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Nonsurgical Correction of a Severe Class III Open-Bite Patient with Long-Face Syndrome
对一名患有长脸综合征的严重 III 类开放性咬合患者进行非手术矫正

LUIS CARRIÈRE, DDS, MSD, PhD
路易斯-卡里尔，牙科医生、医学博士、博士
JOSÉ CARRIÈRE, DDS, MD, PhD
JOSÉ CARRIÈRE，牙科博士、医学博士
An adult patient with a complex Class III malocclusion involving extreme sagittal and vertical disharmony generally requires surgical resolution of the skeletal discrepancy before the orthodontic issues can be resolved. 1 − 4 1 − 4 ^(1-4){ }^{1-4} If the patient refuses surgery, however, an orthodontic camouflage alternative may be needed.
患有复杂的Ⅲ类错颌畸形、矢状和垂直方向极度不协调的成年患者，通常需要先通过手术解决骨骼差异问题，然后才能解决正畸问题。 1 − 4 1 − 4 ^(1-4){ }^{1-4} 但是，如果患者拒绝手术，则可能需要采用正畸伪装替代方案。
Dr. L. Carrière is a Contributing Editor of the Journal of Clinical Orthodontics and in the private practice of orthodontics at Clinica Carrière, C Escoles Pies 109, Barcelona 08017, Spain; e-mail: luis@ carriere.es. Dr. J. Carrière is in the private practice of orthodontics at Clinica Carrière.
L. Carrière 博士是《临床正畸学杂志》的特约编辑，并在西班牙巴塞罗那 08017，C Escoles Pies 109，Clinica Carrière 私人诊所从事正畸工作；电子邮件：luis@ carriere.es。J. Carrière博士在Clinica Carrière私人诊所从事牙齿矫正工作。
Fig. 1 Class III Carriere Motion 3D* appliance (link to demonstration video is included in online version of this article).
图 1 III 级 Carriere Motion 3D* 装置（本文在线版本中包含演示视频链接）。
*Registered trademark of Henry Schein Orthodontics, Melville, NY; www.henryscheinortho.com.

KRAVITZ KEYS 克拉维茨钥匙

& In this case, the upper arch was immediately bonded with fixed appliances, and Class III elastics were worn to an .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} copper nitanium archwire instead of a thermoplastic retainer.
在这个病例中，上牙弓立即粘接了固定矫治器，并在 .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} 钛铜弓丝上佩戴了III类矫治器，而不是热塑保持器。
8t “Shorty” Class III Carriere Motion 3D* appliances were attached from the lower canines to second premolars.
8t "矮小 "III级卡里尔运动3D*矫治器从下犬齿连接到第二前臼齿。
8- Consolidation of the missing lower first-molar spaces facilitated skeletal Class III camouflage treatment.
8- 下第一磨牙缺失间隙的加固为骨骼 III 级伪装治疗提供了便利。
Fig. 2 21-year-old male patient with skeletal Class III malocclusion, hyperdivergent long face, maxillary hypoplasia, transverse constriction, and hyperplastic mandible before treatment (continued on next page).
图 2 21 岁男性患者，治疗前患有骨骼Ⅲ类错颌畸形、过度分叉长脸、上颌骨发育不良、横向收缩和下颌骨增生（续下页）。
The functional occlusal plane is represented by a line traced through the midpoint between the mesial cusps of the first molars and the cusps of the canines (or, in the case of ectopic lower canines, the cusps of the first premolars). Any change in the cant of the functional occlusal plane will directly affect
功能性咬合平面由第一臼齿的中尖和犬齿的尖之间的中点（如果是异位的下犬齿，则是第一前臼齿的尖）的连线表示。功能性咬合平面倾斜度的任何变化都会直接影响到
the sagittal relationship of the maxilla and mandible. Counterclockwise rotation of the occlusal plane can restore proper molar mastication by establishing a Class I posterior platform early in treatment. 4 − 7 4 − 7 ^(4-7){ }^{4-7}
上颌骨和下颌骨的矢状关系。咬合平面的逆时针旋转可以在治疗早期建立I类后平台，从而恢复正常的臼齿咀嚼。 4 − 7 4 − 7 ^(4-7){ }^{4-7}
The Class III Carriere Motion 3D is a onepiece device that positions the dentition in a Class
III 级 Carriere Motion 3D 是一种单件式装置，可将牙槽骨定位在 III 级 Carriere Motion 3D 中。
I platform from molars to canines (Fig. 1).2,8,9 The anterior pad is bonded to the lower canine and incorporates a hook for attachment of Class III elastics. The central arm passes over the two lower premolars with a slight curve following the contour of the dental arch. This segment is oval in its vertical cross-section to add rigidity while maintaining axial control of the lower canines and molars. Between the second premolar and molar, the arm flattens transversely to provide greater lateral flexibility; an offset bayonet bend and toe-in angulation produce a small, 10 ∘ 10 ∘ 10^(@)10^{\circ} distal rotation of the lower posterior pad, which is bonded to the molar. 6 , 9 − 11 6 , 9 − 11 ^(6,9-11){ }^{6,9-11} A Class II Carriere Motion Appliance can be substituted in a Class III patient with missing lower molars.
2,8,9前牙垫粘接在下犬齿上，并带有一个用于连接 III 类弹性体的钩。中央臂穿过两颗下前臼齿，沿着牙弓的轮廓略微弯曲。这一部分的垂直截面为椭圆形，以增加刚性，同时保持对下犬齿和臼齿的轴向控制。在第二前臼齿和臼齿之间，牙臂横向变平，以提供更大的横向灵活性；偏置的卡口弯曲和趾入角使下后牙垫的远端产生微小的 10 ∘ 10 ∘ 10^(@)10^{\circ} 旋转，并与臼齿粘结在一起。 6 , 9 − 11 6 , 9 − 11 ^(6,9-11){ }^{6,9-11} 下磨牙缺失的 III 类患者可以用 II 类 Carriere 活动矫治器替代。
The Carriere Motion 3D phase is usually followed by a finishing stage using low-friction Carriere SLX* passive self-ligating brackets and lowforce nitanium wires. 2 , 9 2 , 9 ^(2,9){ }^{2,9} The following case demonstrates such treatment.
在 Carriere Motion 3D 阶段之后，通常会使用低摩擦力的 Carriere SLX* 被动自锁托槽和低摩擦力的钛丝进行最后阶段的治疗。 2 , 9 2 , 9 ^(2,9){ }^{2,9} 下面的病例展示了这种治疗方法。

