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1 저작자표시 - 비영리 - 변경금지 2.0 대한민국 이용자는아래의조건을따르는경우에한하여자유롭게 이저작물을복제, 배포, 전송, 전시, 공연및방송할수있습니다. 다음과같은조건을따라야합니다 : 저작자표시. 귀하는원저작자를표시하여야합니다. 비영리. 귀하는이저작물을영리목적으로이용할수없습니다. 변경금지. 귀하는이저작물을개작, 변형또는가공할수없습니다. 귀하는, 이저작물의재이용이나배포의경우, 이저작물에적용된이용허락조건을명확하게나타내어야합니다. 저작권자로부터별도의허가를받으면이러한조건들은적용되지않습니다. 저작권법에따른이용자의권리는위의내용에의하여영향을받지않습니다. 이것은이용허락규약 (Legal Code) 을이해하기쉽게요약한것입니다. Disclaimer

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5 감사의글 이논문이완성되기까지격려및충고를아끼지않으시고학문적지도와깊은관심을보여주신황충주지도교수님께깊은감사를전합니다. 또한바쁘신와중에도부족한제논문을꼼꼼히신경써주시고방향을잃지않도록지도해주신이지연교수님과최윤정교수님께도감사의말씀을드립니다. 백지장같았던저를보듬고채워주시며, 교정과라는과에소속되어조금더나은교정의사가되도록일깨워주시는이지연교수님과김정훈교수님께늘감사드립니다. 연세대학교대학원에서배움의기회를주신백형선교수님, 김경호교수님, 유형석교수님, 이기준교수님, 차정열교수님, 정주령교수님께감사의마음을전합니다. 의국생활동안항상아껴주시고많은것을가르쳐주신김경원, 안재찬, 안상인선생님께감사드리며, 더챙겨주지못해미안한이은환, 김찬승선생에게고맙다는말을전합니다. 그리고수련기간동안함께한일산병원의국원들에게도고맙다는말을전하고싶습니다. 마지막으로제가여기에있기까지아낌없는사랑을주신부모님과하나뿐인동생에게도사랑한다는말을전하고싶습니다. 2016년 12월저자씀

6 차례 그림차례 iii 표차례 iv 국문요약 v I. 서론 1 II. 연구대상및방법 4 1. 연구대상 4 2. 연구방법 6 가. Bonded Rapid Palatal Expander 와상악골전방견인장치의임상적용 6 나. 측모두부규격방사선사진촬영및계측 7 다. 기준점, 기준선설정 7 라. 계측항목 11 마. 통계분석 16 III. 연구결과 계측오차검정 상악골급속확장군과상악골급속확장을시행하지않은군사이의차이에대한유의차검정 T0, T1, T2 사이의계측치변화 18 i

7 4. C0, C1 사이의계측치변화의유의성평가 대조군과치료군사이계측치변화의유의성평가 24 IV. 고찰 26 V. 결론 33 참고문헌 35 영문요약 36 ii

8 그림차례 Fig. 1. Cephalometric landmarks 10 Fig. 2. Cephalometric measurements for tongue 13 Fig. 3. Cephalometric measurements for hyoid bone 14 Fig. 4. Cephalometric measurements for airway and head posture 15 Fig. 5. Schematic illustration of changes of tongue 27 iii

9 표차례 Table 1. Distribution of ages(mean±standard deviation) of patients and control subjects according to time period 5 Table 2. Description of cephalometric landmarks 8 Table 3. Description of cephalometric planes 9 Table 4. Definition of cephalometric measurements 12 Table 5. Means and Standard Deviations(SD) at T0, T1, T2 20 Table 6. Comparison of the mean differences of skeletal and dental relationship. tongue position, hyoid position, airway dimension and head posture at T0, T1, T2 21 Table 7. Means and Standard Deviations(SD) of at the C0, C1 23 Table 8. Comparison of the changes between the treated(t1-t0) and control(c1-c0) groups 25 iv

10 국문요약 상악골전방견인에의한 혀와설골및기도공간의변화 ( 지도교수 : 황충주 ) 연세대학교대학원치의학과 황동민 혀는구강내중요근육구조물로서혀의위치나기능은부정교합과밀접한관련을가진다. 설골은주변골조직과직접적으로연결되어있지않고근육과인대와같은연조직에의하여연결되어있는구조물로설골의위치는주변경조직과연조직의영향을받는다. 상악골전방견인치료는짧은기간내에큰악정형효과를가져올수있는술식으로서골격성 III급부정교합을개선하기위하여성장기아동에서사용되고있다. 상악골전방견인에따른상 하악의골격적변화에관하여서는많은보고가있었으나상 하악골이외에주변조직의변화는최근에서 v

11 야보고되고있으며기도공간평가이외의주변조직에대한연구는부족한 실정이다. 이에본연구에서는교정치료를받지않은 20명의골격성 I급부정교합환자 ( 남자 9명, 여자 11명 ; 평균나이 7.95세, 평균관찰기간 8.95개월 ) 의관찰기간시작전 (C0) 과관찰기간종료시 (C1) 의측모두부규격방사선사진과상악골전방견인을통하여성장조절치료를한 35명의골격성 III급부정교합환자 ( 남자 17명, 여자 19명 ; 평균나이 7.75세, 평균치료기간 9.69개월 ) 의치료전 (T0), 상악골전방견인종료직후 (T1), 상악골전방견인종료 1년후 (T2) 의측모두부규격방사선사진을이용하여혀와설골그리고기도공간의변화정도를평가하였으며다음과같은결과를얻었다. 1. 상악골전방견인치료를시행한치료군은대조군에비해유의하게큰상악의전방성장 (P<0.01), 하악의후하방회전 (P<0.01), 상악전치의순측경사를보였다 (P<0.05). 이러한변화는상악골전방견인종료 1년후에도치료전과비교하였을때유의하였다 (P<0.01). 2. 상악골전방견인치료를시행한치료군은대조군에비해혀의위치가유의하게상방으로변위되었으며 (P <0.05) 이러한변화는상악골전방견인종료 1년후에도치료전과비교하였을때유의하였다 (P<0.001). 3. 상악골전방견인치료후치료군과대조군을비교하였을때설골의위치는유의한변화를보이지않았다 (P >0.05). vi

