➕

Dental Clinics of North America

北美牙科诊所
Volume 67, Issue 2, April 2023, Pages 309-321

第67卷 第2期 ， 2023年4月， 页码 309-321

Temporomandibular Disorders: Implications in Restorative Dentistry and

Orthodontics
颞下颌关节疾病：对修复牙科和正畸学的影响
Davis C. Thomas BDS, DDS, MSD, MSc Med, MSc a b , David Briss DMD c, Paul Emile Rossouw MChD, PhD d, Shankar Iyer DDS, MDS e f g

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https://doi.org/10.1016/j.cden.2022.10.003
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Keywords
Temporomandibular disorders; Full-mouth rehabilitations; Orthodontic treatment; Prosthodontic treatment; Occlusion; Restorative dentistry;
Malocclusion;

颞下颌关节疾病全口康复正畸治疗口腔修复治疗咬合修复牙科咬合不正

Key points

• The health of the temporomandibular joint (TMJ) and associated structures are paramount for optimal results from orthodontic and
prosthodontic/restorative treatment.

颞下颌关节 （TMJ） 和相关结构的健康对于正畸和修复/修复治疗的最佳结果至关重要。

• The clinician contemplating orthodontic and restorative treatment should be prudent in checking for any preexisting
temporomandibular disorder (TMD) issues before initiation of treatment. It is essential for the clinician to have a clear understanding
of screening for health of the TMJ and associated structures. This would facilitate prompt referral to the appropriate specialist before
the start of orthodontic/restorative treatment.

考虑正畸和修复治疗的临床医生在开始治疗之前应谨慎检查任何先前存在的颞下颌关节紊乱 （TMD） 问题。临床医生必须清楚地了解颞

下颌关节和相关结构的健康筛查。这将有助于在正畸/修复治疗开始之前及时转诊给适当的专家。

• There is no succinct evidence of orthodontic or prosthodontic treatment (or lack thereof) causing TMD.

没有明确的证据表明正畸或修复治疗（或缺乏正畸治疗）会导致颞下颌关节紊乱。

• There is an immense need for well-controlled, double-blinded prospective studies exploring any possible association between
orthodontic/prosthodontic treatment and TMD.

非常需要控制良好的双盲前瞻性研究，以探索正畸/修复治疗与颞下默氏颌关节紊差之间的任何可能关联。

Introduction
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 Dentists traditionally have always looked for guidance as to the principles of orthodontic treatment and prosthodontic reconstruction, specifically ➕
with a view to avoid “causing” temporomandibular disorders (TMDs). Various philosophies have been proposed, many of them apparently based on
hypotheses and personal observations. Well-controlled, prospective double-blinded studies regarding the causality (or lack thereof) of TMDs
secondary to changes in the bite/occlusion as a result of reconstructive dental management are lacking. For example, in the early pioneer
orthodontic literature, dental occlusion was classified into Class I, II, and III based on certain factors that angle observed in the population at which
he was looking. However, during the subsequent decades, this observation that he made probably was misinterpreted and TMDs were apparently
erroneously attributed to malocclusion. Similarly, in prosthodontics and reconstructive dentistry, certain changes in the patient’s occlusion, by
virtue of dental treatment, was thought of as causally related to TMDs. The relation between occlusion and TMDs is explored in a separate chapter in
this special edition. In this article, the authors enumerate the literature on the current thought process in orthodontic management and
prosthodontics as related to TMDs.

传统上，牙医一直在寻求有关正畸治疗和修复重建原则的指导，特别是为了避免“引起”颞下颌关节疾病 （TMD）。人们提出了各种哲学，其中许多显
然是基于假设和个人观察。缺乏关于继发于牙齿重建管理导致的咬合/咬合变化的 TMD 因果关系（或缺乏因果关系）的良好对照、前瞻性双盲研究。
例如，在早期的先驱正畸文献中，牙齿咬合被分为I类、II类和III类，这是基于在他所观察的人群中观察到的某些角度因素。然而，在随后的几十年
里，他的这一观察结果可能被误解了，TMDs显然被错误地归因于咬合不正。同样，在口腔修复学和重建牙科中，由于牙科治疗，患者咬合的某些变
化被认为与颞下默病有因果关系。闭塞和TMD之间的关系将在本特刊的单独章节中探讨。在本文中，作者列举了当前正畸管理和修复学中与TMD相
关的思维过程的文献。