Diagnosis and Treatment Planning
诊断和治疗计划

A 21-year-old male had visited several orthodontic offices looking for an orthodontic-
一名 21 岁的男性曾到过几家正畸诊所，寻找正畸医生。
only correction with an esthetic result. He was apprehensive about undergoing surgery, and he wanted to preserve his intrinsic familial facial characteristics. His goals were to improve the obvious prognathism; recover a normal masticatory function; and correct the dental-arch alignment, crossbite, open bite, high upper canines, and crooked anterior teeth.
只有矫正才能达到美观的效果。他对接受手术心存顾虑，并希望保留其固有的家族面部特征。他的目标是改善明显的前牙反颌；恢复正常的咀嚼功能；矫正牙弓排列、交叉咬合、开放咬合、上犬齿过高和前牙歪斜。
The morphological diagnosis was a skeletal Class III malocclusion with a hyperdivergent long face, maxillary hypoplasia, transverse constriction, and hyperplastic mandible (Fig. 2). The dental arches increased in divergence from the first permanent molars to a 5 mm anterior open bite, resulting in a negative overjet and a full crossbite-a challenging condition with a high risk of root resorption over a long period of treatment. The lower right first molar and left first and second molars were missing, and the upper arch had two high canines.
形态学诊断结果为骨骼Ⅲ类错颌畸形，表现为长面部过度分叉、上颌骨发育不良、横向收缩和下颌骨增生（图2）。从第一恒磨牙开始，牙弓分叉增加，前方开咬合达5毫米，导致负过咬合和完全交叉咬合--这是一种具有挑战性的情况，在长期治疗过程中牙根吸收的风险很高。右下第一磨牙、左第一和第二磨牙缺失，上牙弓有两颗高犬齿。
The neuromuscular pattern was hypotonic; the patient’s leptosomic body type was reflected in a poor masticatory stroke in the masseter and
患者的神经肌肉模式张力低下；患者的瘦小体型反映在咀嚼时咀嚼肌和咀嚼肌的咀嚼行程较差。
TABLE 1 CEPHALOMETRIC ANALYSIS
表 1 头颅测量分析
Norm 规范 Pretreatment 预处理 Post-Treatment 治疗后
Maxilla to cranial base
上颌骨至颅底
SNA 82.0 ∘ ± 3.5 ∘ 82.0 ∘ ± 3.5 ∘ 82.0^(@)+-3.5^(@)82.0^{\circ} \pm 3.5^{\circ} 81.8 ∘ 81.8 ∘ 81.8^(@)81.8^{\circ} 82.6 ∘ 82.6 ∘ 82.6^(@)82.6^{\circ}
Mandible to cranial base
下颌骨至颅底
SNB 80.9 ∘ ± 3.4 ∘ 80.9 ∘ ± 3.4 ∘ 80.9^(@)+-3.4^(@)80.9^{\circ} \pm 3.4^{\circ} 83.4 ∘ 83.4 ∘ 83.4^(@)83.4^{\circ} 82.2 ∘ 82.2 ∘ 82.2^(@)82.2^{\circ}
SN-GoGn 32.9 ∘ ± 5.2 ∘ 32.9 ∘ ± 5.2 ∘ 32.9^(@)+-5.2^(@)32.9^{\circ} \pm 5.2^{\circ} 40.7 ∘ 40.7 ∘ 40.7^(@)40.7^{\circ} 42.7 ∘ 42.7 ∘ 42.7^(@)42.7^{\circ}
FMA (MP-FH) 财务管理局（MP-FH） 22.9 ∘ ± 4.5 ∘ 22.9 ∘ ± 4.5 ∘ 22.9^(@)+-4.5^(@)22.9^{\circ} \pm 4.5^{\circ} 25.6 ∘ 25.6 ∘ 25.6^(@)25.6^{\circ} 27.5 ∘ 27.5 ∘ 27.5^(@)27.5^{\circ}
Maxillomandibular 上下颌
ANB 1.6 ∘ ± 1.5 ∘ 1.6 ∘ ± 1.5 ∘ 1.6^(@)+-1.5^(@)1.6^{\circ} \pm 1.5^{\circ} − 1.5 ∘ − 1.5 ∘ -1.5^(@)-1.5^{\circ} 0.4 ∘ 0.4 ∘ 0.4^(@)0.4^{\circ}
Maxillary dentition 上颌牙
U1-NA 4.3 mm ± 2.7 mm 4.3 mm ± 2.7 mm 4.3mm+-2.7mm4.3 \mathrm{~mm} \pm 2.7 \mathrm{~mm} 4.0 mm 4.0 毫米 4.2 mm 4.2 毫米
U1-SN 58.7 ∘ ± 8.5 ∘ 58.7 ∘ ± 8.5 ∘ 58.7^(@)+-8.5^(@)58.7^{\circ} \pm 8.5^{\circ} 63.3 ∘ 63.3 ∘ 63.3^(@)63.3^{\circ} 73.2 ∘ 73.2 ∘ 73.2^(@)73.2^{\circ}
Mandibular dentition 下颌牙 4.0 mm ± 1.8 mm 4.0 mm ± 1.8 mm 4.0mm+-1.8mm4.0 \mathrm{~mm} \pm 1.8 \mathrm{~mm}
L1-NB 90.0 ∘ ± 6.0 ∘ 90.0 ∘ ± 6.0 ∘ 90.0^(@)+-6.0^(@)90.0^{\circ} \pm 6.0^{\circ} 4.7 mm 4.7 毫米 1.8 mm 1.8 毫米
L1-GoGn 76.0 ∘ 76.0 ∘ 76.0^(@)76.0^{\circ} 64.2 ∘ 64.2 ∘ 64.2^(@)64.2^{\circ}
Soft tissue 软组织 − 2.0 mm ± 2.0 mm − 2.0 mm ± 2.0 mm -2.0mm+-2.0mm-2.0 \mathrm{~mm} \pm 2.0 \mathrm{~mm} -5.5 mm -5.5毫米 -4.8 mm -4.8毫米
Lower lip to E-plane
下唇至 E 平面		 − 1.0 mm ± 1.0 mm − 1.0 mm ± 1.0 mm -1.0mm+-1.0mm-1.0 \mathrm{~mm} \pm 1.0 \mathrm{~mm} -14.2 mm -14.2毫米 -5.5 mm -5.5毫米
Wits appraisal 智商评估
