http://dx.doi.org/10.5125/jkaoms.2011.37.4.264 하악전돌증환자의양악수술시상악골후상방회전이동여부에따른안면부경조직변화량에대한비교연구 김욱규 이성탁 김태훈 송재민 황대석 정인교부산대학교치의학전문대학원구강악안면외과학교실 Abstract (J Korean Assoc Oral Maxillofac Surg 2011;37:264-71) A comparative study on the change of postoperative facial hard tissue profile after maxillary rotational surgery Uk-Kyu Kim, Sung-Tak Lee, Tae-Hoon Kim, Jae-Min Song, Dae-Seok Hwang, In-Kyo Chung Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea Purpose: This study evaluated retrospectively the postsurgical facial hard tissue profile of a Le Fort I osteotomy with/without posterior impaction and rigid internal fixation to correct mandibular prognathism. After observing a difference between the two groups, this measurement was used to prepare a treatment plan for 2-jaw surgery. Patients and Methods: Thirty patients who had undergone orthognathic surgery in Pusan National University Dental Hospital were enrolled in this study. Fifteen patients were treated using a Le Fort I osteotomy with posterior impaction and mandibular setback bilateral sagittal split ramus osteotomy, and the other fifteen patients were treated without posterior impaction. The preoperative (T0), immediate postoperative (T1) and six-month follow-up period (T2) cephalograms were taken and difference between T1-T0 and T2-T2 was analyzed. Results: Both groups was FH-ABp, SNB and ANB showed significant changes in the measurement, whereas only the posterior impaction group showed a change in the SN-U1, occlusal plane, posterior facial height, surgical movement difference from the L1 and B-point. There was no significant statistical change between the immediate postoperative (T1) and six-month follow-up (T2) hard tissue analysis in the two groups. Conclusion: A Le Fort I osteotomy with posterior impaction is considerable for patients with a flat occlusal plane angle, large posterior facial height, prominent B-point, pogonion and labioversed incisal inclination if the indications are well chosen. Key words: Hard tissue, Rotational orthognathic surgery, Posterior impaction [paper submitted 2011. 4. 14 / revised 2011. 7. 22 / accepted 2011. 7. 25] Ⅰ. 서론 악교정수술은구강악안면기형을수술로치료하여개선해주는것으로, 1849 년미국외과의사 Hullihen 으로부터최초로보고되었다. 그리고 Le Fort I 골절단술은 1859 년독일의 Von Langenbeck 이 1901 년에 Le Fort 가설명한골절의높이에따라비인두용종에접근하기위해상악골절제술을시행한데서처음으로보고되었고, 1927 년 Wassmund 가외상후부정교합과중안모기형을치료하기위해시행한것에서악교정수술로써시작되었다. 