Temporomandibular Disorder and Orthodontics

颞下颌关节紊乱和正畸
According to the overwhelming orthodontic and TMD literature, occlusal disharmonies and most maxillomandibular relationships have no causality
to the development of TMD symptoms.1, 2, 3, 4, 5 The coincidence between the age groups, namely adolescents, of orthodontic treatment and TMD
may become challenging for the orthodontist, although it may be difficult to figure out which of the two entities came first. It is suggested that it
would be prudent to postpone orthodontic treatment and address the TMD issue. Then, orthodontic treatment can be resumed.6 Various protocols
based on hypotheses including centric relation (CR) position, “deprogramming,” neuromuscular dentistry, jaw tracking, electromyographic
recording, and preventive occlusal equilibrations have been proposed by various professionals and organizations in an attempt to optimize
dental/orthodontic treatment. However, most of the published scientific literature contradicts the use of these philosophies and criticizes the
invasive and irreversible nature of many of these procedures. Further, they are considered to be highly biased and arbitrary.6, 7, 8, 9, 10, 11

根据压倒性的正畸和 TMD 文献，咬合不协调和大多数上颌下颌关系与 TMD 症状的发展没有因果关系。1 ， 2 ， 3 ， 4 ， 5 正畸治疗和 TMD 的年龄

组（即青少年）之间的重合可能会对正畸医生造成挑战，尽管可能很难弄清楚这两个实体中哪一个先出现。建议谨慎的做法是推迟正畸治疗并解决颞
下颌关节病问题。然后，可以恢复正畸治疗。 6 各种专业人士和组织提出了基于假设的各种方案，包括中心关系 （CR） 位置、“去编程”、神经肌肉
牙科、颌骨跟踪、肌电图记录和预防性咬合平衡，以试图优化牙科/正畸治疗。然而，大多数已发表的科学文献都与这些哲学的使用相矛盾，并批评了
其中许多程序的侵入性和不可逆性。此外，它们被认为是高度偏见和武断的。6 , 7 , 8 , 9 , 10 , 11

Similar to this myth is the one that said that the so-called Class II malocclusion is related to TMD.12, 13, 14 There was no such relationship found
between Class II malocclusion and TMD in multiple studies/literature published.2,15, 16, 17 Further, there was no association found between
horizontal/vertical dental relationship of the anterior teeth and temporomandibular joint (TMJ) disc derangements.18, 19, 20 The concept of
occlusion as an etiology for overloading of the masticatory system has been popular among various dental groups, including some orthodontists.21 It
must be pointed out, however, that considering the continuous dynamic change that occurs during several months of orthodontic treatment, there is
hardly any evidence for development of TMDs. In the context of sleep-related bruxism (SRB), the status of the current literature is relatively clear
that orthodontic treatment affecting in SRB in any way, is yet to be elucidated. Currently, the literature seems to indicate that orthodontic treatment
has no significant effect on SRB.22,23 As alluded to earlier, orthodontic treatment aimed at “correcting a patient’s occlusion” into a “proper” CR
position, is currently not believed to be of any meaningful significance.24,25 Similarly, the philosophy of “failure to achieve functional occlusion/CR,”
forming an etiology for TMD is also thought to be of no scientific evidence.26, 27, 28, 29 Recent multiple studies and publications have shown that
neither does dental occlusion have any causal role in the etiopathophysiology of TMD, nor the correction of the same by orthodontics can
meaningfully treat or prevent TMD.30, 31, 32

与这个神话类似的是，所谓的II类咬合不正与TMD有关。12,13,14在发表的多项研究/文献中，没有发现II类咬合不正与TMD之间存在这种关系。 2 , 15
， 16 ， 17 此外，前牙的水平/垂直牙齿关系与颞下颌关节 （TMJ） 椎间盘紊乱之间没有关联。18 ， 19 ， 20 咬合作为咀嚼系统超负荷的病因的概念
在各种牙科团体中很流行，包括一些正畸医生。 21 然而，必须指出的是，考虑到在几个月的正畸治疗期间发生的持续动态变化，几乎没有任何证据表
明 TMD 的发展。在睡眠相关磨牙症 （SRB） 的背景下，目前文献的状况相对清楚，正畸治疗以任何方式影响 SRB 尚未阐明。目前，文献似乎表明
正畸治疗对SRB没有显着影响。 22 , 23 如前所述，旨在“矫正患者的闭塞”到“适当”CR 位置的正畸治疗目前被认为没有任何有意义的意义。 24 , 25 同
样，“未能实现功能性闭塞/CR”的哲学也被认为是颞下颌关节紊乱的病因，也被认为没有科学证据。26 ， 27 ， 28 ， 29 最近的多项研究和出版物表
明，牙齿咬合在颞下颌关节紊乱的病因生理学中没有任何因果作用，正畸矫正也不能有意义地治疗或预防颞下颌关节紊乱。30 , 31 , 32