Norm Pretreatment Post-Treatment Maxilla to cranial base SNA 82.0^(@)+-3.5^(@) 81.8^(@) 82.6^(@) Mandible to cranial base SNB 80.9^(@)+-3.4^(@) 83.4^(@) 82.2^(@) SN-GoGn 32.9^(@)+-5.2^(@) 40.7^(@) 42.7^(@) FMA (MP-FH) 22.9^(@)+-4.5^(@) 25.6^(@) 27.5^(@) Maxillomandibular ANB 1.6^(@)+-1.5^(@) -1.5^(@) 0.4^(@) Maxillary dentition U1-NA 4.3mm+-2.7mm 4.0 mm 4.2 mm U1-SN 58.7^(@)+-8.5^(@) 63.3^(@) 73.2^(@) Mandibular dentition 4.0mm+-1.8mm L1-NB 90.0^(@)+-6.0^(@) 4.7 mm 1.8 mm L1-GoGn 76.0^(@) 64.2^(@) Soft tissue -2.0mm+-2.0mm -5.5 mm -4.8 mm Lower lip to E-plane -1.0mm+-1.0mm -14.2 mm -5.5 mm Wits appraisal | | Norm | Pretreatment | Post-Treatment | | :--- | :---: | :---: | :---: | | Maxilla to cranial base | | | | | SNA | $82.0^{\circ} \pm 3.5^{\circ}$ | $81.8^{\circ}$ | $82.6^{\circ}$ | | Mandible to cranial base | | | | | SNB | $80.9^{\circ} \pm 3.4^{\circ}$ | $83.4^{\circ}$ | $82.2^{\circ}$ | | SN-GoGn | $32.9^{\circ} \pm 5.2^{\circ}$ | $40.7^{\circ}$ | $42.7^{\circ}$ | | FMA (MP-FH) | $22.9^{\circ} \pm 4.5^{\circ}$ | $25.6^{\circ}$ | $27.5^{\circ}$ | | Maxillomandibular | | | | | ANB | $1.6^{\circ} \pm 1.5^{\circ}$ | $-1.5^{\circ}$ | $0.4^{\circ}$ | | Maxillary dentition | | | | | U1-NA | $4.3 \mathrm{~mm} \pm 2.7 \mathrm{~mm}$ | 4.0 mm | 4.2 mm | | U1-SN | $58.7^{\circ} \pm 8.5^{\circ}$ | $63.3^{\circ}$ | $73.2^{\circ}$ | | Mandibular dentition | $4.0 \mathrm{~mm} \pm 1.8 \mathrm{~mm}$ | | | | L1-NB | $90.0^{\circ} \pm 6.0^{\circ}$ | 4.7 mm | 1.8 mm | | L1-GoGn | | $76.0^{\circ}$ | $64.2^{\circ}$ | | Soft tissue | $-2.0 \mathrm{~mm} \pm 2.0 \mathrm{~mm}$ | -5.5 mm | -4.8 mm | | Lower lip to E-plane | $-1.0 \mathrm{~mm} \pm 1.0 \mathrm{~mm}$ | -14.2 mm | -5.5 mm | | Wits appraisal | | | |
temporalis muscles. The tongue and its elevating musculature were hypertrophic, with improper function at rest and when chewing and swallowing.
颞肌。舌头及其隆起的肌肉组织肥大，在休息、咀嚼和吞咽时功能不正常。
We wanted to treat the case step by step, in an order determined by the degree of relevance of each problem to the overall malocclusion. These problems included the Class III dolichofacial pattern; extreme anterior open bite; premaxillary hypoplasia with severe upper crowding; transverse discrepancy with bilateral posterior crossbite; severe anterior crossbite, negative overjet, retroclined lower incisors, and lower crowding; retrusive upper lip, protrusive lower lip, flat mentolabial groove, protrusive chin point, and concave profile; and missing lower molars.
我们希望根据每个问题与整个错颌畸形的相关程度来确定治疗顺序，逐步治疗。这些问题包括：三类多利齿面型；前方极度开合咬合；前下颌发育不良，伴有严重的上牙拥挤；横向不一致，伴有双侧后方交叉咬合；严重的前方交叉咬合，负过咬合，下切牙后倾，下牙拥挤；上唇后突，下唇前突，扁平的门唇沟，下巴前突，凹面；以及下臼齿缺失。
When the patient rejected the proposed sur-gical-orthodontic treatment, we applied the “sagittal first” principle in planning nonsurgical orthodontic treatment with a sequence of movements from distal to mesial. 1 , 2 , 7 , 9 1 , 2 , 7 , 9 ^(1,2,7,9){ }^{1,2,7,9} Treatment goals were to correct the Class III malocclusion, close the anterior open bite, correct the posterior crossbite, protract the maxillary teeth, retract the mandibular teeth, and effect a counterclockwise rotation of the posterior functional occlusal plane to balance the Wits appraisal 7 7 ^(7){ }^{7} (Table 1). The soft-tissue Class III relationship would be improved by mesializing the lower right second and third molars into the space of the missing first molar, thus avoiding the need for a future implant.
当患者拒绝接受外科正畸治疗建议时，我们采用了 "矢状先行 "原则，以从远端到中端的移动顺序规划非手术正畸治疗。 1 , 2 , 7 , 9 1 , 2 , 7 , 9 ^(1,2,7,9){ }^{1,2,7,9} 治疗目标是矫正III类错牙合畸形，关闭前方开合咬合，矫正后方交叉咬合，前伸上颌牙，后缩下颌牙，逆时针旋转后方功能性咬合平面以平衡Wits鉴定 7 7 ^(7){ }^{7} （表1）。通过将右下第二和第三磨牙的间隙楔入缺失的第一磨牙的间隙，可以改善软组织 III 级关系，从而避免将来植入种植体的需要。

