）的使用已经多年，由于在严重烧伤病例进行整形手术中的事实作用和科学证据而得到了国际医学界的验证。整形外

The presence of autologous cells like platelets and leukocytes, including CD34+ cells, have been described in the CGF. The histochemical evidences indicate the role of CD34+ cells, circulating on vascular level: neovascularization and angiogenesis. The presence of these cells in the PRP benefit the tissue re-growth. The CGF has a good regenerative capacity and various fields of application. The use of Platelet-rich Plasma (PRP) has already been for years a reality and a scientific evidence verified by the international medical community for plastic surgery in the treatment of severe burned cases. Plastic surgeons and their patients benefit greatly from tissue rege-

neration through PRP, obtaining a clearly superior recovery both in tissue quality and healing speed. In Maxillary facial surgery and Implantology, the potentialities of CGF Concentrated growth factors have been known for years. Its application helps and stimulates the bone regeneration both in managing endosseous implants and in the healing of difficult fractures. This is a well-documented and effective procedure. Already in 1970, using PRP it was proven a 20% increase in the trabecular bone density, a 40% reduction in healing times and an 80% decrease in pain levels. Researcher have investigated this effect also in periodontal problems. Conclusions reported that PRP technique represents a rich source of growth factors able to bring

significant changes in periodontal damages and it is capable to suppress the cytokines release, limit inflammation and promote in such way the tissue regeneration. Orthopaedic surgeons know well how the speed of healing processes for tendons and articular surfaces traumas improves thanks to the use of PRP platelets Growth Factors. The CGF is now used in musculoskeletal medicine with increasing frequency and effectiveness. Soft tissues injuries, such as tendinopathies and tendinitis, have been treated with PRP since the early ‘90s. The PRP has also been used for the treatment of muscle fibrosis, ligament distortions, joint capsular laxity and in intra-articular injuries like arthritis, ar科医生及其患者通过PRP获得组织再生的巨大益处，在组织质量和愈合速度方面获得明显优异的恢复.

4. 由于剧烈的细胞增殖而产更新原蛋白和弹性蛋白纤维

2. 刺激血小板和白细胞来分泌生长因子

3. 剧烈的细胞增殖促进胶原蛋白和弹性纤维的生长 “MEDIFUGE MF 200” Blood Separator - Differentiated acceleration - Speed and fractional - alternating RCF (does not allow the platelet degranulation) - Anti-static and anti-magnetic rotor - Constant temperature maintained by self ventilation / self decontamination

“MEDIFUGE MF 200” 血清分离机 − 不同的速度选择 − 速度和分数– 交替性的RCF (防止血小板脱粒) − 防静电和防磁性的转子 − 通过自我通风和自我净化来保持恒定的温度

在上颌面部手术和种植术中，CGF浓缩生长因子的潜力已为人所知多年。无论是对骨内种植还是复杂的骨折治疗，CGF的应用都有助于促进骨再生. 这是一个记录完备且有效的程序。早在 1970年，就证明了使用PRP小梁骨密度增加20％，愈合时间减少40％，疼痛程度减少80％. 研究人员在牙周问题上也研究了这种效应。结论报道，PRP技术表明了一个丰富的生长因子来源，能够带来牙周损伤的显著变化，并且能够抑制细胞因子的释放，限制炎症并以这种方式促进组织再生. 由于使用PRP血小板生长因子，整形外科医生很好地知道愈合过程的速度以及关节面创伤的改善情况。 CGF现在用于肌肉骨骼医学中，其频率和有效性越来越高。自90年代初以来，软组织损伤，如腱病和腱炎就已经用PRP治疗过。 PRP还用于治疗肌纤维化、韧带扭曲、关节囊松弛

DOCTOR牙医 Infodent International •1 2018

Silfradent

throfibrosis, injuries of the articular cartilage, meniscus injuries, chronic synovitis or joints inflammation. Retrospective assessment in patients treated with a single injection of PRP for chronic tendinopathy, revealed that 78% had a clear clinical improvement within 6 months, avoiding surgical intervention. “Excellent results were found also in the healing of skin sores in diabetic subjects.” In short, a valid technique that optimizes the healing processes of every tissue where it is applied. With the CGF technique instead, all that is necessary for our regeneration is autologous therefore already within us and we make it work for us. In the dermatological field CGF is used for alopecia (bulbar implants and mesotherapy). It’s clear that it opens a new and exciting chapter, a true revolution in the field of aesthetic medicine: the application of the Platelet Growth Factor for skin rejuvenation through the stimulation of skin regeneration. The growth factors contained in the platelets are able to stimulate various cellular mechanisms like the proliferation and migration of fibroblasts (dermis functional units!) and the synthesis of collagen, recalling and reactivating the stem cells present in the area we are treating, improving the skin condition. It is important to point out that the Platelet Growth Factor CGF Treatment is not a mere aesthetic treatment, but a biological method that tends to restore the best vital conditions of our skin with an excellent improvement of the skin’s aesthetic and an optimization of the cutaneous physiological parameters. The number of platelets, concentration and release of the growth factors, strongly depend on the type of kit used, on how the platelets are activated and on the centrifuge used. Could modern Aesthetic Medicine not benefit of this miraculous solution?

DOCTOR牙医 Infodent International •1 2018

和关节内损伤，如关节炎、关节软骨损伤、关节软骨损伤、半月板损伤、慢性滑膜炎或关节炎症. 对一个单次注射PRP治疗慢性肌腱病患者的回顾性评估显示，78％的患者在6个月内有明显的临床改善，避免了手术干预. “在糖尿病患者的皮肤溃疡愈合中也发现了良好结果.” 总之，这是一种有效的技术，用它治疗的每个组织都改善了愈合过程。用CGF技术代替，我们再生所需的一切都是自体的，因此已经在我们自身内部，而我们让它为我所用。在皮肤科领域中，CGF 用于脱发（延髓植入物和美塑疗法）。毫无疑问是它开启了一个令人兴奋的新篇章; 美容医学领域的真正革命：通过刺激皮肤再生应用血小板生长因子进行皮肤再生. 包含在血小板中的生长因子能够刺激各种细胞机制，例如成纤维细胞（真皮的功能性单位）的增殖和迁移以及胶原的合成，唤起并重新激活正在治疗区域中存在的干细胞，来改善皮肤条件。要指出的一个重要的事实是，血小板生长因子CGF 治疗不仅仅是美容治疗，而是一种生物学的方法，它可以恢复皮肤的最佳生命状况，同时极大地改善皮肤的美感和优化皮肤生理参数。血小板的数量，生长因子的浓度和释放都强烈依赖于所使用的设备配套类型，血小板如何被活化以及所使用的离心机. 现代美容医学能从这个奇迹般的解决方案中受益吗? 老化不只是由皱纹组成的。扁平的颧骨也为外表增加了不少的年份。幸运的是，许多明星的美容案例证明了今天的我们可以找回年轻时特有的丰满圆润状态，而不会陷入令人不快的“枕头脸”效应之中. 这项技术是必不可少的！我们可以使用一个元件（PPP）来制造一种体积丰富的填料（A.P.A.G.），通过热冲击达到75° 的高温以获得一种凝胶，一旦冷却，就将凝胶与 CD34 +混合.

Prolif. Pre Osteob. 原骨细胞生长

Prolif. Fibroblast 成纤维细胞生长

PDGF

TGF

Chemotaxis 趋化性

Sint. Extracellular matrix 细胞外基质

Vascularitation 血管生成

+/-

EGF

IFG

VEGF

Aging is not only made of wrinkles. Flattened cheekbones add various years to the ID as well. Luckily, today we can earn back fullness and turgidity typical of youth without falling into the unpleasant “pillow face” effect, showed by many stars. The technique is ESSENTIAL! We can create a volumizing filler (A.P.A.G.) using a component (PPP) to reach, with thermal impulses, a high temperature (75°) to obtain a gel that, once cooled down will be mixed with CD34+. Or we can obtain a filler that creates an aged collagen reconstruction bringing the PRP to 44°, again with thermal impulses. Therefore, with a simple peripheral venous blood sample we can create: • L.P.C.G.F. for cutaneous BIOSTIMULATION

Growth Factors 生长因子 PDGF AB ~100-300 ng/mL PDGF BB ~10-15 ng/mL PDGF AA ~1-5 ng/mL TGF ß1 ~90-400 ng/mL TGF ß2 ~0,5 ng/mL VEGF ~10-30 ng/mL EGF ~30 ng/mL IFG ~50-200 ng/mL + Growth + 生长 - No effects - 没有效果 * Indirect effects * 间接效果

或者我们可以获得一种填料，还是通过热冲击，该填料可以使PRP恢复到44°，从而实现老化胶原蛋白的重建。因此，我们可以创建一个简单的外周静脉血的样本: • L.PC.G.F. 用来皮肤生物刺激 • I.C.F. 为了胶原蛋白的重建 • A.RA.G. 创建饱满的效果在第一阶段结束时，所有患者都会得到一个包含添加了生长因子的面膜，乳膏和乳液的试剂盒，这些产品用于家庭维持护理来延长治疗效果. 建议采用以下治疗规则：在头两个月内做前三次治疗，六个月后进行第四次治疗，年底做第五次治疗，以及每年的维持治疗. 整个疗程都是相对无痛的; 可在注射前20分钟应用麻醉剂.

• I.C.F. for collagen RECONSTRUCTION • A.P.A.G. to create a filling effect At the end of the first session, all patients are given a kit containing mask, cream and lotion, with the addition of growth factors to prolong the treatment effect, for home care maintenance. It is recommended to respect the protocol: three treatments over a two months period, the fourth after six months, the fifth at the end of the year and a maintenance treatment every year. The whole treatment is relatively painless; a topic anaesthetic can be applied, twenty minutes before the injection. info@silfradent.com www.silfradent.com

DOCTOR牙医 Infodent International •1 2018

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SCIENTIFIC UPDATE 学术文章

DOCTOR牙医 Infodent International •1 2018

Scientific Update

Treatment of “white spot lesions” after removal of fixed orthodontic appliances 固定式正畸器械拆除后的 “病变白斑”治疗

Author Dr. Derek Mahony Orthodontist, BDS(Syd) MScOrth(Lon) DOrth RCS(Edin) MDOrth RCSP(Glas) MOrth RCS(Eng) MOrth RCS(Edin)/ FCDS(HK) FRCD(Can) IBO FICD FICCDE Derek Mahony博士悉尼牙科医学院学士，伦敦牙科医院正畸专业硕士，爱丁堡皇家外科医院正畸专业博士，格拉斯哥皇家外科学院骨科医生，英国皇家外科学院正畸学会会员，爱丁堡皇家外科学院正畸学会会员，香港牙科学院院士，加拿大牙科学院院士，国际牙科委员会成员，国际牙医学院院士，国际牙医继续教育学院院士

emineralised white spot lesions occur frequently, after orthodontic treatment. Some teeth are more prone to demineralization (typically the maxillary lateral incisors and the mandibular canine teeth). The disto-gingival area of the labial enamel surface is the area most commonly affected. (Fig. 1) In the first few weeks after removal of the fixed appliances, there is a reduction in white spot lesion size, and appearance, possibly due to the action of saliva. (Fig. 2) Various treatments have been proposed to assist remineralization. It is important to note that fluoride should not be used, in high concentration, as it tends to prevent remineralization and can lead to further unsightly staining. Low concentrations of fluoride may assist remineralisation, such as those amounts found in casein calcium phosphate materials. Stimulation of salivary flow, by chewing sugar- free gum, is also helpful. This article will describe a revolutionary new approach to the cosmetic treatment of white spot lesions (Fig.3). Icon resin represents a rapid approach to the treatment of these carious lesions. The break through, micro invasive technology, fills and reinforces demineralised enamel, without drilling or anesthesia. (Fig. 4 & 5)

Figure 1 – White Spots - typical: C-shaped or irregular.

图 I —病变白斑 – 特征:c形或不规则形状

DOCTOR牙医 Infodent International •1 2018

Figure 2 – Smooth surface caries lesion. 图 2 — 光滑的龋齿病变面.

正畸治疗后的脱矿白斑病变频繁地发生，有些牙齿更容易脱矿（通常是上颌侧切牙和下颌尖牙）.龋齿唇面近齿龈的珐琅质表区域是最常受到影响的部分. (图I)在拆除固定托槽后的几周内，可能由于唾液的作用出现病变白斑的大小和外观得到减小. (图 2) 临床医生对此提出了多种治疗方案帮助再矿化。非常需要注意的是，高浓度氟化物不应该被使用，因为它倾向于防止再矿化并且可能加深难染色难看度。低浓度的氟化物可能有助于再矿化，例如在酪蛋白磷酸钙材料中发现的量。通过咀嚼无糖口香糖刺激唾液流动也是有帮助的。本文将描述一个针对病变白斑的革命性美化治疗方法(图3)。 Icon树脂是治疗这种病变的快速途径，这项突破性的微创技术，无需钻孔或麻醉就可填充和加强脱矿珐琅质 (图 4和5)

Figure 3 – Clinical image of an incipient caries lesion. 图 3 — 初期龋齿病变的临床表现

Figure 4 – Clinical image of an incipient caries lesion. 图 4 — 初期龋齿病变的临床表现.

The reason previous approaches have fallen short, is because fluoride therapy is not always effective in the advanced stages of decay, and the use of restorative fillings almost always sacrifices significant amounts of healthy tooth structure. Instead of adopting a “wait and see” approach, Icon resin can arrest the progress of early enamel lesions, up to the first third of dentine (Fig.6). This is done in one simple procedure, without the unnecessary loss of healthy tooth structure. The procedure, when using Icon, is as follows: the surface area of the white spot lesion is eroded with a 15% HCl gel. This opens the pore system of the lesion. The pore system is then dried with ethanol. Icon resin is then applied to the lesion, with the application aid. The extremely high penetration coefficient of the Icon resin enables it to penetrate into the pores of the carious lesion. Excess material is then removed, and the material is light cured. The total treatment time is about 15 minutes. (Fig.7)

Figure 5 – Pore system of an incipient caries lesion. 图5 — 初期龋齿病变的空隙系统

过去治疗的失败，要归因于氟化疗法在病变晚期是并不总是有效的，况且，在使用修复性填充物时几乎总要牺牲大量健康的牙齿结构。与其采取观望态度，不如用Icon树脂，它可以阻断早期的釉质病变，直达牙本质的三分之一（图6）这只要一个简单的操作，避免了不必要的健康牙齿结构损伤。运用Icon树脂的操作程序如下：用15%的凝胶冲涮病变白斑区域，这将打开病变区域的空隙系统，然后用乙醇干燥空隙系统。用辅助器具把Icon 树脂均匀地涂在病变区，树脂极高的渗透性将渗透到病变空隙中，去除多余材料后进行光固.

Figure 6 – The first treatment to bridge the gap between prevention and restoration. 图 6 —第一个弥补了预防性治疗和修复治疗之间的差距的疗法.

Icon 树脂适用与早期的病变，其影像深度可达牙本质三分之一外 (D1)

DOCTOR牙医 Infodent International •1 2018

Scientific Update

Figure7

Smooth surface procedure. 图 7 — 进行表面光滑过程.

The cosmetic treatment of cariogenic white spots, in one patient visit, is very appealing to patients, and their parents (Fig.8a, b). There is no drilling or anesthesia is required, so there is greater patient comfort. Furthermore, patients that have already demonstrated poor compliance with their brushing, can be treated earlier. This is not just minimally invasive Dentistry; it is micro-invasive Dentistry.

整个操作流程大约需要15分钟 (图7)

I would recommend that all clinicians try the Icon product when attempting to remineralize white spot lesions, post orthodontic treatment.

