3. 讨论

TMD发病原因比较复杂，咬合紊乱、咬合创伤、口颌系统发育异常、偏侧咀嚼、夜磨牙、紧咬牙、环境刺激（如寒冷刺激）、情绪、个性、心理应激和突发性生活事件刺激等精神创伤性因素都可能成为TMD的诱因 [14] 。此外，一些医源性因素，例如鼻咽癌的放射治疗，会导致咀嚼肌的结构和功能改变，也可以引起TMD [15] 。TMD的症状和体征在人群中很常见，调查表明65%的人群出现过颞下颌关节紊乱病的某些症状和体征，较重和严重者占10.3% [16] 。TMD患者中，20~40岁较多，女性明显多于男性，男女比例可达1∶3~1∶5 [17] 。虽然出现颞下颌关节疾病症状的患者较多 [18] ，但实际上只有一小部分患者寻求与颞下颌关节疾病相关的疼痛和功能障碍的治疗和护理。

关于TMD是否与咬合相关的问题是口腔医学领域的讨论热点之一，CSP与TMD之间的关系也一直受到研究者的关注。TMD患者中有偏侧咀嚼习惯者占60.3% [19] 。Nagata等 [20] 研究认为偏侧咀嚼是TMD的首要因素。一些学者 [21] – [22] 认为咬合正常时， 、双侧咀嚼肌以及颞下颌关节功能保持协调，达到一种生理性平衡；但CSP患者仅有一侧后牙接触时，双侧咀嚼肌力、韧带张弛程度及牙齿咬合面的磨耗程度不同，直接影响了 、肌肉、颞下颌关节之间形态及功能上的生理平衡。由于伴CSP者习惯侧肌肉收缩强于非习惯侧，咬合力也发生相应的改变 [23] 。朱娴 [24] 研究了100例偏侧咀嚼者发现，56例（56%）有疼痛症状，36例（36%）有弹响症状，影像学检查发现，68例（68%）非习惯侧髁突功能面骨质粗糙，关节窝骨皮质吸收变薄、关节结节后斜面骨质粗糙，而习惯侧出现骨质改变的仅24例（24%），习惯侧与非习惯侧颞下颌关节窝深度、髁道斜度间的差异有统计学意义（ P <0.05）。非习惯侧的颞下颌关节窝会在偏侧咀嚼习惯的作用下发生向前内方向的重塑，并且这种变化会随着偏侧咀嚼习惯时间的延长而逐渐加重。有研究 [25] 表明，TMD与早接触和咬合不稳定有关，咬合紊乱与咀嚼肌疼痛和下颌髁突不稳定直接相关。早接触可导致髁突移位，这可能导致髁突运动摩擦增大和关节内压力增加，这两种情况都对颞下颌关节有害，并可能导致颞下颌关节结构的改变，进一步导致TMD [26] – [27] 。以往研究 [28] 探讨了无症状CSP者的咬合特点，发现CSP患者的左、右侧咬合力分布不均衡，CSP患者与非CSP者的咬合力不对称指数有明显差异，最大咬合力和最大咬合接触面积均是非CSP>右侧CSP>左侧CSP。

本研究发现，4组受试者牙尖交错位时TOF、TCA均有明显差异（ P <0.05），不伴TMD的非CSP组>不伴TMD的CSP组>伴TMD的CSP组>伴TMD的非CSP组。这说明，不伴TMD的受试者咀嚼效率、咀嚼接触面积优于伴TMD的受试者。有研究 [29] 通过测定咬合面积与咬合力的大小来评估咀嚼功能的优势。Hidaka等 [30] 让受试者在牙尖交错位时分别使用60%的最大咬合力、30%的最大咬合力和自然咬合，进行3种不同力度的咬合检测，结果发现咬合力和接触面积伴随着咬肌的肌电幅度增大而增加，这与本研究结果一致。Ferrario等 [31] 研究也发现，咀嚼肌的肌电幅度水平可以预测咬合力的大小。Wilding等 [32] 通过咬合接触面积和咬合力等参数预测咀嚼效率，并提出咬合接触面积越大则咬合力越大，咀嚼功能越好。一侧后牙缺失时，一侧的咬合接触面积减少，因此更容易出现CSP现象。研究 [33] 表明，具有CSP者的咀嚼效率只有正常者的60%。所以单侧后牙缺失造成的CSP，可能是过度咀嚼的危险因素 [34] 。

