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研究生:陳俊明
研究生(外文):Chun-Ming Chen
論文名稱:以改良式下顎枝垂直截骨術治療下顎前突症之穩定性研究
論文名稱(外文):Stability after modified vertical ramus osteotomy for correction of mandibular prognathism
指導教授:賴聖宗賴聖宗引用關係
指導教授(外文):Shen-Chung Lai
學位類別:碩士
校院名稱:高雄醫學大學
系所名稱:牙醫學研究所
學門:醫藥衛生學門
學類:牙醫學類
論文種類:學術論文
論文出版年:2001
畢業學年度:89
語文別:中文
論文頁數:83
中文關鍵詞:手術後的穩定性下顎前突症下顎枝垂直截骨術
外文關鍵詞:Postoperative StabilityMandibular PrognathismModified Intraoral Vertical Ramus Osteotomy
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下顎前突症的人乃是由於下顎骨發育過度致使下顎骨過長,而破壞臉型之和諧與齒列的功能,影響患者之心理。正顎手術的目的在於經由消除不和諧的外觀,重建顏面的美觀,與改善咀嚼功能。
本篇研究的目的,在於研究下顎前突的患者,在施行改良式下顎枝垂直截骨術後,於術後二年內陸續的追蹤中,下顎骨在水平向與垂直向位差的變化與穩定性,並且探討可能造成術後復發的原因,與其相關性。本次研究的對象為只有單純實施雙側改良式下顎枝垂直截骨術,追蹤超過一年共44人,其中有20人追蹤超過二年。收集測顱X光片包括術前(T1),立即手術後(T2)、拆除顎間固定前(T3) 、手術後三個月(T4) 、手術後半年(T5)、手術後一年(T6)、手術後二年(T7),並選定Me界標點做為下顎骨位移時之測量點。
追蹤滿二年的20位病人在立即手術後的位差(T21),Me平均後退12.3mm,下降0.8mm。其中術後一年的追蹤(T6)跟立即手術後(T2)做此較,這二期都有X光片的病人共有12人,在水平方向Me有4位向前位移平均2.1mm(16% = 2.1/13.1),向後位移有8位1.6mm(12.4% = 1.6/12.9)。在垂直方向Me是向上位移有7位平均1.5mm ,Me向下位移有5位平均0.7mm。追蹤滿二年的病人中,手術後二年的追蹤(T7)跟立即手術後(T2)來此較,在水平方向Me向前位移有14位平均2mm(16.3% = 2/12.3),向後位移有5位平均1.4mm(12.1% = 1.4/11.6),其中有1個病人沒有位移。在垂直方向Me向上位移有11位平均1.7mm, 向下位移有8位平均1.2mm ,其中有1個病人沒有位移,顯示改良式下顎枝垂直截骨術,治療嚴重下顎前突症具有很好的術後穩定性。
為了研究可能會影響手術後下顎骨穩定性的因素,我們進一步考量手術的後退量和骨切線位置(Cut)與下顎枝後下部最後緣的點(Rp)在水平向和垂直向的距離,以及翼咀嚼肌懸帶容納量(pterygomasseteric sling acceptable capacity)等五個變數的關係,利用多元迴歸分析,來探討二年後Me在水平向和垂直向的位差在統計上的相關性。結果顯示在垂直向Me的平均復發量與立即手術後(T21)Me在垂直向的位差之間有相關性存在;而在水平向這五個變數與手術後二年(T72)Me的平均復發量並無相關性存在。但是我們發現所有(T72)術後遠心骨段向後位移的病例(平均1.4mm)都是切線點(Cut)比較前面,亦即有較大的翼咀嚼肌懸帶容納量,所以切線點的位置對術後遠心骨段的穩定性應該具有很大的影響。
改良式下顎枝垂直截骨術的優點包括,翼咀嚼肌懸帶的容納量比較大,所以後退時比較不會卡住,後退量可以此較大,骨骼重疊面積大,手術後下顎骨的穩定性高。所以,我們認為改良式下顎枝垂直截骨術,很適合來治療下顎前突較為嚴重的患者。

Mandibular prognathism is characterized by excessive mandibular growth, which may compromise the masticatory function and facial appearance, and this may distort the personality of the patient. Surgical correction of mandibular prognathism will generally improve both the masticatory function and dentofacial aesthetics. This study was undertaken to examine the factors that might be responsible for skeletal stability occurring during one to two years postoperative mandibular setback.