在试图治愈正畸后的病变白斑时，我向所有的临床医生推荐Icon树脂。

Figure 8a – Lesions before Icon treatment. 图 8a — Icon 树脂治疗前的病变斑

DOCTOR牙医 Infodent International •1 2018

在一次患者就诊中，病变白斑美容治疗引起了患者和其父母的很大兴趣 (图8a, b). 无需钻孔和麻醉，所以患者更舒适，再者，对于不太喜欢刷牙的患者可以尽早使用. 这不仅仅是微创牙科，这是无创牙科。

Figure 8b – After icon treatment. 图 8b —用Icon树脂治疗之后

C L A S S E

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L I M I T L E S S

S O L U T I O N S

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4th-7th April | Dental South China 2018 | Booth F15, Hall 15.1 Area C, China Import & Export Fair Complex, Guangzhou

Scientific Update

Interceptive Treatment for the Class III Malocclusion III类错牙合畸形的阻断性治疗

A Author Dr. Derek Mahony Orthodontist, BDS(Syd) MScOrth(Lon) DOrth RCS(Edin) MDOrth RCSP(Glas) MOrth RCS(Eng) MOrth RCS(Edin)/FCDS(HK) FRCD(Can) IBO FICD FICCDE and Dr.Yosh Jefferson, DMD 本文作者：Derek Mahony 博士，悉尼牙科医学院学士，伦敦牙科医院正畸专业硕士，爱丁堡皇家外科医院正畸专业博士，格拉斯哥皇家外科学院骨科医生，英国皇家外科学院正畸学会会员，爱丁堡皇家外科学院正畸学会会员，香港牙科学院院士，加拿大牙科学院院士，国际牙科委员会成员，国际牙医学院院士，国际牙医继续教育学院院士 Yosh Jefferson医师牙科医学博士

INTRODUCTION developing Class III malocclusion is one of the most challenging problems confronting an orthodontic clinician. If left untreated the Class III malocclusion may worsen, with the majority of these patients ultimately requiring orthognathic surgery, as adults. For this reason, I recommend early interceptive orthodontic treatment to reduce the percentage need for surgery. Unfortunately, when interceptive Class III treatment is initiated at the appropriate age, there is often a significant amount of time between the end of facemask treatment and the beginning of “definitive” orthodontics. I have written this article in an attempt to clarify the correct treatment protocol for Class III patients and to suggest methods of retention during their continued period of facial growth. A developing Class III malocclusion can present with maxillary skeletal retrusion, mandibular skeletal protrusion, or a combination of the two. In addition to these sagittal problems there may also be posterior and anterior crossbites present. Dental compensation, such as maxillary dentoalveolar protrusion and mandibular dentoalveolar retrusion tend to produce poor facial profiles with midface deficiencies often apparent. The prevalence of Class III malocclusion is approximately 5% in the Caucasian population, rising to as much as 50% in the Japanese and Korean population. TREATMENT OF THE CLASS III MALOCCLUSION Although traditional orthodontic treatment, for developing Class III malocclusion, focused on the mandible as the primary cause of the discrepancy, recent studies have suggested that 63% of the skeletal Class III malocclusions display maxillary retrusion. The majority of patients tend to exhibit maxillary hypoplasia in conjunction with a normal or mildly prognathic mandible. Unfortunately, I see too many young patients, for a second opinion, who are told there is nothing the orthodontist can do but wait until their facial growth is complete and then work them up for orthognathic surgery.

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绪言发育中的III类错牙合畸形是正畸临床医生所面临的最具挑战性问题之一。如果不予以治疗，III类错（牙合）畸形可能会恶化，其中大多数患者最后需要接受正颌手术。出于这个原因，我建议尽早接受正畸治疗，以减少需要动手术的可能性。不幸的是，在适当年龄开始III类畸形拦截治疗时，在头套治疗结束和开始“真正”正畸治疗之间经常存在相当长的一段时间。写这篇文章的目的是为了阐明III类患者的正确治疗方案，并建议患者们在面部发育过程中使用保持器。生长中的III类错牙合可以表现为上颌骨后移，下颌骨前突或两者兼具。除了这些矢状向问题之外，还可能存在后牙和前牙错咬。牙齿代偿，上颌骨牙槽前突和下颌牙槽骨的后移，倾向于产生较差的面部轮廓，通常这样的面部缺陷是明显的. 在高加索人群中，III类错牙合患病率约为5％，在日本和韩国人群中上升到50％. III 类错（牙合）的治疗传统的正畸治疗把生长中的Ⅲ类错（牙合）畸形的问题集中在下颌骨上，认为下颌骨是造成这种咬合异常的主要原因；但最近的研究表明，其实 63％的Ⅲ类错（牙合）畸形的原因是出现了上颌骨回缩. 大多数患者倾向于表现出上颌发育不良以及正常或轻度预后的下颌骨. 不幸的是，我看到太多的年轻患者，他们相信第二种观点，认为正畸医生什么都做不了，而是要等到他们的面部发育完成后再进行正颌外科手术，但大部分手术矫正 III类错（牙合）涉及到上颌推进！这意味着，问题不是下颌骨的过度生长，而是缺乏上颌骨的发育。这些问题可能是孩子年轻时由鼻腔气道阻塞造成的. III类错（牙合）畸形的正畸治疗可以分为以下几类:

Yet the majority of surgical procedures to correct Class III malocclusion involve maxillary advancements! This suggests that the problem was never excessive mandibular growth, but rather a lack of development of the maxilla. Such problems may have been caused by nasal airway blockages, when the child was younger. Orthodontic treatment for the Class III malocclusion can be defined into the following categories: 1. Growth modification involving maxillary expansion and protraction face mask therapy 2. Growth modification involving a chin cup to restrain mandibular growth, or 3. Waiting until growth has ceased, thereby, committing the patient to either dental camouflage treatment, or orthognathic surgery. In my orthodontic practice, children exhibiting early signs of a Class III malocclusion are given priority for treatment. My current treatment approach involves protraction and development of the maxilla, but I do not use chin cups as I feel they have an adverse effect on the patient’s temporomandibular joints. Controversy currently exists as to the optimum time to commence Class III orthodontic treat-

ment. Takada examined maxillary protraction therapy and reported that the pre-pubertal and mid-pubertal time frame is best, due to the maxilla’s natural growth (stage C2-C3). TREATMENT OBJECTIVES FOR THE CLASS III PATIENT If we treat patient as early in the growth cycle as possible, i.e. as soon as the Class III problem can be diagnosed, the following treatment objectives may be achieved: 1. Reduce the growth in the size of the mandible. 2. Increase the size of the maxilla to its maximum genetic potential, and 3. Move the maxilla forward to its maximum genetic potential. A cephalometric analysis is essential to confirm the diagnosis of the Class III malocclusion and to formulate either a surgical, or non-surgical, treatment plan. I personally use the Jefferson cephalometric analysis as this is ideally suited to the correct diagnosis of a Class III patient. In the Jefferson analysis the size of the mandible and the position of the mandible can be easily related to the length and position of the anterior cranial base. The size of the maxilla and the position of the maxilla, may also be related to the size and position of the anterior cranial base. The

3. 将上颌骨先前移动至患者的最大遗传潜能的范围内. 头影测量分析对于确定III类错（牙合）畸形的诊断和制定出手术或非手术治疗计划至关重要. 我个人使用杰斐逊头影测量分析，因为这非常适合III类患者的正确诊断。

I. 上颌扩张和前突面罩治疗的生长改变 2. 通过下巴垫抑制下颌骨生长的生长改变 3. 等到发育停止时，可以让患者接受牙科诱导性治疗或正颌外科手术。在我的正畸实践中，表现出III类错牙合畸形早期征象的儿童优先接受治疗。我目前的治疗方法包括上颌骨的伸展和发育，但我不使用下巴垫，因为我觉得它们对患者的颞下颌关节有不利影响. 目前存在着关于III类正畸治疗最佳开始时间的争议。Takada研究了上颌前牵引疗法，并报告由于上颌骨的自然生长，青春期前和中青年时间段是最好的时间段（阶段C2-C3）.

在杰斐逊头影测量分析中，下颌骨的大小和位置可以很可能与前颅底的长度和位置关系密切。上颌骨的大小和位置也很可能与前颅底的大小和位置有关. 杰斐逊头影测量分析为确定上颌/下颌的不对称性提供了一个简单的视觉手段.

III类患者的治疗目标如果我们尽可能在生长周期内尽早治疗患者，那么，诊断出III类问题时，就可以达到以下治疗目标: 1. 减少下颌骨的增长尺寸. 2. 增加上颌骨的尺寸至其最大的遗传潜能范围内

III 类纠型器械的选择头影测量分析应该辅助临床诊断和空间分析。 Schwartz / Korkhau 的空间分析使临床医生能够确定上颌弓和下颌弓的正确尺寸。在上颌足够宽的情况下，可以使用上颌矢状向矫治器，否则需要使用3D 的纠治器。在3D设备中，扩张螺钉应该笔

Jefferson cephalometric analysis provides an easy visual means to identify maxillary/ mandibular disproportions. CLASS III ORTHOPAEDIC APPLIANCE OPTIONS The cephalometric analysis should be supplemented with a clinical diagnosis, and a study cast analysis. The Schwartz/Korkhaus study cast analysis enables a clinician to determine the correct dimensions of the maxillary and mandibular arches. If the maxilla is wide enough a maxillary sagittal appliance may be used, otherwise a 3D appliance is indicated. In the 3D appliance the expansion screw should be placed straight and parallel to the midline palatal suture. This will ensure that there is minimum reciprocal distalising of the maxillary buccal segments during the activation of the sagittal appliance. Such an appliance may also be used for pseudo Class III patients; however, a lower Hawley retainer or a fixed lingual arch, must be worn to minimize further mandibular growth. I have used either a modified Frankel III, a Han appliance, or a reverse twin block for the orthopaedic correction of a growing Class III malocclusion. For any of these appliances to be successful, the maxilla must be only slightly

直且平行于中线腭缝合线。这将确保矢状器具在激活过程中上颌颊侧片的相互远离最小化。这样的器具也可以用于伪 III类患者。此外; 下颌必须戴用Hawley固定器或固定舌弓，以尽量减少下颌骨的进一步生长. 我使用过改良型 Frankel III，Han 矫治器、还有反向双模块来矫正生长的III类错（牙合）畸形。为保证成功地运用这些设备，上颌骨必须只能轻微地后移，并且患者必须能够做到牙齿边缘与边缘的对接咬合。然而，在我最成功的实践治疗方法里; 使用了上颌3D设备来扩大上颌骨，用反拉头套（拉伸头带）将上颌骨作为一个整体向前移动到更有利的位置。反拉头套与“固定下唇”器与III类口内松紧带结合使用，来防止下颚的进一步生长. 这些不同形式的“阻断性”正畸治疗可能会使患者免于正颌手术，并且手术本身并不总是成功的。用牙槽骨基补偿来矫正骨源性III类错牙合的缺点是通常需要提取

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Scientific Update

retruded and the patient must be able to provide an edge to edge bite.The most successful treatment in my practice however, involves the use of a maxillary 3D appliance to enlarge the maxilla, in conjunction with a reverse pull facemask (protraction headgear) to move the maxilla, as a body, forward into a more favourable position. The reverse pull headgear is fitted in combination with a “fixed lower labial” appliance and Class III intraoral elastics in an attempt to prevent further mandibular growth. These varying forms of “interceptive” orthodontic treatment may save your patient from orthognathic surgery, which itself isn’t always successful. The disadvantage of dentoalveolar base compensations to correct a Skeletal III problem, is that extractions of lower bicuspids are often required. Such dental camouflage is rarely inidicated as the lower anterior teeth respond to retraction mechanics by simply tipping backwards. This can lead to periodontal problems, on the labio-gingival portion of the anterior teeth. Such treatment is highly unstable as the lower extraction space reopens with time. If I extract to “orthodontically camouflage” a non-growing Class III malocclusion I prefer to remove a lower incisor in preference to lower first premolars, or place TADs in the superior oblique ridge

of the mandible, and extract the third molars.

下颌双尖牙 , 而下前牙通过简单地向后倾斜而对回缩力学作出反应,这种隐性牙齿畸形很少显示出来。但这种情况可能诱发前牙唇龈部分的牙周问题。由于下颌被回缩的空间会随着时间重新回弹，这种处理极不稳定。在非发育中的III类错牙合上，如果一定需要以拔牙的代价来进行“ 隐形正畸”的话，我宁愿选择拔除下切牙而不是第一磨牙，或者也可以将TAD放置在下颌骨的上斜脊中，并提取第三磨牙.

装置被有人比喻为“被粘住的蹄兔”。中等面部骨扩张可产生A点的轻微前移运动和上颌骨轻微的向下向前移动.

反拉面罩 (反拉头套) 在100多年前，反拉面罩在德国首次被发明。使此技术复苏的最大推手要算Delaire。Petit在1983年通过增加器具产生的力量并减少总体治疗时间的原则修改了 Delaire的面罩。麦克纳马拉（McNamara）在1987年描述了一款Petit的面罩，该面罩连接在与后牙列结合的上颌夹板上。是夹板上安装的钩子连着松紧带固定在面罩上，而扩张螺钉则嵌入面罩内。这个

我倾向于将这些口罩用于骨源性III类开合患者，因为传统口罩会引起上颌骨的向前和垂直方向上的移动。如此导致的开合，正是有下颌过度闭合的深覆牙合患者所期望的效果，不过对开合患者来说是个禁忌。高度安氏错咬患者的理想面罩是 Tandem Bow. 用面罩结合扩张器的疗法矫正三类错（牙合）畸形，其结果是骨骼和牙齿的同时变化，这些变化导致软组织外形的改善。我用这种方法治疗的患者表现出具有统计

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PROTRACTION FACEMASKS (REVERSE PULL HEADGEAR) The reverse pull facemask was first described in Germany, more than 100 years ago. The individual most responsible for reviving interest in this technique is Delaire. Petit (1983) modified the facemask of Delaire by increasing the amount of force generated by the appliance and decreasing the overall treatment time. McNamara (1987) described a version of the petit facial mask that attaches to a maxillary splint, which is bonded to the posterior dentition. The splint is fitted with hooks to attach elastics to the facemask, and the expansion screw is incorporated in the appliance. This is termed as a bonded hyrax. Mid facial orthopaedic expansion can produce a slight anterior movement of Point A and a slight inferior and anterior movement of the maxilla. Downward and backward rotation of the mandible is seen with the use of maxillary protraction particularly in the facemasks which have a chin cap incorporated into the design, e.g. Delaire and Petit styles. These are now reverse pull facemasks available (Grummons) for patients suffering from severe temporomandibular joint dy-

在使用设计有下巴垫的面罩后，尤其可以看到下颌骨的向下和向后旋转。Delaire 和 Petit 设计的就是这种风格. 现在，已经有专门用于患有严重颞下颌关节功能障碍患者的反拉口罩（Grummons）。这种反拉可使下颌骨完全不受任何相互作用力.

sfunction. These reverse pull facemasks are designed to keep all reciprocal forces completely off the mandible. I tend to favour these facemasks for Class III skeletal open bite patients because the conventional facemask causes an anterior and vertical movement of the maxilla. This results in bite opening which is desirable in deep bite patients, exhibiting over closure of the mandible, but is contraindicated in open bite patients. The ideal facemask for high angle patients is the Tandem Bow. Correction of a Class III malocclusion, using facemasks and expansion therapy, results from a combination of skeletal and dental changes which produces an improvement in the soft tissue profile. Patients I have treated with this technique demonstrate a statistically significant hard and soft tissue movement, which favourably improves the entire dentofacial complex. ELASTIC TRACTION A facemask is secured to the face by stretching elastics from hooks on the maxillary splint to the crossbow of the facemask. Heavy forces are generated, usually through the use of 5/8 inch, 14 oz. elastics bilaterally. Lighter forces may be used initially, but the forces increase to orthopaedic strength as

