咬合板治療顳顎關節盤可復性前移位的成效及相關因子影響性之探討

The Effect of Occlusal Splint Therapy for Anterior Disc Displacement with Reduction of the TMJ and Evaluation of Associated Factors

許經偉(Ching-Wei Shu)

指導教授 ： 陳中和

共同指導教授 ： 黃逸岳(I-Yueh Huang)

高雄醫學大學/口腔醫學院/牙醫學研究所/碩士(2008年)

摘要

前言與目的：患有顳顎關節盤可復性前移位(Anterior Disc Displacement with Reduction, ADDR)病患常飽受開閉口時關節聲響之苦，如在公眾場所或交際應酬時，聲響造成尷尬場面無法順利言談。此外隨著病情多樣化，可能併發開閉口時路徑偏斜、關節囊及盤後組織易發炎腫痛，甚至開口偶而受限無法順利張嘴等問題。基於此，本研究探討咬合板對關節盤可復性前移位的治療療效，並分析相關因子對治療的影響。
樣本與方法：本研究收集48位臨床上診斷為關節盤可復性移位病患，總關節數50個；每位病患皆接受咬合板治療，及拍攝靜態和動態核磁共振影像(MRI)以確立疾病診斷，並定期追踪記錄直至治療療程結束。其中有34位病患，總關節數35個，同時拍攝戴入咬合板於口內後的關節影像。於治療療程結束後半年時間，本研究追踪到30位當初核磁共振影像確立診斷為關節盤可復性移位的病患，總關節數32個，再次收集相關臨床資料，進而探討此30位病患的半年後成功率，以及是否受相關因子影響。此些因子在臨床上包括年齡、性別、發生關節彈響(clicking sound)或間歇性卡住(intermittent locking)時開口度、關節聲響或間歇性卡住存在時間、開咬併發症；在影像上包括關節盤形態、關節盤移位型態、關節盤移位量、關節頭形變。
結果：初始50個關節影像中，40個診斷等同於臨床診斷，臨床診斷準確率達80.0%。影像診斷為關節盤可復性前移位，且同時有拍攝戴入咬合板的關節影像有28個，立即關節盤完整復位率達75.0%。治療結束而半年後追踪的32個關節中，治療成功率達62.5%；此外將各個因子分項，利用Fisher’s exact test及Chi-square test探討此些因子和治療成功與否的關係，並以Logistic regression統計方法，評估各相關因子間相互調整後的odd ratios，結果發現並無任何因子有統計上顯著影響性。此外利用Wilcoxon Rank Sum Test，比較治療成功和治療失敗兩組間，關節盤移位量是否有所不同，結果顯示，亦無任何統計上顯著差異。
結論：本研究結果中，證實咬合板確實對關節盤可復性前移位有療效存在。此外在臨床上，以關節彈響或間歇性卡住合併壓舌板測試法，作為診斷方法及決定咬合板治療位置時，結果顯現其準確性很高。最後本研究探討的各項因子和治療成功率，雖然並無統計上地顯著相關性存在，但於此提供此些因子給各位參考，期望將來可朝此方面進一步研究討論。

關鍵字

關節盤可復性前移位 ； 咬合板 ； 核磁共振影像 ； 相關因子

並列摘要

Preface and Aim: Patients who suffered from anterior disc displacement with reduction of temporomandibular joint (ADDR) always bore clicking sound which embarrassed them and couldn’t finish a conversation with others in public place. Besides, with the variation of the disease, ADDR may accompany with painful inflammation of joint and deviation or intermittent locking during mouth opening and closing. Because of these troublesome symptom and sign, the present study was to evaluate the effect of occlusal splint for treatment of ADDR and analyzed associated factors which may have influence on it.
Materials and Methods: The study recruited 48 consecutive patients who clinically were diagnosed as ADDR. The total numbers of participated joint were 52. All of the patients received occlusal splint treatment and magnetic resonance imaging (MRI) taking, including static and movie view, to confirm the diagnosis and were followed up until the course of treatment completed. Besides, among them, there were 34 patients who also received MRI taking with insertion of occlusal splint into their oral cavity. The total numbers of joint we could compare the disc-condyle relationship under insertion of splint were 35. After course of splint treatment accomplished and passing half a year, we traced 30 patients who initially were diagnosed as ADDR by MRI and collected the clinical data again. Then we discussed the success rate of occlusal splint and analyzed if the success rate was influenced by the associated factors. These factors were as below: Clinically — Age, Sex, Mouth opening on clicking or intermittent locking, Duration of clicking or intermittent locking, Open-bite complication; Image finding — Disc morphology, Type of disc displacement, Range of disc displacement, Condyle morphology.
Results: Initially, the 50 joints clinically diagnosed as ADDR were confirm in 40 joints. The accuracy of the clinically diagnostic method for ADDR used in the present study was 80.0%. The diagnosis of MRI was ADDR and simultaneously with image of splint inserted into oral cavity comprised 28 joints. Among these 28 joints, 75.0% could be observed that disc complete recapture to normal disc-condyle relationship. After half a year in the traced 32 joints, the success rate of occlusal splint was 62.5%. Furthermore, when we divided the associated factors into subgroups and utilized the Fisher’s exact test, Chi-square test to analyze the correlation between treatment outcomes and factors, there was no any statistically significant in the results. Logistic regression and Wilcoxon Rank Sum Test, otherwise, were also used to assess the odds ratio after factors mutually adjusted each other and assess the different range of disc displacement between success group and failure group, but there was still no any statistically significant.
Conclusion: In the present study, the result confirmed the good efficacy of occlusal splint to treat anterior disc displacement with reduction of TMJ disc. In addition, we used the clicking sound and intermittent locking as guideline for diagnosis and design of splint, the result showed it’s a reliable method. Although the result in the present study didn’t show any statistically significant, here we provided some factors for further study to investigate.

並列關鍵字

ADDR, Occlusal splint ； MRI ； Associated facotors

參考文獻

1. Lundh H, Westesson PL, Kopp S. A three-year follow-up of patients with reciprocal temporomandibular joint clicking. Oral Surg Oral Med Oral Pathol 1987;63(5):530-3.

2. Westesson PL, Lundh H. Arthrographic and clinical characteristics patients with disk displacement who progressed to closed lock during a 6-month period. Oral Surg Oral Med Oral Pathol 1989;67(6):654-7.

3. Emshoff R, Innerhofer K, Rudisch A, Bertram S. Relationship between temporomandibular joint pain and magnetic resonance imaging findings of internal derangement. Int J Oral Maxillofac Surg 2001;30(2):118-22.

4. Katzberg RW, Bessette RW, Tallents RH, Plewes DB, Manzione JV, Schenck JF, et al. Normal and abnormal temporomandibular joint: MR imaging with surface coil. Radiology 1986;158(1):183-9.

5. Wilkes CH. Surgical treatment of internal derangements of the temporomandibular joint. A long-term study. Arch Otolaryngol Head Neck Surg 1991;117(1):64-72.