It must be noted that a few studies, some of them recent, have stated a “higher prevalence” of TMD with orthodontically treated patients, however,
explicitly stating that a cause-effect relationship between orthodontic treatment and TMD could not be established.33 A few reported orthodontic
parameters that were apparently linked with TMD included, but not limited to, a higher Frankfort-mandibular plane angle, increased anterior facial
height, increased gonial angle, and Class III malocclusion34,35 Other general parameters proposed to have an association with TMD included
untreated crossbite, dental crowding, increased overjet, condylar asymmetry, long facial height, and a skeletal pattern that is hyperdivergent.3,36,37
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▼
Some investigators have proposed that establishment of a flat occlusal plane is a significant end-result parameter when considering orthodontic
 treatment, in an attempt to preserve the health and structure of TMJ and associated structures.38 ➕
必须指出的是，一些研究（其中一些是最近的研究）指出，接受正畸治疗的患者的 TMD 患病率“更高”，然而，明确指出正畸治疗和 TMD 之间的因果
关系无法确定。 33 一些报告的明显与颞下颌关节紊乱相关的正畸参数包括但不限于更高的法兰克福-下颌平面角、更高的面部前高度、增加的性角和
III类错颌畸形 34 , 35 其他被认为与颞下颌关节紊乱相关的一般参数包括未经治疗的错合、牙齿拥挤、过度喷射增加、髁突不对称、面部高度长、 以及
超发散的骨骼模式。 3 , 36 , 37 一些研究人员提出，在考虑正畸治疗时，建立平坦的咬合平面是一个重要的最终结果参数，以试图保持颞下颌关节和相
关结构的健康和结构。 38

The proposal/hypothesis that orthodontic treatment could prevent or alleviate TMD is largely based on the philosophy that malposition of the jaws
and teeth are causally related to TMD. Consequently, some of the orthodontic approaches have proposed that when the concepts of “functional
occlusion” are “violated,” it becomes a trigger for development of TMD.39,40 The older concept/hypothesis of TMD being caused by specific
orthodontic modalities and the retraction of maxillary incisor teeth (“causing condylar distalization and anterior disc displacement”) has been
negated substantially by the more recent orthodontic/TMD literature.3,22,40, 41, 42, 43 In addition, the previous concepts of TMD causation by the
use of “chin cup therapy” for Class III malocclusion correction to be causing TMD has also been disproven in imaging-based studies.44 It must be
noted that recent literature has overwhelmingly debunked the older concepts of the so-called principles of gnathology that proposed occlusion and
malocclusion as linked to TMD.3,22,40, 41, 42, 43 Further, robust evidence in the literature refutes any association of corrective orthodontic
treatment to an increase/decrease in the risk of an individual developing TMD due to any orthodontic treatment.40,45

正畸治疗可以预防或缓解颞下颌关节紊乱的提议/假设主要基于颌骨和牙齿错位与颞下颌关节紊乱有因果关系的理念。因此，一些正畸方法提出，当
“功能性闭塞”的概念被“违反”时，它就会成为颞下颌关节紊乱发展的触发因素。 39 , 40 TMD 是由特定的正畸方式和上颌门牙回缩引起的旧概念/假设
（“导致髁突远端化和椎间盘前移位”）已被最近的正畸/颞下颌关节紊乱文献大大否定。 3 , 22 , 40 ， 41 ， 42 ， 43 此外，先前使用“下巴杯疗法”进行
III 类咬合不正矫正导致 TMD 因果关系的概念在基于影像学的研究中也被推翻。 44 必须指出的是，最近的文献压倒性地揭穿了所谓的颌骨学原理的
旧概念，这些概念提出与颞下颌关节紊乱相关的闭塞和错颌畸形。 3 , 22 , 40 ， 41 ， 42 ， 43 此外，文献中的有力证据驳斥了矫正正畸治疗与因任何
正畸治疗而导致个体患颞下颌关节紊乱的风险增加/减少的任何关联。 40 , 45

