顳顎關節內部紊亂症其嚴重度、相關致病危險因子與顱顏面型態關係之研究

The relationship between severity, risk factors of TMJ internal derangement and craniofacial morphology

簡玉婷(Yu-Ting Chien)

指導教授 ： 陳韻之

共同指導教授 ： 蕭裕源

國立臺灣大學/醫學院/臨床牙醫學研究所/碩士(2007年)

https://doi.org/10.6342/NTU.2007.03213

摘要

目的︰
明顯的顳顎關節重塑現象或是嚴重的退行性關節疾病在顳顎關節內部紊亂症(ID)的患者身上並不少見，即使是在正值身體迅速增長的青春期也不例外。因此，早期發生的顳顎關節病變是否會導致疑似與下顎生長遲緩有關如不對稱下顎或骨性二級顎間關係之特殊顱顏面型態，是顱顏型態學上值得深入探討的課題。如果這些關係真實存在，顳顎關節局部破壞的嚴重度以及可能影響其嚴重度的全身性因素，例如身體質量指數(BMI)和骨質密度(BMD)等因素，其互相之間的關係為本研究的主要目的。此外，本研究亦嘗試利用上述顱顏型態學特徵與全身性體質因素發展出一套簡單又便利篩檢顳顎關節內部紊亂症嚴重度之指標。

材料和方法︰
本實驗受測者共有156位18至30歲之年輕女性 (平均年齡為22.5 ± 2.9歲)，以靜態和動態顳顎關節磁振掃描攝影進行對顳顎關節內部紊亂症的診斷，靜態顳顎關節磁振掃描影像並用來量測顳顎關節髁頭面積大小（CHA）與下顎升枝高度；以正面與側面測顱攝影評估顱顏面之形態；此外，藉由雙能量式X光骨質密度偵測儀(DXA)測得腰椎與股骨頸部的骨質密度，並於照射時同時取得身高和體重以計算身體質量指數(身高/體重2)。卡方統計、單因子變異數分析以及判別分析等統計方法用來分析上述測量變數間之關係。

結果:
於本實驗之樣本中，大部分至少一側之顳顎關節具不可復位之關節盤移位者呈現骨性二級顎間關係。上述診斷族群亦有最低之腰椎骨質密度 (0.929 ± 0.095)，其次為具可復位之關節盤移位者(0.961 ± 0.083)，而具正常髁盤關係者則有最高之腰椎骨質密度(0.993 ± 0.119) （單位：g/cm2）。身體質量指數和關節髁頭平均面積亦與腰椎骨質密度呈現同樣的分布趨勢，其在不可復位者、可復位者，以及正常髁盤關係者間之分布分別是18.65 ± 1.47、19.8 ± 2.5、20.86 ± 2.4（單位：Kg/m2）與0.56 ± 0.18、0.75 ± 0.15、0.82 ± 0.16（單位：cm2）。一側為正常的髁盤關係，一側為不可復位性移位關節盤者其兩側顳顎關節髁頭面積差最大；其次為一側為可復位性移位關節盤，一側為不可復位性移位關節盤者。具正常髁盤關係者的下顎升枝高度平均值最大(5.93 ± 0.43)，其次分別為關節盤可復位性移位(5.7 ± 0.43)與關節盤不可復位性移位(5.5 ± 0.55)。任兩種不同關節內部紊亂狀況之間均有顯著的差異。於骨性二級顎間關係者中，關節盤為不可復位性移位者其下顎升枝高度遠較具正常髁盤關係者短，其差異高達1公分；上述差異在骨性一級與三級顎間關係者中較不明顯。顳顎關節髁頭面積及下顎升枝高度與身高、體重、身體質量指數、以及腰椎骨質密度皆有顯著的關聯性。不對稱之下顎骨似乎與兩側顳顎關節髁頭破壞程度之差異有關。

若僅以顱顏型態學與全身性體質因素等參數進行對數成敗比統計方法分析，可得出以下方程式：
篩檢指標 = -16.862–0.5795*BMI+0.3282*SNA+0.2711*ANB
根據篩檢指標來分辨受測者是否罹患至少一側之顳顎關節為不可復位之關節盤移位，其敏感度（Sensitivity）與特異度（Specificity）分別為71.4%與 89.7%。