이후 1960 년대 Obwegeser, Epker 등에의해발전되어전후방적으로심한 정인교 626-770 경남양산시물금읍범어리부산대학교치의학전문대학원구강악안면외과학교실 In-Kyo Chung Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University Beomeo-ri, Mulgeum-eup, Yangsan, 626-770, Korea TEL: +82-55-360-5100 FAX: +82-55-360-5104 E-mail: inkchung@pusan.ac.kr 하악골전돌증환자및상악골의수직적인과성장을가진환자에서심미적이고, 기능적으로안정된결과를얻기위하여주로시행되었다. 최근심미에대한관심이높아지고저작, 발음등의기능적인측면의개선뿐만이아니라심미적인개선을원하는환자가많아지면서악교정수술에대한관심이더욱증가하고있다. 특히, 양악수술에대한선호도역시높아지고있는데, 실제 2008 년에서 2011 년 2 월까지부산대학교치과병원구강악안면외과에서시행된악교정수술을살펴보면, 편악수술의비율이높았던과거에비해최근양악수술의비율이지속적으로증가하고있으며, 특히, 상악골후상방회전이동을통한양악수술의비율이높게나타났다.(Fig. 1) 즉, 상악골회전이동을통해얻을수있는심미적이고기능적인장점으로인하여양악수술의절대적인시행횟수및전체악교정수술방법에서의비율이크게증가했다고판단할수있다. Enacar 등 1 은양악수술시안모의수직적인길이의감소를얻을수있다고하였고, Reyneke 와 Evans 2, Wolford 등 3 은교합평면각의회전이동 * 이논문은부산대학교자유과제학술연구비 (2년) 에의하여연구되었음. 264
하악전돌증환자의양악수술시상악골후상방회전이동여부에따른안면부경조직변화량에대한비교연구 100% 50% 0% Fig. 1. Annual trend of the surgical treatment modality of orthognathic surgery since 2008 in Department of Oral and Maxillofacial Sugery, Pusan National University Dental Hospital. 이하악각의증가, 턱의후방이동량증가, 후안모고경의감소, 코주위골의전방이동으로인한심미적인변화를얻을수있다고설명하였다. 이러한상악골회전이동으로얻을수있는변화는작고갸름한얼굴형을선호하는현대인들의요구와잘부합된다. 더불어교정치료의발전, 흡입마취방법의발전, 저혈압마취유도에의해상악골후상방회전이동을통한양악수술시행은더욱가속화되고있다 4,5. 이러한상악골회전이동을통한양악수술은 Reyneke 등 6, Wolford 등 7 에의해안정성이확인되었고, 최근후상방회전이동을통한양악수술의초기안정성에대한많은연구가보고되고있어상악골후상방회전이동을통한양악수술시행의가속화에힘을실어주고있으나, 심미적이고기능적인결과에도불구하고여전히부적절한수술계획수립으로교합의불안정, 비심미적인안모등합병증이발생할수있어적절한수술계획수립이필요하다. 이에본연구에서는최근많이시행되고있는하악골전돌증환자에서상악골후상방회전이동을시행한양악수술과시행하지않은양악수술의수술전후경조직을분석하고, 수술전후변화의상관성을산출하여보다효율적이고적절한악교정수술계획수립에활용하고자한다. 1. 연구대상 2008 2009 2010 2011 2-Jaw (Posterior impaction) 2-Jaw (Non-posterior impaction) 1-Jaw Ⅱ. 연구대상및방법 본연구는 2010 년 1 월부터 2010 년 7 월까지부산대학교치과병원구강악안면외과에서하악전돌증으로진단받고 2 인의술자에의해동일한방식의양악수술, 즉상악골 Le Fort I 골절단술및하악골상행지시상면골절단술을시행받은 30 명의환자를대상으로하였다. 상악수술에있어서후상방회전이동을시행한 15 명의환자를 post impaction group, 그외후상방회전이동을시행하지않고, 상악골의전후방적인위치변화, 좌우측의높이변화가필요하여수술한 15 명의환자는 non-posterior impaction group 으로분류하였다.(Tables 1, 2) 상악골후상방회전을시행할경우, 상악 anterior nasal spine (ANS) 를중심으로회전하였고, 두그룹모두수술시 L 자형금속판을좌, 우양측으로 2 개씩사용하여상악을고정하였으며하악은 3 개씩의금속나사를사용하여고정시켰다. 악간고정은술후 1 주일간적용되었다. 표본중교정전선수술증례는제외하였다.(Table 3) 2. 연구방법 두그룹모두수술전 (T0), 수술후 3 일이내 (T1), 추적관찰기간 (6-12 개월, 평균 8 개월, T2) 에측모두부규격방사선사진 (Cephalometer, PM 2002 CC proline, Planmeca, Helsinki, Finland) 을촬영하고, V-Ceph (Ver. 6.0, Osstem, Seoul, Korea) 을이용하여 Fig. 2 와같이계측점을설정하고동일 Table 1. Sex and age distribution of study Age (yr) Male (n) Female (n) Posterior impaction group 19 2 4 20-25 2 3 26 2 2 Total 6 9 Non-posterior impaction group 19 5 1 20-25 1 3 26 1 4 Total 7 8 Table 2. Posterior impaction vs non-posterior impaction Posterior impaction Non-posterior impaction Mean age (yr) 22.6 