Myofunctional Therapy 肌功能疗法

In any open-bite case, we prioritize myofunctional therapy. This patient’s tongue and skeletal condition would have interfered with tooth movement, lengthening treatment and increasing the risk of severe root resorption and future relapse. To correct a tongue dysfunction, we use an in-office rehabilitation program involving three tongue positions: at rest, when chewing, and when swallowing (Fig. 3).
在任何开放性咬合病例中，我们都会优先考虑肌功能治疗。这位患者的舌头和骨骼状况会影响牙齿移动，延长治疗时间，增加严重牙根吸收和未来复发的风险。为了矫正舌功能障碍，我们在诊室内实施了一项康复计划，包括三个舌位：静止时、咀嚼时和吞咽时（图 3）。
A hypertrophic tongue rests between the dental arches, with the lips sealed and in strong contraction. The tongue protrudes between the teeth to produce a third point of contact with the lips. A negative pressure is thus produced inside the mouth relative to the outside atmospheric pressure. The exercise for this position involves the following steps:
肥大的舌头位于牙弓之间，嘴唇紧闭并处于强烈收缩状态。舌头突出于牙齿之间，与嘴唇形成第三个接触点。这样，口腔内就会产生一个相对于外部大气压力的负压。这种姿势的练习包括以下步骤：
  1. The lips are parted to balance the oral-cavity pressure with the pressure outside the mouth.
    嘴唇分开是为了平衡口腔内压力和口腔外压力。
  2. After relaxing the tip of the tongue, the patient directs it to contact a point on the palatal rugae. The tongue should not move beyond this point when at rest.
    放松舌尖后，患者引导舌尖接触腭皱上的一点。静止时，舌尖的移动不应超过该点。
  3. The base of the tongue is then directed back and down to the rear of the oral cavity.
    然后将舌根向后下方引导至口腔后部。
If the dental arches are inefficient in chewing, the tongue compensates by pushing the food bolus against the hard palate and the lingual
如果牙弓在咀嚼时效率不高，舌头就会补偿性地将食团推向硬腭和舌侧。
aspects of the teeth, acting as an alternative masticatory organ. These forces cause hypertrophy of the striated muscular fibers and an increase in tongue volume, aggravating the open bite and interfering with orthodontic treatment. We use chewing gum in the exercise for this position:
这些力会导致横纹肌纤维肥大，舌头体积增大，从而加重开牙合，影响正畸治疗。这些力量会导致横纹肌纤维肥大，舌头体积增大，加重开放性咬合，影响正畸治疗。我们在这种姿势的练习中使用口香糖：
  1. The lips are parted to prevent the tip of the tongue from protruding between the teeth to contact the lips.
    嘴唇分开，以防止舌尖伸出牙齿之间接触嘴唇。
  2. While chewing gum, the patient uses the tongue to direct the gum to the molar regions, thus stimulating the masseter and temporalis muscles to retrain molar chewing function.
    在咀嚼口香糖时，患者用舌头将口香糖引向臼齿区，从而刺激咀嚼肌和颞肌，重新训练臼齿咀嚼功能。
  3. After the patient learns exclusively molar mastication, this exercise can be generalized to chewing during regular meals.
    在患者学会专门的臼齿咀嚼后，这种练习可以推广到正餐时的咀嚼。
In swallowing, a hypertrophic tongue is projected between the anterior teeth, actively contributing to the open bite and the risk of root resorption, interfering with tooth movement, and compromising long-term stability. The patient therefore needs to practice synchronizing these three positions:
在吞咽时，肥大的舌头会伸到前牙之间，从而导致开放性咬合和牙根吸收的风险，影响牙齿的移动，并损害长期稳定性。因此，患者需要练习同步这三个位置：
  1. The lips are parted to prevent protrusion of the tip of the tongue.
    嘴唇分开，防止舌尖突出。
  2. The posterior bite is clenched so that the molars make contact at a specific point.
    后咬合是咬紧牙关，使臼齿在某一点上接触。
  3. The tip of the tongue is placed against the palatal rugae, and the deglutition wave begins from this point backward.
    舌尖抵住腭嵴，脱舌波由此向后开始。
Fig. 3 Tongue rehabilitation exercises for open-bite patient (link to demonstration video is included in online version of this article). A: Point to place tip of tongue at rest and as starting point for deglutition. B: Specific zone for molar mastication and for clenching contact when swallowing. Limit: Line not to be crossed by tip of tongue.
图 3 开放性咬合患者的舌头康复训练（本文在线版本中包含演示视频链接）。A：舌尖静止时的放置点，也是脱臼的起始点。B： 用于臼齿咀嚼和吞咽时咬合接触的特定区域。界限：舌尖不可跨越的线。