CSP在青少年中的发生率约为80% [35] ，生长期间的青少年长期CSP可直接影响口颌系统软硬组织的生长发育，面部双侧对称性改变会导致各种错 畸形、颜面畸形甚至颞下颌关节疾病的发生 [35] 。近年来的研究 [36] – [39] 还发现，CSP是牙隐裂、牙齿磨损、面部疼痛、听力下降等的危险因素。本研究发现，右侧方咬合运动时4组的TOF、TCA均有明显差异（ P <0.05），大小依次为不伴TMD症状的非CSP>伴TMD症状的非CSP>不伴TMD症状的CSP>伴TMD症状的CSP；而在前伸和左侧方运动时未见明显差异（ P >0.05）。咬合分析研究 [40] 表明，右侧咀嚼者占大部分，且右侧的咬合力更大，咀嚼性能更好。Serel Arslan等 [41] 也研究发现，76%的右利手受试者存在右侧CSP，进一步研究发现，咀嚼偏好侧与手偏好侧之间存在低至中度的相关。Nissan等 [42] 对189名受试者进行观察，发现81.6%的人选择右侧咀嚼，右利手者大都存在右侧CSP。本研究结果也表明，伴/不伴TMD症状的CSP组COF都偏右侧更多一些，推测这可能是由于临床上右侧偏侧咀嚼者多于左侧偏侧咀嚼者，长期右侧偏侧咀嚼对右侧方运动的影响更为明显。

COF反映了左右侧 力分布的均衡状态，COF偏离中线越远， 力分布越不均衡 [43] 。本研究对COF距中线垂直距离进行定量分析，4组间比较差异有统计学意义（ P <0.05），与非CSP组相比，CSP组COF距离中线更远，偏向习惯侧更多。COF与偏移方向组间比较有明显差异（ P <0.05），CSP组的COF更大比例位于灰圈外。说明了CSP组患者左右侧 力分布不均衡。左侧方 时，4组的OT有明显差异（ P <0.05），伴TMD症状的CSP组OT明显高于其他3组。OT是衡量咬合稳定性的重要指标之一，OT短则早期咬合接触概率低，此时牙位与肌位一致性高，咬合能够在短时间内获得很好的稳定性；反之，OT时间延长，咬合早期接触可能性大，咬合稳定性差，咬合时的肌位与牙位不一致 [44] ，这样长时间下去形成恶性循环，增加了肌肉的额外负担，患者主观感到肌肉酸痛不适症状。笔者在临床检查时也发现伴TMD症状的CSP/非CSP患者左侧方运动时，大部分侧方运动受限制，存在咬合干扰。Kerstein等 [45] 研究发现，咀嚼肌收缩活动与OT相关，OT延长，肌电水平相应上升，咀嚼肌容易缺血，继而出现疲劳、僵直等一系列肌肉症状。林雪峰 [46] 采用T-ScanⅡ咬合分析仪、BioEMG肌电分析仪分析了牙列完整与单侧磨牙、前磨牙缺失患者的咬合和肌电状态，结果显示牙列完整组COF横向偏移指数明显小于单侧磨牙缺失组；单侧磨牙及前磨牙支撑区缺损患者左侧咬肌肌电活动幅值、咬合力不对称指数明显高于右侧。