24.2 M:F ratio 6:09 7:08 Table 3. Inclusion criteria -Non growing patient -Maxilla surgery: Le Fort I osteotomy Mandibular surgery: bilateral sagittal split ramus osteotomy -No history of congenital defects or syndromes -No previous orthognathic or cosmetic surgery involving the middle and/or lower face -No surgery-first orthognathic approach -Use of rigid internal fixation 265
J Korean Assoc Oral Maxillofac Surg 2011;37:264-71 Fig. 2. Anatomic landmark used in this study. Fig. 3. Reference line. 한분석자에의해서각계측항목을측정하였다. 수술전후안모경조직의변화를측정하기위하여 facial height (FH) line 과 A-B plane 이이루는각 (FH-ABp), Maxilla depth, upper incisor inclination (U1-SN), occlusal plane, Nper-A (distance from N perpenticular line to A-point), SNA (angle between SN line and A point), SNB (angle between SN line and B point), ANB (SNA-SNB), 전안모고경 (anterior facial height, AFH), 후안모고경 (posterior facial height, PFH) 을각각시기별로측정하였다. 또한, Fig. 3 과같이수평기준선 (horizontal reference plane, HRP) 으로는 SN 선을 7 회전시킨선을, 수직기준선 (vertical reference plane, VRP) 으로는 Sella 를지나고수평기준선에수직인선을그어 A-point, B- point, 상악중절치절단연 (U1), 하악중절치절단연 (L1), PNS, pogonion 사이의거리를시기별로측정하여수직및수평적인변화량을관찰하였다.(Table 4) 3. 통계분석 얻어진계측항목에대하여 SPSS for window ver. 12.0 (SPSS, Chicago, IL, USA) 을이용하여측정항목에대한통계처리를시행하였다. 술전 (T0), 수술후 3 일이내 (T1), 수술후추적관찰기간 (T2) 의변화에대해 paired t-test 를이용하여검정하였다.(P<0.05) 측모두부규격방사선사진분석은계측시오차를줄이기위하여동일인이계측을시행하였고계측치의신뢰성검사를위하여적어도 2 주후 10 명의측모두부규격방사선사진을무작위로선택, 역시동일인이재측정하여 paired t-test 를시행하였다. 어떠한변수에서도첫번째계측시와두번째계측치사이에통계학적으로유의한차이가없었다. Table 4. Measurements and it's mean value A. Angular measurements ( ) FH-ABp: Angle between FH plane and A-B plane Mx. depth: Angle between FH plane and N-A plane SNA: Angle between SN line and A point SNB: Angle between SN line and B point ANB: SNA-SNB Occlusal plane angle: Angle between FH plane and occlusal plane U1-SN : Angle between SN line and Is-Ir line B. Horizontal measurements (mm) Nper-A: Distance from N perpenticular line to A-point VRP to U1: Distance from VRP to upper incisor tip VRP to L1: Distance from VRP to lower incisor tip VRP to A: Distance from VRP to A-point VRP to B: Distance from VRP to B-point VRP to PNS: Distance from VRP to PNS VRP to Pg: Distance from VRP to pogonion C. Vertical measurements (mm) AFH: Distance from Nasion (N) to Mentom (Me) PFH: Diatnace from Sella (S) to Gonion (Go) HRP to U1: Distance from HRP to upper incisor tip HRP to L1: Distance from HRP to lower incisor tip HRP to A: Distance from HRP to A-point HRP to B: Distance from HRP to B-point HRP to PNS: Distance from HRP to PNS HRP to Pg: Distance from HRP to pogonion (FH: frankfort horizontal, VRP: vertical referance plane, HRP: horizontal referance plane, AFH: anterior facial height, PFH: posterior facial height) 266
