下顎兩側矢向劈裂截骨術後感覺異常之影響因素探討

A Study of Factors Affecting Neurosensory Disturbance after Mandibular Bilateral Sagittal Split Osteotomy

劉必慧(Pi-Huei Liu)

指導教授 ： 陳羿貞

國立臺灣大學/牙醫專業學院/臨床牙醫學研究所/碩士(2013年)

https://doi.org/10.6342/NTU.2013.01121

摘要

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。

關鍵字

感覺異常 ； 兩側矢向劈裂截骨術 ； 下齒槽神經 ； 正顎手術

並列摘要

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.

並列關鍵字

neurosensory disturbance ； bilateral sagittal split osteotomy ； inferior alveolar nerve ； orthognathic surgery

參考文獻

2. Fonseca RJ MR, Turvey TA. Oral and maxillofacial surgery. Philadelphia 2009;3:87-118.

3. Jacks S, Zuniga J, TURVEY T, Schalit C. A retrospective analysis of lingual nerve sensory changes after mandibular bilateral sagittal split osteotomy. Journal of Oral and Maxillofacial Surgery 1998;56(6):700-04.

4. Langlais RP, Broadus R, Glass BJ. Bifid mandibular canals in panoramic radiographs. J Am Dent Assoc 1985;110(6):923-6.

5. Angel JS, Mincer HH, Chaudhry J, Scarbecz M. Cone-beam Computed Tomography for Analyzing Variations in Inferior Alveolar Canal Location in Adults in Relation to Age and Sex. J Forensic Sci 2011;56(1):216-19.

6. Alantar A, Roche Y, Maman L, Carpentier P. The lower labial branches of the mental nerve: Anatomic variations and surgical relevance. Journal of Oral and Maxillofacial Surgery 2000;58(4):415-18.