臺灣博碩士論文加值系統

下顎前突症是下顎骨過度生長所致, 其顏面特徵與發生率隨種族不同而有所差異, 除了外貌的問題之外, 咀嚼功能的障礙、發音問題、人際關係與心理因素都是患者求助治療的原因。本研究的目的, 在於探討以改良式下顎枝垂直截骨術治療下顎前突的患者, 其下顎骨角區域的改變與穩定性之間的關係。
我們將32位僅接受改良式下顎枝垂直截骨術治療的下顎前突症患者, 其中男性9位, 女性23位, 進行術前(A)、立即術後(B1)與術後兩年(B6)的側顱分析, 結果顯示, (1). 在穩定度方面, 術後兩年Me點向前位移(即復發)的患者有22位, 這些患者的平均退後量為13.96mm, 復發量為1.90mm, 向前位移平均率為13.61%; 在術後兩年Me 點向後位移的患者有10位, 這些患者的平均後退量為11.31mm, 向後位移的量為2.46mm, 平均向後位移率為21.75%。(2). 在Go點的變動方面, 在Me點向前位移的族群裡, 術後Go點平均向後1.35mm, 向上1.90mm, gonial angle 平均增大3.69度, 腭平面與下顎平面的夾角則是增加5.00度; 在Me點向後位移的族群裡, 術後Go點平均向後1.85mm, 向上3.32mm, gonial angle 平均增大4.06度, 腭平面與下顎平面的夾角則是增加5.22度, 不論是向前或是向後的族群, 結果皆顯示翼咀嚼肌懸吊帶有輕微被拉長的跡象。(3). 不論在術中髁突所放置的位置如何, 術後兩年的觀察皆顯示髁突皆會朝原來的位置移動, 不過並不會完全回去, 這也許與骨塑形有關。(4). 在多元迴歸分析中, 我們發現在諸多可能影響穩定性的因子中, 祇有下顎骨的後退量和復發量有關, 當後退量越大時, 復發量越大, 而下顎骨體的旋轉與髁突的位置變化並不會影響穩定性; 在Go點的變動方面, 不論遠心骨段後緣移動量多少, 骨切點與原來Go點的水平距離越大, 也就是越朝前方切時, 術後Go點向後移動的量越少, 當骨切點與原來Rp點的水平距離越長時, 術後Go點向後移動的量越大; 如果不考慮原來切點的位置, 而以立即術後骨切點與原來Go點的水平距離考慮時, 若立即術後骨切點位置未超過原來Go點時, 術後Go點幾乎不會有變動; 當立即術後骨切點在Go點越後面, 術後Go點向後移動的量越大, 這與翼咀嚼肌懸吊帶在下顎骨後退中, 具有可承受被拉長與改變位置的補償作用, 但是超出一限度時, 它會有要回復到原來位置與型態的能力與趨勢有關。
下顎骨角區術後的改變和骨切線位置及骨切點在術中所放置的位置有密切關係, 雖然並沒有結果顯示立即術後遠心骨段後緣與Go點的相關位置與復發量有關, 不過卻有趨勢顯示術後兩年Me點向後位移的族群裡, 大多屬於骨切點切得很前面但是後退量卻沒有很多的病例, 是否因為整個翼咀嚼肌懸吊帶因近心骨段前移而鬆弛所導致, 或是仍有其它因素未被發現, 則有待如此的病例數目增加再做進一步研究。