하악전돌증환자의양악수술시상악골후상방회전이동여부에따른안면부경조직변화량에대한비교연구 Ⅲ. 결과 FH-ABp, Mx. depth, U1 to SN, Occlusal plane, Nper-A, SNA, SNB, ANB, AFH, PFH 에대해서는두그룹의각각시기별로측정항목에대하여수술전 (T0), 수술직후 (T1), 수술후추적관찰기간 (T2) 에대한평균과표준편차를산출하였고 (Tables 5, 6), 그리고수술전후의변화 (T0-T1), 추적관찰기간중의변화 (T1-T2) 를측정하여 paired t-test 로검정하였다. 또한수평기준선및수직기준선에대한변화량측정값에대하여수술전후의변화 (T0-T1), 추적관찰기간중의변화 (T1-T2) 의평균과표준편차를산출하여 paired t-test 로검정하였다.(Tables 7, 8) Non-posterior impaction group 의수술전후의변화값에서는 FH-ABp, SNB, ANB 값및 PNS to HRL, PNS to VRL, L1 to VRL, B to HRL, B to VRL, Pg to VRL 에서유의한변화가있었다. 추적관찰기간이후변화값 (T2-T1) 에서는 A to HRL 에서유의할만한차이가있었고, 그외다른측정값에서의추적관찰기간이후변화값 (T2-T1) 에서는유의한변화가없었다.(Tables 5, 7) 그리고 posterior impaction group 의수술전후의변화값에서는 FH-ABp, U1-SN, SNB, ANB, AFH, PFH, occlusal plane, PNS to HRL, PNS to VRL 및하악골의측정값에서유의한변화가있었는데, 후상방회전이동을시행하지않은그룹에비해 U1-SN, PFH, occlusal plane 에서많은변화가관찰되었다. 추적관찰기간변화값 (T2-T1) 에서는 U1- SN, SNB, ANB 에서유의한변화가있었고, 이외모든측정값에서유의한변화가없었다.(Tables 6, 8) 즉, 각측정치에대하여다음과같은결과를얻을수있다. 1. Occlusal plane 값은술후변화로서 posterior impaction group 은평균 5.7 에서 13.05 로변하였고, non-posterior impaction group 에서는술전 12.38 에서술후 12.59 로변화하여 posterior impaction group 에서변화량이많았다. 2. FH-ABp 값은두그룹모두에서유의성있게변화하였고, 두그룹의술후평균값에서약간의차이는존재하였지만약 81-84 로비슷한값이측정되었다. 3. SN line 에대한상악중절치치축이이루는각이 posterior impaction group 에서많이개선이되었고, 술후평균값은 106 를나타내었다. Table 5. Descriptive statistics for non-posterior impaction group Measurement T0 T1 T2 FH-ABp 90.11±13.5 80.57±6.3 80.69±5.98 Mx. depth 84.02±11 87.78±3.55 87.94±3.56 U1-SN 105.61±5.22 103.68±4.73 104.73±5.54 Nper-A 4.43±5.7 2.12±3.45-2.01±3.56 SNA 77.62±10.4 81.25±2.88 81.07±3.21 SNB 80.65±3.98 77.54±3.36 77.70±3.66 ANB difference -1.49±6.17 3.56±1.96 3.14±2.2 Anterior facial height 132.43±9.39 130.22±7.23 130.58±7.44 Posterior facial height 85.17±6.19 82.93±6.08 82.63±5.75 Occlusal plane 12.38±4.71 12.59±4.65 12.77±4.58 Data is presented by means±sd. Table 6. Descriptive statistics for Posterior impaction group Measurement T0 T1 T2 FH-ABp 93.55±7.97 84.9±3.63 84.82±3.90 Mx. depth 90.87±3.69 89.49±2.59 89.67±2.58 U1-SN 113.59±4.74 106.75±5 107.92±4.07 Nper-A 0.84±3.82-0.11±2.4-0.11±2.45 SNA 83.30±2.77 82.85±3.11 82.78±3.31 SNB 84.40±4.21 79.14±3.11 80.33±3.35 ANB difference -1.10±3.7 3.77±1.63 2.48±1.85 Anterior facial height 125.49±8.68 123.11±8.36 122.89±8.13 Posterior facial height 82.62±8.11 74.94±7.94 75.12±8.89 Occlusal plane 5.72±4.71 13.05±2.96 13.20±2.92 Data is presented by means±sd. 267
