臺灣博碩士論文加值系統

前言與目的：患有顳顎關節盤可復性前移位(Anterior Disc Displacement with Reduction, ADDR)病患常飽受開閉口時關節聲響之苦，如在公眾場所或交際應酬時，聲響造成尷尬場面無法順利言談。此外隨著病情多樣化，可能併發開閉口時路徑偏斜、關節囊及盤後組織易發炎腫痛，甚至開口偶而受限無法順利張嘴等問題。基於此，本研究探討咬合板對關節盤可復性前移位的治療療效，並分析相關因子對治療的影響。
樣本與方法：本研究收集48位臨床上診斷為關節盤可復性移位病患，總關節數50個；每位病患皆接受咬合板治療，及拍攝靜態和動態核磁共振影像(MRI)以確立疾病診斷，並定期追踪記錄直至治療療程結束。其中有34位病患，總關節數35個，同時拍攝戴入咬合板於口內後的關節影像。於治療療程結束後半年時間，本研究追踪到30位當初核磁共振影像確立診斷為關節盤可復性移位的病患，總關節數32個，再次收集相關臨床資料，進而探討此30位病患的半年後成功率，以及是否受相關因子影響。此些因子在臨床上包括年齡、性別、發生關節彈響(clicking sound)或間歇性卡住(intermittent locking)時開口度、關節聲響或間歇性卡住存在時間、開咬併發症；在影像上包括關節盤形態、關節盤移位型態、關節盤移位量、關節頭形變。
結果：初始50個關節影像中，40個診斷等同於臨床診斷，臨床診斷準確率達80.0%。影像診斷為關節盤可復性前移位，且同時有拍攝戴入咬合板的關節影像有28個，立即關節盤完整復位率達75.0%。治療結束而半年後追踪的32個關節中，治療成功率達62.5%；此外將各個因子分項，利用Fisher’s exact test及Chi-square test探討此些因子和治療成功與否的關係，並以Logistic regression統計方法，評估各相關因子間相互調整後的odd ratios，結果發現並無任何因子有統計上顯著影響性。此外利用Wilcoxon Rank Sum Test，比較治療成功和治療失敗兩組間，關節盤移位量是否有所不同，結果顯示，亦無任何統計上顯著差異。
結論：本研究結果中，證實咬合板確實對關節盤可復性前移位有療效存在。此外在臨床上，以關節彈響或間歇性卡住合併壓舌板測試法，作為診斷方法及決定咬合板治療位置時，結果顯現其準確性很高。最後本研究探討的各項因子和治療成功率，雖然並無統計上地顯著相關性存在，但於此提供此些因子給各位參考，期望將來可朝此方面進一步研究討論。