Mandibular prognathism due to excessive growth of mandible, varies in facial characteristics and incidences amoung the different ethnic proups. People who are seeking management of mandibular prognathism are usually disturbed by prominent lower third of the face, poor chewing function and psychological factors. In Taiwan, the high incidences and more severely dentofacial deformity in mandibular prognathism was noted and the problem could only be solved by combined orthodontic treatment and surgery. The purpose of this study was to investigate the changes in gonial region and the factors contributing to skeletal stability in mandibular prognathism treated by modified intraoral vertical ramus osteotomy.
Thirty-two patients( 9 males and 23 females ), treated for absolute mandibular prognathism by modified intraoral vertical ramus osteotomy, were evaluated cephalometrically at least two-years postoperatively. A set of three standardized lateral cephalograms were obtained from each subject, i.e., preoperative (A), immediately postoperative (B1) and two-years postoperatively (B6). Some cephalometric landmarks were used for evaluating the positional and angular change postoperatively. The results showed that (1). In stability, during the postoperative period, the Me moved forward with 1.9mm in 22 patients( group I ) whose mean setback of Me was 13.96mm, and the relapse was 13.61%. In other group, the Me moved backward with 2.46mm in 10 patients( group II ) whose mean setback of Me was 11.31mm, and the backward instability rate was 21.75%( 2.46/11.31). (2). The Go moved backward with 1.35mm and upward with 1.90mm in group I, the gonial angle increased for 3.69°, and angle between palatal plane and mandibular plane was increased for 5.00°; In group II, the Go moved backward with 1.85mm and upward with 3.32mm , the gonial angle increased for 4.06°, and angle between palatal plane and mandibular plane was increased for 5.22°. Both in group I and II, there was a tread for clockwise rotation of mandibular corpus. The length of pterygomasseteric sling was mild increased due to the backward movement of Go. (3). The displacement of condylar process( forward or backward ) didn’t influence the stability, but the condyle could not return to its original position completely. The position of condyle may be controlled by bone remodeling. (4). The results of multiple regression showed that the postoperative stability was only correlated with amount of mandibular setback, and rotation of mandibualr corpus and amount of displacement of condyle could not influence the stability. The amount of Go backward movement depends on two factors, one is the position of osteotomy site in distal segment, and the other is the position of osteotomy site in distal segment immediately postoperative. The more horizontal distance between Go and osteotomy site, the less tread of posterior movement of Go postoperatively. When the distal segment setback to ideal position of occlusion and the osteotomy site was behind to Go, the more distance between osteotomy site and Go, the more tread of posterior movement of Go postoperatively. But when the osteotomy site was before to Go, we found that the horizontal position of Go postoperatively was unchanged nearly. The pterygomasseteric sling could be lengthened and distorted under the limitation and it has potential to recover the original length and position if the stretch was larger then the upper limitation.
In our study, there was no relationship between the stability and positional change of Go postoperatively. But in group II, we found the distance between the Rp and osteotomy site was larger then amount of mandibular setback. We suspected that the backward movement of Me was caused by loosening the pterygomasseteric sling or other else. It needs more study cases for further examination.

中文摘要 ……………………………………………………………….. I
英文摘要 ………………………………………………………………. III
誌 謝 ………………………………………………………………. V
目 錄 ……………………………………………………………. VII
表 次 ……………………………………………………………. IX
圖 次 …………………………………………………………… XII
第一章前言………………………………………………………….. 1
第二章文獻回顧…………………………………………………….. 5
第一節下顎骨的生長發育與下顎前突症的發生……………….. 5
第二節下顎前突症的流行病學與顏面特徵…………………….. 10
第三節下顎骨手術的生物力學考量…………………………….. 13
第四節治療下顎前突症的常用術式…………………………….. 15
第五節下顎骨術後穩定度與骨角區變化……………………….. 19
第三章材料與方法…………………………………………………. 24
第一節研究對象………………………………………………….. 24
第二節預備性的研究…………………………………………….. 27
第三節主體的研究……………………………………………….. 29
第四節資料之分析統計………………………………………….. 32
第四章研究結果……………………………………………………. 33
第一節立即術後與術前的變化………………………………….. 33
第二節術後兩年與立即術後的比較…………………………….. 37
第三節術後兩年與術前的比較………………………………….. 40
第四節多元迴歸分析結果……………………………………….. 46
第五章討論…………………………………………………………. 51
第一節界標點與參考平面的選擇……………………………….. 51
第二節骨切點的位置與術後Go點的變化……………………... 54
第三節遠心骨段所擺置的位置與術後Go點的變化…………... 56
第四節翼咀嚼肌懸吊帶的特性與在骨角區的改變
以及骨段穩定性的角色………………………………… 58
第五節影響術後骨段穩定性的其它因素……………………….. 61
第六章結論…………………………………………………………. 66
參考文獻………………………………………………………………... 68
附 圖 表………………………………………………………………... 73

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