Another interesting proposed concept is that stability of the condyles and the occlusion “reduces the risk of TMD.” The clinician should assess and
manage this aspect before orthodontic intervention.46 Meanwhile, other published papers have described the concept of “adaptation” to occlusal
changes in orthodontic treatment without any measurable TMD.47 Observational studies and smaller cohort studies have reported milder transient
TMD symptoms occurring with orthodontic treatment.39 There have been other hypotheses and proposals linking what is termed as transverse
malocclusions to “uneven loading” of the TMJ.39 TMD symptoms have also been reported to be associated with orthognathic surgeries.48 Transient
masticatory muscle pain was also reported more often in females undergoing orthodontic treatments compared with males.1 Most of these studies
and published papers conclude universally by saying that further, well-controlled, prospective studies are necessary for elucidating the link between
any of these factors with TMD.

另一个有趣的概念是，髁突和闭塞的稳定性“降低了TMD的风险”。临床医生应在正畸干预前评估和管理这方面。 46 同时，其他已发表的论文描述了在
正畸治疗中“适应”咬合变化的概念，而没有任何可测量的 TMD。 47 观察性研究和较小的队列研究报告了正畸治疗中出现的较轻的短暂性颞下颌关节
紊乱症状。 39 还有其他假设和建议将所谓的横向错颌畸形与颞下颌关节的“不均匀负荷”联系起来。 39 据报道，颞下颌关节紊乱症状也与正颌手术有
关。 48 与男性相比，接受正畸治疗的女性也更常发生短暂性咀嚼肌疼痛。 1 这些研究和发表的论文中的大多数都普遍认为，进一步的、控制良好的前
瞻性研究对于阐明这些因素与TMD之间的联系是必要的。

Association of Temporomandibular Disorder and Prosthodontics

颞下颌关节紊乱与口腔修复学的关联
One of the first references in the published literature is from Costen, where he hypothesized that when that a loss of vertical dimension caused by
tooth loss and a subsequent collapsed facial profile, it leads to tinnitus.49 The profession was awakened by this newfound etiology for ear, nose, and
throat abnormalities. This was further explored by Hirschfeld, who attributed “over 80 changes” that can occur from the loss of the first molar, TMJ
changes being one of them.50 We explore the dogmas that have been prevalent in prosthetic dentistry and will attempt to clarify some of these
controversies based on scientific evidence. The following are some of the concepts that will be discussed to question the practices that have steered
practitioners into various philosophies that may have locked them into a particular apparently inflexible approach.

在已发表的文献中，最早的参考文献之一来自Costen，他假设，当牙齿脱落导致垂直尺寸的损失和随后的面部轮廓塌陷时，它会导致耳鸣。 49 这个新
发现的耳鼻喉异常病因唤醒了这个行业。Hirschfeld 对此进行了进一步探索，他将第一颗臼齿的丧失可能导致“80 多种变化”，颞下颌关节变化就是其
中之一。 50 我们探讨了修复牙科中普遍存在的教条，并将尝试根据科学证据澄清其中一些争议。以下是将要讨论的一些概念，以质疑那些将从业者引
导到各种哲学中的做法，这些哲学可能将他们锁定在一种特定的、显然不灵活的方法中。

1. Do occlusal interferences and “high points” cause muscle hyperactivity and precipitate TMD?

咬合干扰和“高点”是否会导致肌肉过度活跃并诱发颞下颌关节紊乱？

2. Can altering a patient’s vertical dimension precipitate TMD symptoms?

改变患者的垂直尺寸会诱发TMD症状吗？

3. Can gnathological principles protect a patient from developing TMD (Is it necessary to follow principles of “gnathology” to obtain correct occlusal
schemes)? ⇡
▼ 颌骨学原理能否保护患者免于患上颞下颌病（是否有必要遵循“颌骨学”原则以获得正确的咬合方案）？
 4. Should every prosthodontic rehabilitation end up in a Class I relationship? ➕
每个修复康复都应该以 I 级关系结束吗？

5. Are occlusal reconstructions a way to mitigate the symptoms of TMD?

咬合重建是减轻TMD症状的一种方式吗？

Do occlusal interferences and “high points” cause muscle hyperactivity and precipitate temporomandibular disorder?
咬合干扰和“高点”是否会导致肌肉过度活跃并诱发颞下颌关节紊乱？
A flawed understanding of etiology has kept in the subsequent treatment rendered. In this regard, it must be borne in mind that occlusal
interferences have not been considered as one of the etiologic factors for TMD for a long time in literature. Although some investigators have
attempted to elicit the role of occlusion in TMD via some electromyogram (EMG) studies,51 numerous contributors have negated that viewpoint.
Weinberg (1979) in a three-part series article attributed the etiology of TMD symptoms to multiple causes, including neurologic, vascular, the TMJ
itself, muscular, and hysterical conversion (“psychogenic?”). Clearly, “bad occlusion” or occlusal interferences were not accounted for as a causative
factor for TMD.52, 53, 54