意义的硬软组织显著的移动，这有利于改善整个牙合面的复合体. 松紧带牵拉松紧带的一端钩住上颌夹板上的钩子把另一端拉至面罩的弩弓上固定，从而将面罩固定到面部。一股大的拉力由此产生，通常使用5/8英寸、14盎司的双边弹性的松紧带。最初可以使用较轻的力量，但一旦患者习惯了器械之后，就可以增加到矫形力量. 松紧带连接在上颌夹板的犬齿区域。这些松紧带应该每天至少戴用12小时，患者应该尽可能多地坚持到超过最小量。当患者不在公共场所并且能够这样做时，我主张总是使用反拉面罩。如果把松紧带固定在上颌后方太远，就会出现“克氏效应”。这导致上颌骨向前倾斜并导致难看的牙龈组织. 如果是连接到下颌骨的保持弓上，也可以使用口内III类松紧带。把松紧带沿着上颌第一磨牙到保持弓上的焊接钩方向

soon as the patient is used to the appliance. The elastics are attached in the canine area of the maxillary splint. These elastics should be worn for a minimum of 12 hours per day, with the patient exceeding the minimal amount as much as possible. I advocate full time use of the reverse pull facemask when a patient is not in public and is able to do so. If the elastics are placed too far posteriorly in the maxillae the “Kline Effect” can be seen. This causes the maxilla to tip anteriorly and leads to an unsightly display of gingival tissue (gummy smile). Intra oral Class III elastics may also be used if attached to a holding arch in the mandible. These elastics are placed in a Class III direction from the maxillary first molars to the soldered hooks on the holding arch. The size of these elastics is 3/16 inch, 4½ oz., in the primary and mixed dentition and 5/16-inch, 4 ½ oz. in the permanent dentition. It is very important to understand that the intraoral Class III elastics have a different vector of force when compared to extraoral Class III elastics. Extraoral Class III elastics pull at a horizontal, or parallel, relationship to the maxillary plane. Therefore, their reciprocal force is balanced between the frontal bone and the mandible. This in turn creates a horizontal force wi-

放置在三类牙合中。松紧带尺寸选择：用 3/16英寸，4½ 盎司在初期牙列和混合牙列中，用5 / I6英寸，4½ 盎司在永久性牙列中。理解口内III类松紧带与口外III类松紧带具有不同的力矢量是非常重要的。口外III类松紧带以水平或平行的关系牵拉上颌骨平面。因此，它们在额骨和下颌骨之间的相互作用力是平衡的。这促使颞下颌关节内产生水平力，即没有向上的远中侧力矢量. 然而，口内III类松紧带在下颌骨上施加斜向力，这可能导致下颌骨髁从凹面偏移。因此，口内松紧带如果要用于治疗第三类错（牙合）畸形的话，则必须遵守以下指南: A. 坚决不用于有颞下颌关节症状的患者， B. 如果患者出现任何一种形式的关节功能障碍时必须停止使用 C. 必须间接性地戴用松紧带，以允许下颌髁在关节窝内得到解压。这样可以在颞下颌关节TMJ内恢复适当的循环。口腔内和口外III类牵引最令人满意的组合方式是

A facemask is secured to the face by stretching elastics from hooks on the maxillary splint to the crossbow of the facemask.

thin the temporomandibular joints i.e. no upward distalising force vector. Intraoral Class III elastics, however, place a diagonal force upon the mandible, which can in turn cause the mandibular condyle to be displaced off the meniscus. Intraoral elastics, therefore, must have the following guidelines if they are to be used during the treatment of a Class III malocclusion:

a. they must never be used for any patient who is experiencing temporomandibular joint symptoms, b. they must be terminated if the patient acquires any form of joint dysfunction, and c. they must be worn intermittently to allow the mandibular condyles to decompress within the glenoid fossa. This permits proper circulation to be restored within the TMJ

患者在白天戴口内松紧带，只有在进食时才将其移除。而口外松紧带则应在晚上戴用，并尽可能在白天穿戴与口内松紧带一起戴用。

刻牙齿的颊侧和舌侧表面。咬合面不能被蚀刻，以便于器械的移除。用LED灯激活之前，我主张使用光固化玻璃离子水泥，它可以防止脱钙，并促进去除多余的水泥.无论使用哪种GIC粘合剂，它都应该具有低粘度和一个教长的工作寿命。丙烯酸夹板的组织配合表面应该在实验室中微蚀刻以提高保持效果.

上颌扩张器的设计使用粘结上颌夹板是骨科III类治疗的重要手段。该器械是丙烯酸和丝粘合到上颌后牙列上的扩张器。夹板通常覆盖第一和第二乳磨牙。对于具有完整牙列的患者，上颌犬齿也可以包括进去. 上颌夹板是由一个0.045英寸圆形不锈钢丝的框架连接扩张器螺丝的装置。如果存在第二磨牙，则将牙合支撑延伸至这些牙齿上以防止其治疗期间的过度发育。两个连接松紧带的钩子焊接到不锈钢丝框架上。这些钩子通常位于犬牙或第一乳牙臼齿的附近。夹板的最小厚度应不小于 1.5mm，否则会由于相对牙列的磨损而导致牙合脱钙在口腔中粘合上颌骨夹板时，应当小心蚀

上颌扩张器每天激活两次，持续八天，来瓦解缝间系统。这将有助于面罩的活动。之后，扩张速度减慢至每周两次，以限制垂直尺寸的增加，但允许上颌骨继续发育，直到达到所需的横向变化。我推荐使用超级弹簧，因为它可以提供理想的力度，其刚性设计可最大限度地减少倾翻. 生长发育期的矫形变化保持如果患者处于乳牙晚期或早期混合牙列，在我的面罩治疗结束时，我决定使用改良型Frankel III矫治器作为“主动型”保持器。修改后的 Frankel III 矫治器在前上颌

DOCTOR牙医 Infodent International •1 2018

Scientific Update complex. The most satisfactory combination of intraoral and extraoral Class III traction is for the patient to wear the intraoral elastics during the day, removing them only for eating. The extraoral elastics should be worn at night, and as much as possible during the day, in conjunction with the intraoral elastics. MAXILLARY EXPANSION APPLIANCE DESIGN As essential part of the orthopaedic Class III treatment is the use of bonded maxillary splint. This appliance is an acrylic and wire maxillary expansion appliance that is bonded to the posterior dentition. The splint usually covers the first and second deciduous molars. The maxillary canines may also be included on patient with a complete deciduous dentition. The maxillary splint is made of a framework of 0.045 inch round stainless steel wire to which an expansion screw is attached. If second molars are present an occlusal rest is extended to these teeth to prevent their over-eruption during treatment. Two hooks, to which elastics are attached, are soldered to the wire framework.

limit increases in the vertical dimension, but allow continued development of the maxilla until desired transverse change has been achieved. I recommend the super screw as it delivers ideal forces, and its rigid design minimizes tipping.

When bonding the maxillary splint, in the mouth, the teeth should be carefully etched on their buccal and lingual surfaces. The occlusal surfaces are not etched, to facilitate removal of the appliance. I advocate the use of a light cured glass ionomer cement to prevent decalcification and facilitate removal of the excess cement, before activating with a LED light. Whichever GIC bonding agent is used it should have a low viscosity, and a long working time. The tissue fitting surface of the acrylic splint should be micro-etched in the laboratory to improve retention.

RETENTION OF ORTHOPEDIC CHANGES DURING THE CONTINUED GROWTH PHASE If a patient is in a late deciduous, or early mixed dentition, at the conclusion of my facemask therapy I advocate the use of a modified Frankel III appliance to act an “active” retainer. The modified Frankel III appliance has sagittal expansion screws in the pre-maxillary region. The use of acrylic palots, in the labial sulcus, stretch the mucoperiostium to encourage bone deposition where it is needed. A Han appliance may also be used as a functional retainer. This appliance is a bi-maxillary design which resembles an upper sagittal appliance joined to a lower Hawley retainer. The Han virtually eliminates any reciprocal movement of the upper posterior teeth. I find that I get better patient compliance with a Han

The maxillary expansion appliance is activated twice a day, for eight days, to produce a disruption in the sutural system. This facilitates the action of the facemask. Expansion is then slowed down to two turns a week to

骨区域有矢状扩张螺丝。在唇沟中使用丙烯酸树脂可以拉伸粘膜 - 骨膜以诱导骨骼沉积在需要的地方. Han扩张器也可以用作功能保持器。该器具是双上颌式设计，类似于连接到下 Hawley固定器的上矢状面器械。Han几乎消除了上颌后牙的任何往复运动。我发现，与Frankel III相比，更喜欢使用Han。 Frankel III器械的主要缺点是患者接受性差。但是，如果你可以说服你的病人使用它的话，它确实是个很好的器械.

c. 后面腭侧的纺锤体允许肌功能性吞咽治疗开始. d. Frankel III 粘骨膜垫可以刺激上颌骨的生长, e. 先将钩子焊接到 Adams扣勾上，再把钩子放置于上颌第一磨牙，这是为了放置口内松紧带而设计的, f．焊接好的钩子在犬齿区域的omega环上，用于放置口外松紧带, g. 扩张螺丝被接入纠治器，来增加上颌骨的矢状和横向尺寸.

Han 系列扩张器和改良后的 Frankel III扩张器的共同缺点之一是， III类松紧带和反拉面罩不能与它们同时使用。但是Truitt III扩张器允许口内III类和口外III类松紧带应用于反拉面罩。然而，Truitt III扩张器如此运用的前提是需要一个永久的牙列以便于保持.

Truitt III 纠治器的下颌部分是带有唇弓的改良后的Hawley 。唇弓由重0.036钢丝所制。它从咬合丙烯酸向下延伸，并形成标准的Hawley环。它进入下颚门齿的龈三分之一处。通过每周转动一次扩张螺丝（I / 4mm）来激活Truitt III纠治器。如果患者有前开合，激活应该减少到两周一次。根据反拉面罩治疗的规则戴用口内和口外松紧带. Truitt III 矫治器咬合面丙烯酸酯的覆盖要像一个平薄的夹板。不应该有牙合尖牙的制导，以防止颞下颌关节内半月板的位置前移.

Truitt III 矫治器的上颌骨部分就像一个改良后的Schwartz矫正板。可能会增加修正的可能: a. 后面咬合覆盖最小厚度为1.5 mm, b. 舌侧的弓丝来刺激舌头的前推习惯,

These hooks usually lie adjacent to the canines or first deciduous molars. The minimum thickness of the splint should be no less than 1.5 mm, otherwise it can promote occlusal decalcification due to abrasion of the appliance by the opposing dentition.

DOCTOR牙医 Infodent International •1 2018

必须每月调整Truitt纠治器的下唇弓以确定跟下颌门牙紧密接触。用三爪钳来缩小 Ω环的大小来调整。确保唇弓与下颌门牙的牙龈1/3接触是非常重要的，这样才可以避免这些牙齿发生倾斜. 直丝弓托槽来结束三类咬合畸形纠治一旦发育中的III类问题整形纠治后，我主张使用Han，Frankel III或Truit III纠治器作为保持器，直到下颌骨生长完成（阶段 C6）。然后患者已经可以使用固定纠治器疗法进行最终的正畸矫正。治疗的正畸部分最好延迟到患者完成青春期生长后进行. 任何正畸治疗都必须以保持III级牙槽嵴基骨代偿的原则来开展，下颌弓内的“燃烧锚”和上颌弓内（C型锚定）的继续。对于三类错牙合的上颌牙列，不应使用任何后向力学的操作. 我在上颌弓中使用了“制动弓丝技术”，以将上颌门牙向前推至I级切牙关系。其具体步骤是将 Guerin 锁的内侧置于第一磨牙的中间并使0.016 X 0.022热镍钛弓丝躺在距离上颌托槽4mm处。当弓丝被结扎到上颌切牙后，由Guerin锁来防止弓丝向远侧移动，如此，弓丝将上颌门牙向前推动.

appliance than I do with a Frankel III. The major drawback of the Frankel III appliance is its poor patient acceptance. If, however, you can motivate your patient to wear it, it really works well. One of the disadvantages of the Han appliance and the modified Frankel III appliance is that Class III elastics and reverse pull facemasks cannot be worn simultaneously with them. The Truitt III appliance, however, permits the use of intraoral Class III elastics and extraoral Class III elastics, applied to a reverse pull facemask. The Truitt III appliance does, however, require a permanent dentition for retention. The maxillary portion of the Truitt III appliance is like a modified Schwartz plate. The following modifications may be added: a. Occlusal coverage with a minimum thickness of 1.5 mm posteriorly, b. Anterior tongue wires to curb a tongue thrust habit, c. Posterior palatal spinner to allow myofun-

在用直弓丝期间为了保持矫形的正确，我建议使用Vesco弓。 Vesco弓是一种固定的弓丝纠治器，它是特意为有效纠正骨源性 III类错（牙合）而设计的。像Frankel 博士的功能调节器一样; Vesco 弓丝有上颚唇垫来充当防滑扣片，以便将松紧带从弓丝桥接至反拉面罩。把丙烯酸唇垫的从中心分离开，以允许正牙医生根据口腔解剖结构对唇垫作出适当的调整，来消除患者的不适。此外，由于弓丝反向拉伸弹性的悬臂效应，唇根扭矩传递到上颌切牙。这抵消了他们在上颌前伸期间的初始倾斜。Vesco弓允许在治疗的直弓丝阶段继续使用反拉面罩疗法。需要正畸运动时，则对Vesco弓施加较轻的力度，即200克。但是，如果我们希望继续矫正上颌骨的话，则需要更大的力度，一边600 克. 下颌弓的固定纠治器的治疗是用圆形不锈钢弓丝（0.016）完成的。如果做个矩形方弓丝的话就会产生下切牙的唇冠扭矩。这将促使他们进入III级位置。我在上颌骨中使用0.021-x 0.025’TMA弓丝，而

ctional swallowing therapy to be initiated. d. Frankel III mucoperiosteal pads to stimulate maxillary growth, e. Elastic hooks placed on the maxillary first molars by soldering the hooks to Adams clasps. These are designed for the placement of intraoral elastics, f. Soldered hooks on the omega loop of the labial bow, in the canine region, for the placement of extraoral elastics, g. Expansion screws are incorporated into the appliance, to develop the sagittal and transverse size of the maxilla. The mandibular portion of the Truitt III appliance is a modified Hawley with a labial bow. The labial bow is constructed of heavy 0.036 steel wire. It extends from the occlusal acrylic, downward, and is formed into the standard Hawley loop. This engages into the gingival third of the mandibular incisors. The Truitt III appliance is activated by turning an expansion screw once a week (1/4mm). This adjustment should be redu-

在下颌骨中使用了圆形0.016“不锈钢弓丝，来完成了我的III类直弓丝纠治器治疗。如前所述;如果还存在下唇区拥挤，当患者生长发育结束时，我可能会提倡邻间分离或切除下切牙。由于下前牙会通过简单的倾斜对回缩力学作出反应，所以拔除下双切牙是个禁忌, 在患者需要手术治疗性代偿的情况下，则提倡在上下颌弓中都使用扁弓丝，将门牙置于各自的骨骼基部上。 III类松紧带和II 类松紧带一起使用来推进牙列代偿. 对早期三类错（牙合）的情况总结大多数III类错（牙合）涉及到上颌骨太小（垂直向和/或横向）或离前颅底太远。有可能是这两个问题的组合。了解问题的根源是确定使用哪种类型设备的关键。彻底的头影测量分析对做出正确诊断有非常大的帮助. 对中间面部缺陷的III类错牙合畸形来说，一旦被诊断出来，临床医生应该立即实施治疗。我发现有时会过早治疗II类错牙合，就是在下颌骨开始向前生长之前。在许多情况下，当发生下颌骨生长时，六岁的II类患者可以自我纠正。另一方面，

ced to once a fortnight if the patient has an anterior openbite. The intraoral and extraoral elastics are worn as per the rules of facemask therapy. The occlusal acrylic coverage on the Truitt III appliance is adjusted just like a flat plane splint. There should be no lower cuspid guidance to prevent an anterior displacement of the meniscus within the temporomandibular joint. The lower labial bow of the Truitt appliance must be adjusted monthly to be in firm contact with the mandibular incisors. This adjustment is done with three-jaw pliers to constrict the size of the omega loops. It is important to ensure that the labial bow contacts the gingival 1/3 of the mandibular incisors to avoid tipping of these teeth. FINISHING CLASS III MALOCCLUSIONS IN STRAIGHTWIRE (PSL) BRACKETS Once the developing Class III problem is corrected orthopedically I advocate the use of a Han, Frankel III or Truit III appliance to act as a retainer until mandibular growth is complete (stage C6). The patient is then

一名六岁的III类错牙合患者已经脱离了正常的轨迹，并且不会再发育成I类牙合。这些患者需要早期干预，并需要长期的保持治疗（整个后青春期）以维持矫形的更正. 临床医生应始终警告患者和父母，早期治疗机制不是百分百能够避免手术，但至少可以将手术限制在一个颌弓上，或减少需要正颌手术的可能性。深覆盖Ⅲ级错牙合患者的预后总是好于开牙合，即垂直向增加的Ⅲ类问题。在一个开牙合且垂直向增加的III类问题中，重要的是观察牙合覆盖面的需要并观察舌的前推力。这些病例还是需要使用非下巴垫式的面罩.