Preface and Aim: Patients who suffered from anterior disc displacement with reduction of temporomandibular joint (ADDR) always bore clicking sound which embarrassed them and couldn’t finish a conversation with others in public place. Besides, with the variation of the disease, ADDR may accompany with painful inflammation of joint and deviation or intermittent locking during mouth opening and closing. Because of these troublesome symptom and sign, the present study was to evaluate the effect of occlusal splint for treatment of ADDR and analyzed associated factors which may have influence on it.
Materials and Methods: The study recruited 48 consecutive patients who clinically were diagnosed as ADDR. The total numbers of participated joint were 52. All of the patients received occlusal splint treatment and magnetic resonance imaging (MRI) taking, including static and movie view, to confirm the diagnosis and were followed up until the course of treatment completed. Besides, among them, there were 34 patients who also received MRI taking with insertion of occlusal splint into their oral cavity. The total numbers of joint we could compare the disc-condyle relationship under insertion of splint were 35. After course of splint treatment accomplished and passing half a year, we traced 30 patients who initially were diagnosed as ADDR by MRI and collected the clinical data again. Then we discussed the success rate of occlusal splint and analyzed if the success rate was influenced by the associated factors. These factors were as below: Clinically — Age, Sex, Mouth opening on clicking or intermittent locking, Duration of clicking or intermittent locking, Open-bite complication; Image finding — Disc morphology, Type of disc displacement, Range of disc displacement, Condyle morphology.
Results: Initially, the 50 joints clinically diagnosed as ADDR were confirm in 40 joints. The accuracy of the clinically diagnostic method for ADDR used in the present study was 80.0%. The diagnosis of MRI was ADDR and simultaneously with image of splint inserted into oral cavity comprised 28 joints. Among these 28 joints, 75.0% could be observed that disc complete recapture to normal disc-condyle relationship. After half a year in the traced 32 joints, the success rate of occlusal splint was 62.5%. Furthermore, when we divided the associated factors into subgroups and utilized the Fisher’s exact test, Chi-square test to analyze the correlation between treatment outcomes and factors, there was no any statistically significant in the results. Logistic regression and Wilcoxon Rank Sum Test, otherwise, were also used to assess the odds ratio after factors mutually adjusted each other and assess the different range of disc displacement between success group and failure group, but there was still no any statistically significant.
Conclusion: In the present study, the result confirmed the good efficacy of occlusal splint to treat anterior disc displacement with reduction of TMJ disc. In addition, we used the clicking sound and intermittent locking as guideline for diagnosis and design of splint, the result showed it’s a reliable method. Although the result in the present study didn’t show any statistically significant, here we provided some factors for further study to investigate.

頁次
中文摘要．．．．．．．．．．．．．．．．．．．．．．．． I
英文摘要．．．．．．．．．．．．．．．．．．．．．．． III

第一章 前言．．．．．．．．．．．．．．．．．．．．．．1
第一節 研究背景．．．．．．．．．．．．．．．．．．．． 1
第二節 研究目的．．．．．．．．．．．．．．．．．．．． 3

第二章 文獻回顧．．．．．．．．．．．．．．．．．．．．5
第一節 顳顎關節紊亂命名學及診斷分類．．．．．．．．．． 5
第二節 顳顎關節盤移位．．．．．．．．．．．．．．．．． 7
第三節 顳顎關節盤移位型態分類．．．．．．．．．．．．．11
第一項 靜態下觀察．．．．．．．．．．．．．．．．．． 11
第二項 動態下觀察．．．．．．．．．．．．．．．．．． 13
第四節 顳顎關節盤形態分類．．．．．．．．．．．．．．．16
第五節 核磁共振影像．．．．．．．．．．．．．．．．．．18
第六節 顳顎關節盤可復性前移位之治療．．．．．．．．．．20

第三章 樣本與方法．．．．．．．．．．．．．．．．．． 23
第一節 樣本．．．．．．．．．．．．．．．．．．．．．．23
第二節 方法．．．．．．．．．．．．．．．．．．．．．．25
第一項 臨床檢查．．．．．．．．．．．．．．．．．．． 26
第二項 咬合板設計．．．．．．．．．．．．．．．．．． 27
第三項 咬合板治療療程．．．．．．．．．．．．．．．． 28
第四項 核磁共振影像拍攝及設定．．．．．．．．．．．． 30
第五項 顳顎關節盤形態分類．．．．．．．．．．．．．． 33
第六項 顳顎關節盤移位型態分類．．．．．．．．．．．． 33
第七項 戴上咬合板後關節盤位置分類．．．．．．．．．． 35
第八項 顳顎關節頭形變分類．．．．．．．．．．．．．． 35
第九項 顳顎關節盤移位測量．．．．．．．．．．．．．． 35
第十項 統計分析方法．．．．．．．．．．．．．．．．． 37