在随后的治疗中，对病因学的理解一直存在缺陷。在这方面，必须记住，长期以来，咬合干扰在文献中一直没有被认为是TMD的病因之一。尽管一些
研究人员试图通过一些肌电图（EMG）研究来引出闭塞在TMD中的作用， 51 但许多贡献者否定了这一观点。Weinberg（1979）在一篇由三部分组成
的系列文章中将TMD症状的病因归因于多种原因，包括神经、血管、颞下颌关节本身、肌肉和歇斯底里转换（“心因性？显然，“不良咬合”或咬合干
扰并未被解释为TMD的致病因素。52 , 53 , 54

Deliberate introduction of interferences in a group of patients failed to show an obligatory relationship with TMD. These clinical results have been
backed by EMG findings as well.55, 56, 57

在一组患者中故意引入干扰未能显示出与TMD的强制性关系。这些临床结果也得到了肌电图结果的支持。55 , 56 , 57

Contrary reports by investigators have also been documented in the literature.58 However, with mounting evidence in the literature failing to find
that occlusal disharmony causes any long-term deleterious effects on TMJ, it can be concluded that indiscriminate adjustment of occlusion can
probably do greater irreversible harm than good in the long run, and practitioners should be cautious to implement any irreversible changes without
a sound scientific backing.32,59, 60, 61, 62 In fact, occlusal changes secondary to changes in the joint is also a possibility and may manifest, either as
a momentary event or as a prolonged condition.31,32,63, 64, 65, 66

文献中也记录了调查人员的相反报告。 58 然而，由于文献中越来越多的证据未能发现咬合不协调对颞下颌关节造成任何长期有害影响，因此可以得出
结论，从长远来看，不分青红皂白地调整咬合可能弊大于利，从业者在没有可靠科学支持的情况下应谨慎实施任何不可逆转的改变。 32 , 59 ， 60 ，
61 ， 62 事实上，继发于关节变化的咬合变化也是一种可能性，并且可能表现为瞬间事件或长期情况。 31 , 32 , 63 , 64 , 65 , 66

Can altering a patient’s vertical dimension precipitate temporomandibular disorder symptoms?

改变患者的垂直尺寸会诱发颞下颌关节紊乱症状吗？
A relatively recent literature review concluded that there is very little or weak correlation between altering the occlusal vertical dimension (OVD)
and initiation of TMD symptoms.67 Further, this article also alludes to the fact that there is a lack of well-controlled studies in this regard.67 Multiple
studies that looked at the effect of increasing OVD failed to show any correlation or causality with TMD symptoms.68, 69, 70, 71, 72 Similarly, other
studies including prospective have also shown that reduction in the vertical dimension, whether brought about by attrition, erosion, or loss of teeth,
is not correlated or causally related to long-lasting TMD signs and symptoms.67,73 Tooth wear/loss or changes in the existing prostheses over time
are the clinical conditions that may demand increasing the patient’s existing OVD.74 It is well documented in the scientific literature that making
changes in OVD is a safe and predictable procedure, without detrimental consequences, as long as physiologic tolerance is not challenged.75,76 A
relatively recent review of the literature concluded that there is very little or weak correlation between altering vertical dimension and TMD
symptoms.67 These investigators opine that the basis of the theory that increasing OVD causing TMD is anecdotal or just solitary case reports and
not evidence-based. In fact, they suggest that the moderate changes in stomatognathic system tend toward adaptation.67 It is noteworthy that
unfavorable consequences that have been documented in a few studies due to increase in OVD are transient and self-limiting.77,78 Therefore, it has
been suggested that irreversible alteration in the occlusion should be preceded by the use of a reversible occlusal appliance to give the patient time to
adapt to the change in vertical dimension. Most of the data from studies support the fact that the stomatognathic system has the ability to adapt
quickly to moderate changes in OVD of less than 5 mm, with orthopedic stability being maintained.67 It must be emphasized that in the pretext of
preventing TMD, occlusal therapy and full-mouth rehabilitation should not be promoted for conditions such as bruxism, erosion, and parafunctional
habits.79