本实验从咬合数据的分析发现，4组的COF、COF偏移方向、COF距中线垂直距离均有明显差异（ P <0.05）。CSP组左右侧咬合力的差异表现为最大咬合力的分布不对称。在TMD患者中，CSP患者比非CSP患者COF更多位于灰圈外和分布左右两侧，咬合不平衡更明显。牙尖交错 时，伴/不伴TMD症状的非CSP组左右咬合力分布未见明显差异，伴/不伴TMD症状的CSP组习惯侧与非习惯侧咬合力分布有明显差异（ P <0.05）；Spearman相关性分析表明，习惯侧最大咬合力、习惯侧最大接触面积、COF位置与CSP均有相关性（ P <0.05），表明CSP会影响咬合力的分布。其他学者的研究结果与本研究一致。Dzingutė等 [47] 利用T-can Ⅱ分析系统记录TMD患者和非TMD患者的咬合情况，探讨静态咬合参数与TMD临床症状的关系，结果显示，TMD患者的COF平均值（6.55 mm±0.99 mm）高于非TMD患者（5.88 mm±0.69 mm），咬合力距离和咬合力不对称指数也明显高于非TMD患者。Lila-Krasniqi等 [48] 利用T-can分析系统比较固定义齿组、TMD组和非TMD组3组对象的咬合情况，发现3组间咬合力分布差异有统计学意义（ P <0.05）。本研究结果显示，伴TMD症状的受试者在牙尖交错位TOF、TCA的Spearman相关性分析结果均有差异（ P <0.05），证实了咬合分析指数与TMD相关。Abekura等 [49] 研究发现，偏侧咀嚼时两侧咀嚼肌肌电活动的不对称性增加常伴随有TMD病情加重。因此，两侧的咬合力分布不均，导致一侧或两侧咀嚼肌的肌电异常，可能导致TMD。Khan等 [50] 选取95名已建立CSP的受试者（年龄20~35岁），记录受试者下颌两侧的咬合力测量值，结果发现，男性和女性的最大咬合力在主要咀嚼侧分别为694.73 N和507.20 N，主要咀嚼侧的最大咬合力均显著高于非主要咀嚼侧。这与本研究的研究结果一致。Rovira-Lastra等 [33] 调查了146名牙列完整成人的咀嚼习惯与咬合接触、最大咬合力、咀嚼效率、咀嚼循环时间的关系，发现咬合力不对称与CSP关系最为密切。

综上，本研究表明，牙尖交错位时，4组的TOF、TCA有明显差异（ P <0.05）；右侧方咬合运动时4组的TOF、TCA也有明显差异（ P <0.05）；左侧方 时，4组的OT有明显差异（ P <0.05）；习惯侧最大咬合力、习惯侧最大接触面积、COF位置与CSP呈正相关（ P <0.05）；TMD与牙尖交错位时TOF、TCA呈负相关（ P <0.05）；伴CSP者的咬合特点发生了改变，习惯侧与非习惯侧最大咬合力分布不对称，COF更分散。长期的偏侧咀嚼导致了咬合接触改变，引起咬合干扰，造成COF的偏移。当达到生理调节极限，打破了这种协调一致的生理平衡关系，就会对咀嚼肌及颞颌关节造成直接的影响，同时由于两侧咬合力分布不均和咀嚼肌功能状态不同使得两侧关节的功能负荷不同，也更加剧了关节的变化，因此可以认为偏侧咀嚼是TMD的危险因素之一。本研究通过数字化咬合系统检查获得伴TMD症状的CSP患者咬合特点量化性指标，为进一步探讨CSP的咬合情况与临床症状的相关性提供了一定的研究基础，为临床上伴CSP的TMD患者的诊治提供了新的思路。

Funding Statement

[基金项目] 国家自然科学基金（81970957）；解放军总医院医疗大数据与人工智能研发项目（2019MBD-013）

Supported by: The National Natural Science Foundation of China (81970957); Research and Development Project of Medical Big Data and Artificial Intelligence in Chinese PLA General Hospital (2019MBD-013).

