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研究生:劉必慧
研究生(外文):Pi-Huei Liu
論文名稱:下顎兩側矢向劈裂截骨術後感覺異常之影響因素探討
論文名稱(外文):A Study of Factors Affecting Neurosensory Disturbance after Mandibular Bilateral Sagittal Split Osteotomy
指導教授:陳羿貞
指導教授(外文):Yi-Jane Chen
口試委員:郭生興張晉豪
口試委員(外文):Sang-Heng KokChin-Hao Chang
口試日期:2012-06-19
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:臨床牙醫學研究所
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:2013
畢業學年度:101
語文別:中文
論文頁數:79
中文關鍵詞:感覺異常兩側矢向劈裂截骨術下齒槽神經正顎手術
外文關鍵詞:neurosensory disturbancebilateral sagittal split osteotomyinferior alveolar nerveorthognathic surgery
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目的:
目前本院齒顎矯正科之正顎手術病患常以矯正合併正顎手術之方式改善牙齒咬合功能及改善顏面外觀,本院下顎手術為以兩側矢向劈裂截骨術(Bilateral sagittal split osteotomy, BSSO)的方式進行下顎向前、後退、或側向移動為主,BSSO這類手術常見的併發症就是在嘴唇、下巴或口內黏膜發生術後感覺異常,因此了解手術後之感覺異常變化有其必要性。本篇前瞻性研究希望以主觀之問卷及相對客觀之感覺檢測方式以了解病患之術後感覺異常變化,並且比較不同感覺測驗間之相關性,並且找出影響術後感覺異常的可能因素。

實驗病患及方法:
本研究蒐集從2011年5月份至2012年3月於台大醫院口腔顎面外科接受兩側矢向劈裂截骨術並於齒顎矯正科進行矯正治療之病患共30位,包括15名男性與15名女性,正顎手術方式包含兩側矢向劈裂截骨術、兩側矢向劈裂截骨術合併頦成形術、兩側矢向劈裂截骨術合併勒弗氏一型上顎截骨術、兩側矢向劈裂截骨術合併勒弗氏一型上顎截骨術合併頦成形術四種術式。所有病患於術前、術後一周、術後一個月、術後三個月及術後六個月皆於門診回診時接受問卷及客觀的感覺測驗,測驗區域則為下唇、下巴及口角以外1公分處,本實驗中記錄了病患之性別、手術時之年齡、手術失血量、手術時間、手術方式、是否有頦成形術、下顎前後移動量、下巴偏移量、以及手術前下顎骨結構,進而分析這些因素與術後感覺異常之相關性。

結果:
在本研究中所有病患在術後一周幾乎皆有感覺異常之狀況,但於術後有顯著的恢復情況。在問卷與不同客觀感覺測驗之相關性方面,輕觸感與其他感覺測驗皆有較高的相關性,在下唇與下巴處之問卷與輕觸感及兩點分辨能力也都有較高的相關性。在影響術後感覺異常的因素分析方面,則發現在術後一個月、術後三個月、術後六個月時手術前下巴偏移量以及下顎骨在神經管外側壁與下顎頰側皮質板的內側壁的距離與術後感覺異常有顯著相關,其餘因素皆沒有看到與術後感覺異常有關。術後追蹤六個月的結果,大約有三成的患者仍有術後感覺異常,且其表現比例依不同感覺測試而異。

結論:
根據本研究之結論可知正顎手術後感覺異常最容易受到下顎偏移量以及神經管外側壁與下顎頰側皮質板的內側壁的距離之影響。在未來如果要進行更大規模的研究,可以考慮以問卷之方式進行以更多病例之收集,如此更能夠了解影響下顎感覺異常的可能因素及不同因素的相關性。