12 4. 상악골전방견인치료를시행한치료군은대조군에비해비인두공간의유의한증가를보였으며 (P<0.01) 이러한변화는상악골전방견인종료 1년후에도치료전과비교하였을때유의하였으나 (P<0.001) 구인두공간의경우두군간에유의한차이가없었다 (P >0.05). 골격성 III급성장기환자의상악골전방견인을통한악정형치료시상 하악골의변화와함께혀의상방변위와비인두공간의증가가관찰되었으나설골과구인두공간은치료전후차이를보이지않았다. 혀와비인두공간의변화는치료종료 1년후에도안정적으로유지되었으며, 혀의상방으로의위치이동에따른구강내 외균형의회복은상악골전방견인후상 하악치열궁폭경조화및유지에도움을줄수있을것이다. 핵심되는말 : 상악골전방견인, 혀, 설골, 비인두공간, 구인두공간 vii

13 상악골전방견인에의한 혀와설골및기도공간의변화 ( 지도교수 : 황충주 ) 연세대학교대학원치의학과 황동민 Ⅰ. 서론 제 III급부정교합은상악의열성장이나하악의과성장또는이둘의복합으로발생되며 (Dellinger, 1973) 이중상악열성장을동반하는경우가 1/3에서 2/3정도를차지한다 (Ellis and McNamara, 1984; Guyer et al., 1986; Mouakeh, 2001). 골격성 III급부정교합의해소를위한상악골전방견인치료는짧은기간내에큰악정형효과를가져올수있는치료로서성장기아동에서성장조절치료를위해서사용된다. 상악골전방견인치료는골격적으로상악의전하방성장을촉진시키고하악의후하방회전을유도하며, 치성적으로상악전치의순측경사를유도한다고알려져있다. 상악 - 1 -

14 골전방견인에따른상 하악의골격적변화에관하여서는많은보고가있었으나상 하악골이외에주변조직의변화는최근에서야보고되고있다. Sayinsu와 Kaygisiz 등은상악골전방견인이비인두공간의증가를가져올수있다고보고하였으며 (Hiyama et al., 2002; Kaygisiz et al., 2009; Sayinsu et al., 2006), Kilinc, Oktay와 Ulukaya 등은상악골전방견인이비인두공간뿐만아니라구강인두공간의증가도가져올수있다고하였다 (Kilinc et al., 2008; Oktay and Ulukaya, 2008). 설골은주변골조직과직접적인연결없이근육과인대에의하여연결되어있으며, 혀와하악골, 두개골, 쇄골등에연결되어영향을받는다. 설골의위치와기도공간과의관련성에대해여러연구들이보고되었으며, Verin 등은상기도저항이설골에서하악평면까지의거리와상관관계가있다고하였고 (Verin et al., 2002), Jiang 등은기도공간의크기와설골의위치사이에상관관계가있다고보고하였다 (Jiang, 2016). 상악골전방견인이기도공간의증가를가져올수있다는것과설골의위치가기도공간과관련되어있다는것을근거로할때상악골전방견인치료시설골의위치변화가나타날수있을것이다. 설골의위치변화는치료의안정성과관련이있다고알려져있으며 (Bibby and Preston, 1981), 따라서악정형치료시설골의위치변화및안정성에대한연구는환자의예후평가에중요할것이다

15 혀는중요한구강내근육구조물로서발음, 연하, 구강및주변골격의성장에중요한역할을한다. 혀의위치나크기와같은환경적요인이골격성 III급부정교합의원인중하나가될수있으며 (Lee and Kim, 1993), 골격성 III급부정교합환자는 I급부정교합에비하여상대적으로혀가하방으로위치되어있다고보고되었다 (Gorgulu et al., 2011; Primozic et al., 2013). 혀의하방위치는상악궁의협착과하악전치사이의공극을야기할수있으며, 이는골격성 III급부정교합환자에서자주관찰되는특징이기도하다. 상악골전방견인을통하여골격성 III급부정교합환자를치료할시에골격적변화와함께연조직의변화도나타나게되며, 구강내가장큰근육인혀또한상 하악의악골관계수정에따라위치변화가일어날수있으나이에대한연구는부족한실정이다. 이에본연구에서는교정치료를받지않은골격성 I급부정교합환자와상악골전방견인을통하여성장조절치료를한골격성 III급부정교합환자의측모두부규격방사선사진을이용하여혀와설골그리고기도공간의변화정도를평가하고성장기아동에서상악골전방견인이주변조직에미치는영향및그안정성에대해서알아보고자하였다

16 Ⅱ. 연구대상및방법 1. 연구대상 2010년 2월에서 2015년 2월사이국민건강보험일산병원교정과에서골격성제 III 급부정교합으로진단되어상악골전방견인치료를받은환자를대상으로후향적연구를진행하였다. 위의환자중 1) 전치부절단교합이나, 반대교합을보이는 III급구치관계를가지는환자, 2) 상악골열성장으로진단된환자, 3) Wits appraisal 값이 -3mm이하인환자, 4) 치료전, 상악골전방견인직후그리고상악골전방견인종료약 1년후에측모두부규격방사선사진을촬영한환자, 5) 상악골확장을시행하지않았거나확장량이 2mm 이내인환자, 6) 악안면기형을동반하지않는환자를대상으로하였다. 조건을만족한총 35명의환자 ( 남성 17명여성 18명 ) 를대상으로하였으며, 모든환자는사춘기전기의환자로 cervical vertebrae maturity indicator stage 1, 2에해당하였고평균연령은 7.75세, 평균치료기간은 9.69개월이었다. 대조군의경우 2007년 1월부터 2016년 2월사이국민건강보험일산병원에내원한환자중이전에교정치료를받은적이없으며, 악골부조화가없는골격성 I급부정교합으로진단받은총 20명의환자 ( 남성 9명여성 11명 ) 를대상으로하였다. Wits apprisal이 -2mm이상, 4mm이하, 사춘기 - 4 -