若是將磁振掃描影像中所量得之顳顎關節定量結構參數亦放入對數成敗比統計模型，下列篩檢指標用以分辨受測者是否罹患至少一側之顳顎關節為不可復位之關節盤移位，其敏感度與特異度則可提升至81.6%與 90.7%。
篩檢指標 =-11.7954-13.4376*CHA-0.5568*BMI+0.3785*SNA
此指標方程式顯示影響關節盤是否復位的主要因素依序為: 顳顎關節髁頭面積、身體質量指數、上顎骨相對於前顱底之突出程度與上、下顎骨相對關係。

結論:
在較嚴重的顳顎關節內部紊亂症患者身上，身體質量指數與特定顱顏面型態學參數之間似乎存在某種關係。

關鍵字

顳顎關節內部紊亂症 ； 身體質量指數 ； 骨質密度 ； 顱顏面型態 ； 篩檢指標

並列摘要

Objectives:
Obvious TMJ remodeling or severe degenerative joint disease (DJD) are not uncommonly seen in the patients of TMJ internal derangement (ID), even in the rapid-growing puberty stage. Therefore, whether the early-onset TMJ disorder can result in asymmetrical mandible or class II jaw relationship, which seems to be related to interfered jaw growing, deserves further investigations. The aims of this study were to explore the relationship among the severity of TMJ ID, craniofacial morphology, and systemic risk factors of TMJ ID, such as body mass index (BMI) and bone mineral density (BMD). We also wanted to develop a TMJ ID stastistical screening model by using variables derived from craniofacial morphology and systemic risk factors of TMJ ID.

Materials & Methods:
156 young females (18 to 30 years old, mean age 22.5 ± 2.9) have participated to this study. Both static and dynamic TMJ MRI have been used to obtain the diagnosis of TMJ ID. The static TMJ MRI were also used to measure the cross-sectional conylar head area (CHA) and the ascending ramus height (ARH). The craniofacial morphology of the subjects were assessed by using both PA and lateral cephalograms. The bone mineral density in the lumbar spines and femoral head were obtained by using dual energy X-ray absorptiometry (DXA). The body height and weight were measured in the BMD study for calculating the BMI (height/weight2).Chi square, one way ANOVA, and logistic regression analysis were used to perform the statistical analyses.

Results:
From the subjects recruited for this study, most TMJ anterior disc displacement without reduction (ADDw/oR) patients have class II jaw relationship. The averaged lumbar BMD（0.929 ± 0.095，0.961 ± 0.083，0.993 ± 0.119 g/cm2）, BMI (18.65 ± 1.47，19.8 ± 2.5，20.86 ± 2.4 Kg/m2）and TMJ condylar area （0.56 ± 0.18，0.75 ± 0.15，0.82 ± 0.16 cm2） are all lowest in the ADDw/oR group, followed by the disc anterior displacement with reduction (ADDwR) group, and the normal condyle/disc relationship (Normal) group. The difference of CHA between both sides TMJ is largest in patients with one normal TMJ and one TMJ with ADDw/oR, followed by patients with ADDwR and ADDw/oR in either TMJ. The ARH is largest in normal TMJ (5.93 ± 0.43 cm), followed by TMJ with ADDwR (5.7 ± 0.43 cm) and TMJ with ADDw/oR (5.5 ± 0.55). For subjects with class II jaw relationship, the averaged ARH is significantly shorter in ADDw/oR TMJ than that in the ADDwR TMJ. Such difference can be up to 1 cm. The CHA and ARH are significantly correlated with body height, body weight, BMI, and lumbar BMD. Asymmetrical mandible is associated with the side difference of condylar destruction.

By using the craiofaical morphological variables and systemic risk factors, the following logistic regression model can be obtained. By using only 3 variables, namely BMI, SNA and ANB, to differentiate patients with ADDw/oR from ADDwR and Normal status, the sensitivity and specificity are up to 71.4% and 89.7%, respectively.
score = -16.862–0.5795*BMI+0.3282*SNA+0.2711*ANB

If we put quantitiatve measurments of the condyle and mandible, such as CHA and ARH, into the logistic regression model, the sensitivity and specificity of differentiating of subjects suffered ADDw/oR from ADDwR and Normal can be raised up to 81.6% and 90.7%, respectively, according to the following statistical model.
score =-11.7954-13.4376*CHA-0.5568*BMI+0.3785*SNA

It seems CHA is the most significant factor in differentiating ADDw/oR from ADDwR and Normal, followed by BMI, SNA, and ANB, respectively.

Conclusions:
For TMJ ID patients of certain severity, there seems to exist association between BMI and some craniofacial morphological characters.

並列關鍵字

TMJ ID ； BMI ； BMD ； craniofacial morphology ； screen score

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