대한악안면성형재건외과학회지 : Vol. 28, No. 1, 2006 Ⅰ. 서론 설골은설골상근등 11 개근육들에의해지지되며, 하악골의기능운동, 연하, 경추각도, 두부자세등의여러요소에의해영향을받는다 1-4). 상기도는비인두, 구인두, 하인두, 비강및구강으로이루어져있으며,

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1 골격성 3 급부정교합자의악교정수술후설골위치와상기도크기의변화 골격성 3급부정교합자의악교정수술후설골위치와상기도크기의변화 김지용 안제영 임재형 허종기 박광호연세대학교치과대학구강악안면외과학교실영동세브란스병원 Abstract CHANGES OF THE HYOID BONE POSITION AND THE UPPER AIRWAY DIMENSION AFTER ORTHOGNATHIC SURGERY IN SKELETAL CLASS III PATIENTS Ji-Yong Kim, Je-Young Ahn, Jae-Hyung Lim, Jong-Ki Huh, Kwang-Ho Park Department oforal and Maxillofacial Surgery, College of Dentistry, Yonsei University, Yongdong Severance Hospital After orthognathic surgery in skeletal class III patients, the hyoid bone position and the upper airway dimension could be changed due to mandibular setback. There has been many studies about airway dimension of the patients with skeletal class II malocclusion or obstructive sleep apnea. but not with skeletal class III. The purpose of this study was to examine the change of position of the hyoid bone and the consequent change of airway space as the result of retrusion of mandible after orthognathic surgery in skeletal Cl III malocclusion patients. It is also to apply this results in predicting, diagnosing and treating the subsequent obstructive sleep apnea. Forty patients who were diagnosed as skeletal Cl III maloccusion, received orthoganthic surgery of both jaws including mandibular setback, and were followed up post-operatively for more than 6 months were selected. There were 10 male patients 30 female patients. The preoperative and postoperative lateral cephalograms were traced and the distances and angles were measured. The nasopharyngeal space increased postoperatively while the oropharyngeal space decreased. Except for the change of oroparyngeal space, the changes in male patients were greater than female patients. The hyoid bone moved in the posterior-inferior direction, and the change was greater in males than in females. If the postoperative mandibular setback is great, then a significant decrease of airway space and posterior and inferior movement of the hyoid bone were observed. This can result in symptoms related to obstructive sleep apnea. This result should be considered in the diagnosis and treatment planning of orthognathic surgery patients. Key words : Hyoid bone, Upper airway dimension, Nasopharyngeal space, Oroparyngeal space 27

2 대한악안면성형재건외과학회지 : Vol. 28, No. 1, 2006 Ⅰ. 서론 설골은설골상근등 11 개근육들에의해지지되며, 하악골의기능운동, 연하, 경추각도, 두부자세등의여러요소에의해영향을받는다 1-4). 상기도는비인두, 구인두, 하인두, 비강및구강으로이루어져있으며, 이들은상악골, 하악골, 구개골, 서골및경추등의경조직과혀, 연구개및인후부점막등의연조직에의해구성된다 5). 최근악교정술을이용한악안면기형환자의교정이보편화되면서, 악골변화에따른설골위치와기도공간의변화가폐쇄성무호흡증에미치는영향이관심의대상이되고있다. 설골위치와기도공간에대한연구는해부학적으로그위치와형태가불리한골격성 2 급부정교합자나폐쇄성수면무호흡증환자를대상으로많이연구되었다. 본교실에서도폐쇄성수면무호흡증진단을위한한국인성인정상교합자와부정교합자각각에대한두부방사선계측값의측정과비교, 그리고골격성 2 급부정교합자의술전과술후설골위치와상기도크기에대한비교연구와같은일련의연구를진행하여왔다. 