17 전기의 cervical vertebrae maturity indicator stage 1, 2에해당하는환자로상악골전방견인치료를받은치료군과비슷한골격성숙도와연대연령을가진환자들중관찰기간동안 2장의측모두부방사선사진을채득한환자들을대상으로하였으며, 평균연령은 7.95세, 평균관찰기간은 8.95개월이었다 (Table 1). Table 1. Distribution of ages(mean±standard deviation) of patients and control subjects according to time period C0 C1 T0 T1 T2 Patient age (years) 7.95± ± ± ± ±1.36 C0, beginning of control period; C1, end of control period: T0, before maxillary protraction; T1, immediate after maxillary protraction; T2, 1 year after maxillary protraction; - 5 -

18 2. 연구방법 가. Bonded Rapid Palatal Expander(Bonded RPE) 와상악골전방견인장치의임상적용상악골급속확장을시행한 11명은 Bonded RPE는 hyrax type의 expansion screw및구치부의바이트블록을포함한형태로제작되었으며, 평균확장량은 1.8mm였다. 상악골급속확장을시행하지않은 24명은구치부 expansion screw를제외한바이트블록만을포함한형태로제작되었다. 유견치상방으로 0.5~1cm가량의 hook을연장하여전방견인시탄성고무줄을장착할수있도록하였으며상악골전방견인장치로는 Petit type의상악골전방견인장치를사용하였다. 편측당 gm의견인력을적용하였으며전치부의개방교합이생기는것을방지하기위하여교합평면에대하여 30 하방으로전방견인하였다. 환자에게 14시간이상상악골전방견인장치를착용하도록교육하였으며, 전치부반대교합이해소되고 I급구치부관계가얻어졌을때상악골전방견인치료를중단하였다

19 나. 측모두부규격방사선사진촬영및계측대조군의 C0,C1시기와치료군의 T0, T1, T2시기에두부규격방사선사진촬영장치 (Orthoceph OC100D, GE Healthcare, USA) 를모두동일한설정 ( 노출량 10초, 12mA, 85kV) 하에촬영하였다. 모든환자는측면에서 natural head position에서촬영하였다. 촬영된환자의측모두부규격방사선사진은확대율을확인한후동일한조사자에의해 V-ceph 5.5 (Osstem Implant Co., Ltd., Seoul, Korea) 를이용하여 tracing 및계측하였다. 길이계측은 0.01mm, 각도계측은 0.01 단위로계측하였다. 다. 기준점, 기준선설정 본연구에서사용된기준점및기준선은다음과같다. 1) 기준점 (Table 2, Fig.1) - 7 -

20 Table 2. Description of cephalometric landmarks Landmark Sella(S) Nasion(N) Orbitale(Or) Anterior nasal spine(ans) Posterior nasal spine(pns) Menton(Me) Pogonion(Pog) Porion(Po) Basion(Ba) A-Point(A) B-Point(B) Gonion(Go) H Retrognathion(RGN) C3 Cv2tg Cv4ip Base of epiglottis(eb) Pterygomaxillary fissure(ptm) TT TP TD P Description The center of the pituitary fossa of the sphenoid bone Junction of frontonasal suture The most inferior point of bony orbital margin The most anterior point of maxilla The most posterior point of palatal bone The most inferior point on the symphyseal outline The most anterior point on the contour of the symphysis The most superior point of external auditory meatus The most forward the lowest point on the anterior margin of the frontal magnum Subspinale Supramentale The constructed point of intersection of ramus plane and the mandibular plane The most superior and anterior point on body of hyoid bone The most posterior point on the mandibular symphysis The most anteroinferior point on the corpus of 3 rd cervical vertebra The tangent point at the superior posterior extremity of the odontoid process of the second cervical vertebra The most inferoposterior point on the corpus of 4 nd cervical vertebra The deepest point of epiglottis The most inferior point of pterygomaxillary fissure Tip of tongue The most posterior point of tongue The most close point of tongue from palatal plane The most inferior tip of soft palate - 8 -

21 2) 기준선 (Table 3, Fig.1) Table 3. Description of cephalometric planes Plane SN plane Frankfort(FH) plane Mandibular plane Palatal plane Pterygomaxillary vertical(pmv) Description Line from the Sella to Nasion Line from Porion to Orbitale Line from the most inferior border of the ramus of the mandible to Menton Line from ANS to PNS Line from PTM perpendicular to Frankfort plane - 9 -

22 Fig. 1. Cephalometric landmarks

23 라. 계측항목다음은본연구에서사용된계측항목으로 Kaygisiz 등 (Kaygisiz et al., 2009) 과 Lee 등 (J. W. Lee et al., 2011) 의연구를참고하여계측치를선정하고골격, 치축각도, 혀, 설골, 기도공간에대하여평가하였다 (Table 4, Fig.2, Fig.3, Fig.4). 비인두공간을측정하기위한계측항목으로 PNS-ad1, PNS-ad2를, 구인두공간을측정하기위한계측항목으로 SPAS, MAS, IAS 를설정하였다

24 Table 4. Definition of cephalometric measurements Variable 12 Definition Skeletal & dental SNA( ) The angle between the SN line and NA line relationship SNB( ) The angle between the SN line and NB line ANB( ) The angle between the NA line and NB line SN-GoMe( ) The angle between SN plane and line from Go to Me PFH/AFH(mm) Posterior facial height(s-go) / Anterior facial height(n-me) Palatal plane The angle between SN plane and palatal plane angle( ) U1 to SN( ) The angle between SN plane and long axis of upper central incisor IMPA( ) The angle between mandibular plane and long axis of lower central incisor Interincisal The angle between long axis of upper central incisor and lower central incisor angle( ) Tongue TGL(mm) Tongue length ( distance between EB and TT) TGH(mm) Tongue height ( Maximum height of line perpendicular to EB-TT line at tongue dorsum) PMV-TT(mm) Distance along perpendicular from TT to PMV line PMV-TP(mm) Distance along perpendicular from TP to PMV line TD-PP(mm) Distance along TD to palatal plane TT-PP(mm) Distance along TT to palatal plane T-H(mm) Maximum height from H to tongue dorsum Hyoid SN-LAH( ) The angle between SN line and Long axis of hyoid bone S-H(mm) Distance between S and H Mn-H(mm) Distance between mandibular line and H C3-H(mm) Distance between C3 and H Me-H(mm) Distance between Me and H RGN-H(mm) Distance between RGN and H PMV-H(mm) Distance from H to PMV Airway PNS-Ad1(mm) Distance from PNS to pharyngeal wall along the line from Basion to PNS PNS-Ad2(mm) Distance from PNS to adenoid tissue along the line from PNS to the midpoint of the line intersecting Ba to S SPAS(mm) Superior posterior airway space (distance from posterior part of soft palate intersecting midpoint of the line P to PNS to posterior pharyngeal wall parallel to FH plane) MAS(mm) Middle airway space (distance from P to posterior pharyngeal wall parallel to FH plane) IAS(mm) Inferior airway space (distance from TD to posterior pharyngeal wall parallel to FH plane) Head posture SN-CVT( ) Angle between SN and line from Cv2tg to Cv4ip