第四章 結果．．．．．．．．．．．．．．．．．．．．． 38
第一節 臨床診斷準確率．．．．．．．．．．．．．．．．．38
第二節 顳顎關節盤形態分類及移位型態分類百分比．．．．．40
第三節 戴上咬合板後關節盤位置分類百分比．．．．．．．．41
第四節 治療成功率．．．．．．．．．．．．．．．．．．．42
第一項 基本資料及預後．．．．．．．．．．．．．．．． 42
第二項 臨床相關因子影響性．．．．．．．．．．．．．． 43
第三項 影像相關因子影響性．．．．．．．．．．．．．． 45
第四項 因子間相互調整後影響性．．．．．．．．．．．． 46
第五項 關節盤移位量影響性．．．．．．．．．．．．．． 48

第五章 討論．．．．．．．．．．．．．．．．．．．．． 50
第一節 臨床診斷準確率探討．．．．．．．．．．．．．． 50
第二節 顳顎關節盤可復性前移位特性之探討．．．．．．． 53
第一項 性別．．．．．．．．．．．．．．．．．．．．． 53
第二項 年齡．．．．．．．．．．．．．．．．．．．．． 54
第三項 關節盤形態．．．．．．．．．．．．．．．．．． 54
第四項 關節盤移位型態．．．．．．．．．．．．．．．． 56
第三節 咬合板探討．．．．．．．．．．．．．．．．．． 60
第一項 咬合板設計．．．．．．．．．．．．．．．．．． 60
第二項 戴入咬合板後立即關節盤-關節頭相對位置關係．．．62
第四節 治療成功率．．．．．．．．．．．．．．．．．． 64

第六章 結論．．．．．．．．．．．．．．．．．．．．． 68

參考文獻．．．．．．．．．．．．．．．．．．．．．．．．69
附表．．．．．．．．．．．．．．．．．．．．．．．．．．81
附圖．．．．．．．．．．．．．．．．．．．．．．．．．．88

表目次
表一：本研究病患之基本資料表．．．．．．．．．．．．．．81
表二：核磁共振診斷為關節盤可復性前移位資本資料表．．．．81
表三：戴入咬合板於口內後關節盤有無立即復位基本資料表．．82
表四：咬合板治療後半年成功率與相關因子探討基本資料表．．83
表五：臨床相關因子中咬合板治療成功率資料表．．．．．．．84
表六：核磁共振影像相關因子中咬合板治療成功率資料表．．．85
表七：因子間相互調整過後對治療失敗的odd ratios值．．．．86
表八：半年後治療結果和關節盤移位量關係資料表．．．．．．87

圖目次

圖1：臨床取得咬合設計位置的方法．．．．．．．．．．．． 88
圖2：咬合板外觀．．．．．．．．．．．．．．．．．．．． 88
圖3：咬合板治療流程圖．．．．．．．．．．．．．．．．． 89
圖4：動態影像拍攝．．．．．．．．．．．．．．．．．．． 90
圖5：關節盤形態分類．．．．．．．．．．．．．．．．．． 91
圖6：關節盤整體向前方移位．．．．．．．．．．．．．．． 91
圖7：關節盤外側部份向前移位．．．．．．．．．．．．．． 92
圖8：關節盤內側部份向前移位．．．．．．．．．．．．．． 92
圖9：關節盤旋轉性向前外側移位．．．．．．．．．．．．． 93
圖10：關節盤旋轉性向前內側移位．．．．．．．．．．．．．93
圖11：關節盤整體向外側方移位．．．．．．．．．．．．．．94
圖12：關節盤整體向內側方移位．．．．．．．．．．．．．．94
圖13：戴入咬合板於口內後關節盤相對關節頭位置關係．．．．95
圖14：關節盤移位量基本參考點．．．．．．．．．．．．．．96
圖15：關節盤移位量參考軸線．．．．．．．．．．．．．．．96
圖16：關節盤移位量測量圖示．．．．．．．．．．．．．．．97
圖17：核磁共振影像診斷圖示．．．．．．．．．．．．．．．97
圖18：關節盤可復性前移位中各關節盤形態分類百分比．．．．98
圖19：關節盤可復性前移位中各關節移位型態分類百分比．．．98
圖20：影像上判讀誤差．．．．．．．．．．．．．．．．．．99

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