Footnotes

References

1. Poikela A, Kantomaa T, Pirttiniemi P, et al. Unilateral masticatory function changes the proteoglycan content of mandibular condylar cartilage in rabbit[J] Cells Tissues Organs. 2000; 167 (1):49–57. [ PubMed ] [ Google Scholar ]

2. Poikela A, Pirttiniemi P, Kantomaa T. Location of the glenoid Fossa after a period of unilateral masticatory function in young rabbits[J] Eur J Orthod. 2000; 22 (2):105–112. [ PubMed ] [ Google Scholar ]

3. Bakke M, Michler L. Temporalis and masseter muscle activity in patients with anterior open bite and craniomandibular disorders[J] Scand J Dent Res. 1991; 99 (3):219–228. [ PubMed ] [ Google Scholar ]

4. 郑 德鑫. 锥形束CT对偏侧咀嚼伴颞下颌关节紊乱病患者颞下颌关节骨性结构的测量分析[D] 遵义: 遵义医科大学; 2019. [ Google Scholar ] Zheng DX. Cone beam CT measurement and analysis of temporomandibular joint bone structure in TMD patients with unilateral mastication[D] Zunyi: Zunyi Medical University; 2019. [ Google Scholar ]

5. Jiang H, Liu H, Liu G, et al. Analysis of brain activity involved in chewing-side preference during chewing: an fMRI study[J] J Oral Rehabil. 2015; 42 (1):27–33. [ PubMed ] [ Google Scholar ]

6. Yu Q, Liu Y, Chen X, et al. Prevalence and associated factors for temporomandibular disorders in Chinese civilian pilots[J] Int Arch Occup Environ Health. 2015; 88 (7):905–911. [ PubMed ] [ Google Scholar ]

7. Diernberger S, Bernhardt O, Schwahn C, et al. Self-reported chewing side preference and its associations with occlusal, temporomandibular and prosthodontic factors: results from the population-based Study of Health in Pomerania (SHIP-0)[J] J Oral Rehabil. 2008; 35 (8):613–620. [ PubMed ] [ Google Scholar ]

8. 姜 华, 刘 洪臣. 偏侧咀嚼对口颌系统的影响[J] 中华老年口腔医学杂志 2006; 4 (4):235–237. [ Google Scholar ] Jiang H, Liu HC. Effect of chewing side preference on oral and maxillofacial system[J] Chin J Geriatric Stomatol. 2006; 4 (4):235–237. [ Google Scholar ]

9. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group[J] J Oral Facial Pain Headache. 2014; 28 (1):6–27. [ PMC free article ] [ PubMed ] [ Google Scholar ]

10. Jiang H, Li C, Wang Z, et al. Assessment of osseous morphology of temporomandibular joint in asymptoma-tic participants with chewing-side preference[J] J Oral Rehabil. 2015; 42 (2):105–112. [ PubMed ] [ Google Scholar ]

11. Yun P. Tee-Test咬合分析系统评价减数治疗对咬合的影响[D] 上海: 上海交通大学; 2014. [ Google Scholar ] Yun P. Tee-Test occlusion analysis system to evaluate the effect of subtraction therapy on occlusion[D] Shanghai: Shanghai Jiaotong University; 2014. [ Google Scholar ]

12. 李 平, 胡 晓阳, 周 崇阳. T-ScanⅡ咬合分析系统在修复临床中的应用[J] 中国医药导报 2011; 8 (18):17–20. [ Google Scholar ] Li P, Hu XY, Zhou CY. Application of T-scanⅡocclusion analysis system in prosthodontics[J] China Med Herald. 2011; 8 (18):17–20. [ Google Scholar ]

13. 马 明宇. T-Scan Ⅲ评价安氏Ⅱ ² 亚类患者排齐整平前后咬合功能状态改变的研究[D] 郑州: 郑州大学; 2019. [ Google Scholar ] Ma MY. A primary study on the changes of occlusal function in patients with Class II division 2 subdivision malocclusion before and after aligning and leveling by T-Scan III occlusal analysis system[D] Zhengzhou: Zhengzhou University; 2019. [ Google Scholar ]