골격성 3 급부정교합자의경우악교정수술전에는기도공간의협소화로생기는문제가거의없는것으로알려져있다. Athanasiou 등 6) 과 Wicwire 등 7) 은하악골이후방으로이동함에따라기도공간이감소했다가, 시간이경과하면서연조직의생리적적응으로원상태를회복한다고하였고, Greco 등 8) 은상당기간후에도공간이회복되지않는다고보고한바있다. 하지만하악후퇴량에따른설골위치와상기도공간의변화정도는각기다르며, 과도한하악골의후 퇴로인하여기도공간이좁아질수있고, 이로인해폐쇄성수면무호흡증과관련된증상을유발할가능성이있으리라사료된다. 이에본교실에서는악교정수술을시행받은골격성 3 급부정교합자에서술후하악골후퇴와회전등으로인하여발생하는혀와설골의위치및기도공간의변화를연구하고, 이를골격성 2 급부정교합환자에있어하악골전진시의변화와비교분석하며, 악교정수술후발생할수있는폐쇄성수면무호흡증과연관된증상의예견및치료를위한기초자료로활용하고자한다. Ⅱ. 연구대상및방법 2000 년 1 월부터 2002 년 8 월까지연세대학교영동세브란스병원에내원하여악교정수술을시행받은환자 91 례중, 술전에골격성 3 급부정교합으로진단받고, 하악후퇴술을포함한상하악악교정수술을시행받았으며최소 6 개월에서 1 년이상주기적추적관찰이가능했던환자 40 명을연구대상으로하였다. 40 명의환자를성별에따라남자 10 명, 여자 30 명으로분류하였으며, 이들의평균연령은남자 24.6±4.03 세, 여자 24.3±3.45 세였다. 각각의환자는상악의 advance, posterior impaction, 또는 superior repositioning 하였으며그후하악후퇴술을시행하였다. 술전과술후 6 개월이상의두부규격방사선사진을묘사지위에그리고투사도상에서계측점과기준선을설정하고거리및각도를계측하였으며계측된자료를 paired t - test, 2 - sample t - test 로통계처리하였다 (Fig. 1-3, Table 1-3). Fig. 1. Landmarks and Reference Lines. Fig. 2. Cephalometric Distances (mm). Fig. 3. Cephalometric Angles ( ). 28

3 골격성 3 급부정교합자의악교정수술후설골위치와상기도크기의변화 Table 1. Cephalometric Landmarks & Reference Lines Cephalometric landmarks S Sella Midpoint of fossa hypophysealis N Nasion Anterior point at frontonasal suture O Orbitale Most inferior point of the orbit ANS Spina nasalis ant. Most anterior point of anterior nasal spine PNS Spina nasalis post. Most posterior point of hard palate A A-point Deepest anterior point in concavity of anterior maxilla B B-point Deepest anterior point in concavity of anterior mandible Pg Pogonion Most anterior point of bony chin Pm Pm-point Halfway B-Point--Pogonion Gn Gonion Most antero-inferior point of bony chin Me Menton Most inferior point of bony chin Go Gonion A mid-plane point at the gonial angle located by bisecting the posterior and inferior borders of the mandible Ar Articulare A mid-plane point at the intersection of posterior ramus with inferior cranial base C Condylion Most postero-superior point of mandibular condyle Pt Pterygon Inferior border of foramen rotundum bisecting posterior border of pterygomaxillary fissure Xi Xi-Point Constructed point in the center of the ramus CF Pterygoid-Vertical bisecting Frankfurt horizontal DC Middle of condyle on plane Ba-N Ba Basion Most inferior point on anterior foramen magnum Po Porion Most superior point of bony external auditory meatus PhW1 Ba-PNS bisecting posterior pharyngeal wall PhW2 ANS-PNS bisecting posterior pharyngeal wall PhW3 Occlusal polane bisecting posterior pharyngeal wall PhW4 Mandibular plane bisecting posterior pharyngeal wall PhW5 Me-H bisecting posterior pharyngeal wall PhWUT Shortest distance point of posterior pharyngeal wall from UT PhWV Shortest distance point of posterior pharyngeal wall from V PhWH Shortest distance point of posterior pharyngeal wall from H H Hyoid Most antero-superior point of hyoid V Vallecula Most antero-inferior point of epiglottic fold T1 Tongue base ML-bisecting posterior margin of the tongue base T2 Back of tongue