Forty-four patients, treated for absolute mandibular prognathism by modified intraoral bilateral vertical ramus osteotomy, were evaluated cephalometrically at least 1-year postoperatively. A set of 7 standardized lateral cephalograms were obtained from each subject, i.e., preoperative (T1) and immediately postoperative (T2), prior to removing the maxillomandibular fixation (T3), 3 months (T4), 6 months (T5), 1-year (T6) and 2-years postoperative (T7). There were 20 patients who underwent a 2-year follow-up with cephalograms. The mean setback of the menton was 12.3mm in the horizontal direction and 0.8mm downward in the vertical direction. Relapse was
defined as forward movement of the menton during the 2-year postoperative period.
The average movement for 1-year follow-up (12 of 20 patients) in the horizontal direction was as follows; 4 with 2.1mm (16% = 2.1/13.1) in forward movement and 8 with 1.6mm (12.4% = 1.6/12.9) in backward movement. The average movement during the 1-year follow-up (12 of 20 patients) in the vertical direction was 7 patients with 1.5mm in upward movement and 8 with 0.7mm in downward movement. The average movement during the 2-year follow-up (20 patients) in the horizontal direction was as follows; 14 with 2mm (16.3% = 2/12.3) in forward movement and 5 with 1.4mm (12.1% = 1.4/11.6) in backward movement. The average movement during the 2-year follow-up (20 patients) in the vertical direction was as follows; 11 patients with 1.7mm in upward movement and 8 with 1.2mm in downward movement.
The variables included vertical and horizontal Me (T21) distance, Rp-Cut (distance between osteotomy point and the most posterior point of inferior ramus)(T1), and area of the pterygomasseteric sling (Rp-Cut-H ×V-T1) The multiple regression showed that the vertical amount of setback (T21) that predicated the vertical relapse (T72) was significant, whereas no significant
correlations were noted between the variables and horizontal relapse (T72). In patients whose distal segments were still in the backward group 2-years postoperaviely, their osteotomy positions were anterior to the forward group.
This tell us: the more anterior osteotomy position the more acceptable capacity of the pterygomasseteric sling will be created and this allow the distal segment to setback more without distend the pterygomasseteric sling.
These results suggest that this technique can provide greater acceptable capacity for larger amount of distal segment setback and is feasible for the correction of severe mandibular prognathism.