25 Fig. 2. Cephalometric measurements for tongue (a) TGL, (b) TGH, (c) PMV-TT, (d) PMV-TP, (e) TD-PP, (f) TT-PP, (g) T-H

26 Fig. 3. Cephalometric measurements for hyoid bone (h) SN-LAH, (i) S-H, (j) Mn-H, (k) C3-H, (l) Me-H, (m) RGN-H, (n) PMV-H

27 Fig. 4. Cephalometric measurements for airway and head posture (o) PNS-ad1, (p) PNS-ad2, (q) SPAS, (r) MAS, (s) IAS, (t) SN-CVT

28 마. 통계분석 1) 계측오차검정 측정의신뢰성을판단하기위한 Intraclass correlation coefficient (ICC) 를시행하였다. 측모두부규격방사선사진 145장중무작위로 30장을뽑아서 3주간격을두고동일한계측자에의하여재측정하여계측점의재현성과신뢰성을평가하였다. 2) 상악골급속확장군과상악골급속확장을시행하지않은군사이의차 이에대한유의차검정 (Mann-Whitney U-test) 3) T0, T1, T2 에서와 C0, C1 에서의치아와골격, 설골, 혀, 기도공간계측 치변화의유의차검정 모든통계분석은 IBM SPSS Statistics version 22 (IBM Corp., Armonk, NY, USA) 을이용하였다. 치료군내에서 T0, T1, T2 시기의차이를확인하기위해 T1-T0, T2-T1, T2-T0을각각 paired t-test를이용하였다. 대조군의관찰기간 (C1-C0) 동안의변화는 Wilcoxon signed-rank test를사용하여그차이를확인하였으며, 상악골전방견인치료를시행한치료군과대조군사이에는 Mann-Whitney U-test를사용하였다

29 Ⅲ. 연구결과 1. 계측오차검정 계측값측정의신뢰성을판단하기위한 Intraclass correlation coefficient 를조사한결과그범위는 r=0.90 에서 0.99 (P<0.001) 사이로 높은신뢰도를보였다. 2. 상악골급속확장군과상악골급속확장을시행하지않은군 사이의차이에대한유의차검정 측정한계측치에대해 Mann-Whitney U-test 를시행한결과통계적으 로유의한차이가없었다

30 3. T0, T1, T2 사이의계측치변화 (Table 5, Table 6) 가. T0, T1, T2 사이의골격및치아계측치변화골격계측치를살펴보면 T1에서는 T0에비해 SNA는 1.45±1.52, SNB 는 -2.01±1.39, SN-GoMe는 2.09±2.20 변화하였으며모두유의하였다. 상악골은전방으로, 하악골은후하방으로회전하였으며, 이러한변화는구개평면을제외하고보정기간 (T2-T1) 동안어느정도의재발경향을보였다. SNA는 -0.55±1.43, SNB는 0.96±1.43, SN-GoMe는 -1.49±2.22 변화하였고모두유의하였다. 치아계측치를살펴보면 T1에서는 T0에비해상악전치의각도만이유의하게컸으며, 하악전치의각도와절치간각도의경우유의차가없었다. 총변화 (T2-T0) 를보았을때상악전치의각도는유의하게증가, 절치간각도는유의하게감소하였으며, 하악전치의각도는유의차가없었다. 나. T0, T1, T2 사이의혀의위치변화혀의경우 T1에서는 T0에비해 TGH, PMV-TP, TD-PP, T-H 수치가통계적유의차를보였다. TGH, TD-PP, T-H는모두혀의수직적높이를평가하는계측값으로 TGH는 1.27±2.42mm, TD-PP는 -2.30±2.47mm, T-H는 1.85 ± 3.03mm 변화하였으며, 혀의높이가증가하고혀가구개평면에가까워지는양상을보였다. 보정기간 (T2-T1) 동안 TGL, TGH,

31 PMV-TT 만이유의하게증가하였다. T0 에비해서 T1 에서혀의배면의 위치가유의하게수직적으로증가되었으며, T2 에서도 T1 과비교하였을때 유의차없이안정적으로유지되었다. 다. T0, T1, T2 사이의설골의위치변화설골의경우 T1에서는 T0에비해 Mn-H만이통계적으로유의하게감소하였다. Mn-H는 -1.25±2.85mm 변화하여, 하악평면과설골사이의거리가감소하였다. 보정기간 (T2-T1) 동안 S-H만이유의차를나타냈으며, 총변화 (T2-T0) 를살펴보았을때 S-H, C3-H만이유의차를나타냈고주위구조물에대한설골의위치는일정하게유지되었다. 라. T0, T1, T2 사이의기도공간의변화 T1에서는 T0에비해비인두공간 (PNS-ad1, PNS-ad2) 만이통계적으로유의하게증가하였다 (P <0.001). 보정기간 (T2-T1) 에서는어떠한계측치들도통계적으로유의하지않았다. 총변화 (T2-T0) 를보았을때 PNS-ad1, PNS-ad2, SPAS가유의하게증가하였다

32 Table 5. Means and Standard Deviations(SD) at T0, T1, T2. Skeletal & dental relationship T0 T1 T2 Mean SD Mean SD Mean SD SNA( ) SNB( ) ANB( ) SN-GoMe( ) PFH/AFH(mm) Palatal plane angle( ) U1 to SN( ) IMPA( ) Interincisal angle( ) Tongue TGL(mm) TGH(mm) PMV-TT(mm) PMV-TP(mm) TD-PP(mm) TT-PP(mm) T-H(mm) Hyoid SN-LAH( ) S-H(mm) Mn-H(mm) C3-H(mm) Me-H(mm) RGN-H(mm) PMV-H(mm) Airway PNS-ad1(mm) PNS-ad2(mm) SPAS(mm) MAS(mm) IAS(mm) Head posture SN-CVT( )