Most superior point of the back of the tongue to V-TT TT Tongue tip Most anterior point of the tip of the tongue U1 Most superior point of soft palate distal to PNS U2 Posterior margin of soft palate at its greatest thickness U3 Occlusal plane bisecting posterior margin of soft palate UT Uvula tip Tip of uvula or soft palate U4 Anterior margin of soft palate at its greatest thickness U5 Most antero-superior margin of the soft palate AA anterior Atlas Most anterior point of bony atlas 29

4 대한악안면성형재건외과학회지 : Vol. 28, No. 1, 2006 Table 2. Cephalometric Distances (mm) Cephalometric distances (mm) S-Go Posterior facial height N-Gn Anterior facial height A/N-Pog Convexity PAS (ML) Distance posterior pharyngeal wall-tongue base on ML PAS (Occl.) Distance posterior pharyngeal wall-tongue base on occlusal plane PAS (NL) Distance posterior pharyngeal wall-tongue base on NL PAS (UT) Distance posterior pharyngeal wall-uvula tip AA-PNS Distance ant. atlas-post. nasal spine Ba-PNS Distance basion-post. nasal spine Ba-PhW1 Distance basion-posterior pharyneal wall on Ba-PNS PhW1-PNS (PAS) Distance posterior pharyngeal wall-pns on Ba-PNS Go-PNS Posterior lower facial height Ba-A Distance basion-point A PNS-UT Length of the soft palate (uvula-length) U2-U4 Thickness of the soft palate (uvula-thickness) V-Me Distance vallecula-menton V-ANS Distance vallecula-ant. nasal spine V-S Distance vallecula-sella T1-ANS Distance tongue base-ant. nasal spine T1-B Distance tongue base-point B T1-PNS Distance tongue base-post. nasal spine T1-TT Distance tongue base-tongue tip V-PhW (PAS) Shortest distance V-posterior pharyngeal wall V-TT Axis of the tongue tip T2/V-TT Tongue height H-ML Shortest distance hyoid to mandibular plane H-Me Distance hyoid-menton H-B Distance hyoid-point B H-PhW (Me-H) Disstance hyoid-posterior pharyngeal wall on Me-H H-PhW Shortest distance hyoid to posterior pharyngeal wall AA-H Distance hyoid-ant. atlas H-S Distance hyoid-sella Table 3. Cephalometric Angles ( ) Cephalometric angles ( ) SNA NL-NSL N-S-Ba ML-NSL SNB ML-NL Saddle-Angle Articular Angle Gonion Angle Sum Angle Lower Gonion Angle Facial Axis Facial Depth Mandibular Plane Angle LFH-Angle Mandibular Arc Angle Maxillary Depth Maxillary Height Palatal Plane Ramus Position Uvula-Angulation V-TT/ML V-TT/FH N-S-H NSL/Ar-H ML/H Angle between S-N and N-A Angle between NSL and NL Angle between N-S and S-Ba Angle between NSL and ML Angle between S-N and N-B Angle between NL and ML Angle between S-N and S-Ar Angle between S-Ar and Ar-Go Angle between Ar-Go and Go-Me Sum of saddle-, articular-, gonion angle Angle between N-Go and Go-Me Angle between Pt-Gn and Ba-N Angle between FH and N-Pog Angle between FH and ML Angle between ANS-Xi and Xi-Pm Angle between DC-Xi and Xi-Pm Angle between FH and N-A Angle between N-CF and CF-A Angle between FH and NL Angle between FH and CF-Xi Angle between NL and PNS-UT Angle between V-TT and ML Angle between V-TT and FH Angle between N-S and S-H Angle between NSL and Ar-H Angle between Go-Me-H 30