J Korean Assoc Oral Maxillofac Surg 2011;37:264-71 Table 7. Paired t tests evaluating surgical and postsurgical change Non-posterior impaction group Measurement T1-T0 T2-T1 Difference SD P value Difference SD P value FH-ABp 9.540 10.600 0.007* -0.115 7.880 0.607 Mx. depth 3.770 9.760 0.190 0.162 0.583 0.338 U1-SN -1.930 5.100 0.197 1.049 2.152 0.104 Nper-A 0.998 2.335 0.149 0.115 0.611 0.509 SNA 1.325 2.649 0.096-0.186 0.878 0.459 SNB -3.109 2.309 0.000* 0.162 0.936 0.546 ANB difference 4.590 4.200 0.002* -0.422 1.171 0.325 Anterior facial height -2.210 5.700 0.187 0.358 1.068 0.075 Posterior facial height -2.230 5.180 0.146-0.300 0.509 0.055 Occlusal plane 0.211 0.948 0.438 0.178 0.474 0.199 PNS to HRL -2.372 2.798 0.010* 0.221 0.789 0.333 PNS to VRL 0.987 1.103 0.007* -0.228 1.147 0.488 A to HRL -0.590 4.590 0.649 0.442 0.567 0.016* A to VRL 4.07 12.240 0.253 0.270 0.786 0.2390 U1 to HRL -0.270 5.140 0.850-0.528 3.355 0.581 U1 to VRL 0.745 3.357 0.439 0.696 2.449 0.326 L1 to HRL -2.940 5.180 0.063 0.341 1.748 0.496 L1 to VRL -7.340 5.050 0.003* 1.349 2.314 0.057 B to HRL -3.500 5.150 0.031* 0.584 2.097 0.335 B to VRL -6.340 5.640 0.002* 0.738 2.467 0.303 Pg to HRL -3.080 7.510 0.164 0.120 1.954 0.829 Pg to VRL -5.530 6.710 0.012* 0.209 2.545 0.772 (+) value: anterior or inferior movement, (-) value: posterior or superior movement *P<0.05 Table 8. Paired t tests evaluating surgical and postsurgical change Posterior impaction group Measurement Surgical changes T1-T0 Postsurgical changes T2-T1 Difference SD P value Difference SD P value FH-ABp 8.650 6.500 0.001* 0.077 0.566 0.608 Mx. depth -1.38 2.690 0.067 0.191 0.759 0.329 U1-SN -6.837 3.870 0.001* 1.176 1.960 0.036* Nper-A -0.948 2.798 0.211-0.003 0.324 0.975 SNA -0.450 1.537 0.276-0.068 0.750 0.731 SNB -5.262 2.430 0.001* 1.195 0.772 0.001* ANB difference 4.878 3.437 0.000* -1.297 0.823 0.000* Anterior facial height -2.375 3.511 0.020* -0.223 1.022 0.412 Posterior facial height -2.683 2.199 0.000* 0.185 2.539 0.782 Occlusal plane 6.572 3.032 0.000* 0.157 0.444 0.193 PNS to HRL -4.787 1.413 0.000* 0.321 0.648 0.076 PNS to VRL 1.510 1.760 0.010* 0.025 0.990 0.924 A to HRL 0.740 6.110 0.646-0.720 4.350 0.531 A to VRL 1.460 6.230 0.380-1.180 5.870 0.447 U1 to HRL 1.980 8.710 0.393-0.280 7.310 0.884 U1 to VRL -1.110 5.540 0.449 0.940 6.510 0.584 L1 to HRL -1.720 3.381 0.069-0.093 3.425 0.917 L1 to VRL -7.620 3.128 0.002* 3.507 2.339 0.086 B to HRL -2.078 3.263 0.027* -0.423 1.907 0.405 B to VRL -7.620 2.983 0.011* 0.550 1.793 0.255 Pg to HRL -2.330 1.544 0.000* -0.342 1.662 0.439 Pg to VRL -7.915 3.790 0.000* 0.689 1.808 0.162 (+) value: anterior or inferior movement, (-) value: posterior or superior movement, *P<0.05 268