最近的一项文献综述得出结论，改变咬合垂直维度 （OVD） 与 TMD 症状的开始之间存在非常小或微弱的相关性。 67 此外，本文还暗示了在这方面

缺乏良好对照的研究这一事实。 67 多项研究着眼于增加 OVD 的影响，但未能显示与 TMD 症状有任何相关性或因果关系。68,69,70,71,72同样，包括
前瞻性在内的其他研究也表明，垂直尺寸的减少，无论是由磨损、侵蚀还是牙齿脱落引起的，都与长期的颞下颌关节疾病体征和症状无关或因果关
系。 67 , 73 牙齿磨损/脱落或现有假体随时间的变化是可能需要增加患者现有 OVD 的临床状况。 74 科学文献中有充分的记载，只要生理耐受性不受挑
战，改变 OVD 是一种安全且可预测的程序，不会产生有害后果。 75 , 76 最近一项文献综述得出结论，改变垂直维度与 TMD 症状之间的相关性很小或
很弱。 67 这些研究人员认为，增加 OVD 导致 TMD 的理论基础是轶事或只是孤立的病例报告，而不是基于证据的。事实上，他们认为口腔颌系统的 ⇡
▼ 适度变化趋向于适应。 67 值得注意的是，在一些研究中记录的由于 OVD 增加而记录的不利后果是短暂的和自限性的。 77 , 78 因此，有人建议，在不
 可逆的咬合改变之前，应使用可逆咬合矫治器，让患者有时间适应垂直尺寸的变化。大多数研究数据都支持这样一个事实，即口腔颌系统能够快速适 ➕
应小于 5 mm 的 OVD 的中度变化，同时保持骨科稳定性。 67 必须强调的是，不应以预防颞下颌关节紊乱为借口，针对磨牙症、糜烂和功能异常习惯
等疾病推广咬合治疗和全口康复。 79

Can gnathological principles protect a patient from developing temporomandibular disorder (is it necessary to follow
principles of “gnathology” to obtain correct occlusal schemes)?
颌骨学原理能否保护患者免于发生颞下颌关节紊乱（是否有必要遵循“颌骨学”原则以获得正确的咬合方案）？
Occlusion in prosthodontics became mechanically-based since the birth of gnathology in the early 1920s.80, 81, 82, 83 The articulators evolved and
got more sophisticated and there were developers trying to mimic the mandibular movements.84, 85, 86, 87 The carvings of the occlusion were
mechanically and geometrically determined, defined by angles and arcs created by pantographs and jaw tracking devices.88 Later, however, it was
concluded that these rigid gnathological standards were not based on scientific grounds and the concept of “ideal occlusion” was no more than a
result of individual observations and should not be considered as a synonym for physiologic occlusion.89, 90, 91, 92, 93

自1920年代初颌骨学诞生以来，口腔修复学中的咬合就变得以机械为基础。 80,81,82,83 咬合器不断发展并变得更加复杂，并且有开发人员试图模仿

下颌运动。84,85,86,87 闭合的雕刻是机械和几何确定的，由受电弓和下颌跟踪装置产生的角度和弧线定义。 88 然而，后来得出的结论是，这些严格
的颌骨学标准并非基于科学依据，“理想闭塞”的概念只不过是个人观察的结果，不应被视为生理闭塞的同义词。89 , 90 , 91 , 92 , 93

In fact, Mohl negated that attempts to develop “ideal occlusion” by mechanics following rigid occlusal schemes in otherwise well-functioning
patients were not always tolerated by the patient, despite the adaptive potential of TMJ.94 The concept of “point centric” with no freedom in lateral
or anterior to the point was strongly negated, and concept of functionally optimal occlusion was appreciated.36,42,43 Celenza’s treatise on CR as a
treatment position, and not a position of constancy was met with much skepticism.95 By the 1990s, the use of sophisticated fully adjustable
articulators was slowly diminishing in specialty practice, and the gnathological concepts gave way to simpler practical facial analyzers and average
settings on semi-adjustable articulators.96

事实上，尽管颞下颌关节具有适应性潜力，但Mohl否定了在其他方面功能良好的患者中遵循刚性咬合方案的力学发展“理想咬合”的尝试并不总是被患
者耐受。 94 强烈否定了在点的外侧或前方没有自由度的“点中心”的概念，并赞赏功能最佳闭塞的概念。 36 , 42 , 43 Celenza 关于 CR 作为治疗立场而不
是恒定立场的论文遭到了很多怀疑。 95 到 1990 年代，复杂的完全可调咬合器在专业实践中的使用正在慢慢减少，颌骨学概念让位于更简单的实用面
部分析仪和半可调咬合器的平均设置。 96