Treatment Progress 治疗进展

Although a vacuformed maxillary retainer can be used for attachment of Class III elastics, we decided to start with upper leveling in this case to help develop the maxillary arch and maximize soft-tissue support in the upper lip. After MBT**prescription .022" Carriere SLX passive self-ligating brackets were bonded, a maxillary .014 " round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) archwire was used for four
虽然可以使用真空成型的上颌保持器来连接 III 类矫治器，但我们还是决定从这个病例的上部矫治开始，以帮助上颌牙弓发育，并最大限度地增加上唇的软组织支持。粘结 MBT**prescription 0.022" Carriere SLX 被动自锁托槽后，上颌 0.014" 圆形镍钛铜弓丝 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) 被用于上颌的四个位置。
*Registered trademark of Henry Schein Orthodontics, Melville, NY; www.henryscheinortho.com.
**Trademark of 3M, Monrovia, CA; www.3M.com.
** 加利福尼亚州蒙罗维亚 3M 公司的商标；www.3M.com。
weeks (Fig. 4). 周（图 4）。
The maxillary archwire was then changed to .016 " .016 " .016".016 " round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right), and “shorty” Class III Carriere Motion 3D appliances were placed from the lower canines to second premolars to begin distalizing the lower posterior segments with Class III elastics and thus correct the negative overjet (Fig. 5). Lower posterior build-ups were bonded to avoid occlusal interference with the upper molar tubes. This temporarily increased the anterior open bite but enabled us to work on the transverse dimension while simultaneously beginning the sagittal correction.
然后将上颌弓丝改为 .016 " .016 " .016".016 " 圆形钛铜 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) ，并从下犬齿到第二前磨牙戴上 "短 "的III类卡瑞尔移动3D矫治器，开始用III类弹性矫治器对下后牙段进行远端矫治，从而纠正负性过咬合（图5）。为了避免与上磨牙管发生咬合干扰，还粘结了下后建。这虽然暂时增加了前牙开放咬合，但使我们能够在开始矢状矫正的同时进行横向尺寸的矫正。
Fig. 4 Upper-arch leveling with MBT**-prescription .022" Carriere SLX* passive self-ligating brackets and .014" round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) archwire.
图 4 使用 MBT** 规定的 0.022 英寸 Carriere SLX* 被动自锁托架和 0.014 英寸圆形钛铜 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) 弓丝进行上牙弓矫平。
Fig. 5 After four weeks of treatment, upper .016 " round copper nitanium ( 27 ∘ C 27 ∘ C 27^(@)C27^{\circ} \mathrm{C} ) archwire inserted; “shorty” Class III Carriere Motion 3D appliance placed from lower canines to second premolars to distalize lower posterior segments and correct negative overjet.
图 5 治疗四周后，插入上部 0.016 英寸圆形钛铜弓丝（ 27 ∘ C 27 ∘ C 27^(@)C27^{\circ} \mathrm{C} ）；从下犬齿到第二前磨牙放置 "矮小 "的 III 类 Carriere Motion 3D矫治器，以远端矫治下颌后段并矫正负性过咬合。
Fig. 6 Four weeks later, upper archwire changed to .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) to complete sagittal correction.
图 6 四周后，上弓丝改为 .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) 钛铜，完成矢状矫正。
Fig. 7 After 16 weeks of treatment, Carriere Motion 3D appliances removed, upper archwire changed to .017" × .025 ′ ′ .025 ′ ′ .025^('').025^{\prime \prime} copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ), . 022 ′ ′ 022 ′ ′ 022^('')022^{\prime \prime} Carriere SLX passive self-ligating brackets and .014 " .014 " .014".014 " round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) archwire placed in lower arch, and four tongue tamers bonded to lower incisors.
图 7 治疗 16 周后，取下 Carriere Motion 3D矫治器，上弓丝改为 0.017" × .025 ′ ′ .025 ′ ′ .025^('').025^{\prime \prime} 钛铜丝 ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} )，. 022 ′ ′ 022 ′ ′ 022^('')022^{\prime \prime} 卡里尔 SLX 被动自锁托槽和 .014 " .014 " .014".014 " 圆形钛铜弓丝（ ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) ）放置在下牙弓上，并在下切牙上粘结了四个驯舌器。