作者联系方式 Derek Mahony医师专业正畸医生 — 澳大利亚悉尼 info@derekmahony.com www.fullfaceglobal.com

DOCTOR牙医 Infodent International •1 2018

Scientific Update

ready for final orthodontic correction using fixed appliance therapy. The orthodontic portion of the treatment is best delayed until the patient has completed their pubertal growth. Any orthodontic treatment must be centred around the principles of maintaining the Class III dentoalveolar base compensation, within the lower arch and “burning anchorage” in the upper arch (type C anchorage continued). No retrusive mechanics should ever be used, to the maxillary dentition, in a Class III malocclusion. I used a “stopped archwire technique” in the maxillary arch to push the maxillary incisors forward into a Class I incisor relationship. This is achieved by placing Guerin locks mesial to the first molars and allowing a 0.016 X 0.022 thermal nickel titanium archwire to lie about 4 mm ahead of the maxillary brackets. When this archwire is ligated into the maxillary incisor teeth the wire is prevented from distal driving by the Guerin locks, so the wire pushes the maxillary incisors forward. To maintain my orthopaedic correction, during straightwire, I recommend the use of a Vesco arch. The Vesco arch is a fixed wire appliance, which is designed to correct dental and skeletal Class III malocclusions efficiently. Like Dr. Frankel’s functional regulator, the Vesco arch contains maxillary lip pads which act as a cleat to bridge elastics from the archwire to the reverse pull facemask. A separation is incorporated through the centre of the acrylic lip pad to allow the orthodontist the option adapting the pad to the oral anatomy and eliminating patient discomfort. Also, due to the cantilever effect of the reverse pull elastics from the archwire, labial root torque is transmitted to the maxillary incisors. This counteracts their initial proclination during maxillary protraction.

SUMMARY FOR EARLY CLASS III MALOCCLUSION Most Class III malocclusions involve a maxilla which is too small (sagitally and/or transversely) or too far back in relation to the anterior cranial base. There may be a combination of both of these problems. Understanding the problem is the key to determining which type of appliance to use. A thorough Cephalometric analysis is an invaluable aid in helping to make the correct diagnosis. The clinician should treat a mid-face deficient Class III malocclusion as soon as it is diagnosed. I find that Class II malocclusions are sometimes treated too early, before the forward growth of the mandible. In many cases a six-yearold Class II patient may self correct, when mandibular growth occurs. On the other hand, a six-year-old Class III patient is already one step out of normal and will not grow into a Class I occlusion. These patients need early intervention and require prolonged retention (throughout the post pubertal period) to maintain this orthopaedic correction. The clinician should always warn the patient, and the parents, that it is not always possible to avoid surgery, but early treatment mechanics can at least limit surgery to one jaw or reduce the percentage chance of requiring orthognathic surgery. A deep bite Class III malocclusion always has a better prognosis than an openbite, increased vertical, Class III problem. In the open bite, increased vertical Class III problem, it is important to observe the need for occlusal coverage and to watch for an anterior tongue thrust. These cases should also employ a non-chin cup style facemask.

The Vesco arch permits the continued use of reverse pull facemask therapy during the straightwire phase of treatment. If orthodontic movement is required, lighter forces are applied to the Vesco arch, i.e. 200 gms. per side, but if we wish to continue orhthopedic correction of the maxilla, heavier forces are required, i.e. 600 gms. per side. The fixed appliance therapy in the lower arch is completed on a round stainless steel archwire (0.016). If we were to progress to a rectangular archwire we would express labial crown torque of the lower incisors. This will push them into a Class III position. I finish my Class III straightwire cases with a 0.021””x 0.025’ TMA archwire in the maxilla and a round 0.016” stainless steel wire in the mandible. As mentioned earlier, if there is still crowding in the lower labial segment, when growth is complete I may advocate interproximal stripping, or the removal of a lower incisor. Extraction of lower bicuspids is contraindicated as the lower anterior teeth respond to retraction mechanics by simply tipping back. If the patient requires surgical treatment, decompensation is advocated with the use of rectangular wires, in both arches, to place the incisors over their respective skeletal bases. Class III elastics are replaced with Class II elastics to further decompensate the dentition.

Contact Dr. Derek Mahony Specialist Orthodontist – Sydney Australia info@derekmahony.com www.fullfaceglobal.com

DOCTOR牙医 Infodent International •1 2018

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Scientific Update

New Therapeutic Management of TMDs, Through the Immediate Re-educational Device: “Lingual Ring Ri.P.A.Ra.” 颞下颌关节紊乱综合症（TMDs）的新疗法，运用“Lingual RingRi.P.A.Ra.”即刻恢复训练纠治器

Author

Dr. Alessandro Rampello University of Rome La Sapienza, Chair of Clinical Gnathology, Contract Professor, President of Stomatology and Postural Interdisciplinary Rehabilitation Federation (FRISP), Freelancer in Rome. www.bruxismsolution.com Alessandro Rampello医师， La Sapienza罗马大学，临床病理学会主席，签约教授，口腔医学和姿态跨学科康复联合会（FRISP）总裁，自由撰稿人

AIM OF THE WORK

目的

he aim is to present the authors’ protocol-based experience on an alternative therapeutic use of the bite in patients with TMDs (Temporo Mandibular Disorders), which also included the active repositioning of the tongue. The protocol requires a more active cooperation of the patient and the use of the bite also as a re-educational tool. To achieve this the Ri.P.A.Ra. Lingual Ring was used; this occlusal device is not just a simple bite, but a device for positional and functional rehabilitation, which has been used by the authors for several years in the gnathological field.

介绍一个(TMDs)颞下颌关节紊乱症的替代性治疗方案，在这个疗法中，让患者使用咬合器，其中还包括主动的舌头重新定位。该疗法需要患者更积极的配合，并把咬合器作为恢复训练工具来使用。为了实现这一点，我们使用了Ri.P.A.Ra. Lingual Ring咬合器; 这种咬合装置并不是个简单的咬合器，它是一款具有位置和功能康复作用的咬合装置，此装置已被本文作者在咀嚼系统研究领域内运用了好多年。

MATERIALS AND METHODS A consecutive series of 600 patients were observed, from February 2014 to February 2016. All subjects were evaluated using a codified clinical, anamnestic, instrumental protocol for the analysis of the presence of TMJ dysfunctions, developed according to the Research Diagnostic Criteria for Temporo Mandibular Disorders (RDC/TMD). From the initial 600 patients, 160 subjects were selected based on the inclusion and exclusion criteria, all with disc displacement with reduction that was treated according to the new protocol using the Ri.P.A.Ra. Lingual Ring. RESULTS AND CONCLUSIONS The present study showed interesting results in the treatment of patients with TMD. In fact, 99 patients out of 160 (62%) experienced remission of all symptoms in 3 months. This confirms that the protocol is certainly valid to detect articular imbalances (clicking, TMJ pain, myalgia) arising from possible occlusal alterations, but especially by neuromuscular problems and tensions, also confirmed by the instrumental tests performed: MRI of TMJ with and without the Lingual Ring in the mouth and electromyography.

DOCTOR牙医 Infodent International •1 2018

材料和方法在2014年2月至2016年2月之间，我们连续观察了 600例患者。对所有受试者都使用编码的临床、记录、仪器方案进行评估，来分析颞下颌关节TMJ功能障碍的情况，根据颞下颌关机紊乱研究诊断标准（RDC/TMD）。根据纳入和排除标准，从最初的600例患者中，最终选择了160例，所有患者都有关节盘移位，在接受了Ri.P.A.Ra Lingual Ring 咬合器疗法后关节盘移位都得到了减轻。

结果和结论本研究最终得出了对TMD患者治疗有着重大意义的结果。事实上，160例患者中有99例（62％）在3 个月内出现所有症状得到缓解。这证实了该疗法对可能由咬合改变而引起的关节不平衡（咔哒声，颞下颌关节疼痛，肌痛）是有效的；尤其是对由神经肌肉问题和紧张引起的关节不平衡的效果，也在进行仪器测试中得到了证实：口中戴用和不戴用咬合器下的颞下颌关节盘 MRI磁共振图像对比和肌电图的结果。

The diagnostic and therapeutic setting for RDC/1992 (1) and DC/2014 (2) of Temporo Mandibular Disorders (TMD) through axis 1 and axis 2 as well as its etiological framework have changed a lot in recent years. Most of all, the causal role attributed to dental occlusion (3, 4) has changed. While in the past

对于颞下颌关节絮乱综合症（TMD）来说，无论是1992年得出的研究用诊断标准RDC（I）还是 2014年提出的分类诊断标准DC（2），那些通过I 类和II类以及其病因框架的诊断和治疗方案，在近年来发生了很大的变化。

NEW THERAPEUTIC MANAGEMENT OF TMDS THROUGH THE IMMEDIATE RE-EDUCATIONAL DEVICE: “LINGUAL RING RI.P.A.RA.”

BEFORE; THREE DIFFERENT TYPES OF THERAPIES, SEPARATED:

THERAPY WITH “BITE”

(B)

(C)

THERAPY WITH “COUNSELLING” and “BEHAVIORAL-THERAPY”

THERAPY WITH “PHYSIOTHERAPEUTIC EXERCISES”

Photo 1.

NOW; NEW THERAPEUTIC PROTOCOL: THREE DIFFERENT TYPES OF THERAPIES, TOGETHER

New therapeutic protocol with Ri.P.A.Ra. Lingual Ring. 图. I 用 Ri.P.A.Ra. Lingual Ring.咬合器的新疗法

with the BITE LINGUAL RING RI.P.A.RA. is now possible, to do them together: THERAPY with BITE; COUNSELLING and BEHAVIORAL-THERAPY; PHYSIOTHERAPEUTIC EXERCISES; EXERCISES AT HOME with the BITE LINGUAL RING RI.P.A.RA. in the mouth

EXERCISES IN DENTAL PRACTICE with the BITE LINGUAL RING RI.P.A.RA. in the mouth

用于颞下颌关节絮乱TMDS新疗法的即刻再教育设备：

对所有受试者都使用编码的临床

(A)

(B)

(C)

对所有受试者都使用编码的临床

THERAPY WITH “咬合器”

LINGUAL RING RI.P.A.RA.咬合器,使联合运用三种疗法变成了可能

THERAPY WITH

咬合疗法; 咨询和行为疗法; 理疗练习;

“咨询” and “行为疗法”

THERAPY WITH “理疗锻炼”

EXERCISES 家中练习把 LINGUAL RING RI.PARA 咬合器戴在嘴里

EXERCISES 在诊所练习还是把 LINGUAL RING RI.PARA 咬合器戴在嘴里

DOCTOR牙医 Infodent International •1 2018

Scientific Update

Photo 2.

Parts that make up the bite Ri.P.A.Ra. Lingual Ring. 图.2 组成Ri.PARa Lingual Ring咬合器的2个部分

it was highly focused on an etiological action (5, 6, 7, 8); now, instead, neuromuscular factors, linked to psychosocial (9) issues and to stress (10), as already cited in the past (11, 12, 13), combined to specific facial morphologies (14), have gained broad consensus. As such, bite therapy also needs to adapt to international literature which provides new therapeutic approaches: “Cognitive Awareness, Counseling, Self-Care, Patient Education, Lifestyle Modification, Behavioral Therapy” (15-23, 32), and needs to adapt to the “BioPsycho-Social” model through “conservative therapies based on evidence and on low invasiveness” (2, 24, 32). Therefore, traditional concepts of bite therapy must be reviewed. The bite should no longer be used passively only at night and a few hours during the day, with check-ups limited to the evaluation of occlusal contacts, but being an important therapeutic device, recognized and validated by the scientific community (25, 27, 32, 33), it must also turn into a re-educational device, in consideration of the role attributed to neuromuscular and psychosocial factors, together with the occlusal factor. This can be achieved through active involvement and collaboration of the patient with behavioral strategies and physical exercises performed by the patient with the bite. The review of international literature, in fact, now agrees in recognizing as valid, and sometimes on the same level, the following therapies: A. Therapy with bite; B. Therapy with counseling and self-care; C. Therapy with physiotherapeutic exercises done by the patient at home and with the therapist (15-23) (fig. 1). In the following work we present a new therapeutic protocol with a different use of the bite which includes more collaboration from the patient. The bite becomes a true re-educational tool with which the patient also implements the above mentioned therapies, B and C, and the clinician doesn’t just check the occlusal contacts but uses the bite as a mean for neuromuscular deprogramming and for functional and cognitive-behavioral re-education (fig. 1). Such protocol, in order to be applied, requires the use of a new immediate device: the bite Ri.P.A.Ra. Lingual Ring (fig.2,3,4,5) already in use for some years in different public and private structures, among which the Department of Clinical Gnathology at the Polyclinic Umberto I, University of Rome La Sapienza, (25, 26, 27), the Department of Orthodontics and the Department of Surgical, Oncological and Dental Disciplines at the Polyclinic “Paolo Giaccone” in Palermo, and in several other Public Healthcare Centers (ASL). MATERIALS AND METHODS Sample and Study Protocol A consecutive series of 600 patients were observed, from February 2014 to February 2016 at the different mentioned structures. All subjects were evaluated using basic clinical, anamnestic, instrumental pro-