33 Table 6. Comparison of the mean differences of skeletal and dental relationship, tongue position, hyoid position, airway dimension and head posture at T0, T1, T2. Mean differences (T1-T0) Mean differences (T2-T1) Mean differences (T2-T0) Mean SD P Mean SD P Mean SD P Skeletal & dental relationship SNA( ) *** * ** SNB( ) *** *** *** ANB( ) *** *** *** SN-GoMe( ) *** ** ** PFH/AFH(mm) *** ** * Palatal plane *** * ** angle( ) U1 to SN( ) *** *** *** IMPA( ) Interincisal angle( ) Tongue * * TGL(mm) ** *** TGH(mm) ** *** *** PMV-TT(mm) *** *** PMV-TP(mm) * ** TD-PP(mm) *** *** TT-PP(mm) T-H(mm) *** *** Hyoid SN-LAH( ) S-H(mm) *** *** Mn-H(mm) * * C3-H(mm) *** Me-H(mm) RGN-H(mm) PMV-H(mm) Airway PNS-ad1(mm) *** *** PNS-ad2(mm) *** *** SPAS(mm) * MAS(mm) IAS(mm) Head posture SN-CVT( ) Paired t-test; * P <0.05; ** P <0.01; *** P <

34 4. C0, C1 사이의계측치변화의유의성평가 (Table 7) 대조군의관찰기간동안의골격, 치축각도, 혀, 설골, 기도공간의변화가 Table 7 에나타나있다. 관찰기간동안대조군은 SPAS 를제외한어떠한 계측치에서도통계적으로유의한변화를보이지않았다

35 Table 7. Means and Standard Deviations(SD) at C0, C1 Skeletal & dental relationship C0 C1 P Mean SD Mean SD SNA( ) SNB( ) ANB( ) SN-GoMe( ) PFH/AFH(mm) Palatal plane angle( ) U1 to SN( ) IMPA( ) Interincisal angle( ) Tongue TGL(mm) TGH(mm) PMV-TT(mm) PMV-TP(mm) TD-PP(mm) TT-PP(mm) T-H(mm) Hyoid SN-LAH( ) S-H(mm) Mn-H(mm) C3-H(mm) Me-H(mm) RGN-H(mm) PMV-H(mm) Airway PNS-ad1(mm) PNS-ad2(mm) SPAS(mm) * MAS(mm) IAS(mm) Head posture SN-CVT( ) Wilcoxon signed-rank test; * P <0.05; ** P <0.01; *** P <

36 5. 대조군과치료군사이계측치변화의유의성평가 (Table 8) 치료군의골격계측치의변화를평가하였을때 SNA의유의한증가, SNB의유의한감소, 하악평면각의유의한증가가나타났다. 상악전치는대조군과비교하였을때유의하게순측으로경사되었으며, 절치간각도는감소하였다. 혀의위치를평가한계측치에서대조군과비교하였을때 TGH는통계적으로유의하게증가하였고 TD-PP는유의하게감소하였다. 즉, 혀의위치는상방으로이동하고구개평면에가까워지는양상을보였다 (Fig.5). 설골의경우대조군과비교하였을때모든계측치에서유의한변화를보이지않았다. 기도공간을평가하였을때 PNS-ad1, PNS-ad2만이대조군과비교하였을때유의하게증가하였으며, 구인두공간을평가한계측치들에서는유의한변화가없었다. Fig. 5. Schematic illustration of changes of tongue Before maxillary protraction (dotted line), tongue posture is low. Increase in volume of oral cavity and superior movement of tongue was observed after maxillary protraction (solid line)

37 Table 8. Comparison of the changes between the treated(t1-t0) and control(c1-c0) groups. Skeletal & dental relationship C1-C0 T1-T0 P Mean SD Mean SD SNA( ) ** SNB( ) *** ANB( ) *** SN-GoMe( ) ** PFH/AFH(mm) ** Palatal plane angle( ) *** U1 to SN( ) * IMPA( ) Interincisal angle( ) * Tongue TGL(mm) TGH(mm) * PMV-TT(mm) PMV-TP(mm) TD-PP(mm) *** TT-PP(mm) T-H(mm) Hyoid SN-LAH( ) S-H(mm) Mn-H(mm) C3-H(mm) Me-H(mm) RGN-H(mm) PMV-H(mm) Airway PNS-ad1(mm) ** PNS-ad2(mm) *** SPAS(mm) MAS(mm) IAS(mm) Head posture SN-CVT( ) Mann-Whitney U-test; * P <0.05; ** P <0.01; *** P <

38 Ⅳ. 고찰 혀는구강내의중요한근육구조물로서악골과치열궁의형태와위치를유지하고결정하는역할을한다. 혀의위치와습관은부정교합의원인이될수있을뿐만아니라치료후의안정성에도영향을미칠수있다 (Behlfelt et al., 1989). Seo 등은 tongue elevator를통한근기능요법은전치부의개방교합양상을개선할수있고, 이는혀의위치변화를통한결과라고보고하였으며 (Seo et al., 2014), Huang 등은 tongue crib을통한개방교합의개선역시혀의올바른자세성위치에기인한다고하였다 (Huang et al., 1990). 골격성 III급부정교합은골격성 I급부정교합환자보다혀의위치가상대적으로하방에위치한다고보고되었으며 (Gorgulu et al., 2011; Primozic et al., 2013) 이러한혀의하방위치는상 하악폭경차이를유발할뿐만아니라상악의바람직한성장을저해할수있다. 본연구에서치료군은상악골급속확장을시행한 11명과시행하지않은 24명의환자를대상으로하였으며, 상악골급속확장을시행한환자는오직봉합의분리만을위하여확장을시행한환자들로하여상악골급속확장에의한영향을최소화하고자하였다. 상악골급속확장군과상악골급속확장을시행하지않은군사이계측치에서는유의한차이가없었으며, 본연구에서상악골확장에의한영향은미미할것이라생각된다. 상악골급속확장