Fig. 8 Four weeks later, upper .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ) and lower .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} round copper nitanium ( 27 ∘ C 27 ∘ C 27^(@)C27^{\circ} \mathrm{C} ) archwires inserted, along with power chain to move lower right second molar into space of first molar and third molar into space of second molar.
图 8 四周后，插入上 .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} 钛铜弓丝（ 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ）和下 .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} 钛铜圆弓丝（ 27 ∘ C 27 ∘ C 27^(@)C27^{\circ} \mathrm{C} ），并用动力链将右下第二磨牙移入第一磨牙的空间，将第三磨牙移入第二磨牙的空间。
Four weeks later, the maxillary archwire was changed to .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) to finish the sagittal correction (Fig. 6). A positive overjet was achieved in eight weeks. At this point, we noted a slight increase in the open bite caused by a premature occlusal contact of the lower third molars and the upper second and third molars, which were undergoing transverse correction.
四周后，上颌弓丝改为 .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} 钛铜 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) ，完成矢状矫正（图 6）。八周后实现了正过咬合。此时，我们注意到由于正在进行横向矫正的下第三磨牙与上第二和第三磨牙咬合接触过早，导致开合咬合略有增加。
After the Carriere Motion 3D appliances were removed, the mandibular arch was bonded with .022 ′ ′ .022 ′ ′ .022^('').022^{\prime \prime} Carriere SLX passive self-ligating brackets, and an .014 " .014 " .014".014 " round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) archwire was inserted (Fig. 7). Four tongue tamers were also bonded to the lingual surfaces of the lower incisors, and the maxillary archwire was changed to .017 ′ ′ × .025 ′ ′ .017 ′ ′ × .025 ′ ′ .017^('')xx.025^('').017^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right).
取下卡里尔 Motion 3D矫治器后，下颌牙弓粘结了 .022 ′ ′ .022 ′ ′ .022^('').022^{\prime \prime} 卡里尔 SLX 被动自锁托槽，并插入了 .014 " .014 " .014".014 " 圆形钛铜 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) 弓丝（图 7）。在下切牙的舌面也粘结了四个驯舌器，上颌弓丝改为 .017 ′ ′ × .025 ′ ′ .017 ′ ′ × .025 ′ ′ .017^('')xx.025^('').017^{\prime \prime} \times .025^{\prime \prime} 钛铜 ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right) 。
Four weeks later, we placed maxillary .019 ′ ′ × .019 ′ ′ × .019^('')xx.019^{\prime \prime} \times .025 ′ ′ .025 ′ ′ .025^('').025^{\prime \prime} copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ) and mandibular .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} round copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) archwires, along with power chain to begin moving the lower right second molar into the space of the first molar and the third molar into the space of the second molar (Fig. 8).
四周后，我们放置了上颌 .019 ′ ′ × .019 ′ ′ × .019^('')xx.019^{\prime \prime} \times .025 ′ ′ .025 ′ ′ .025^('').025^{\prime \prime} 钛铜弓丝（ 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ）和下颌 .016 ′ ′ .016 ′ ′ .016^('').016^{\prime \prime} 钛铜圆弓丝 ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) ，同时使用动力链开始将右下第二磨牙移入第一磨牙的间隙，将第三磨牙移入第二磨牙的间隙（图 8）。
In another four weeks, the archwires were changed to maxillary .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ) and mandibular .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right), and the lower right second molar tube was rebonded more mesiogingivally for molar uprighting. A nickel titanium closed-coil spring and ligature were applied to move the lower right second molar mesially into the space of the first molar.