Despite ample evidence that occlusion plays a limited role in influencing TMD, neuromuscular dentistry and other bio-functional concepts continue
to be fostered by certain groups of dentists. There are no randomized control trials to verify if any of these have worked consistently and remains as
anecdotal evidence.79

尽管有充分的证据表明闭塞在影响颞下颌关节紊乱方面的作用有限，但神经肌肉牙科和其他生物功能概念继续由某些牙医群体培养。没有随机对照试
验来验证其中任何一项是否始终如一地起作用，并且仍然是轶事证据。 79

Should every prosthodontic rehabilitation end up in a Class I relationship?

每个修复康复都应该以 I 级关系结束吗？
Seligman and Pullinger evaluated conditions such as deep bite, overjet, crossbite, and open bites and found no correlation between any of the
occlusal interrelationships and TMD.97

Seligman 和 Pullinger 评估了深咬合、过度咬合、交叉咬合和开放咬合等条件，发现任何咬合相互关系与 TMD 之间没有相关性。 97

In restorative dentistry, a deliberate attempt to create anterior guidance has been the mainstay with natural teeth and implants. It has been
traditionally proposed that to achieve a mutually protected occlusal scheme, cases have to be restored in a Class I relationship. The fallacy of a
normal Class I relationship as being ideal can be questioned by the racial distribution of the occlusal schemes around the world. If Class I occlusion
is the ideal tooth relationship, we would have seen an explosion of TMD cases in populations where Class III occlusion is a normal finding. In fact, it
has been demonstrated by numerous investigators that the prevalence of malocclusions is the same in populations with TMD and in the general
population and there is no association between risk of developing TMD and occlusal characteristics.3,5,26,31,32,98, 99, 100, 101, 102, 103, 104, 105, 106

在修复牙科中，有意识地尝试创建前部引导一直是天然牙齿和种植体的支柱。传统上有人提出，为了实现相互保护的咬合方案，必须在 I 类关系中恢
复病例。正常的 I 类关系是理想的谬误可能会受到世界各地咬合方案的种族分布的质疑。如果 I 类咬合是理想的牙齿关系，我们会在 III 类咬合是正常
发现的人群中看到 TMD 病例的爆炸式增长。事实上，许多研究人员已经证明，颞下颌畸形的患病率在颞下颌下� 3 , 5 , 26 , 31 , 32 , 98 , 99 , 100 , 101 ,
102 , 103 , 104 , 105 , 106

Are occlusal reconstructions a way to mitigate the symptoms of temporomandibular disorder?

咬合重建是缓解颞下颌关节紊乱症状的一种方式吗？
There are several conditions such as bruxism, erosion, and parafunctional habits that may cause tooth wear and other types of tooth loss. Full-
mouth rehabilitation and occlusal therapy should not be promoted as a means of preventing TMD, as there is no evidence of the benefits or necessity
for this type of seemingly aggressive management.
⇡
▼
 磨牙症、糜烂和功能异常习惯等多种情况可能会导致牙齿磨损和其他类型的牙齿脱落。全口康复和咬合治疗不应作为预防颞下默氏颞紊乱的一种手 ➕
段，因为没有证据表明这种看似积极的治疗有益或必要。

Centric Relation
There is no real evidence of condylar positioning in the glenoid fossa having any causality for initiation of TMD.40,107, 108, 109 Further, none of the
traditionally described ways of registering a so-called “stable centric relation position” has been proven to be foolproof and evidence-based. As a
matter of fact, imaging-based studies have shown that all of the procedures looked at, are in effect “blind procedures” and unable to independently
repeat and verify.110,111 It also must be noted that numerous publications have successfully questioned the accuracy and repeatability of such
recording instruments as facebows, tracings, articulators, and condylar position indicators, basically due to the multitude of possible errors112,113
Concepts of TMD, as related to orthodontics, has been drastically changed over the last few decades, basically due to succinct science and evidence-
based approaches of looking at the validity of the philosophies and the approaches that have evolved during this period. This drastic change has
been catalyzed by advances in the fields of pain management, pain pathophysiology and neurophysiology, genetics, principles of physiatry,
behavioral and psychological sciences, and orthopedics. The older rigid mechanical models of TMJ and the dependent TMD literature are being
overwhelmingly debunked. A new era of the biopsychosocial model of orofacial pain in general, and TMD in particular, has risen. The relatively
crude anecdotal literature of orthodontic treatment as a cause of TMD is largely disappearing. It is our opinion based on evidence, science, and
literature that sound management principles of restorative dentistry and orthodontics have no etiology in causing TMDs and will continue to drive
restorative dentistry and orthodontics into a new century.