Key Words: Postoperative Stability, Mandibular Prognathism
Modified Intraoral Vertical Ramus Osteotomy

中文摘要 …………………..………………………………… I
英文摘要 …………………..…………..……………………. III
致 謝 ………………………..…………………………… V
目 錄 …………………………………..………………… VI
表 次 …………………………….……..……………….. VIII
圖 次 ……………………………………………………. IX
第一章 前 言 ………..…………….……………………. 1
第二章 下顎骨前突正顎手術的文獻回顧 …………....… 5
第一節 下顎骨的生長與發育 ……………………… 5
第二節 下顎骨前突症的顏面特徵和齒列狀況 ……. 7
第三節 下顎骨前突正顎手術的歷史起源與發展 …. 8
第三章 材料與方法 …………………………….……..…… 16
第一節 研究對象 ……………………………………. 16
第二節 預備性的研究 …………………………..…... 18
第三節 主體的研究 …………………………………. 21
第四節 資料處理與統計分析 ………………………. 22
第四章 研究結果 …………………………………………. 23
第一節 手術前與立即手術後,每個界標點在垂直向
與水平向的測量 ……………………………. 23
第二節 手術後不同階段的遠心骨段的位差 ……… 24
第三節 追蹤滿二年的病人術前與立即術後每個界標
點在垂直向與水平向的位 .………………… 26
第四節 追蹤滿二年的病人術後不同階段的遠心骨段
的位差 …..………………………………...….. 27
第五節 追蹤滿二年的病人在立即術後與手術後二年
Me點在垂直向與水平向位差之多元迴歸
分析 …….…………………………………… 30
第五章 討 論 …………..…………………….………. 31
第一節 下顎骨復發的界標點的選擇 ………….… 31
第二節 個人誤差值的檢定 …………………..……… 33
第三節 影響手術後下顎骨穩定性的因素 …………. 34
第六章 結 論 ……….…………..…………………….. 48
參考文獻 ………….……………………………………… 49
表 次
表一 病人的性別、年齡分佈及術後追蹤期間表 …………. 55
表二 病人在T1、T2、T3、T4、T5、T6和T7期X光片數 …... 56
表三 X光片頭顱界標點的定義 …….………………………. 57
表四 X光片頭顱測量線段的定義與度量 …..……………… 58
表五 界標點(Pog、Me、Sb)的穩定性檢定 ….…………….. 59
表六 界標點測量上的誤差值檢驗 ….……………………..... 60
表七 從T1到T7各期的SN與S1N線段距離,及每個界
標點的垂直距離和水平距離的平均值和標準差 …….. 61
表八 T21、T32、T43、T54、T65和T76的SN與S1N線段
距離,及每個界標點的垂直向和水平向位差的平均值
和標準差 …………………………………………..…. 62
表九 追蹤滿二年的病人在T21、T32、T42、T52、T62和T72
的SN與S1N線段距離,及每個界標點的垂直向和
水平向位差的平均值和標準差 ……………....………. 63
表十 追蹤滿二年的病人在T21、T32、T42、T52、T62和
T72,Me的垂直向和水平向位差的t 檢定 ………... 64
表十一 追蹤滿二年的病人,Me-T72在垂直向和水平向位
差之多元迴歸資料 .…………………….………..... 65
表十二 追蹤滿二年的病人,Me-T72在水平向向前復發與
向後位移之多元迴歸分析的結果 ………….…….. 66
表十三 追蹤滿二年的病人,Me-T72在垂直向向上與向下
復發之多元迴歸分析的結果 ………………..…… 67
圖 次
圖一 手術前切線的設計及手術後下顎骨的位置 …………. 68
圖二 界標點(Pog、Me、Sb)與IiB的相關位置 ………….…. 69
圖三 X光片頭顱界標點的位置 …………………………….. 70
圖四 全部病人在 T1時Overbite和Overjet的數值 ……….. 71
圖五 全部病人在T21時,Me在垂直向與水平向的位差 … 72
圖六 全部病人在T32時,Me在垂直向與水平向的位差 … 73
圖七 全部病人在T43時,Me在垂直向與水平向的位差 … 74
圖八 全部病人在T54時,Me在垂直向與水平向的位差 … 75
圖九 全部病人在T65時,Me在垂直向與水平向的位差 … 76
圖十 全部病人在T76時,Me在垂直向與水平向的位差 … 77
圖十一 追蹤滿二年的病人在T21時,Me在垂直向與
水平向的位差 …………………………………… 78
圖十二 追蹤滿二年的病人在T32時,Me在垂直向與
水平向的位差 …………………………………….. 79
圖十三 追蹤滿二年的病人在T42時,Me在垂直向與
水平向的位差 …………………………………….. 80
圖十四 追蹤滿二年的病人在T52時,Me在垂直向與
水平向的位差 …………………………………….. 81
圖十五 追蹤滿二年的病人在T62時,Me在垂直向與
水平向的位差 …………………………………….. 82
圖十六 追蹤滿二年的病人在T72時,Me在垂直向與
水平向的位差 …………………………………….. 83

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