再过四周，将弓丝更换为上颌 .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} 钛铜弓丝（ 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ）和下颌 .014 ′ ′ × .025 ′ ′ .014 ′ ′ × .025 ′ ′ .014^('')xx.025^('').014^{\prime \prime} \times .025^{\prime \prime} 钛铜弓丝（ ( 27 ∘ C ) 27 ∘ C (27^(@)C)\left(27^{\circ} \mathrm{C}\right) ），并将右下第二磨牙管重新向中龈方向粘接，以实现磨牙直立。使用镍钛闭合线圈弹簧和结扎器将右下第二磨牙向中线移动到第一磨牙的空间。
Four weeks later, we inserted maxillary .019" × .025 ′ ′ × .025 ′ ′ xx.025^('')\times .025^{\prime \prime} copper nitanium ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right) and mandibular .017 ′ ′ × .025 ′ ′ .017 ′ ′ × .025 ′ ′ .017^('')xx.025^('').017^{\prime \prime} \times .025^{\prime \prime} copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ) archwires, which were again worn for four weeks. Maxillary .019 " × .025 ′ ′ .019 " × .025 ′ ′ .019"xx.025^('').019 " \times .025^{\prime \prime} beta titanium and mandibular .019 " × .025 ′ ′ × .025 ′ ′ xx.025^('')\times .025^{\prime \prime} copper nitanium ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right) archwires were applied for the next eight months (Fig. 9). The mandibular archwire was then changed to .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} beta titanium for five additional months.
四周后，我们插入了上颌 ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right) .019" × .025 ′ ′ × .025 ′ ′ xx.025^('')\times .025^{\prime \prime} 钛铜弓丝和下颌 .017 ′ ′ × .025 ′ ′ .017 ′ ′ × .025 ′ ′ .017^('')xx.025^('').017^{\prime \prime} \times .025^{\prime \prime} 钛铜弓丝（ 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ），并再次佩戴四周。在接下来的八个月里，上颌 .019 " × .025 ′ ′ .019 " × .025 ′ ′ .019"xx.025^('').019 " \times .025^{\prime \prime} β钛和下颌0.019" × .025 ′ ′ × .025 ′ ′ xx.025^('')\times .025^{\prime \prime} 镍钛铜 ( 35 ∘ C ) 35 ∘ C (35^(@)C)\left(35^{\circ} \mathrm{C}\right) 弓丝一直被使用（图 9）。然后将下颌弓丝换成 .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} β钛，再使用五个月。
Maxillary .021 ′ ′ × .027 ′ ′ .021 ′ ′ × .027 ′ ′ .021^('')xx.027^('').021^{\prime \prime} \times .027^{\prime \prime} nickel titanium and mandibular .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} beta titanium archwires were used, along with finishing intermaxillary vertical elastics, during the final four weeks of treatment (Fig. 10).
在治疗的最后四周，使用了上颌 .021 ′ ′ × .027 ′ ′ .021 ′ ′ × .027 ′ ′ .021^('')xx.027^('').021^{\prime \prime} \times .027^{\prime \prime} 镍钛弓丝和下颌 .019 ′ ′ × .025 ′ ′ .019 ′ ′ × .025 ′ ′ .019^('')xx.025^('').019^{\prime \prime} \times .025^{\prime \prime} β钛弓丝，以及颌间垂直矫正器（图 10）。
Fig. 9 After 32 weeks of treatment, archwires changed to upper .019 " × .025 × .025 xx.025\times .025 " beta titanium and lower .019" × .025" copper nitanium ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} ).
图 9 治疗 32 周后，弓丝改为上部 0.019" × .025 × .025 xx.025\times .025 " β 钛和下部 0.019" × 0.025" 镍铜 ( 35 ∘ C 35 ∘ C 35^(@)C35^{\circ} \mathrm{C} )。
Fig. 10 Upper .021 ′ ′ × .027 ′ ′ .021 ′ ′ × .027 ′ ′ .021^('')xx.027^('').021^{\prime \prime} \times .027^{\prime \prime} nickel titanium and lower .019 " × .025 .019 " × .025 .019"xx.025.019 " \times .025 " beta titanium archwires used for four weeks of finishing at end of treatment.
图 10 上部 .021 ′ ′ × .027 ′ ′ .021 ′ ′ × .027 ′ ′ .021^('')xx.027^('').021^{\prime \prime} \times .027^{\prime \prime} 镍钛弓丝和下部 .019 " × .025 .019 " × .025 .019"xx.025.019 " \times .025 "β钛弓丝在治疗结束时用于四周的抛光。