Objectives:
It is very often to use orthodontic combined orthoganthic surgery to correct facial profile, facial asymmetry and increase occlusal function. Bilateral sagittal split osteotomy (BSSO) was most common method used in our Department. Because neurosensory disturbance is commonly reported by patients after BSSO, it is important to know the incidence and degree of neurosensory disturbance after surgery. This prospective study was to subjectively and objectively evaluate the inferior alveolar nerve disturbance after BSSO and its spontaneous recovery. In this study we analysis and compare the results of objective neurosensory tests with subjective questionnaire. The purpose of this study was to evaluate the potential risk factors for postoperative neurosensory disturbance after BSSO.
Patients and Methods:
From May 2011 through March 2012, 30 patients (15 male, 15 female) from Oral and Maxillofacial Surgery division and Orthodontic and Dentofacial Orthopedic division of National Taiwan University Hospital who had been treated with BSSO were identified. Subjective questionnaire and relatively objective sensory test on lower lip, chin, and outside mouth angle 1 cm area was performed before surgery, 1 week, 1 month, 3 months, and 6 months after surgery. Orthognathic surgery included BSSO, BSSO plus genioplasty, BSSO plus LeFort I, and BSSO plus Le Fort I plus genioplasty. We investigated the possible influence factors such as sex, age at the time of surgery, total operation time, blood loss during surgery, intraoperative nerve encounter, surgery method, additional genioplasty, mandibular anterior-posterior movement distance, chin deviation distance, and mandibular ramus structure.

Results:
Almost all patients showed sensibility loss at the 1-week evaluation time, but all area presented significant recovery. The relationship between subjective questionnaire and different relatively objective tests showed that Semmes-Weinstein monofilaments test showed high related rate to each other test. The questionnaire also show high related rate to Semmes-Weinstein monofilaments test and two-point discrimination test at lower lip and chin area. Preoperative chin deviation distance and bone marrow space width at buccal side show significant effect on postoperative neurosensory disturbance. All other factors did not have significant effect on postoperative neurosensory disturbance. There was about 30% of patients still had neurosensory disturbance after 6 months of surgery.

Conclusions:
Neurosensory disturbance of the inferior alveolar nerve is most influenced by preoperative chin deviation distance and bone marrow space and little influenced by surgery method and blood loss during surgery. Using subjective questionnaire is suitable in future large scale experiments. Further large scale study is needed to find out more specific affecting factors.


致謝 i
中文摘要 ii
Abstract iv
第一章 緒論 1
1.1 研究背景 1
1.2 正顎手術 1
1.2.1正顎手術之手術方式 1
1.2.2下顎之神經走向及支配 2
1.2.2下顎神經管解剖構造及下齒槽神經走向 3
1.3 感覺異常測試 4
1.3.1純粹主觀的測試 (purely subjective) 4
1.3.2 相對客觀的測試 (relatively objective) 4
1.3.3 純粹客觀的測試 (purely objective) 5
1.3.4 其他 5
1.3.5 感覺測試範圍及時間點 5
1.4 術後感覺異常之可能因素 6
1.4.1基本狀況 6
1.4.2顱顏結構 7
1.4.3手術方式及過程 7
1.5研究目的 9
第二章 研究材料與方法 10
2.1 研究對象 10
2.2 研究流程 10
2.3 資料之蒐集處理評估 11
2.3.1 問卷調查(詳見附錄三) 11
2.3.2 手術紀錄 11
2.3.3 手術前後之側向測顱X光片分析 12
2.3.4 手術前之正面測顱X光片分析 13
2.3.5 矯正治療前之錐狀電腦斷層掃描 14
2.3.6 相對客觀之感覺異常測量方式與工具 15
2.3.6.1 冷感覺(Cold test) 15
2.3.6.2 兩點分辨能力(Two point discrimination test) 16
2.3.6.3 輕觸感(Light touch test) 16
2.4 統計分析 16