DOCTOR牙医 Infodent International •1 2018

其中，最重要的一点是，最初把MTD归因于牙齿咬合的因果作用观点（3,4）已经改变。过去学者们把高度的注意力都集中在病因学行为上（5,6,7,8）; 与之相反，现在的牙科界更倾向于把MTD的诊断与治疗于特定的面部形态，心理社会问题和压力相关的神经肌肉因素相结合，就如过去已经被人引用过（11， 12， 13）；如今，这种理论已经获得了业界的广泛共识。因此，咬合疗法还需要提供新的治疗方法来适应国际文献的更新：“认知意识，咨询自我护理、病人教育、生活方式修正和行为疗法”（15-23,32），而且需要通过效果明显且低侵入性的保守疗法来适应 “生物心理社会” 模式（2,24,32）。因此，必须重新审视传统的咬合治疗概念。咬合器不应该再被动地只在夜间和白天使用几个小时，并只进行仅限于咬合接触情况的评估；它应该作为一种重要的治疗装置，来得到科学界的认可和验证(25, 27, 32, 33)。考虑到经肌肉和心理社会因素的作用以及咬合因素，它也必须转变为恢复训练设备。可以通过患者积极的参与和协作以及行为策略和机能训练来实现由患者自己进行咬合。事实上，如今国际文献的审查愿意承认其有效性，有时候也相同程度地认可以下疗法。: A. 咬合器疗法; B. 咨询结合自我护理治疗; C. 在患者家中和治疗师进行理疗锻炼。（I 5-23）（图1）在下面的研究报告中，我们描述了一个新的治疗方案，其中包括咬合器的不同用途与患者的更多协作。咬合器成为一种真正的恢复训练工具，病人也可以使用上述治疗方法B和C，临床医生不仅检查咬合接触情况，而且将咬合器用作放松神经肌肉和功能与认知行为恢复训练的手段（图1）。这个疗法需要使用到这款新的即用设备：Ri.PA.Ra。 Lingual Ring咬合器（图2,3,4,5），我们已经在数个公立和私人机构中使用了很多年。这些结构包括 Umberto I 综合医院的临床咀嚼科、罗马 La Sapienza 大学（25, 26, 27），巴勒莫“Paolo Giaccone综合医院的正畸科、外科，肿瘤科和牙科，还有一些其他的公共医疗中心。材料和方法样本和研究方法在2014年2月至2016年2月期间，我们连续观察了600 例不同结构的患者。根据颞下颌关节絮乱综合症的分类诊断标准（DC / TMD），用基础临床特征、病史和器械使用方法来评估所有受试者的功能障碍和/或骨关节结构异常情况。观察到几种不同的病状之后，根据如下所示的纳入和排除标准来选择患者。纳入标准:

tocols to analyze dysfunctions and/or osteoarticular structural anomalies, according to the Diagnostic Criteria for Temporo Mandibular Disorders (DC/TMD). Several pathologies were observed, and the patients were selected based on the inclusion and exclusion criteria as indicated below. Inclusion criteria: • disc displacement; • joint pain =/> 20 scale NVS (Numerical Verbal Scale); •muscular pain “myalgia” =/> 20 scale NVS; • tension headache and/or migraine =/> 20 scale NVS; • cervical pain and/or column pain arising from tension =/> 20 scale NVS; • parafunctions associated to muscular and/or joint pain; • consent to take part in the study. Exclusion criteria: • dislocations not linked to the joint disc; • post-trauma outcomes, malformations, TMJ or maxillofacial surgery; • patients already in therapy for such pathology; • systemic joint pathologies (rheumatoid arthritis, arthrosis, psoric arthritis, Ehlers-Danlos Syndrome EDS); • neurological and/or psychic headache and/or pathologies; • partial edentulous with 8 or more missing teeth; • positivity to axes 2. From the initial 600 visited patients, 440 were not considered as they did not fall within the inclusion criteria. Of these 64 had joint lock; 26 referred to trauma or fracture outcomes; 120 had a pain threshold inferior to 20 VNS; 26 were missing more than 8 teeth and had no adequate prosthesis; 24 denied their consent in taking part in the study. The remaining 160 have been included in the new protocol. The sample was therefore represented by a consecutive series of 160 subjects of which 128 were female and 32 male, aged between 21 and 63, with average of 42 years. All patients (100%) were affected by joint disc displacement with reduction; 109 patients (68%) had TMJ pain; 115 patients (72%) had muscular pain; 123 patients (77%) had headache; 82 (51%) cervical pain; 130 (81%) had parafunctions with clear signs of abrasion, problems in teeth clenching or bruxism noises. All patients were adequately informed on how to use the bite Ri.P.A.Ra. Lingual Ring and on the new protocol to follow (fig. 1): A. Therapy with bite Ri.P.A.Ra. Lingual Ring to wear every night; B. Therapy with counseling and self-care; C. Therapy with physiotherapeutic exercises done by the patient at home and guided by the therapist in the different structures using the bite Ri.P.A.Ra. Lingual Ring (15-23) (fig. 1). Detailed description of the shape and function of the Ri.P.A.Ra. Lingual Ring Before presenting the clinical protocol in all its details, we hereby describe the Ri.P.A.Ra. Lingual Ring specific features – the Rampello* Active Positional Re-educational Lingual Ring (fig. 2).

• 关节盘移位; • 关节疼痛度=/> 20 scale NVS (Numerical Verbal Scale); • 肌肉疼痛程度 “myalgia” =/> 20 scale NVS; • 紧张性头痛和或偏头痛 =/> 20 scale NVS; • 由于紧张引起的颈椎疼痛和或脊柱疼痛=/> 20 scale NVS; • 与肌肉和或关节疼痛相关的功能障碍; • 同意配合研究. 排除标准: • 错位与关节盘无关; • 外因创伤, 畸形,经过 TMJ 或颌面部手术; • 已经在进行治疗此类病理的患者; • 全身性关节病变(类风湿性关节炎, 关节病, 银屑病关节炎, Ehlers Danlos 综合症 EDS); • 神经性或和精神性病痛或和病症; • 缺牙8颗以上的部分缺牙患者; • 极有可能过渡到2类病. 在最初就诊的600名患者中，有440名未达到纳入标准，因此不予考虑。其中64人有联合锁; 26人有创伤或骨折; 120人的疼痛阈值低于20 VNS; 26人缺牙超过8颗也没有相应的义齿; 24人不同意参加研究其余的160个被列入新方案的研究。因此，该研究由160名受试者组成，其中 128名女性和32名男性，年龄在21至63岁之间，平均年龄为42岁。所有患者（100％）均因关节盘移位而需要还原; 其中109例（占所有受试者的68％）有颞颚关节（TMJ）疼痛; 115名患者（72％）有肌肉疼痛; 123名患者（77％）头痛; 82名患者（51％）颈痛; 130例（81％）出现了明显的磨擦、牙齿紧缩或磨牙症噪音等习惯性功能障碍。所有患者都充分了解了如何使用Ri.PA.Ra Lingual Ring咬合器，并遵循新疗法的几个规

Photo. 3

Scheme of the correct positioning of the tongue and the bite Ri.P.A.Ra. Lingual Ring (sagittal view). 图. 3 舌头正确定位方案和Ri.PARa 咬合器（矢状图）

DOCTOR牙医 Infodent International •1 2018

Scientific Update 则（图1）：A.治疗期应当每晚戴用Ri.P.A.Ra. Lingual Ring咬合器; B.咨询和自我护理; C. 患者在家中进行理疗锻炼，根据不同结构，在治疗师指导下使用Ri.PA.Ra咬合器进行治疗。 Lingual Ring 咬合器（15-23）（图1）。

Photo 4

Above: MRI without the Ri.P.A.Ra. bite in the mouth with disc displacement. Below: MRI with the Ri.P.A.Ra. bite in the mouth without disc displacement. 图. 4 上面:嘴中没有佩戴Ri.PA.Ra. 咬合器时 MRI关节盘移位情况，下面： MRI 嘴中戴着 Ri.PARa. 咬合器时MRI关节盘无移位现象

WITH RI.P.A.RA.

WITH FARRAR

Photo 5

Correct positioning of bite Farrar and bite Ri.P.A.Ra.. To notice the different positioning of the tongue. 图. 5 Ri.PARa咬合器正确咬合位置..可以看到不一样的舌头位置.

Shape The Ri.P.A.Ra* means= Rampello* Active Positional Re-educational Lingual Ring, as per registered patent**, is made up of several parts that we have conveniently divided into central C and peripheral P (fig. 2). The central part C is made up of the Lingual Ring and two horizontal plates and it is the most “active” part. The peripheral part P is made up of balancing systems, anchorage, assessment and stabilization and it is the “passive” part. In part C, the Lingual Ring is made up of two arches: inferior arch “1” and superior arch “2”, which are literally attached, forming a whole with the two symmetric horizontal plates which are to be positioned between teeth: plate “3d” on the right and plate “3s” on the left (fig. 2 and 3). The whole makes up the most important, universal and functional “active” unit. In part P, corresponding to the peripheral part with reinforcement systems, anchorage, assessment and stabilization, we have: two small symmetric palatal, vertical, reinforcement rims “4d” and “4s”, two symmetric balancing, vertical and lateral cheek shields “5d” on the right and “5s” on the left, a linking front vestibular band “6” connecting the two lateral cheek shields. After countless technical compression, torsion, traction and cut tests, studies on similar devices already on the market and after many years of clinical trials on prototypes, a platinum medical silicone was chosen to produce the device. The chosen silicone is nontoxic, hypoallergenic, biocompatible and compliant with the legislation (UNI EN ISO 109931:2010) and EU 93-42 CE directives, hardness 55-60 Shore (class 1 medical device).

DOCTOR牙医 Infodent International •1 2018

Ri.P.A.Ra. Lingual Ring咬合器的形状与功能的详细描述在介绍所有临床方案细节之前，我们先在此描述 Rampello的Ri.P.A.Ra. Lingual Ring - *再教育活动定位固舌环的特定功能（图2）。 Fig. 2 组成Ri.PARa Lingual Ring咬合器的2个部分形状根据注册专利**，Ri.P.A.Ra *表示= Rampello *主动定位恢复训练咬合器，我们将其简单地划分为以中心的C区和外围P区为主而（图2）组成的几个部分。中心部分C由环形圈和两块水平板组成，是最“活跃”的部分。周边部分P由平衡系统、锚定、评估和稳定系统构成，是相对“被动”的部分。其中C部分固舌环由两个拱形构成：下拱“1”和上拱“2”，这两个拱实际上是连接在一起的，形成一个整体，两个对称的水平板位于牙齿之间：右侧的 3d板和左侧的”3s“板（图2和3）。整体构成了最重要，最普遍和最实用的“活跃”的部位。在部分P中，就是具有加固系统，锚固，评估和固定作用的周边部分，有两个小对称腭，垂直加强轮缘“4d”和“4s”，两个对称、平衡，垂直系统的外侧颊部护罩，右边的“5d”，和左边的“5”，一个连接前部前庭带状“6”连接两个侧颊盾。在经过多次技术性的压缩、扭转、牵引和切割测试之后，业内已有针对类似设备的研究，经过对样板的多年临床试验，我们决定选择铂医用硅酮来生产该设备。所选硅胶具有无毒、低过敏性和生物兼容性特征，并符合（UNI EN ISO 109931：2010）法规和EU 93-42 CE 指令，硬度55-60 邵氏（1类医疗器械）。 *Ri: 意为再教育性装置：用于认知行为疗法; P：定位：因为它可以改变髁突、下颌骨、舌头和咀嚼肌的姿势; A：意为主动：因为它不是牙齿之间的被动装置，而是患者进行特定练习的装置; Ra：Rampello 的缩写：创作者姓氏。 **工业专利N. RM2014A000673已推广至欧洲和美国。由卫生部注册为医疗器械，编号为1175800，编号以“N”开头，器械等级编号为“A1”，商业名称为“Ri.P.A.Ra. Lingual Ring，CND Q010499”，从2014 年起在市场上定期上市，上有“CE”标志。

*Ri: Re-educator: for cognitive-behavioral therapy; P: Positional: as it modifies the posture of condyles, mandible, tongue and masticatory muscles; A: Active: as it is not a passive device among teeth but a device with which the patient makes specific exercises; Ra: Rampello: the creator’s surname. **Industrial patent N. RM2014A000673 extended to Europe and the USA. Registered by the Ministry of Health as medical device with identification number 1175800, repertory “N”, class code “A1”, with commercial name “Ri.P.A.Ra. Lingual Ring”, CND Q010499, regularly on the market since 2014 with “CE” mark. Function Ri.P.A.Ra. Lingual Ring has very specific features as a result of many years of research and clinical validations (25, 26, 27). As described, in central part C there is a ring made up of two arches and two horizontal plates. The ring with the inferior arch “1” has two main functions: it brings the mandible and condyles in advanced position; it raises the tongue in advanced position with the tip against the “spot”. While the superior arch “2” has the function of keeping the device lifted up through the tongue. The two horizontal plates have other important functions: they modify the vertical dimension; they release the occlusal relation and they change the occlusal-articular relationship. Part “P”, consisting of the lateral cheek shields and the front band, balances the buccinator muscles’ forces and helps to stabilize and retain the whole device. The new

功能得益于多年的研究和临床验证，Ri.P.A.Ra. Lingual Ring咬合器具有非常明确的特征（25,26,27）。如上所述，在中心部分C中，有一个由两个拱和两个水平板组成的环。具有下拱“1”的环具有两个主要功能：它使下颌骨和髁突进入靠前位置，舌头处于靠前的位置，舌尖对着“圆孔”。而上拱“2”具有通过榫舌来保持装置被提升的功能。两个水平板也具有其他重要功能：它们可以起到修改垂直尺寸、释放咬合关系，并改变咬合关节关系的作用。部分“P”由外侧面颊护罩和前带组成，平衡了颊肌的力量，有助于稳定和保持整个装置。舌和下颌的新姿势以及改变的垂直尺寸，都会刺激所有口腔肌肉的拉伸，包括垂直肌（咬肌，颞肌和颞肌）水平肌（外肌和颊肌）和舌的肌肉。结果，它改变了两臂的杠杆和力量，同时保持了舌头的高度和靠前位置，尖端抵住“斑点”来进一步进行神经刺激（28-31）。最终下颌骨和舌的新姿势改变舌骨以及脊椎旁肌的位置。进而促使Ri.P.A.Ra. Lingual Ring舌定位环对所有这些部分的动作可以起到对舌头、下颌骨和整个口腔的位置恢复训练的作用（图3）。这与其他所有通用设备不同，它们只是倾向于保持牙弓远离而没有任何重新定位或再教育功能，因为只考虑到把它作为对抗垂直肌肉力量（咬

Tab. 1

Absolute values as number of patients. 表 I – 绝对值为患者数量.

CLICKING 响弹

TMJ PAIN TMJ 疼痛

MUSCULAR PAIN 肌肉疼痛

HEADACHE 头疼

CERVICAL PAIN 颈椎疼痛

PARAFUNCT. 机能异常

Beginning

160

109

115

123

130

Got worse

Stationary

Improved

101

Much improved

103

开始

恶化

无变化

得到改善

大大得到改善

Patients that have much improved all the symptoms simultaneously = 99 所有症状同时的到改善的患者数量= 99

DOCTOR牙医 Infodent International •1 2018

Scientific Update

CLICKING 响弹

TMJ PAIN TMJ 疼痛

MUSCULAR PAIN 肌肉疼痛

HEADACHE 头疼

CERVICAL PAIN 颈椎疼痛

PARAFUNCT. 机能异常

Beginning

160

109

115

123

130

Got worse

Stationary

28%

34%

22%

Improved

32%

33%

28%

24%

32%

78%

Much improved

64%

67%

72%

48%

34%

开始

恶化

无变化

得到改善

大大得到改善

Patients that have much improved all the symptoms simultaneously = 99 = 62% 所有症状同时的到改善的患者数量= 99 = 62%

Tab. 2

Percentage values compared to the number of patients. 表. 2 – 患者总人数的百分比

posture of tongue and mandible, as well as modifying the vertical dimension, stimulates the stretching of all oral cavity muscles, both vertical (masseter, internal and temporal pterygoids) and horizontal (external pterygoids and buccinators), as well as those of the tongue. As a consequence, it changes the lever and force of the arms and at the same time it keeps the tongue high and in advanced position with the tip against the “spot” for further neurological stimulation (28-31). Therefore, the new posture of mandible and tongue modifies the hyoid bone position as well as that of the rachis paravertebral muscles. As such, the Ri.P.A.Ra. Lingual Ring encompasses and acts on all these components aiming at the positional re-education of the tongue, mandible and the entire oral cavity (Fig. 3). This differentiates it from all the other universal devices which instead only tend to keep dental arches distant without any repositioning or re-educational function as only thought to work as contrast “cushions” to the load of the vertical muscles forces (masseter, internal and temporal pterygoids). The occlusal-articular reprogramming, with tongue re-education obtained through new posture and exercises has beneficial effects on all parts of the oral cavity and on mandibular, cervical and cranium disorders or TMDs. Therapeutic protocol The therapeutic protocol adopted by us has combined three big therapeutic concepts all recognized by international literature (15-23). They have not been separated or carried out at different times but they have all been integrated together and carried out simultane-