Treatment Results 治疗结果

Total treatment time was 22 months (Fig. 11). The patient showed an improvement in the sagittal spatial geometry of the intermaxillary relationship, with a consequent improvement in his facial esthetics 12 12 ^(12){ }^{12} (Table 1). A minor distal movement of the mandible was seen, with no change in the size of the maxilla or mandible, and proper molar mastication was recovered.
总治疗时间为 22 个月（图 11）。患者颌间关系的矢状空间几何有所改善，面部美观 12 12 ^(12){ }^{12} 也随之改善（表1）。下颌骨出现轻微的远端移动，上颌骨和下颌骨的大小没有变化，臼齿的咀嚼功能也得到了恢复。
Fixed upper and lower lingual retainer wires and nighttime vacuformed retainers were prescribed; in addition, a small segment of wire was bonded buccally to stabilize the lower right second molar by interproximal connection with the lower second premolar (Fig. 12). After 18 months of retention, only the buccally bonded wire was continued (Fig. 13).
使用了固定的上下舌侧保持器钢丝和夜间空泡保持器；此外，还在颊侧粘结了一小段钢丝，通过与下第二前磨牙的颊侧连接来稳定右下第二磨牙（图12）。保持18个月后，只继续使用颊侧粘结的钢丝（图13）。

Discussion 讨论

The complexity of this case required us to prioritize the various problems contributing to the
这个案例的复杂性要求我们对造成以下问题的各种问题进行优先排序
skeletal Class III malocclusion. The most urgent issue was to recover a proper tongue function. Along with the use of light force, that made it possible to avoid the occurrence of root resorption during treatment.
骨骼三级错合畸形。当务之急是恢复正常的舌功能。在治疗过程中，除了使用轻力外，还可以避免牙根吸收。
Since the patient refused surgery, we took advantage of the many beneficial effects offered by the Class III Carriere Motion 3D appliance, in addition to mandibular distalization. The cant of the functional occlusal plane was tipped back, producing a direct improvement in the Wits appraisal. The elastic traction on the appliance enabled a counterclockwise rotation of the functional occlusal plane, improving the intermaxillary relationship and the prognathic appearance of the patient’s face.
由于患者拒绝手术，除了下颌远端矫治外，我们还利用了 III 类 Carriere Motion 3D矫治器的许多有益效果。功能性咬合平面向后倾斜，直接改善了 Wits 评价。矫治器上的弹性牵引使功能性咬合平面逆时针旋转，改善了颌间关系和患者面部的前倾外观。
This nonsurgical treatment enhanced the patient’s facial esthetics without changing his intrinsic family traits, thus addressing his primary concern. His psychosocial relationships, selfesteem, and confidence had improved by the end of treatment. 4 − 6 , 9 4 − 6 , 9 ^(4-6,9){ }^{4-6,9}
这种非手术治疗增强了患者的面部美感，同时又不改变其固有的家族特征，从而解决了他最关心的问题。治疗结束后，他的社会心理关系、自尊心和自信心都得到了改善。 4 − 6 , 9 4 − 6 , 9 ^(4-6,9){ }^{4-6,9}

Fig. 12 Patient 18 months after treatment.
图 12 治疗 18 个月后的患者。

Fig. 13 Patient five years after treatment, with no retention after 18 months other than buccal interproximal connector between lower right second molar and second premolar.
图 13 患者接受治疗五年后，除右下第二磨牙和第二前磨牙之间的颊侧近端连接体外，18 个月后无其他残留。

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  1. *Registered trademark of Henry Schein Orthodontics, Melville, NY; www.henryscheinortho.com.