39 에의한영향을본연구에서상악골전방견인치료후 TGH와 TD-PP는통계적으로유의하게변화하였으며이는혀의위치가치료전과비교하였을때상방으로위치되었음을의미한다. 이후의보정기간에도이러한혀의위치는재발경향없이안정적으로유지되는것으로나타났다. Bench는연령에따른종단적연구를통해유치열기와혼합치열기를지나면서혀의크기는점차증가하지만 PNS에대한혀의배면의위치는 PNS에대해멀어지는방향으로이동, 혀가점차하방으로위치한다고보고하였으며 (Bench, 1963), 본연구의대조군에서는관찰기간동안혀의위치의유의한변화가나타나지않았다. 따라서상악골전방견인치료를받은그룹에서나타난혀의상방변위는악정형효과에의한것으로판단되며이는상악골전방견인으로인하여상악골이전방성장되면서구강내공간의증가가일어나기때문으로보인다 (Fig.5). 골격성 I급부정교합에비해서골격성 III급부정교합환자에서혀가상대적으로하방으로위치한다는점을고려하였을때 (Gorgulu et al., 2011; Primozic et al., 2013) 이러한혀의상방으로의변화는협근기전에따라혀와뺨사이, 혀와입술사이의평형을이루어치열궁의조화에도움을줄수있을것이다. 골격성 III급부정교합환자는상대적으로큰하악골의크기와상대적으로작은상악골의크기를가진다고보고되었고 (Miyajima et al., 1997; Sato, 1994) functional matrix theory에따르면, 상악골복합체는혀의위치에영향을받기때문에 (Moss and Young, 1960) 혀의상방으로의위치변화는상하악폭경조화에도움을줄수있을것이다

40 설골은주변골조직과직접적인연결없이근육과인대에의하여연결되어있으며, 혀와하악골, 두개골, 쇄골등에연결되어영향을받는다. 설골의 T1에서 T0의변화를대조군과비교하였을때어떠한계측치들에서도통계적으로유의한변화가나타나지않았다. 이는상악골전방견인치료전후설골의위치는인접구조물에대해상대적으로일정한위치를유지한다는것을의미한다. 보정기간 (T2-T1) 동안의경조직, 연조직변화를살펴보았을때치료후의변화는안정적으로유지되었다. Bibby의교정치료와설골의위치관계에대한보고에서 (Bibby and Preston, 1981) 교정치료후설골의위치가변하지않는다는것은주위연조직들이서로균형을이루고있는상태로볼수있으며치료후의재발경향성은작다고하였다. 하지만설골의위치가교정치료후변화된다면재발경향성은더커지며더긴보정기간이필요하다고하였다. 본연구에서상악골전방견인치료전후설골은일정한위치를유지하였기때문에재발경향은적을것임을유추할수있으며, 실제보정기간 (T2-T1) 에서상악골전방견인에의한치료효과는안정적으로유지되었다. 본연구에서보정기간 (T2-T1) 과총변화 (T2-T0) 에서 S-H값의증가가유의하게나타났다. 이러한변화는연령이증가함에따른성장으로인하여두개저에대한설골의하방변위로인한것으로생각되며, Tourne의연구결과와일치하였다. 두부자세와설골의위치, 기도공간은서로연관이있다고알려져있으며, Stepovich 는자세에따른설골의위치변화를연구한결과두경부의자세

41 에따라설골의위치가변함을보고하였으며 (Stepovich, 1965), King은머리위치에따라설골의위치가변화하게되는데머리를뒤로젖히면설골도뒤로젖혀지고머리를숙이게되면설골도전방으로이동한다고하였다 (King, 1952). 기도공간은두경부자세에따른영향을받는다고보고되었다 (Hiyama et al., 2002; Pracharktam et al., 1994). 따라서측모두부규격방사선사진촬영시일정한두부자세를유지하여야한다. Yagci 등은상악골전방견인치료후고개가숙여지는쪽으로 natural head position의변화가생긴다고하였으나 (Yagci et al., 2011) 본연구에서 SN-CVT를측정하여각군간의두부자세를평가하였을때통계적으로유의한차이가없었다. 이는 Yagci 등은동적인상태에서두부에부착된경사계를이용하여 natural head position을측정하였던반면본연구에서는측모두부규격방사선촬영시에 ear rod를사용하여환자의두부를고정하였기때문이라고사료되며, 본연구에서는각군간의두부자세를평가하였을때통계적으로유의한차이가없었기때문에설골과기도공간의변화평가시에환자의두부자세에의한영향을배제할수있을것이다. 본연구에서상악골전방견인후비인두공간을평가하는 PNS-ad1, PNS-ad2를대조군과비교하였을때유의한증가가나타났으나구인두공간을평가하는 SPAS, MAS, IAS에서는대조군과비교하였을때유의차가없었다. 이러한결과는상악골전방견인시비인두공간만이증가한다고보고한 Sayinsu와 Kaygisiz 등의연구와일치하나 (Kaygisiz et al., 2009;

42 Sayinsu et al., 2006) 비인두공간과구인두공간이모두증가한다는 Oktay와 Ulukaya의연구와는차이를보였다 (Oktay and Ulukaya, 2008). 이는 Oktay와 Ulukaya의연구에서는대조군을설정하지않고치료전과치료후를비교함에따른것으로보인다. 본연구에서치료군의경우 T2-T0, 대조군의경우 C1-C0 기간동안에구인두공간을평가하는계측치인 SPAS가유의하게증가하였음을확인할수있으며 T2-T1 기간동안에도상대적으로낮은유의확률을보였다 (P=0.058). 이를토대로 Oktay와 Ulukaya가보고한구인두공간의증가는상악골전방견인에의한효과보다는성장에의한영향으로볼수있을것이다. 상악골전방견인에따른비인두공간의증가는보정기간 (T2-T1) 동안유의한변화없이안정적으로유지되었다. 기도공간평가시기도후방의연조직인아데노이드의에대한평가가동반되어야하는데 Taylor 등의인두의성장변화에관한누년적연구에서 6-9세, 12-15세아동에서후방인두조직의변화가크며 9-12세, 15-18세에서는그크기가안정적이라고보고하였다 (Taylor et al., 1996). 본연구에서치료군의평균연령은 7.75세로상대적으로아데노이드의변화가클수있으나비슷한골격성숙도와연대연령을가지는대조군을설정하여오차를줄이고자하였다. 상악골전방견인치료로호흡기능의개선이일어날수있는가와관련하여 Hiyama 등은상악골열성장환자에서상악골전방견인이호흡기능의증