14. 郑 洁, 李 鸿波, 姜 华, et al. 第十二次全国口腔修复学学术会议论文汇编. 长春: 中华口腔医学会口腔修复学专业委员会; 2018. 下颌轨迹运动分析系统在颞下颌关节紊乱综合征患者咬合重建中的治疗初探[C] [ Google Scholar ] Zheng J, Li HB, Jiang H, et al. Proceedings of the 12th national conference on prosthodontics. Changchun: Professional Committee of Prosthodontics of Chinese Stomatological Association; 2018. Preliminary study on the treatment of TMD patients with occlusal reconstruction by mandibular trajectory motion analysis system[C] [ Google Scholar ]

15. 刘 源, 陈 明, 赵 充, et al. 鼻咽癌患者调强放射治疗后颞颌关节损伤及其影响因素[J] 癌症 2007; 186 (1):64–67. [ Google Scholar ] Liu Y, Chen M, Zhao C, et al. Temporomandibular joint injury and its influencing factors in patients with nasopharyngeal carcinoma after intensity modulated radiotherapy[J] Cancer. 2007; 26 (1):64–67. [ PubMed ] [ Google Scholar ]

16. 傅 开元. 第八届全国颞下颌关节病学及|HE|学大会论文汇编. 北京: 中华口腔医学会颞下颌关节病学及|HE|学专业委员会; 2011. 正畸和修复治疗中对颞下颌关节问题的判断和处理[C] [ Google Scholar ] Fu KY. Proceedings of the 8th national conference on temporomandibular joint disease and occlusion. Beijing: Professional Committee of Temporomandibular Arthropathy and Occlusion of Chinese Stomatological Association; 2011. Judgment and treatment of temporomandibular joint problems in orthodontic and prosthetic treatment[C] [ Google Scholar ]

17. Shimada A, Hara S, Svensson P. Effect of experimental jaw muscle pain on EMG activity and bite force distribution at different level of clenching[J] J Oral Rehabil. 2013; 40 (11):826–833. [ PubMed ] [ Google Scholar ]

18. Bristela M, Schmid-Schwap M, Eder J, et al. Magnetic resonance imaging of temporomandibular joint with anterior disk dislocation without reposition—long-term results[J] Clin Oral Investig. 2017; 21 (1):237–245. [ PMC free article ] [ PubMed ] [ Google Scholar ]

19. 张 欣. 新疆医科大学维吾尔族及汉族大学生颞下颌关节紊乱与心理因素的相关性研究[D] 新疆: 新疆医科大学; 2016. [ Google Scholar ] Zhang X. Study on the correlation between temporomandibular joint disorders and psychological factors of Uygur and Han college students in Xinjiang Medical University[D] Xinjiang: Xinjiang Medical University; 2016. [ Google Scholar ]

20. Nagata A, Nakayama K, Nakamura S, et al. Serotonin1B receptor-mediated presynaptic inhibition of proprioceptive sensory inputs to jaw-closing motoneurons[J] Brain Res Bull. 2019; 149 :260–267. [ PubMed ] [ Google Scholar ]

21. Turcio KH, Zuim PR, Guiotti AM, et al. Does the habitual mastication side impact jaw muscle activity[J] Arch Oral Biol. 2016; 67 :34–38. [ PubMed ] [ Google Scholar ]

22. 姜 华. 偏侧咀嚼患者不同形式咀嚼运动的功能性磁共振成像研究[D] 北京: 中国人民解放军军医进修学院; 2006. [ Google Scholar ] Jiang H. Functional magnetic resonance imaging study on different forms of masticatory movement in patients with unilateral mastication[D] Beijing: Military Medical Training College of PLA; 2006. [ Google Scholar ]

23. Cao Y, Xie QF, Li K, et al. Experimental occlusal interference induces long-term masticatory muscle hyperalgesia in rats[J] Pain. 2009; 144 (3):287–293. [ PubMed ] [ Google Scholar ]

24. 朱 娴. 偏侧咀嚼习惯对颞下颌关节形态及功能的影响[J] 中国卫生产业 2014; 11 (31):171–172. [ PubMed ] [ Google Scholar ] Zhu X. Research progress on the preferred chewing side[J] China Health Industry. 2014; 11 (31):171–172. [ Google Scholar ]