하악전돌증환자의양악수술시상악골후상방회전이동여부에따른안면부경조직변화량에대한비교연구 4. Nper-A 값에대하여는 n-posterior impaction group 에서는 -4.11 mm 에서 -2 mm 로변화하였고, posterior impaction group 에서는 0.84 mm 에서 -0.11 mm 으로변화하였는데, 두측정치모두한국인평균치 0±1 mm 과비슷한값이다. 5. PFH 값이 non-posterior impaction group 에는변화가없었지만, posterior impaction group 에서는그값이감소하였고, 평균 75 mm 로측정되었다. 6. SN-7 선에대한변화값을관찰하였을때, non-posterior impaction group 에서는하악중절치교두점, B-point 의후퇴값이비슷하였지만, posterior impaction group 에서는하악중절치교두점의후퇴값보다 B-point 의후퇴값이더많았다. 7. 전반적인 relapse 에대하여는두그룹의대부분의측정값에서유의할만한변화가없었으며, 안정적인것으로관찰되었다. Ⅳ. 고찰 임상가가악교정수술의성공을객관적으로측정할수있는방법은거의없다 8. 주로수술후교합과두부방사선학적계측값이수술의성공을판단하는기준이되어왔다 9. 그러나술자는안정적인교합과만족할만한골격적형태를얻어만족하지만, 환자는자신들의심미적기준에맞지않아불만족하는경우가많다 10. Laufer 등 11 은악교정수술을원하는대다수의환자는기능적개선보다는정신적요소를포함하는심미적개선이주된수술동기였다고하였다. 근래심미적인안모가개인적인삶, 더나아가사회, 문화적으로많은영향을끼치게되면서다수의사람들이심미적인안모를얻기위한많은노력을하고있다. 이러한사회적인분위기에편승하여최근양악수술에대한관심이많이높아지고있고, 특히, 상악골회전이동을동반한양악수술이크게유행을하고있다. 사회적으로유행하고선호하는안모가상악골회전이동으로얻을수있는안모, 즉, 중안모가볼록하고, 후안모고경이줄어들고, 상대적으로작은턱을가진안모이기때문이다. 상악골회전이동을동반한양악수술은교합평면의변화를가져온다. Reyneke 와 Evans 2 는상하악동시수술로인위적으로교합평면을시계방향으로회전시키면술후안정성면에서유리하며, 하악골 pogonion 의후상방이동으로인하여턱끝이현저한 3 급부정교합의수술시부가적인심미적증진을가져올수있다고하였다. 또한 Wolford 등 3,7 도비정상적인교합평면은악교정수술이고려되는환자의심미적, 기능적결함에중대한영향을끼칠수있다고하였다. Jeong 등 12 에의하면서양인에비해코가낮고평면적인골격을지닌한국인에서상악골을전방으로이동시킬경우양악전돌과유사한측모를가질수있고이는심미적으로좋지못한결과를얻을수있다고하였다. 한편 Epker 와 Schendel 13 은전치부개방교합환자의수술시하악골만이동할시교합평면이시계반대방향으로회전하여술후안정성이저하되므로상하악골동시수술에의한교합평면의변화가필요하다고언급하였다. LaBanc 와 Epker 14 은재발감소를위하여하악이시계방향으로회전하게하는상하악동시수술법을발표하기도하였다. 이러한상악골회전운동을동반한양악수술이많이시행되고있지만, 수술계획수립시적응증으로삼을만한일정한기준은아직잘정립되어있지않은실정이다. 더욱이교합평면은각각의치아절단면과교합면에의해이루어지는기능적인복합체이며, 평면각값에따라다양한생리학적인효과를야기하는데, 이렇게교합평면의변화를가져오는상악골회전운동을동반한양악수술로인하여오히려불안정한교합, 비심미적인안모를가져올수도있을것이다. 본연구에서는 FH 평면에대하여상악골의교합평면을기준으로연구하였으며, 상악골후상방회전이동을동반한양악수술과동반하지않은양악수술의경조직연구를통하여차이점을연구하여수술계획수립시참고자료로활용하고자하였다. 먼저, 두그룹간에차이가나는것은교합평면이었다. 상악골후상방회전이동을시행하지않은양악수술그룹은평균교합평면각도는약 12.5 였고, 술후에도변화는없었다. 그리고상악골후상방회전이동을시행한양악수술그룹에서는술전평균교합평면각도는약 6 였고, 술후에는약 13 였다. 두그룹모두술후정상범위의상악교합평면각도를가졌다. 그리고교합평면의경사도가증가하는시계방향의회전이실제 Table 6 에서관찰되는것과같이하악절치절단연의후방이동보다하악골의 B-point, pogonion 부위의후상방이동이더많고, 그로인하여이부가돌출된 3 급부정교합의수술시부가적으로심미적인증진을가져올수있었다 2. 이결과는 Kim 15 이편악혹은양악수술을받은환자중양호한안모를가진환자는정상범위의상악교합평면각도를가졌고, 편악수술후안모개선이부족한환자군은유의성있게편평한상악교합평면각도를가지고있었다고보고한내용과일치한다. 실제본연구에서는 B- point 의변화값에비해 Pogonion 의평균변화값이작게나타내었는데, 이부성형술로턱끝을전방이동시킨것의영향인것으로보인다. 추가적인이부성형술의시행을하지않기위해상악골의후상방이동을동반하는양악수술을시행한다는점에관련되어이부성형술시행에대한논란이있다. 그러나 Table 6 에서와같이교합평면의회전으로후안모고경값이줄어들어정면에서보았을때하악골하연의윤곽이더갸름해지고작아지는심미적인안모를얻을수있기때문에, 환자의심미적인수술동기와교합평면회전으로얻을수있는기능적인결과에의해이부성형술의시행여부는술자및환자에따라결정된다고여겨진다. 교합평면이시계방향으로회전을하면서 S-N 선에대한 269