5 골격성 3 급부정교합자의악교정수술후설골위치와상기도크기의변화 1. 이동량 Ⅲ. 연구결과 상악은 advance, posterior impaction, superior repositioning 이단독혹은복합적으로이동하였으며그평균이동량은상방으로 1.68mm, 전방으로 3.32mm 였다. 하악은 menton, hyoid 를기준으로평균후방으로 5.45mm, 상방으로 0.08mm 이동하였다 (Table 4). 2. 기도의크기변화 비인도계측치인 PAS(NL) 와 PHW1-PNS 는증가하였으며평균값은였고그양은남자가여자보다더큰것으로나타났다. 구인두계측치인 PAS(ML), PAS(UT) 는유의성있는감소를보였으며, PAS(OL) 또한감소하는경향을보였고성별에따른차이는보이지않았다. 하인두계측치인 H-Phw, H-Phw(Me-H) 는감소하였으며남자가여자보다더크게감소하였다 (Table 5). 3. 설골의위치변화 설골의수직적위치를나타내는지표인 AA-H 는감소하는경향을보였으나유의성은없었으며, H-ML, H-S 는증가하는경향을보였고, 남자가여자보다더큰것으로나타났다. 설골의전후방위치를나타내는 N-S-H, NSL/Ar-H 는증가하는경향을보였고, 남자가여자보다더큰것으로나타났으나유의성은없었다 (Table 5). Table 4. Analysis for Skeleton Male N = 10 Female N = 30 Male~Female Total N = 40 T1-T0 Aver (SD) p-value T1-T0 Aver (SD) p-value p-value T1-T0 Aver (SD) p-value SNA (3.00) (2.60) (2.68) NL-NSL (3.46) (3.77) (3.89) N-S-Ba (3.12) (1.93) (2.29) ML-NSL (3.81) (3.88) (3.82) SNB (4.27) (2.38) (2.90) ML-NL (3.20) (4.75) (4.41) S-Go (3.18) (2.59) (2.73) N-Gn (5.20) (3.65) (3.53) Saddle angle (3.17) (2.61) (2.74) Articular angle (5.18) (4.19) (4.39) Gonion angle (4.46) (5.53) (5.26) Sum angle (3.81) (3.88) (3.82) Lower Gonion angle (2.72) (4.23) (3.88) Facial axis (3.43) (5.07) (4.67) Facial depth (3.02) (2.41) (2.55) Mandibular plane Angle (2.97) (3.50) (3.35) LFH angle (2.89) (4.26) (3.93) Mandibular Arch Angle (5.92) (5.15) (5.36) Maxillary depth (3.42) (2.83) (2.95) Maxillary height (2.76) (4.07) (3.76) Palatal plane (4.20) (3.82) (3.88) Ramus position (4.47) (3.93) (4.03) Angle :, Another : mm T0 : Pre-OP Data, T1 : Post-OP 31

6 대한악안면성형재건외과학회지 : Vol. 28, No. 1, 2006 Table 5. Analysis for Pharynx Male N = 10 Female N = 30 Male~Female Total N = 40 T1-T0 Aver (SD) p-value T1-T0 Aver (SD) p-value p-value T1-T0 Aver (SD) p-value PAS (ML) (5.20) (3.08) (3.70) PAS (Occl) (5.81) (3.82) (4.34) PAS (NL) (2.15) (3.22) (2.99) PAS (UT) (3.00) (3.11) (3.08) AA-PNS (2.34) (3.22) (3.01) Ba-PNS (2.17) (3.15) (2.91) Ba-PhW (1.68) (2.02) (1.92) PhW1-PNS (PAS) (2.38) (2.96) (2.82) Go-PNS (3.98) (3.00) (3.22) Ba-A (3.49) (3.90) (3.77) Uvula length (3.14) (3.47) (3.35) Uvula thickness (1.57) (1.97) (1.87) Uvula angulation (4.85) (7.43) (6.83) Vallecula-Me (8.35) (5.07) (6.16) Vallecula-ANS (4.95) (3.42) (4.10) Vallecula-S (3.58) (3.09) (3.18) Tongue base-ans (2.86) (3.94) (3.78) Tongue base-b (5.77) (3.52) (4.12) Tongue base-pns (4.04) (2.78) (3.08) Tongue base-tt (5.85) (3.69) (4.25) Vallecula-PhW (PAS) (5.74) (2.72) (3.65) Vallecula-TT (7.20) (5.18) (5.72) Tongue height (5.19) (3.37) (3.91) V-TT/ML (8.27) (4.21) (5.59) V-TT/FH (8.11) (3.18) (4.94) H-ML (5.80) (3.24) (4.22) H-Me (4.96) (4.81) (5.04) H-B (5.20) (4.41) (5.08) H-PhW (Me-H) (5.00) (2.23) (3.10) H-PhW (3.41) (2.07) (2.43) AA-H (3.95) (4.17) (4.07) H-S (4.32) (3.84) (3.96) N-S-H (2.97) (2.19) (2.49) NSL/Ar-H (4.55) (3.06) (3.56) ML/H (6.37) (3.65) (4.60) Angle :, Another : mm T0 : Pre-OP Data, T1 : Post-OP Data 32