43 가를가져올수있다고하였으며 (Hiyama et al., 2002), Lee 등은성장기환자에서상악골전방견인에의한상기도공간의증가가호흡기능에도움을줄수있다고하였다 (J. W. Lee et al., 2011). Conley는폐쇄성수면무호흡증을가진소아와치과치료의효과를평가한연구에서하악의열성장뿐만아니라상악의열성장또한폐쇄성수면무호흡증의원인이될있으며상악골전방견인을통한악정형치료는호흡개선의효과를가져올수있을것이라고제시하였다 (Conley, 2011). 이를바탕으로볼때본연구에서상악골전방견인치료후나타난비인두공간의증가는호흡기능의개선을가져올수있을것이다. 하지만본연구에서는방사선학적인계측만을통해기도공간을평가하였으며 apnea-hypopnea index(ahi) 나 nasal flow와같은호흡기능의지표를측정하지않았다는한계점이존재하며실질적인호흡기능의평가를동반한추가적인연구가필요할것이다. 본연구는상악골전방견인치료를받은환자에서혀와설골, 기도공간의변화와그안정성을측모두부규격방사선사진을통하여평가한것으로측모두부규격방사선사진은두개안면부위의경조직뿐만아니라혀와기도공간과같은연조직을평가하는데있어서신뢰성있는정보를제공하며 (Bronoosh and Khojastepour, 2015; Feng et al., 2015; Vizzotto et al., 2012), 연속된측모두부규격방사선사진에서기도공간과혀와설골의위치는높은재현성을가지는것으로보고되었다 (Malkoc et al., 2005). 하지만연조직의경우두개안면구조와의중첩이나대조도에따른문제와같은

44 한계점이존재한다. 이를보완하기위하여측모두부규격방사선촬영시혀의위치평가를위한방사선불투과성염료를사용하거나 cone-beam computed tomography(cbct), computed tomography(ct) 등을이용하여 3차원적인계측을시행한다면보다정확한평가가이루어지리라생각된다

45 Ⅴ. 결론 본연구는교정치료를받지않은골격성 I급부정교합환자와상악골전방견인을통하여성장조절치료를시행한골격성 III급부정교합환자의측모두부규격방사선사진을이용하여혀와설골그리고기도공간의변화정도를평가하였으며다음과같은결과를얻었다. 1. 상악골전방견인치료후치료군은대조군에비해유의하게큰상악의전방성장 (P<0.01), 하악의후하방회전 (P<0.01), 상악전치의순측경사를보였다 (P<0.05). 이러한변화는상악골전방견인종료 1년후에도치료전과비교하였을때유의하였다 (P<0.01). 2. 상악골전방견인치료후치료군은대조군에비해혀의위치가유의하게상방으로변위되었으며 (P <0.05) 이러한변화는상악골전방견인종료 1년후에도치료전과비교하였을때유의하였다 (P<0.001). 3. 상악골전방견인치료후치료군과대조군을비교하였을때주변구조물에대한설골의위치는유의한변화를보이지않았다 (P >0.05). 4. 상악골전방견인치료후치료군은대조군에비해유의하게큰비인두공간의증가를보였으며 (P<0.01) 이러한변화는상악골전방견인종료 1 년후에도치료전과비교하였을때유의하였으나 (P<0.001) 구인두공간의경우두군간에유의한차이가없었다 (P >0.05)

46 골격성 III급성장기환자의상악골전방견인을통한악정형치료시상 하악골의변화와함께혀의상방변위와비인두공간의증가가관찰되었으나설골과구인두공간은치료전후차이를보이지않았다. 혀와비인두공간의변화는치료종료 1년후에도안정적으로유지되었으며, 혀의상방으로의위치이동에따른구강내 외균형의회복은상악골전방견인후상 하악치열궁폭경조화및유지에도움을줄수있을것이다

47 참고문헌 Behlfelt K, Linder-Aronson S, McWilliam J, Neander P, Laage-Hellman J: Dentition in children with enlarged tonsils compared to control children. Eur J Orthod 11: , Bench RW: Growth of the cervical vertebrae as related to tongue, face, and denture behavior. Am J Orthod 49: , Bibby RE, Preston CB: The hyoid triangle. Am J Orthod 80: 92-97, Bronoosh P, Khojastepour L: Analysis of Pharyngeal Airway Using Lateral Cephalogram vs CBCT Images: A Cross-sectional Retrospective Study. Open Dent J 9: , Conley RS: Evidence for dental and dental specialty treatment of obstructive sleep apnoea. Part 1: the adult OSA patient and Part 2: the paediatric and adolescent patient. J Oral Rehabil 38: , Dellinger EL: A preliminary study of anterior maxillary displacement. Am J Orthod 63: , Ellis E, 3rd, McNamara JA, Jr.: Components of adult Class III malocclusion. J Oral Maxillofac Surg 42: , Feng X, Li G, Qu Z, Liu L, Nasstrom K, Shi XQ: Comparative analysis of upper airway volume with lateral cephalograms and cone-beam computed tomography. Am J Orthod Dentofacial Orthop 147: , Gorgulu S, Sagdic D, Akin E, Karacay S, Bulakbasi N: Tongue movements in patients with skeletal Class III malocclusions evaluated with real-time balanced turbo field echo cine magnetic resonance imaging. Am J Orthod Dentofacial Orthop 139: e , Guyer EC, Ellis EE, 3rd, McNamara JA, Jr., Behrents RG: Components of class III malocclusion in juveniles and adolescents. Angle Orthod 56: 7-30, Hiyama S, Suda N, Ishii-Suzuki M, Tsuiki S, Ogawa M, Suzuki S, et al.: Effects of maxillary protraction on craniofacial structures and upper-airway dimension. Angle Orthod 72: 43-47, Huang GJ, Justus R, Kennedy DB, Kokich VG: Stability of anterior openbite treated with crib therapy. Angle Orthod 60: 17-24; discussion 25-16, Jiang YY: Correlation between hyoid bone position and airway dimensions in Chinese adolescents by cone beam computed tomography analysis. Int J Oral Maxillofac Surg 45: , Kaygisiz E, Tuncer BB, Yuksel S, Tuncer C, Yildiz C: Effects of maxillary protraction and fixed appliance therapy on the pharyngeal airway. Angle Orthod 79: , Kilinc AS, Arslan SG, Kama JD, Ozer T, Dari O: Effects on the sagittal pharyngeal dimensions of protraction and rapid palatal expansion in Class III malocclusion subjects. Eur J Orthod 30: 61-66, King EW: A roentgenographic study of pharyngeal growth. Angle Orthod 22: 23-25,