J Korean Assoc Oral Maxillofac Surg 2011;37:264-71 전치부각도또한영향을주게되는데, 본연구에서는상악골회전이동을한그룹에서술전 114 에서술후 106 로변화를하였다. 이는비발치로인하여술전교정중탈보상이불충분하여전치부순측경사정도가증가하였지만상악골회전이동을통하여상악전치의각도가개선되고, 상순부의연조직은비순각이증가하여심미성이개선된것으로, 발치후술전탈보상기간도줄어짧은기간내심미적인결과를얻을수있었다. Yang 과 Suhr 16 는 FH 평면이 A point 과 B point 를연결한선과이루는각도 (FH-ABp) 를악골의전후방적인관계를평가하는신뢰성있는측정치라고언급하였고, 본연구의두그룹에서수술전후변화량에서는차이가있었지만술후측정치는두그룹모두 81-85 로비슷하였다. 이처럼양악수술후환자의안모가상악골이하악골에비해전방에위치하여평면적인얼굴에서입체적인얼굴로변화하였다. 상악골의전후방적인위치는 Nper-A 값으로측정된다. 대부분의악교정수술은전후방적으로이루어지므로 nasion perpendicular line 에대한상악골의위치는명확하면서중요하다. 한국인의정상 Nper-A 값은 0±1 mm 이다 17. 본연구에서상악골후상방회전이동을시행하지않은그룹의술전 Nper-A 평균값은 4.43 mm 였고, 술후 2 mm 였다. 그리고상악골후상방회전이동을시행한그룹의술전 Nper-A 평균값은 0.84 mm 였고, 술후에는 -0.11 mm 였다. 전치부순측경사도가정상치에가깝고, 상악이후방으로후퇴된경우주로후상방회전이동없이상악골의전후방적인이동을통한양악수술을시행하였다. 수평기준선및수직기준선에대한계측점의변화에대해서는주로전후방적인위치가많이변화하였는데, 최근장안모가주소인환자보다정상교합자일지라도평면적인안모에서입체적인안모를원하는환자가많아진것이원인으로보인다. 수술직후와최소 6 개월이상기간후계측값에서두그룹모두 SNB, ANB 값에서유의할만한변화가있었는데, 교합장치의제거로인한것으로여겨지며, 후상방회전이동을하지않은그룹에서는추가적으로 A to HRL 이유의할만한변화를보였는데, 수술중 ANS 를삭제한후골재형성으로인한것으로여겨진다. 그리고, 후상방회전이동을시행한그룹에서는 U1-SN 값에서유의할만한변화가있었는데, 이변화는술후교정으로인한상악전치의기울어짐으로인한것으로여겨진다. 그외다른계측점들은두그룹모두에서유의할만한변화가보이지않았다. 따라서, 두그룹모두안정적인술식이며, 상악골후상방회전이동을동반한양악수술이기존의양악수술에비해안정성면에서차이나지않는다고볼수있다. 현대악교정수술은악구강계의기능회복뿐만아니라안모의심미성향상을주목적으로하고있다. 따라서경조직수술에따르는연조직변화를고려하여야하지만, 현재악교정수술이나교정치료를계획하기위하여이용되는 여러분석법들은대부분경조직분석법이며, 대부분의연조직연구에서도경조직변화에따른연조직변화가개인과부위에따라차이가다양하므로연조직변화를정확히예측하기가어렵다고하였다 18. 이에골격적인분석을통한계측점연구가수술시참고자료로서의의의가있지만, 향후연조직분석법이더연구가되어야하겠고, 향후 3D 분석을통해측모뿐아니라정모에서의경, 연조직변화또한관찰하여좀더예측성있고, 정확한수술계획수립을도모하여야할것이다. Ⅴ. 결론 부산대학교치과병원구강악안면외과에서하악전돌증으로진단받고상악골의후상방회전이동을동반한양악수술을시행받은 15 명의환자와상악골후상방회전이동을동반하지않은양악수술을시행받은 15 명의환자의술전, 술후안모경조직을분석한결과다음과같은결론을얻었다. 1. Non-posterior impaction group 에비해 posterior impaction group 에서많이개선된측정값은 occlusal plane, SN-U1, PFH 이다. 2. Occlusal plane 값이낮은환자는상악골후상방회전이동을통하여그값이증가하여정상적인 occlusal plane 값을가질수있다. 3. SN line 에대한상악중절치치축이이루는각이큰환자는상악골후상방회전이동을통하여그값이개선되었다. 4. AFH 값에비하여 PFH 값이큰환자는상악골후상방회전이동을통하여그값이감소하여개선된술후안모를가질수있다. 5. 상악골후상방회전이동을통하여하악중절치교두점보다 B-point 에서추가적인후퇴값을얻을수있다. 이상의결과를살펴보면 non-posterior impaction group 과 posterior impaction group 모두안정적인술식으로판단되어수술계획시후상방회전이동의결정은개선하고자하는계측값들에주목하여야하겠다. 특히, 상악골후상방회전이동을시행한군에서는술전에비해술후교합평면값, 상악절치각도및후안모고경에서변화가많았고, 하악 B- point 와 pogonion 변화가더커서이부분에대한안면골격수정이필요한환자군에서는상악골후상방회전이동술식이보다유용한술식으로판단되었다. References 1. Enacar A, Taner T, Manav O. Effects of single- or double-jaw surgery on vertical dimension in skeletal Class III patients. Int J Adult Orthodon Orthognath Surg 2001;16:30-5. 2. Reyneke JP, Evans WG. Surgical manipulation of the occlusal plane. Int J Adult Orthodon Orthognath Surg 1990;5:99-110. 270