7 골격성 3 급부정교합자의악교정수술후설골위치와상기도크기의변화 Table 6. Analysis Male N = 10 Female N = 30 Male~Female Total N = 40 T1-T0 Aver (SD) p-value T1-T0 Aver (SD) p-value p-value T1-T0 Aver (SD) p-value PAS (ML) (5.20) (3.08) (3.70) PAS (Occl) (5.81) (3.82) (4.34) PAS (NL) (2.15) (3.22) (2.99) PAS (UT) (3.00) (3.11) (3.08) Ba-PhW (1.68) (2.02) (1.92) PhW1-PNS (PAS) (2.38) (2.96) (2.82) Uvula length (3.14) (3.47) (3.35) Uvula thickness (1.57) (1.97) (1.87) Uvula angulation (4.85) (7.43) (6.83) Vallecula-PhW (PAS) (5.74) (2.72) (3.65) H-ML (5.80) (3.24) (4.22) H-PhW (Me-H) (5.00) (2.23) (3.10) H-PhW (3.41) (2.07) (2.43) SNA (3.00) (2.60) (2.68) SNB (4.27) (2.38) (2.90) Fig. 2. Differences of Average Distance. (T0 : Red line, T1 : Blue line) Ⅳ. 총괄및고찰 하악전돌증을주소로하는골격성 III 급부정교합환자의악교정수술은하악골을후퇴시켜구강주위의연조직변화와골격의변화를가져온다. 설골및기도공간은이러한변화에의해새로운환경에적응하게되는데, 하악골후퇴에따른혀와설골의후퇴가기도공간의폐쇄를일으켰다는보고는거의없다. 본교실에서는과거골격성 II 급부정교 합환자의하악골전진시비인두공간의증가, 구인두와하인두공간의유의성있는증가, 설골의전상방이동을관찰할수있었다 9). 본연구는이와는상반된골격성 III 급부정교합환자에있어하악골의후퇴가설골의위치와기도공간에미치는영향과, 하악골의전진및후퇴에따른설골과기도공간반응의상관관계를알아보기위함이다. 이를위해골격성 III 급부정교합으로악교정수술을받은 40 명환자의술전과술후두부규격방사선사진을비교분석하였다. 이연구에서사용된두부규격방사선사진은이미 Henriksson 등 10) 과 Holmberg 등 11) 에의해상당히간편하고신뢰성있는검사임이입증되었고, Riley 등 12) 은이를이용하여폐쇄성수면무호흡증을진단한바있다. Wickwire 등 7) 과 Takagi 등 13) 은하악골후퇴시설골이생리적반사기전으로인하여후하방으로이동하고이를새로운환경에적응하는과정으로설명하였다. 또한추적조사시원래의위치를회귀한다고하였는데이는하악골의전방회귀량과상관관계가있다고하였다. 본연구에이와연관된 H-Phw, H-Phw(Me-H) 는다소감소된경향을보였으며남자가여자보다더크게감소하였다. 비인두부위에서이 14), 정등 15) 은공간의감소가일어나지않는다고하였으며, Wenzel 등 16) 은기도공간이감소한다고하였으나, 본연구에서는비인두계측치인 PAS(NL), PHW1-PNS 가다소증가하였으며남자가여자보다더크게증가한것을확인할수있었다. 이러한결과는실험군의환자중다수가상악의후방이전상방으로이동하였고, 이에따라비인두공간이증가한다는 33

8 대한악안면성형재건외과학회지 : Vol. 28, No. 1, 2006 Waite의 17) 연구결과와일치한다. 또한 De Ponte FS 등 18) 도상악이전상방으로이동시비인후기도공간이증가한다고보고한바있다. 구인두와하인두부위에서이 14), 정등 15) 및김등 19) 은하악골후퇴시기도공간이감소한다고하였으며, 이 14), 진등 15) 의연구에서는별다른변화를주지않는다고하였다. 본연구에서는구인두계측치인 PAS(ML), PAS(UT) 는감소하고, 성별의차이는보이지않았으며, 하인두계측치인 H-Phw(Me-H) 역시감소한양상을보였고, 남자가여자보다더크게감소하였다. 특히공간의감소형태는하악의후퇴량과밀접한관계가있는데김등 5) 의연구에서는하악골의후방이동량이 mm미만일경우유의성이없었다는보고가있었고, 이등 15) 도하악골의이동량이 10 mm이하인군에서는유의할만한변화를보이지않는다고하였는데, 본연구에서는 10 mm이하의하악골후퇴시에도후퇴량이큰경우는유의할만한기도공간의감소를확인할수있었다. 또한성별의차이는구인두의경우비인두부위가증가함에따른영향으로유의할만한차이를보이지않았으며, 하인두의경우는남자의하악후퇴량이여자보다큰것에기인하는것으로사료된다. 본연구에서알수있듯이 III급부정교합환자의하악후방이동시인후기도공간은감소하였고, 특히하악골의후퇴량이큰경우폐쇄성수면무호흡증과연관된증상을유발할수있으리라사료된다. 또한이는본교실에서연구한바있는 II급부정교합환자의하악전방이동시의결과와상반되는결과를보였음을확인할수있었다. 향후하악골의움직임만이아닌상악골의이동양상에따른비인후공간에대한추가적인연구가요하리라사료된다. 참고문헌 1. Stepovich ML : A cephalometric positional study of hyoid bone. Am J Orthod 51 : 882, Bibby RE, Preston CB : The hyoid triangle. Am J Orthod 80 : 92, Myung-kuk Kim : Head and neck anatomy. Vol 3 : , Yung-il Chang : The study of hyoid bone position. Kor J Orthodontics 17 : 7, Kyung-wook Kim, Jong-il Choung, Chul-hwan Kim : A cephalometric study on changes in hyoid bone, tongue and upper airway space according to skeletal change in persons with mandible prognathsm after orthognathic surgery. J