DOCTOR牙医 Infodent International •1 2018

肌，内部和颞翼突）的垫。通过新的姿势和锻炼获得的舌关节重新定位，对所有口腔部位，下颌骨、颈椎和颅骨功能障碍症和TMDs都能起到有益的作用。治疗方案我们采用的治疗方案结合了国际文献所公认的三大治疗概念（I 5-23），它们并没有在不同的时间段被分离或实施，而是在同一时间内被整合在一起（图1）它们分为以下几部： A.用 Ri.P.A.Ra. Lingual Ring舌定位咬合器的治疗; B.咨询和自我护理配合使用Ri.P.A.Ra. Lingual Ring 咬合器的治疗; C.由患者进行理疗训练，无论在家中还是在诊所医生的指导下都戴用Ri.P.A.Ra. Lingual Ring咬合器因此，新疗法同时整合了 A ，B 和 C ，口中戴用 Ri.P.A.Ra舌定位咬合器（图1）。所有患者都充分了解了治疗类型、特征以及Ri.RA.Ra咬合器的使用方法、佩戴Lingual Ring咬合器的练习、以及认知行为疗法的完整程序，以便于履行如下方案：

ously, that is (fig. 1): A. Therapy with bite Ri.P.A.Ra. Lingual Ring; B. Therapy with counseling and self-care together with the use of the bite Ri.P.A.Ra. Lingual Ring; C. Therapy with physiotherapeutic exercises done by the patient, wearing the bite Ri.P.A.Ra. Lingual Ring, both at home and under the direction of the clinician. Therefore, the new protocol will include A, B and C simultaneously, wearing the bite Ri.P.A.Ra. Lingual Ring in the mouth (Fig. 1). All patients were adequately informed on the type of protocol, its characteristics and on the use of the bite Ri.P.A.Ra. Lingual Ring, on the exercises to carry out with the bite Lingual Ring and on cognitive behavioral therapy with the complete program to follow according to the following scheme: • Detailed information, explanation and instructions on the actual pathology so as to give the patient the conscious perception of the problem and the best possible compliance; • Detailed information, explanation and instructions on self-care and behavioral precautions; • Detailed information, explanation and instructions on the Ri.P.A.Ra. Lingual Ring device with indications on its use: to wear every night (6-8 hours) and for at least 2 hours during the day, to carry out the exercises with instructions to position the tongue high at the “spot”; cognitive information not to clench the teeth on the horizontal plates (3d and 3s); • Detailed information and explanation on the exercises to carry out wearing the Ri.P.A.Ra. Lingual Ring device at home, at least three times a day on the first 21 days of therapy: in the morning on waking up; on returning home from work; at night before going to bed. Afterwards, at least once a day for the next 10 days and again with the instructions to position the tongue high at the “spot” and cognitive information not to clench the teeth on the horizontal plates (3d and 3s); • During clinical check-ups, all patients were asked: to describe the evolution of symptoms, the presence or absence of disturbances or annoyances and the timing of use. At every check-up the patients were asked to carry out the prescribed physiotherapy exercises wearing the Ri.P.A.Ra. Lingual Ring while the clinician observed and eventually corrected movements coordination, underlining the importance of the tongue posture against the “spot” and, most of all, of the cognitive perception not to clench the teeth on the horizontal plates; • The only occlusal therapeutic device used by all patients was the Ri.P.A.Ra. Lingual Ring; • The established maximum duration of the entire cycle of treatment was 3 months. All patients were adequately informed and a previous written consent to use the Ri.P.A.Ra. bite was obtained by each one of them. A timing of regular check-ups was planned with check-ups every 15-20 days. All patients were evaluated according to a comparison of parameters measured at the beginning (TO): pain, analysis of mandibular movements with fluidity, symmetry and asymptomatic qualitative and quantitative compari-

• 对病理的实际情况进行详细的解释和指导，以便让患者清醒地认识到问题并尽可能达到合规; • 对自我护理和行为预防措施的信息做出详细说明和指导; • 对Ri.P.A.Ra. Lingual Ring咬合器的详细信息进行解释和说明，并给与其具体的使用说明：每天晚上戴用6至8小时，白天每天至少戴用2小时，指导将舌头放在正确的圆孔上，并让他们意识到牙齿不能咬紧水平板（点3d和点3s上） • 详细解释在家戴用Ri.P.A.Ra. Lingual Ring 咬合器的操作要点，在治疗期的头21天内每天至少要戴用 3次: 早晨起床后，下班回家到晚上，之后，在接下来的10天中每天至少戴用一次，并记住把舌头伸进高出的圆孔内，有意识地不去紧咬水平板。 • 在每次检查期间，每个患者都被要求描述症状的演变，以及是否存在干扰或烦扰，还有使用的时间，要求患者在诊所的观察下戴用Ri.RA.Ra. Lingual Ring 咬合器的理疗练习，因此临床医生可以观察并最终纠正和协调患者练习的方式，此外强调舌头对准高位的圆孔姿势，最重要的一点是牙齿要有意识地不去紧咬水平板； • Ri.RA.Ra. Lingual Ring 咬合器，是本研究中所有患者使用的唯一咬合治疗设备 • 整个治疗周期最长持续时间为3个月，每个患者获得相应的信息，并在研究开始之前取得每位患者运用Ri.RA.Ra. Lingual Ring 咬合器的书面知情同意书。计划每15至20天进行一次定期检查，先根据参数比我们开始对患者进行评估: 疼痛、下颌运动的流畅度、对称性和无症状的定性和定量比较。在治疗结束时作分段评析，并进行了以下几项评估： • 病情加重: 至少有个症状或一种情况有恶化或没有得到改善 • 无改变: 没有症状得到改善或恶化 • 得到改善: 至少一个症状得到改善并且没有出现任何恶化的现象； • 得到非常大的改善: 没有任何症状存在。在症状分析总结中我们运用了绝对值和百分比值，其中绝对值表示患者数量，而百分比值表示通过使用Ri.P.A.RaLingual Ring咬合器综合方案的有效性，见表I和表2。功能和症状的预期结果使用Ri.RA.Ra. Lingual Ring 咬合器的新疗法的预期功能和症状结果如下： • 关节和肌肉疼痛的减少 • 头痛的减少 • 颞下颌关节功能障碍TMJ的减轻或消失的噪音从主观与客观上定性定量运动得到改善。 • 患者或牙科医师都没有观察到明显的牙齿接触变化.

DOCTOR牙医 Infodent International •1 2018

Scientific Update sons. At the end of treatment a segmentation analysis was carried out with the following evaluation: • W: got worse: at least one symptom or sign of having got worse and no sign of improvement; • S: stationary: no symptom of improvement, no sign of having got worse; • I: improved: at least one symptom of improvement and no sign of having got worse; • MI: much improved: complete absence of signs or symptoms. A summary of the analyzed symptoms, expressed both in absolute values as number of patients, and in percentage values, for a final evaluation of the effectiveness of the new integrated protocol, through the use of the Ri.P.A.Ra. Lingual Ring, are summarized in tables 1 and 2. Expected functional and symptomatic answers The expected functional and symptomatic answers from the application of the new protocol using the bite Ri.P.A.Ra. Lingual Ring were: • Reduction of joint and muscular pain; • Headache reduction; • Reduction and disappearance of TMJ noises with subjective and objective qualitative and quantitative movement improvement; • No significant changes in the dental contact observed by the patient or the clinician. RESULTS Analyzing the results has allowed us to come to the following considerations. The new protocol application time using the bite Ri.P.A.Ra. Lingual Ring was about 3 months for all patients. Minimum time for significant improvement in the symptoms was about 1 month in 52 patients. Maximum time was 3 months in 20 patients. Average time was 2 months in 88 patients. Minimum bite Ri.P.A.Ra. Lingual Ring time of use was 4 hours in 16 patients. Maximum time of use was 13 hours in 95 patients between day and night including the time for physiotherapy exercises done at home. The average daily use was 8.5 hours. The initial joint pain found in 109 patients, 68% of the sample, disappeared in 73 patients (67% of the 109 patients and 46% of the total 160) and improved in 36 patients (33% of the 109 with TMJ pain and 22.5% of the total 160). As such, TMJ pain disappeared in 2/3 of the patients and diminished in intensity in about 1/3 of the patients, while no one reported of getting worse. Myalgia, initially found in 115 patients, 72% of the sample, disappeared in 83 patients after treatment (72% of the initial 115 and 52% of the total sample) and diminished in intensity in 32 patients (28% of patients with myalgia and 20% of the total 160) confirming, here too, that over 2/3 of patients stopped having muscular pain and less than 1/3 had a pain reduction while no one had gotten worse. Headache, reported by 123 patients, corresponding to 77% of the sample, disappeared after treatment in 59 patients (48% of the 123 and 37% of the total sample) and among the 64 still affected by headache, for 29 (24%)

DOCTOR牙医 Infodent International •1 2018

结果通过分析结果我们得出以下几点考虑。所有患者在新疗法中应用Ri.P.A.Ra. Lingual Ring 咬合器的时间，为大约3个月。其中 52例患者的症状得到明显改善的最短时间约为1个月。 20名用了最长时间的患者为3个月。另外88名患者的平均所用时间为2个月。咬合器运用时间最短的16名患者使用时间为4小时。在95例患者中昼夜所用的最大时间为13小时，包括患者在家中进行理疗练习的时间。平均每天使用时间为8.5小时。在109例患者中发现了自发性关节疼痛（占所有样本的68％）在治疗结束时73例患者中的疼痛消失（占109例患者中的67％和160例所有受试者的46％）在36例患者中得到改善（占109例患有TMJ疼痛患者的33 ％，和160个总受试者的22.5％）。由此可见，2/3患有颞下颌关节疼痛的患者症状消失，大约1/3患者的强度降低，没有患者表示出现症状恶化。最初在115名患者中发现有肌痛，83名患者相当于 72％的受试者在治疗后症状消失（初始患有肌痛者的72％和总受试者的52％），32名患者的肌痛强度减弱（肌痛患者数的28％和所有受试者数量的20％）在这里再次证实了超过2/3的患者没有了肌肉疼痛，少于1/3的患者疼痛得到减轻，没有人的症状恶化。有123例患者报告有头痛，相当于总样本的77％，在治疗后59例患者的疼痛消失（相当于123例患者中的48％和总样本数的37％），其中 64例仍然有头痛，其中29例（24％）的头痛得到好转或者比开始治疗时有得到缓解；而27例患者保持轻度疼痛状态不变，8例有强烈的头痛（分别占总数的22％和6％共28％），由此表明在疼痛症状与功能障碍相关的情况下，有得到改善的倾向。开始之初，有82例患者（相当于样本的51％）有颈部疼痛；治疗之后，28例患者颈部疼痛消失（相当于82例患者中的34％），所有患者在治疗前均提到有颈椎的紧张或垂直受限。在54名变化不大的患者中，有26名（相当于82个患者的32％）表明有得到轻微的改善，并且他们当中的大多数患有颈部区域病变，例如：由于突然的头部运动引起的椎骨压迫关节病或颈椎变形；其余28名（相当于82个患者的34％）被初步诊断为脊柱前突过度。这个数字使我们相信，用Ri.PA.Ra. Lingual Ring咬合器的疗法对颈椎椎管畸变患者的优势要明显大于那些患有脊柱过度前突的患者。因此，我们认为对这个参数的深入分析对于进一步的临床，器械和跨学科研究来说是非常重要的。在130名功能絮乱的患者中，占总受试者的81％，其中101名（130名中78％）表示在咬紧牙齿时有不同的感觉，并且在早上醒来的时候肌肉紧张症状减少，而其他29名患者 22％）则没有变化，保持了原来的症状。所有受试者160例患者（100％）

the headache had improved or was milder compared to beginning of treatment, while 27 patients remained stationary with mild and 8 with strong headache (22% and 6% = 28%) confirming that if the symptoms are linked to the dysfunction they tend to improve. Cervical pain, initially present in 82 patients, corresponding to 51% of the sample, disappeared in 28 patients after treatment (34% of the 82) and all of them referred to tensions or had verticalizations of the cervical spine before treatment. Among the 54 stationary patients, 26 (32% of the 82) reported of a slight improvement and they mostly had pathologies of the cervical district such as: vertebral crushing, arthrosis or cervical distortion due to an abrupt head movement. While, the remaining 28 (34% of the 82) had an initial diagnosis of hyperlordosis. This figure leads us to believe that our protocol, with the Ri.P.A.Ra. Lingual Ring, can be of greater advantage to subjects with rectilinization of the cervical spine tract rather than subjects with hyperlordosis. Therefore, we believe that an in-depth analysis of this parameter would be fundamental with further clinical, instrumental and interdisciplinary investigations. Among the 130 patients with parafunctions, 81% of the total sample, 101 (78% of the 130) reported of perceiving a different feeling while clenching the teeth and to waking up in the morning with less muscular tension, while for 29 patients (22%) there was no change and all remained stationary. TMJ noises, affecting the whole sample (160 patients, 100%), disappeared in 103 patients (64%), improved in 51 subjects (32%) and remained stationary in 6 patients (4%). No one reported of getting worse. These figures lead us to believe that our protocol has an excellent feedback in the medium and long term for symptoms such as TMJ pain, myalgia and muscular hyperactivity, while for more mechanical problems, whether or not linked to muscular hyperactivity and/ or occlusal alterations, even if we had an excellent feedback, we believe in the need for a longer treatment time of more than 3 months, compared to the treatment time used in this first study, to further strengthen the anatomical-functional rebalancing. To finalize the results’ evaluation we have summarized the final analysis, based both on the symptoms as well as on the answers given by the patients regarding how they felt before starting treatment (Table 1 and 2). DISCUSSION AND CONCLUSIONS Traditional bites used in gnathology today are mainly passive, they are not used by clinicians to carry out functional exercises and are not structured to do so. Patients only need to wear them and clinicians, during check-ups, only need to check if there are changes in occlusal contacts. Even the many immediate bites on the market in the last few years are mainly to protect teeth from the wearing out of bruxism and/or clenching of the teeth and are not re-educational or functional. The novel device Ri.P.A.Ra. Lingual Ring differs very much from classic devices and from the simple immediate devices as it is thought as re-educational bite. As shown in the protocol description, the patient, as well as wearing the Lingual Ring, also be-

都有TMJ响弹音，治疗之后，103例患者的TMJ响弹音完全消失（64％），51例患者有得到改善（32％），6 例患者（4％）保持了原来的症状。没有患者表示有症状恶化的情况。这些数字表明，无论从中期或长期来讲，我们的疗法对TMJ疼痛、肌痛和肌肉运动过度等症状都有很好的效果。而对于更多的机能问题来说，无论是否与肌肉活动过度和/或咬合改变相关，虽然我们得到了良好的结果，但是，要进一步加强解剖功能再平衡的话需要的时间要多于3个月，比第一次研究中所用治疗时间更长。为了最终确定一个结果评估，我们根据个种症状的表现以及患者经过对比治疗前与治疗后的感受给出的答案，总结了最终的分析结果，（见表I和表2）。讨论和结论如今，大部分用于咀嚼系统领域的传统咬合器都是被动型的，临床医生不用它们来进行功能锻炼，而且也不建议这样做。在检查过程中，患者只需戴用它们并由临床医生来检查咬合接触是否有变化。即使是在过去的几年中，市场上的许多即时咬合器也主要只是为了保护牙齿来自磨牙症和紧咬的损伤，并不具备再训练性或功能性。新颖的Ri.P.A.Ra. Lingual Ring咬合器，不同于传统的简单即时咬合器，因为它具有再训练功能。如本次新型疗法中所述，患者在戴用舌环咬合器时也在积极参与治疗，特别是在舌姿势的正确保持、戴用Ri.P.A.Ra咬合器的理疗练习，以及牙齿有意识地不紧咬水平板的行为态度。同时结合A 、B和 C三种治疗方法，已经有相关的文献综述（图I）（25,27,32,33）。因此，在过去的几年中，我们的治疗策略已经在朝这个方向发展，所采用的疗法使我们取得上述结果，并得以提出以下考虑和结论。 160名患者中没有一个患者出现情况恶化，考虑到临床管理成本低、作为即用型设备。有限的经济和生物成本、最重要的一点是其低侵入性、可逆性和保守治疗，使这个数据具备了高度的相关性。 • 在160名患患者中，只有6名 (4%)有响弹的患者症状保持了原状，没有一名患者(0%)有TMJ疼痛，没有患者有肌肉疼痛(0%)，35名患者有头疼 (28%)， 28 (34%)名患者有颈部疼痛，29 (22%)名患者有功能障碍. 因此只有极少数患者保持了原状，很有可能是因为他们有更加复杂的或是结构性的异变，特别是上面已提及的颈椎疼痛问题，似乎更倾向于跟颈部病理有关，例如创伤后的紧张和脊柱前突过度，事实上，我们已经注意到，此疗法对颈椎病患者的效果比对脊柱前凸过度患者的效果要好得多。需要强调的是，在这方面还需要进行更深入的研究。