没有真正的证据表明关节盂窝中的髁突定位与颞下颌关节紊乱的发生有任何因果关系。 40 , 107 ， 108 ， 109 此外，传统上描述的所谓“稳定中心关系

位置”的登记方法都没有被证明是万无一失和基于证据的。事实上，基于成像的研究表明，所有所研究的程序实际上都是“盲程序”，无法独立重复和验
证。 110 , 111 还必须指出的是，许多出版物成功地质疑了面弓、描摹、咬合器和髁突位置指示器等记录仪器的准确性和可重复性，这主要是由于存在许
多可能的错误 112 , 113 与正畸相关的 TMD 概念在过去几十年中发生了巨大变化，主要是由于简洁的科学和基于证据的方法来研究哲学和在此期间发展
的方法。疼痛管理、疼痛病理生理学和神经生理学、遗传学、物理学原理、行为和心理科学以及骨科领域的进步推动了这一巨大变化。颞下颌关节的
旧刚性机械模型和相关的颞下颌关节文献正在被压倒性地揭穿。口面部疼痛的生物心理社会模型，特别是TMD的生物心理社会模型的新时代已经兴
起。关于正畸治疗作为颞下颌关节紊乱病因的相对粗糙的轶事文献在很大程度上正在消失。 我们根据证据、科学和文献认为，修复牙科和正畸的健全
管理原则与导致颞下颌关节紊乱无关，并将继续推动修复牙科和正畸进入新世纪。

Clinical Pearls
With all the advances in the fields of orthodontics and prosthodontics/restorative dentistry, one of the areas our field of dentistry is lacking, is the
question of any association of these treatment modalities to TMD. The astute clinician must educate himself/herself to screen for TMD issues before
initiating orthodontic correction or prosthodontic/restorative intervention. Prompt referral to an orofacial pain specialist or a clinician well-versed
in the management of TMDs may be a prudent step if the screening is positive for TMD signs and symptoms. There is no evidence found in the
literature hitherto published, establishing any level of causal relationship between orthodontic–prosthodontic–restorative treatment to TMD.
Conversely, there is little/no evidence linking occlusion, interferences, loss of vertical dimension, malocclusions, or occlusal prematurities to TMDs.
The use of so-called ancillary testing devices such as jaw tracking, kinesiography, total occlusal equilibration, and many other anecdotal principles
seem to have little or no evidence in the literature published to date. The traditional principles of prosthodontic reconstruction, orthodontic
treatment, and restorative dentistry, including sound occlusal principles, should be followed in an attempt to stabilize the patient’s occlusion and
optimize esthetics and function.

随着正畸学和修复学/修复牙科领域的所有进步，我们的牙科领域缺乏的领域之一是这些治疗方式与TMD的任何关联问题。精明的临床医生在开始正
畸矫正或修复/修复干预之前，必须自学筛查颞下颌关节紊乱问题。如果颞下颌关节紊乱体征和症状筛查呈阳性，应及时转诊至口面部疼痛专科医生或
精通颞下颌关节管理的临床医生。在迄今为止发表的文献中没有发现任何证据，可以确定正畸-修复-修复治疗与TMD之间存在任何程度的因果关系。
相反，几乎没有证据表明闭塞、干扰、垂直维度损失、咬合不正或咬合早熟与 TMD。使用所谓的辅助测试设备，如下颌跟踪、运动机能图、全咬合
平衡和许多其他轶事原理，在迄今为止发表的文献中似乎很少或根本没有证据。应遵循修复重建、正畸治疗和修复牙科的传统原则，包括健全的咬合
原则，以稳定患者的咬合并优化美学和功能。

Disclosure
D.C. Thomas, D. Briss, P.E. Rossouw, and S. Iyer have no commercial or financial conflicts of interest. No funding was received for this article.

D.C. Thomas、D. Briss、P.E. Rossouw 和 S. Iyer 没有商业或财务利益冲突。本文未收到任何资助。

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