第三章 結果 18
3.1 樣本分析 18
3.2 感覺異常之變化及不同測驗之相關性 18
3.2.1 問卷之感覺異常變化分析 18
3.2.2 冷感覺之感覺異常變化分析 19
3.2.3 兩點分辨能力之感覺異常變化分析 20
3.2.4 輕觸感之感覺異常變化分析 21
3.2.5 四種感覺異常紀錄之相關性 22
3.3 各因素與術後感覺異常之相關性 22
3.3.1 性別、年齡及BMI 23
3.3.2 手術過程、移動量及時間 23
3.3.3 下顎骨結構 25
3.4 感覺異常對病患之影響 26
第四章 討論 27
4.1 各感覺測驗之比較 27
4.1.1 手術前之感覺測驗結果 28
4.1.2 手術後之感覺變化 29
4.1.3 使用問卷進行術後感覺異常紀錄之可信度 30
4.2 可能之影響因素探討 31
4.2.1 病患基本狀況之影響 31
4.2.2 手術過程之影響 32
4.2.3 骨骼結構之影響 34
4.3 感覺異常對病患日常生活之影響 36
第五章 結論 38
第六章 未來展望 39
參考文獻 64
附件一、臨床試驗/研究許可書 72
附件二、臨床試驗/研究受試者說明暨同意書 73
附件三、感覺變化紀錄問卷 77


圖目錄
圖一、 兩側矢向劈裂截骨術截骨示意圖 40
圖二、 下顎管(mandibular canal)走向之分類 40
圖三、 下齒槽神經於嘴唇處之神經走向 41
圖四、 口腔周圍之感覺神經支配 41
圖五、 視覺模擬評分法(Visual analog scale) 42
圖六、 感覺測驗常用分區 42
圖七、 感覺測驗之分區方式 42
圖八、 所使用之側向測顱X光片界標 43
圖九、 術前與術後側向測顱X光片之最大重疊及測量 44
圖十、 所使用之正面測顱X光片界標及測量 45
圖十一、 錐狀電腦斷層掃描影像之界標及參考平面 46
圖十二、 水平切面下所測量長度之定義 46
圖十三、 冠狀切面下所測量長度之定義 47
圖十四、 Two-point discriminator 47
圖十五、 BaselineR Tactile Semmes-Weinstein monofilaments Sets 48
圖十六、 問卷之左右側及整體感覺異常比例 48
圖十七、 冷感之左右側及整體感覺異常變化 49
圖十八、 兩點分辨能力之左右側及整體感覺異常比例 49
圖十九、 輕觸感之左右側及整體感覺異常比例 50
圖二十、 四種感覺測驗之整體感覺異常比例 50
圖二十一、 左側mandibular canal雙分支之電腦斷層 51
圖二十二、 各個時間點以視覺模擬評分法看對日常生活影響之影響 51


表目錄
表一. 問卷之各區域感覺異常比例 52
表二. 各測驗於各時間點之整體感覺異常比例 52
表三. 各測驗於各時間點之左右側感覺異常比例 52
表四. 各區域冷感覺異常之比例 53
表五. 問卷與冷感覺之左右側統計檢定(P value) 54
表六. 手術前(T0)各區之兩點分辨能力 54
表七. 各區域兩點分辨能力之感覺變化 54
表八. 各區兩點分辨能力異常之比例 55
表九. 手術前(T0)各區之輕觸感程度 55
表十. 各區域輕觸感之感覺變化 55
表十一. 各區輕觸感覺異常之比例 56
表十二. 兩點分辨能力與輕觸感之左右側統計檢定(P value) 56
表十三. 兩點分辨能力與輕觸感於手術前各區相比之統計檢定 (P value) 57
表十四. 四種測驗於T1時之相關性 (Kappa value) 57
表十五. 手術前(T0)研究病患之年齡分佈 58
表十六. 不同性別及年齡層於手術前之感覺測驗統計檢定 (P value) 58
表十七. 手術前(T0)不同性別感覺能力之平均值及標準差 59
表十八. 手術時間及失血量統計 59
表十九. X光片與電腦斷層測量之觀察者組內誤差 (P value) 59
表二十. 治療前之下顎骨結構統計 60
表二十一. 治療前之下顎骨左右側結構比較之統計分析 (P value) 60
表二十二. 下巴偏移方向與下顎骨左右側差異之相關性 (P value) 60
表二十三. 治療前下巴偏左或偏右之下顎骨結構 61
表二十四. 各因素與不同測驗於各時間點之統計檢定 (P value) 62
表二十五. 下顎偏移方向及marrow space與術後左右側感覺異常之統計檢定 63
表二十六. 術後感覺異常種類於各時間點之狀況 63


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