48 Lee JW, Park KH, Kim SH, Park YG, Kim SJ: Correlation between skeletal changes by maxillary protraction and upper airway dimensions. Angle Orthod 81: , Lee KH, Kim JC: A radiographic study of tongue posture at rest position and during the phonation of /s/ in Class III malocclusion. Korean J Orthod 23: , Malkoc S, Usumez S, Nur M, Donaghy CE: Reproducibility of airway dimensions and tongue and hyoid positions on lateral cephalograms. Am J Orthod Dentofacial Orthop 128: , Miyajima K, McNamara JA, Jr., Sana M, Murata S: An estimation of craniofacial growth in the untreated Class III female with anterior crossbite. Am J Orthod Dentofacial Orthop 112: , Moss ML, Young RW: A functional approach to craniology. Am J Phys Anthropol 18: , Mouakeh M: Cephalometric evaluation of craniofacial pattern of Syrian children with Class III malocclusion. Am J Orthod Dentofacial Orthop 119: , Oktay H, Ulukaya E: Maxillary protraction appliance effect on the size of the upper airway passage. Angle Orthod 78: , Pracharktam N, Hans MG, Strohl KP, Redline S: Upright and supine cephalometric evaluation of obstructive sleep apnea syndrome and snoring subjects. Angle Orthod 64: 63-73, Primozic J, Farcnik F, Perinetti G, Richmond S, Ovsenik M: The association of tongue posture with the dentoalveolar maxillary and mandibular morphology in Class III malocclusion: a controlled study. Eur J Orthod 35: , Sato S: Case report: developmental characterization of skeletal Class III malocclusion. Angle Orthod 64: ; discussion , Sayinsu K, Isik F, Arun T: Sagittal airway dimensions following maxillary protraction: a pilot study. Eur J Orthod 28: , Seo YJ, Kim SJ, Munkhshur J, Chung KR, Ngan P, Kim SH: Treatment and retention of relapsed anterior open-bite with low tongue posture and tongue-tie: A 10- year follow-up. Korean J Orthod 44: , Stepovich ML: A cephalometric positional study of the hyoid bone. Am J Orthod 51: , Taylor M, Hans MG, Strohl KP, Nelson S, Broadbent BH: Soft tissue growth of the oropharynx. Angle Orthod 66: , Verin E, Tardif C, Buffet X, Marie JP, Lacoume Y, Andrieu-Guitrancourt J, et al.: Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol 129: , Vizzotto MB, Liedke GS, Delamare EL, Silveira HD, Dutra V, Silveira HE: A comparative study of lateral cephalograms and cone-beam computed tomographic images in upper airway assessment. Eur J Orthod 34: , Yagci A, Uysal T, Usumez S, Orhan M: Effects of modified and conventional facemask therapies with expansion on dynamic measurement of natural head position in Class III patients. Am J Orthod Dentofacial Orthop 140: e ,

49 ABSTRACT Changes of tongue posture, hyoid bone position and pharyngeal airway space after maxillary protraction DONGMIN HWANG Department of Dentistry The Graduate School, Yonsei University (Directed by Professor Chung-ju Hwang, D.D.S., M.S.D., Ph. D.) Tongue is a major muscle in oral cavity and its position and function have close relation to malocclusion. Also, position of hyoid bone is influenced by both hard tissue and surrounding soft tissue because hyoid bone is not directly connected to bone but to soft tissue such as muscles and ligaments. Maxillary protraction by using facemask has great orthopedic effect in short period and has been used to treat Skeletal Class III patient in prepubertal stage. Many clinical researches describe the changes of maxilla and mandible after maxillary protraction but there are limited reports about the changes of surrounding tissue

50 The purpose of this study was to compare the tongue posture hyoid bone position and airway space of untreated skeletal class I patients(9 males and 11 females, mean age 7.95 years, mean observation period 8.95 months) at beginning of control period(c0) and at end of control period(c2) with maxillary protraction treated patients(17 males and 19 females, mean age 7.75 years, mean treatment period 9.69 months) at before maxillary protraction(t0), immediate after maxillary protraction(t1), 1 year after maxillary protraction(t2) by using lateral cephalogram. The results were listed below. 1. Forward growth of maxilla(p<0.01), clockwise rotation of mandible(p<0.01) and labioversion of maxillary incisor(p<0.05) were observed after maxillary protraction(p<0.001) compared to untreated group. When comparing measurements of 1 year after maxillary protraction(t2) with pre-treatment(t0), these changes were statically significant(p<0.01). 2. Superior movement of tongue was observed after maxillary protraction(p<0.05) compared to untreated group. When comparing measurements of 1 year after maxillary protraction(t2) with pretreatment(t0), these changes were statically significant(p<0.001). 3. There were no significant differences in hyoid bone position after maxillary protraction compared to untreated group(p>0.05). 4. Increase of nasopharyngeal airway space was observed after maxillary protraction(p<0.01) compared to untreated group. When comparing measurements of 1 year after maxillary protraction(t2) with pretreatment(t0), these changes were statically significant(p<0.001). In oropharyngeal airway space measurements, there were no significant differences after maxillary protraction compared to untreated group

51 Maxillary protraction for skeletal class III patients resulted in the changes of maxillary and mandibular position, superior movement of tongue and the increase of nasopharyngeal airway space. But there was no significant difference in oropharyngeal airway space and hyoid position after maxillary protraction. After 1 year of treatment, the changes of tongue posture and nasopharyngeal airway space remained stable. The superior movement of tongue posture established proper intraoral and extraoral balance so that it may help coordinating the relationship between upper and lower dental arches. Key words: Maxillary protraction, Tongue, Hyoid bone, Nasopharyngeal airway space, Oropharyngeal airway space