Kor Acad Maxillo Pla Reconstr Surg 26 : 3, Athanasious AE, Nick T, Dimitrios M et al : Alternations of hyoid bone position pharyngeal deph and their relationship after surgical correction of mandibular pprognathism. Am J Orthod 100 : , Wickwire NA, White RP Jr, Proffit WR : The effect of mandibular osteotomy on tongue position. J Oral Surg 30 : 184, Greco JM, Frohberg U, Van sickeles JE : Long-term airway space changes after mandibular setback using bilateral sagittal split osteotomy. Int J Oral Maxillofac Surg 19 : 103, Kwang-ho Park, Jin-song Bae, Kyung-ho Kim : Cephalometric study of posterior airway space and hyoid bone position in patients affected by class II malocclusion and treated with orthognathic surgery. Kor J Maxillofac plast Reconst 23 : 527, Henriksson CO, Linder-Aronson S, Westborg B : Roentgenological changes in anteroposterior nasopharyngeal dimensions in 6 to 15 year old. Dentomaxillofac Radiol 4 : 19, Holmberg H. Linder-Aronson S : Cephalometric radiographs as a mean of evaluating the capacity of the nasal and nasopharyngeal airway.am J Orthod Dentfac Orthop 76 : 497, Reley RW, Powell NB, Guilleminault C : Current surgical concepts for treating obstructive sleep apnea syndrom. J Oral Maxillofac Surg 45 : 149, Tagagi Y, Gambe JW, Proffit WR et al : Postural change of hyoid bone following osteotomy of mandible. Oral Surg Oral Med Oral Pathol 23 : 668, Sang-han Lee : A study of relapse and position of hyoid bone following orthognathic surgery. J Kor Acad Maxillo Plas Reconstr Surg 13 : 8, Dong-hee Chung, Ki-soo Lee : A study on changes of airway. tongue, and hyoid positioin following orthognathic surgery. Kor J Orthodontics 28 : 487, Wenzel NA, Williams S, Ritzau M : Change in head position and nasopharygeal airway following surgical correction of mandibular prognathism. European J Orthod 11 : 37, Jamieson A, Guilleminault C, Partinen M et al : Obstructive sleep apnetic patient have craniomandibular abnormalities. Sleep 9 : 469, DePonte FS, Brunelli A, marchetti E : Cephalometric study of posterior airway space in patient affected by Class II occlusion and treated with orthognathic surgery. J Craniofac Surg 10 : 252, Hyo-yong Kim, Hyun-gue choi, Eun-kyung Kim : The effects of mandibular setback osteotomy on the orthopharyngeal airway space in mandibular prognathic patients. Kor J orthodontics 27 : 저자연락처우편번호 서울시강남구도곡동 연세대학교치과대학구강악안면외과학교실 ( 영동세브란스병원 ) 박광호 원고접수일 2005년 10월 8일게재확정일 2006년 1월 11일 Reprint Requests Kwang-Ho Park Department of OMFS, College of Dentistry, Yonsei University Dogok-Dong, Gangnam-Gu, Seoul, , Korea Tel: Fax: omspark@yumc.yonsei.ac.kr Paper received 8 October 2005 Paper accepted 11 January

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저작자표시 - 비영리 - 변경금지 2.0 대한민국 이용자는아래의조건을따르는경우에한하여자유롭게 이저작물을복제, 배포, 전송, 전시, 공연및방송할수있습니다. 다음과같은조건을따라야합니다 : 저작자표시. 귀하는원저작자를표시하여야합니다. 비영리. 귀하는이저작물을영리목적으로이용할수없습니다. 변경금지. 귀하는이저작물을개작, 변형또는가공할수없습니다. 귀하는, 이저작물의재이용이나배포의경우,