25. Baldini A, Nota A, Cozza P. The association between occlusion time and temporomandibular disorders[J] J Electromyogr Kinesiol. 2015; 25 (1):151–154. [ PubMed ] [ Google Scholar ]

26. Wang C, Yin XM. Occlusal risk factors associated with temporomandibular disorders in young adults with normal occlusions[J] Oral Surg Oral Med Oral Pathol Oral Radiol. 2012; 114 (4):419–423. [ PubMed ] [ Google Scholar ]

27. Koos B, Godt A, Schille C, et al. Precision of an instrumentation-based method of analyzing occlusion and its resulting distribution of forces in the dental arch[J] J Orofac Orthop. 2010; 71 (6):403–410. [ PubMed ] [ Google Scholar ]

28. 章 巧, 黄 东宗, 李 鸿波, et al. 无症状偏侧咀嚼者咬合分析[J] 口腔颌面修复学杂志 2020; 21 (3):162–167. [ Google Scholar ] Zhang Q, Huang DZ, Li HB, et al. Occlusion analysis of asymptomatic unilateral masticators[J] Chin J Prosthod. 2020; 21 (3):162–167. [ Google Scholar ]

29. Gomes SG, Custodio W, Faot F, et al. Chewing side, bite force symmetry, and occlusal contact area of subjects with different facial vertical patterns[J] Braz Oral Res. 2011; 25 (5):446–452. [ PubMed ] [ Google Scholar ]

30. Hidaka O, Iwasaki M, Saito M, et al. Influence of clen-ching intensity on bite force balance, occlusal contact area, and average bite pressure[J] J Dent Res. 1999; 78 (7):1336–1344. [ PubMed ] [ Google Scholar ]

31. Ferrario VF, Sforza C, Zanotti G, et al. Maximal bite forces in healthy young adults as predicted by surface electromyography[J] J Dent. 2004; 32 (6):451–457. [ PubMed ] [ Google Scholar ]

32. Wilding RJ, Adams LP, Lewin A. Absence of association between a preferred chewing side and its area of functional occlusal contact in the human dentition[J] Arch Oral Biol. 1992; 37 (5):423–428. [ PubMed ] [ Google Scholar ]

33. Rovira-Lastra B, Flores-Orozco EI, Ayuso-Montero R, et al. Peripheral, functional and postural asymmetries related to the preferred chewing side in adults with natural dentition[J] J Oral Rehabil. 2016; 43 (4):279–285. [ PubMed ] [ Google Scholar ]

34. Yamasaki Y, Kuwatsuru R, Tsukiyama Y, et al. Objective assessment of mastication predominance in healthy dentate subjects and patients with unilateral posterior missing teeth[J] J Oral Rehabil. 2016; 43 (8):575–582. [ PubMed ] [ Google Scholar ]

35. 邱 丽娜. 偏侧咀嚼对青少年的不良影响[J] 现代养生 2015 (14):247. [ Google Scholar ] Qiu LN. Adverse effects of unilateral mastication on adolescents[J] Modern Health Preserv. 2015 (14):247. [ Google Scholar ]

36. Lee YR, Choi JS, Kim HE. Unilateral chewing as a risk factor for hearing loss: association between chewing habits and hearing acuity[J] Tohoku J Exp Med. 2018; 246 (1):45–50. [ PubMed ] [ Google Scholar ]

37. Lee JY, Lee ES, Kim GM, et al. Unilateral mastication evaluated using asymmetric functional tooth units as a risk indicator for hearing loss[J] J Epidemiol. 2019; 29 (8):302–307. [ PMC free article ] [ PubMed ] [ Google Scholar ]

38. 姜 华, 董 宪喆, 胡 园, et al. 偏侧咀嚼对小鼠学习记忆能力的影响及相关机制研究[J] 口腔颌面修复学杂志 2018; 19 (5):280–284. [ Google Scholar ] Jiang H, Dong XZ, Hu Y, et al. Effects of chewing side perference on learning and memory ability of mice and related mechanisms[J] Chin J Prosthodont. 2018; 19 (5):280–284. [ Google Scholar ]