DOCTOR牙医 Infodent International •1 2018

Scientific Update comes actively involved especially as regards tongue posture, physiotherapy exercises wearing the Ri.P.A.Ra. and the behavioral attitude not to clench the teeth on the bite’s horizontal plates. This combines simultaneously the three therapeutic treatments A, B and C, already reviewed by the literature (fig. 1) (25, 27, 32, 33). Therefore, in the last few years our treatment strategies have evolved in this direction and the mentioned protocol has been adopted allowing us to achieve the mentioned results and to draw the following considerations and conclusions. • Not one patient out of the 160 in the sample has worsened his/her situation. This data is highly relevant given the low cost of clinical management, being a ready to use device, the limited economic and biological cost, but above all its low invasiveness, its reversibility and the conservative therapy based on evidence. • Of the patients that remained stationary only: 6 (4%) out of 160 patients had clicking from the beginning; no one (0%) with TMJ pain; no one (0%) with muscular pain; 35 (28%) with headache, 28 (34%) with cervical pain; 29 (22%) with parafunctions. Therefore, very few subjects remained stationary and most likely they all had more complex or structural alterations, especially as regards cervical pain that, as already mentioned, seems to be linked more to pathologies of the cervical district such as post-traumatic tensions or hyperlordosis. In fact, we have noticed that patients with rectilinization have benefitted the most from our protocol rather than those with hyperlordosis; underlining as such the need for an in-depth investigation on this regard. • Patients that have improved: 51 (32%) patients with clicking; 36 (33%) with TMJ pain; 32 (28%) with muscular pain; 29 (24%) with headache; 26 (32%) subjects with cervical pain; 101 (78%) patients with clenching of teeth and/or bruxism from the beginning. • Patients that have much improved with total disappearance of the symptom: 103 (64%) patients out of the 160 with clicking from the beginning; 73 (67%) with TMJ pain; 83 (72%) with muscular pain; 59 (48%) with headache; 28 (34%) with cervical pain. • Lastly, by making a thorough evaluation of symptoms remission, we have seen that 99 patients, corresponding to 62% of the sample, reported a simultaneous disappearance of all symptoms. This figure, together with the figure of the patients that have improved and those that have much improved, confirms that the novel universal device Lingual Ring is certainly valid, together with the new protocol, to detect articular imbalances (clicking, TMJ pain, myalgia) arising from possible occlusal alterations but above all from neuromuscular problems and tensions. This conclusion is above all confirmed by the instrumental tests performed: MRI of TMJ with and without the Lingual Ring in the mouth (fig. 4 and 5); “T0” electromyography without the device and “T3” after 3 months of Lingual Ring utilization; axiography with and without the device in the mouth documenting the occlusal and condylar tridimensional repositioning. Overall, our study conclusions can only be positive, if we also consider the 3 months of protocol, which is a short time. The novel universal bite Lingual Ring, immedia-

DOCTOR牙医 Infodent International •1 2018

• 症状得到改善的患者： 51名患者 (32%) 有响弹; 36名患者 (33%)有TMJ疼痛 ; 32名患者 (28%) 有肌肉疼痛; 29名患者 (24%) 有头疼; 26 名患者(32%) 有颈椎痛; 101名患者 (78%) 在开始就有紧咬或和磨牙症. • 所有症状都消失的患者：在160名开始时有响弹的患者中有 103名患者 (64%) 在治疗后症状消失; 73名 (67%) 有TMJ疼痛; 83 (72%)名有肌肉疼痛的患者; 59 (48%)名有头疼的患者; 28 (34%)名有颈椎痛的患者. • 最后，通过对症状缓解情况的全面评估，我们看到99个患者（相当于总体受试者的62%）表示所有症状消失了。这个数据和那些得到改善和很大得到改善的患者数据，证实了新型舌环咬合器是确实有效的，配合新疗法运用此咬合器可以检测到由可能性的咬合关系改变而引起的关节不平衡情况（响弹声、颞下颌关节疼痛和肌肉痛）尤其能检测到精神肌肉问题和紧张引起的问题。这一结论首先被我们进行的仪器测试所证实： TMJ的关节盘MRI在口中戴用和不戴用咬合器时的不同表现（图4和图5）”TO”为没有咬合器时的肌电图，”T3” 是用咬合器3个月后的效果; 用口中戴用和不戴用咬合器时的轴图数据，记录了咬合关系和髁三角的重新定位情况. 总体而言，我们的研究结论只能是积极的，如果我们也考虑到仅仅3个月治疗，这是一个很短的时间。这种通用型新款咬合器，可供患者和临床医生立即使用，只需结合自我护理和锻炼、咨询、行为治疗，在家中或在临床医生的指导下锻炼即可. (8-12), 而且已经被行为病理学界也证明了上述方案对治疗 TMDs是有效的(图1) 优缺点说完了最重要的信息，现在我们需要对本治疗方案的优缺点做个简单的总结。优点 • 把多个治疗方法结合并运用在一个更加完整的治疗计划中的可能性: 咬合器治疗法、信息性和教育性治疗法、机能锻炼和肌功能恢复治疗法、行为疗法. • 作为即时器械舌环咬合器可以随时供患者和医疗操作者使用 • 很低的经济和临床管理费用、很低的生物入侵性、能做到有效的保守治疗. • 减少等待时间，一般情况下，不管是在私立还是公共机构中就诊都需要等待很长时间. • 方便患者和临床医生的管理. • 在功能性再恢复治疗中使用舌头.

tely available for the patient and clinician, combined to self-care and exercises – counseling, behavioral therapy and exercises at home and with the clinician. – (8-12), and to behavioral gnathology (fig. 1), has demonstrated to be an effective device for the immediate treatment of TMDs. Advantages and disadvantages On the sidelines of what said it is important to briefly summarize advantages and possible disadvantages of this new therapeutic approach. Advantages • Possibility to combine different therapeutic approaches in a more complete treatment plan, that is: bite therapy, information and educational therapy, therapy with physical exercises and myofunctional re-education, behavioral therapy. • The immediate use of the bite Lingual Ring, ready to use, both for the patient and the operator. • Low economic and clinical management; low biologic invasiveness, attaining to valid conservative therapies. • Reduction of waiting times (often long), both in private practices but especially in public structures. • Easy management for the patient and clinician. • The use of the tongue in functional re-educational therapy. • Good tolerability and versatility. • Possibility of having differential responses from the different types of TMDs, to be able to eventually differently adjust the continuation of therapeutic treatment. This last point reinforces the logic behind “conservative therapy based on evidence and low invasiveness”, requested by the scientific community, to obtain the highest benefit with the minimum effort and only subsequently plan more complex therapies. On this regard we underline the fact that all patients will continue to be monitored and those that remained stationary or just improved will be examined again and included in the program using specific therapies or traditional bites. As well as the mentioned advantages, the clinician can also prescribe the bite Lingual Ring to patients that have finalized rehabilitative or prosthetic dental treatments for deconditioning and/or occlusal protection. Disadvantages The disadvantage of this new device and its protocol is mostly linked to a higher need of collaboration from the patient that needs to learn how to manage the bite both strategically and with timing. Another possible disadvantage could be the management of tongue posture, which is important for the correct positioning of the device in the mouth. Obviously, advantages and disadvantages are also linked to a clinician’s training and ability. The present study, even if carried out on a population of 160 subjects, needs further in-depth analysis and a longer monitoring for clinical risks.

• 良好的耐受性和多功能性. • 可以在不同TMD中获得不一样的反映，由此可以根据不同情况做出调整使得治疗正确地持续进行. 最后一点强化了科学界要求“保证效果明显和低侵入性保守疗法”背后的逻辑，以最小的努力获得最大的益处，并且只有到不得已时才去选择计划更加复杂的疗法。在这方面，我们强调，所有患者将得到继续跟踪监测，而那些保持原状或得到一点改善的患者将再次接受检查，并使用特定疗法或传统治疗方法纳入该计划。除了上述优点之外，临床医师还可以给已经完成修复或安装了义齿的患者开Lingual Ring舌环咬合器，它可以起到防止功能失调和咬合保护的作用。缺点这种新设备及其疗法的缺点主要体现在需要患者高度的配合，这需要患者去学习咬合的技巧和时间上的把握。另一个有可能性的缺点是舌头姿势的把握，舌头的姿势对于将设备正确定位在嘴中是至关重要的。显然，优点和缺点也与临床医生的训练和能力有关系。本研究虽然是针对160名受试者的研究，但也需要进一步的深入分析和更长的临床风险监测。

A sincere thank you to Prof. Carlo Di Paolo, Dr. Giuseppe Currò, Dr. Ferlisi Mario and all colleagues from the Department of Clinical Gnathology at the Polyclinic Umberto I, University of Rome La Sapienza, the Department of Orthodontics at the Polyclinic “Paolo Giaccone” in Palermo and all colleagues from private and public practices. 在此真诚地感谢Carlo Di Paolo教授，Giuseppe Curra医师，Ferlisi Mario医师和来自Umberto综合诊所临床肿瘤学部的所有同事们，还有La Sapienza罗马大学Palermo分校的Paolo Giaccone牙科正畸科学院，以及私人和公立诊所的所有们。

DOCTOR牙医 Infodent International •1 2018

Scientific Update

BIBLIOGRAPHY 参考文献 1. Dworkin SF, Leresche L. The researchdiagnosticcriteria for TMD (RDC/TMD), developed by The Journal of Craniomandibular Disorders, Facial & OralPain; 1992. 2. Ohrbach R, Gonzalez Y, List T, Michelotti A, Schiffman E. Diagnostic Criteria for Temporo Mandibular Disorders (DC/TMD). Clinical Examination Protocol. Version: January 6, 2014. 3. Turp JC, Schindler H. Review Article: The dental occlusion as a suspected cause for TMDs: epidemiological and etiological considerations. J Oral Rehabil 2012 Jul;39(7):50212. doi: Epub Apr 9, 2012. 4. Badel T, Marotti M, Pavicin IS, Basic-Kes V. Temporomandibular disorders and occlusion. Acta Clin Croat 2012 Sep;51(3):419-24. 5. Shore NA. Occlusal equilibration and TMJ disfunction. Philadelphia: JB Lippincott Co; 1959. 6. Gerber A. Temporomandibular joint and dental occlusion. Dtsch Zahnarzt Z 1971; 26:119-41. 7. Ramfjord SP, Ash MM. Occlusion. Philadelphia: WB Saunders Co; 1971. p. 275–312. 8. Farrar WB, Mc Carty WL Jr. Inferior joint space arthrography and characteristics of condylar paths in internal derangements of the TMJ. J Prosthet Dent 1979 May;41(5):548-55. 9. Salameh E, Alshaarani F, Hamed HA, Nassar JA. Investigation of the relationship between psychosocial stress and temporomandibular disorder in adults by measuring salivary cortisol concentration: A case-control study. J Indian Prosthodont Soc 2015 Apr-Jun;15(2):148-52. 10. Nevalainen N, Lähdesmäki R, Mäki P, Ek E, Taanila A, Pesonen P, Sipilä K. Association of stress and depression with chronic facial pain: a case-control study based on the Northern Finland 1966 Birth Cohort. Cranio 2016 Jun;21:1-5 [Epub ahead of print]. 11. Laskin DM. Etiology of the Pain-Dysfunction Syndrome. JADA archive 1969 Jul;79(1):147–53. 12. Schwartz LL. A TMJ Pain-Dysfunction Syndrome. J Chronic Dis Mar 1957;3(3):284-93. 13. Schwartz LL. Disorders of the Temporomandibular Joint. Philadelphia; 1959.

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14. Manfredini D, Segù M, Arveda N, Lombardo L, Siciliani G, Rossi A, Guarda-Nardini L. Temporomandibular Joint Disorders in Patients With Different Facial Morphology. A Systematic Review of the Literature. J Oral Maxillofac Surg 2016 Jan;74(1):29-46. 15. De La Torre Canales G, Manfredini D, Grillo CM, Guarda-Nardini L, Machado Gonçalves L, Rizzatti Barbosa CM. Therapeutic effectiveness of a combined counseling plus stabilization appliance treatment for myofascial pain of the jaw muscles: A pilot study. Cranio 2016 Apr;7:1-7. 16. Vollaro S, Michelotti A, Cimino R, Farella M, Martina R. Epidemiologic study of patients with craniomandibular disorders. Report of data and clinical findings. [Article in Italian] Minerva Stomatol 2001 JanFeb;50(1-2):9-14. 17. Tuncer AB, Ergun N, Tuncer AH, Karahan S. Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: A randomized controlled trial. J Bodyw Mov Ther 2013 Jul;17(3):302-8. doi: 10.1016/ j.jbmt.2012.10.006. Epub Nov 16. 2012. 18. De Freitas RF, Ferreira MÂ, Barbosa GA, Calderon PS. Counselling and self-management therapies for temporomandibular disorders: a systematic review. J Oral Rehabil 2013 Nov;40(11):864-74. doi: 10.1111/joor.12098. 19. Michelotti A, Iodice G, Vollaro S, Steenks MH, Farella M. Evaluation of the short-term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles. JADA Middle East 2012 Mar-Apr;3(2). 20. Wirtz A, Zhang X. Amsterdam institute; Review: Which treatment is more effective in adults who suffer from TMD? Exercise therapy or splint therapy? Amsterdam Institute of Allied Health Education Hogeschool van Amsterdam Tafelbergweg 51 1105 BD Amsterdam. 21. Moraes AR, Sanches ML, Ribeiro EC, Guimarães AS. Therapeutic exercises for the control of temporomandibular disorders. Dental Press J Orthod 2013;18:134-9. 22. Roldán-Barraza C, Janko S, Villanueva J, Araya I, Lauer HC. A systematic review and meta-analysis of usual treatment versus psychosocial interventions in the treatment of myofascial temporomandibular disorder pain.

J Oral Facial Pain Headache; Summer 2014. 23. Martins WR, Blasczyk JC, Aparecida Furlan De Oliveira M, Lagôa Gonçalves KF, Bonini-Rocha AC, Dugailly PM, De Oliveira RJ. Efficacy of muscu loskeletal manual approach in the treatment of temporomandibular joint disorder: a systematic review with meta-analysis. Man Ther 2016 Feb;21:10-7. doi: 10.1016/j.math.2015.06.009. Epub Jun 25. 2015. 24. Glaros AG, Marszalek JM, Williams KB. Longitudinal Multilevel Modeling of Facial Pain, Muscle Tension, and Stress. J Dent Res 2016 Apr;95(4):416-22. 25. Rampello A, Saccucci M, Falisi G, Panti F, Polimeni A, Di Paolo C. A new aid in temporomandibular joint disorders’ therapy: the universal neuromuscular immediate relaxingappliance. J Biol Regul Homeost Agents 2013;27(4):1011-9. 26. Rampello A, Falisi G, Panti F, Di Paolo C. A new aid in TMD Therapy: the Universal Neuromuscular Immediate Relaxing appliance “UNIRA”. Oral Implantol (Rome) 2010 Jan;3 (1):20-32. Epub Nov 19. 2010. 27. Di Paolo C, Cascone P. Diagnosis and management of TMJ disorders: gnathological issues. Dental Cadmos 2016;84(6):352-63. 28. Ferrante A, Reed-Knight E, Bello A, Comentale P. Variazioni posturali conseguenti a cambiamento della posizione linguale ed a trattamento miofunzionale. Ortognatodonzia Italiana 2002;11(3). 29. Rollet D. The functional education with young children: the dysmorphis based on the functional problems. Arch Pediatr Jun;17(6):984. doi: 10.1016/S0929693X(10)70210-4. 2010 30. Weber P, Corrêa EC, Bolzan GDE P, Ferreira FDOS S, Soares JC, Silva AM. Chewing and swallowing in young women with temporomandibular disorder. Codas 2013;25(4):375-80. Epub Aug 16. 2013 31. Parada C, Chai Y. Mandible and Tongue Development. Curr Top Dev Biol 2015;115:3158. doi: 10.1016/bs.ctdb.2015.07.023. Epub Oct 1. 2015. 32. De Leeuw R. The Fifth Edition of The AAOP Guidelines for Assessment, Diagnosis and Management. Chicago: Quintessence; 2013. 33. Okeson JP. Il trattamento delle disfunzioni e dei disordini temporomandibolari. Bologna: Martina Edizioni; 2015.