39. Rikmasari R, Yubiliana G, Maulina T. Risk factors of orofacial pain: a population-based study in west Java province, Indonesia[J] Open Dent J. 2017; 11 :710–717. [ PMC free article ] [ PubMed ] [ Google Scholar ]

40. Haralur SB, Majeed MI, Chaturvedi S, et al. Association between preferred chewing side and dynamic occlusal parameters[J] J Int Med Res. 2019; 47 (5):1908–1915. [ PMC free article ] [ PubMed ] [ Google Scholar ]

41. Serel Arslan S, İnal Ö, Demir N, et al. Chewing side preference is associated with hemispheric laterality in healthy adults[J] Somatosens Mot Res. 2017; 34 (2):92–95. [ PubMed ] [ Google Scholar ]

42. Nissan J, Gross MD, Shifman A, et al. Chewing side preference as a type of hemispheric laterality[J] J Oral Rehabil. 2004; 31 (5):412–416. [ PubMed ] [ Google Scholar ]

43. 赵 颖, 丁 张帆, 康 龙, et al. TeeTester与T-Scan Ⅲ咬合分析仪对正常 青年学生咬合力特征的比较[J] 中国组织工程研究 2015; 19 (51):8289–8293. [ Google Scholar ] Zhao Y, Ding ZF, Kang L, et al. Comparison of bite force characteristics between teetester and T-scan III occlusion analyzer in normal young students[J] Chin J Tissue Eng Res. 2015; 19 (51):8289–8293. [ Google Scholar ]

44. Abdelnabi MH, Swelem AA, Al-Dharrab AA. Influence of denture adhesives on occlusion and disocclusion times[J] J Prosthet Dent. 2016; 115 (3):306–312. [ PubMed ] [ Google Scholar ]

45. Kerstein RB, Farrell S. Treatment of myofascial pain-dysfunction syndrome with occlusal equilibration[J] J Prosthet Dent. 1990; 63 (6):695–700. [ PubMed ] [ Google Scholar ]

46. 林 雪峰. 第十一次全国颞下颌关节病学术研讨会. 北京: 中华口腔医学会颞下颌关节病专业委员会; 2014. 单侧咬合支撑区缺损对咬合平衡及咀嚼肌肌电平衡的影响[C] [ Google Scholar ] Lin XF. Proceedings of the 11th national symposium on temporomandibular joint disease. Beijing: Professional Committee of Temporomandibular Arthropathy of Chinese Stomatological Association; 2014. Effects of unilateral occlusal support area defect on occlusal balance and masticatory muscle EMG balance[C] [ Google Scholar ]

47. Dzingutė A, Pileičikienė G, Baltrušaitytė A, et al. Evaluation of the relationship between the occlusion parameters and symptoms of the temporomandibular joint disorder[J] Acta Med Litu. 2017; 24 (3):167–175. [ PMC free article ] [ PubMed ] [ Google Scholar ]

48. Lila-Krasniqi ZD, Shala KS, Pustina-Krasniqi T, et al. Differences between centric relation and maximum intercuspation as possible cause for development of temporomandibular disorder analyzed with T-scan III[J] Eur J Dent. 2015; 9 (4):573–579. [ PMC free article ] [ PubMed ] [ Google Scholar ]

49. Abekura H, Kotani H, Tokuyama H, et al. Asymmetry of masticatory muscle activity during intercuspal maximal clenching in healthy subjects and subjects with stomatognathic dysfunction syndrome[J] J Oral Rehabil. 1995; 22 (9):699–704. [ PubMed ] [ Google Scholar ]

50. Khan SIR, Rao D, Ramachandran A, et al. Comparison of bite force on the dominant and nondominant sides of patients with habitual unilateral chewing: a pilot study[J] Gen Dent. 2020; 68 (2):60–63. [ PubMed ] [ Google Scholar ]