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BUENOS AIRES 2018

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World Dental Congress

ITME M M O A PASSION FOR MANY, A C

L AL R FO

SIA ORTHODONTICS

Trial of “Leonardo” a new rapid palatal expansion screw “Leonardo”新快速颚扩张器的临床试验

apid palatal expansion has been a well-established procedure in orthodontic practice for many years now.

The first expansion was performed in 1860 by Emerson C. Angell, who, in San Francisco, expanded the maxillary arch of a fourteen and a half year old girl by a quarter of an inch in two weeks and noted the creation of an interincisal diastema, a sign that the expansion of the palatal suture had occurred. This expansion was published in Dental Cosmos San Francisco Medical Press in 1860. Different types of screws and activation protocols have been developed over the years. In the following project, we tested an innovative screw named Leonardo and made by SIA Orthodontic Manufacturer (Italy), the characteristics of which allow for safe and effective activation, the quantity of which can be easily controlled. External examination of the screw (Fig. 1a – 1b). • Compact in appearance (7.5 x 12 millimeters) with rounded edges and a very smooth structure. • The small screw cylinder has four teeth for preventing return. • Small casing to prevent the screw from unwinding. • Notches for controlling the amount of activation: each notch corresponds to 2 mm of activation. • Stopping pins which firmly block the [Expander] once opened. This device prevents complete separation of the screw, with its subsequent disconnection and accidental opening of the two parts of the Expander. Bench testing (Fig. 2a – 2b) The opening of the screw with the special key was tested. The direction of activation is clearly indicated with a very visible arrow printed on the body of the Expander. The screw is activated by turning the key as far as it will go. At the end of each activation a loud click sound is heard, which is made when it meets the braking ring,

DOCTOR牙医 Infodent International •1 2018

多年来，正畸实践中的快速腭扩张方法已经是个成熟的疗法. 第一个扩张器是在1860年由Emerson C. Angell研发的，在旧金山他将一名14岁半女孩的上颌弓在两周内扩张了四分之一英寸，并注意到一个切牙间隙的产生，这是已经发生了腭裂缝扩张的迹象. 这个扩张病例于1860年在旧金山牙科体系医学出版社出版. 多年来已经开发出不同类型的正畸螺旋和激活方案。在接下来的项目中，我们测试了由VA正畸器械制造商（意大利）生产的一种名为Leonardo的创新型扩张螺旋，其特征是可以安全有效的激活，可以很容易地控制激活数量和力度。螺丝的外部检查 (图 I a — I b). 外形紧凑 (7.5 x 12 毫米) 边缘圆滑，结构流畅平滑小螺丝圆柱体有四个卡齿以防止反回. 小外壳防止螺丝变松. 控制激活量的凹槽，每个凹槽对应2毫米的激活量. 扩张器一旦打开，就用制动钉来固定. 该装置可防止螺钉完全分离、可能性的连接断开或意外打开扩展器两个部分的情况。台架测试（图2a-2b）用专用钥匙打开螺丝进行了测试。激活的方向清晰可见，在扩展器的主体上印有非常明显的箭头。将钥匙尽可能旋转即可激活螺钉。在每次激活结束时，会听到一声巨大的咔哒声，当它与设备一起提供的制动环相遇时会发出咔哒声。[制动环]可防止在取下激活螺钉时螺钉松开。这可确保螺钉被正确激活并允许在下一次激活时简单地重新插入钥匙，使插入孔完全可用。控制扩张器的激活有多个凹槽。前两个凹槽压印在扩张器的主体上, 而其他的凹槽则在同心滑动导轨上。因此，在激活期间当螺钉打开后就可以看到这些凹槽。凹槽彼此间隔2毫米：每次激活将螺杆向前移动0.2毫米，相当于螺杆总周长的A圈。因此螺杆在整个扩张过程都特别稳定，这是双重同心滑动导轨的原因，也是这个扩张器的特点之一。扩张器会保持稳定的扩张，直到达到其最大开放极限，用专门的钥匙把激活解除为止，这要归功于牢固的制动装置。这意味着可以绝对安全地利用螺丝全长. 临床试验 (图 3a — 3b — 3c — 3d — 3e) 我们在一个5岁的左侧错咬患者身上测试了扩张器.

Figure 1a 图Ia

Figure 1b 图Ib

provided with the device. The [braking ring] prevents the screw from unwinding when the activation screw is removed. This ensures the screw has been activated correctly and allows for the simple reinsertion of the key at the next activation, leaving the insertion hole perfectly accessible. There are notches for controlling how much the Expander is activated. The first two notches are stamped onto the body of the Expander, whilst the others are stamped on the concentric sliding guides. The latter notches are therefore visible during activation whilst the screw is opening. The notches are positioned two millimeters

Figure 2a Screw activated at 4mm 图2a 扩张螺丝被激活在4mm上

Figure 2b Screw activated at 8mm - note the stopping device 图 2b 扩张螺丝被激活在 8mm上 – 此时可以看见制动装置

我们希望选择一个非常年轻而且颚很小的患者，主要原因是在这样的患者中激活螺钉时经常遇到困难。这些困难于可用来操作的密闭空间相关。因此，几乎每次在家长在激活螺丝后取下钥匙时，倾向于再次将螺丝带回原位，从而减少了激活螺丝的次数。导致临床医师很难评估实际的扩张量. 激活方式把扩张器两端连接到两根固定带上并把固定带粘合到第二乳磨牙上，来开始快速扩张程序，每天两次激活螺丝。 (图4a — 4b) 我们要求父母自己来完成这个激活螺丝的操作, DOCTOR牙医 Infodent International •1 2018

Scientific Update

apart from each other. Each activation moves the screw forward by 0.2 mm, corresponding to a ¼ turn of the total circumference of the screw. The screw is therefore particularly stable for the whole expansion process and this is thanks to the double concentric sliding guide, one of the peculiarities of this Expander. The Expander remains stable until its maximum opening limit is reached, at which point it blocks without disconnecting the screw itself, thanks to a solid stopping device. This means it is possible to take advantage of the full length of the screw in absolute safety. Clinical test (Fig. 3a – 3b – 3c – 3d – 3e)

Figure 3a

图 3a

DOCTOR牙医 Infodent International •1 2018

We asked the Parents to do this themselves, but remained contactable at all times for anything they needed or in case of emergency. The Patient was examined after one week: The Parents reported that they had noted the creation of an inter-incisive diastema on the fifth day, as is generally the case at this age, from our experience.

We tested the Expander on a five years old Patient with a left-sided cross-bite. We wanted to choose a very young Patient with a very small palate, given that it is mainly in these Patients that difficulties are most frequently encountered when activating the screws. These difficulties are linked to the confined spaces available for operating in. As a result, almost always, when the Parent removes the key after activating the screw, he/ she tend to bring the screw back again, reducing how much they have activated it by. As a result, it is difficult for the Clinician to evaluate the real amount of expansion.

We discharged the Patient after having personally activated the screw to check its stability and the efficacy of the stopping device.

但出现紧急情况或有任何疑问时可以随时联系医师。患者在一周后接受了检查：父母报告说他们第五天时已经注意到切牙间出现了间隙，根据我们的经验属于这个年龄的患者会普遍出现的情况. 我们亲自启动螺钉检查了其稳定性和停止装置的功效后，患者就离开了诊所. 在第14天，我们终止了激活，因为扩张已经达到了5.5毫米的预期（图5a-5b）。通过参考凹槽可确认正确的激活量。从照片中可以看到，第三个凹槽即将出现，表示六毫米，但仍然被滑动导轨稍微隐藏，而前两个凹槽在扩展器主体上清晰可见. 没有被激活的扩张器在口中保持了一个月，然后用四螺旋线替换（图6），其上面有一个用于舌头重新定位的标记.

事实上，我们认为一个月的时间来巩固中腭缝线是绰绰有余的，这是巩固骨折通常所需的时间.

四螺旋线继续在嘴里留了四个月，之后再也没有其他类型的束缚了。该方法是在激活结束后一个月时用四螺旋线替换快速扩张器。这是一项我们已经使用了二十多年的扩张方法，在一百多个病例中进行了测试，并证明了其高有效性且没有任何禁忌症.

Activation protocol The Expander was bonded to two bands and cemented onto the second deciduous molars and the rapid expansion protocol was implemented, which provides for the activation of the screw twice a day. (Fig. 4a – 4b)

On the fourteenth day we terminated activation as the pre-determined amount of expansion of 5.5 millimeters had been reached (fig. 5a – 5b). The correct amount of activation was confirmed by the reference notches. As you can see from the photo, the third notch is about to appear, indicating six millimeters, but is still slightly hidden by the sliding guide, whilst the two previous notches are clearly visible on the body of the expander.

用带有舌标记的四螺旋线替换扩张器具有以下优点：它减少了对腭的负担. 事实上，由于它的负担，快速扩张器通常迫使舌头进入向下、前倾位置，随后由舌侧功能障碍导致开合。除了保持快速扩张器所获得的宽度外，四螺旋线还可以通过激活来增加所需的扩张程度。由于四螺旋线所提供的舌头标记和适度阻碍（注意其建模在照片中），可以立即启动肌功能再训练鉴于扩张的稳定性和作为后续扩张保持器这点来看，四螺旋线的意义肯定是更重要的，因为它的运用可以保证正确的舌头重新定位，这对保证长期治疗的稳定性是不可或缺的条件。此外，由于它是一种弹性装置，四螺旋线不会将上颌的两侧紧固在一起，从而允许颚适应咬合力，这对于颅骨结构来说当然

Figure 3b 图 3b

Figure 3d 图 3d

Figure 3c 图 3c

Figure 3e 图 3e

The expander remained blocked in the mouth for one month and was then replaced with a Quad helix (Fig. 6), which includes a marker for lingual repositioning. The Quad helix remained in the mouth for another four months, after which no other type of restraint was required. This protocol provides for the replacement of the rapid expander with a Quad helix one month after the end of activation. It is a protocol we have been using for more than twenty years and has been tested on more than a hundred cases, proving to be particularly effective and free of any contraindications. In fact in our opinion, one month is more than enough for the consolidation of the midpalatal suture, given that this is the average time required for the consolidation of fractures. The replacement of the expander with a Quad helix provided with a lingual marker offers the following advantages: it reduces the encumbrance to the palate. In fact, often owing to its encumbrance, the rapid expander forces the tongue into a low, forward position, with a subsequent open bite from lingual dysfunction. As well as maintaining the breadth obtained

是一种有利的条件，这也适用于整骨疗法. 结论通过台架和临床测试，Leonardo Expander 扩张器已被证明是个非常精确的，组装精细、牢固且没有任何弯曲的器械。患者的父母通过制动装置以特别方便和精确的方式在家中激活了螺钉。事实上，这个制动功能使他们能够在每次激活时听到“咔嗒”声，最重要的是，在拔出钥匙的瞬间不会将螺丝拧回去而解除刚刚完成的激活. 在传统扩张器的激活过程中，这种情况却经常发生。整个过程没有任何问题，对于受试的小女孩而言，最大程度的舒适度也得益于Leonardo扩张器紧凑的尺寸，他可以有效且安全地使用在非常年轻的患者上. Leonardo扩张器的两臂和螺丝被证明是精确且没有任何弯曲。打印在螺丝上的参考凹槽使临床医生能够检查激活是否被正确执行。所有这些都为患者和治疗师带来了更大的安全感，并被确认它具有一个高指标的专业水平.

DOCTOR牙医 Infodent International •1 2018

Scientific Update

Figure 4a / 4b The expander was bonded to two bands and cemented onto the second deciduous molars 图 4a / 4b 扩张器连接到两根弓丝上，再粘固到乳磨牙上

with the rapid expander, the Quad helix can also increase it, by activating it by the required amount. Thanks to the lingual marker together with the modest encumbrance to the palate offered by the Quad helix (note its modeling in the photo), myofunctional re-education can be initiated immediately. This is definitely more important, in terms of the stability of the expansion and the prolonged use of the expander as a maintenance guard, given that the same prevents correct lingual repositioning, an indispensable condition for the stability of our treatment in the long term. In addition, since it is an elastic device, the Quad helix does not block the two hemimaxillae together, thus allowing the jaw to adapt to the occlusal forces, certainly a useful condition for the cranial architecture, which is also welcomed for osteopathic treatment.

DOCTOR牙医 Infodent International •1 2018

Conclusions In both bench and clinical testing, the Leonardo Expander has proven to be extremely precise, assembled with care, solid and without any flexion. The Parents of the Patient activated the screw at home with particular ease and precision, thanks to the braking device. In fact this feature enabled them to hear a “click” upon each activation, and above all to not turn the screw back when removing the key, thus undoing the activation they had just completed. This is such a frequent occurrence during the activation of traditional Expanders. The whole process went ahead without any problems and with the maximum level of comfort for the young girl, thanks also to the compact size of the Leonardo Expander, permitting effective and safe use in very young Patients. The arm and the screw of the Leonardo Expander were proven to be precise and without any flexion. The reference notches printed on the screw enabled the Clinician to check that the activation had been performed correctly. All this resulted in a greater sense of security for both the Patient and the Therapist, as well as being appreciated as an indicator of a high level of professionalism.

Figure 5a / 5b On the fourteenth day we terminated activation as the pre-determined expansion level of 5.5 millimeters had been reached 图 5a / 5b 在第5天的时候我们解除了激活状态，因为得到了一个5、5毫米的预期扩张

References 参考文献 • Font Jaume JM. Treatment in the deciduous dentition: four clinical cases. Prog Orthod 2006; 7(2):202-19. • Baccetti T, Franchi L, Mc Namara JA jr, Tollaro I. Early dentofacial features in Class II malocclusion: A longitudinal study from the deciduous through the mixed dentition. Am J Orthod Dentofac Orthop 1997 May;111(5): 502-9. • Mc Namara JA. Maxillary trasverse deficency. Am J Orthod Dentofac Orthop 2000; 117(5): 567-70. • Da Silva Filho OG, Boas MC, Capelozza Filho L. Rapid maxillary expansion in the primary and mixed dentitions: a cephalometric evalutation. Am J Orthod 1991 Aug; 100(2):171-81. • Gandolfini M, Molinari L, Mandelli G, Di Blasio A. Uso precoce del Quad-helix in ortodonzia intercettiva. Mondo ortodontico 2003;4:269-275.

Figure 6 The expander remained blocked in the mouth for one month and was then replaced with a Quad helix

图 6 扩张器在口中保持了一个月，之后用四螺旋线代替

• Cozza P, Pachì F, Mucedero M, Macchiarlo E. La terapia precoce del deficit di tipo trasversale. Mondo ortodontico 2003;4:289-300. • C. Alicino, I. Paini, M. Folli, G. Farronato. Asimmetria mandibolare in soggetti in fase di crescita con inversione monolaterale. Ortognatodonzia Italiana Vol.11,4-2002. • Donald J. Timms. Rapida espansione del palato. Scienza e tecnica dentistica edizioni internazionali Milano 1984. • G. Alesandri Bonetti, I. Marini, U. Capurso. Il disgiuntore rapido del palato. Edizioni Martina Bologna 1999.

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Scientific Update

Authors Dr. Gabriele Galassini Surgeon, Orthodontist Contract Professor at Scuola di Specialità in Ortognatodonzia, University of Trieste from 2005 to 2015 Lecturer at Osteopathic College in Trieste Dr. Gabriele Galassini Via Crociera 10 - 34074 Monfalcone (Go) segreteria@studiogalassini.it www.studiogalassini.it

作者 Gabriele Galassini医师牙外科正畸医生 2005年至2015年意大利Trieste 大学正畸专科学校签约教授 Trieste正骨学院讲师联系地址： Gabriele Galassini Via Crociera I 0 - 34074 Monfalcone (Go) segreteria@studiogalassini.it www.studiogalassini.it

Dr. Elena Marcuzzi Surgeon, Orthodontist Specialist

Elena Marcuzzi医师外科医生，正畸专家

Dr. Paulina Natasa Orthodontist

PaulinaNatasa医师，正畸专家

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