하악전돌증환자의양악수술시상악골후상방회전이동여부에따른안면부경조직변화량에대한비교연구 3. Wolford LM, Chemello PD, Hilliard F. Occlusal plane alteration in orthognathic surgery-part I: Effects on function and esthetics. Am J Orthod Dentofacial Orthop 1994;106:304-16. 4. Praveen K, Narayanan V, Muthusekhar MR, Baig MF. Hypotensive anesthesia and blood loss in orthognathic surgery: a clinical study. Br J Oral Maxillofac Surg, 2001:39;138-40. 5. Chang HH, Ryu SH, Kang JH, Lee SH, Kim JS. Blood loss and hematologic change after orthognathic surgery. J Korean Oral Maxillofac Surg 2001;27:435-41. 6. Reyneke JP, Bryant RS, Suuronen R, Becher PJ. Postoperative skeletal stability following clockwise and counter-clockwise rotation of the maxillomandibular complex compared to conventional orthognathic treatment. Br J Oral Maxillofac Surg. 2007;45:56-64. 7. Wolford LM, Chemello PD, Hilliard F. Occlusal plane alteration in orthognathic surgery-part I: Effects on function and esthetics. Am J Orthod Dentofacial Orthop 1994;106:304-16. 8. Travess HC, Newton JT, Sandy JR, Williams AC. The development of a patient-centered measure of the process and outcome of combined orthodontic and orthognathic treatment. J Orthod 2004;31:220-34. 9. Cunningham SJ, Garratt AM, Hunt NP. Development of a condition-specific quality of life measure for patients with dentofacial deformity: II. Validity and responsiveness testing. Community Dent Oral Epidemiol 2002;30:81-90. 10. Burke L, Croucher R. Criteria of good dental practice generated by general dental practitioners and patients. Int Dent J 1996;46:3-9. 11. Laufer D, Glick D, Gutman D, Sharon A. Patients motivation and response to surgical correction of prognathism. Oral surg Oral Med Oral Pathol 1976;41:309-13. 12. Jeong MH, Choi JH, Kim BH, Kim SG, Nahm DS. Soft tissue changes after double jaw rotation surgery in skeletal class III malocclusion. J Korean Oral Maxillofac Surg 2006;32:559-65. 13. Epker BN, Schendel SA. Total maxillary surgery. Int J Oral Surg 1980;9:1-24. 14. LaBanc JP, Epker BN, Changes of the hyoid bone and tongue following advancement of the mandible. Oral Surg Oral Med Oral Pathol 1984;57:351-6. 15. Kim BH et al. Treatment goals and planning in class III 2-jaw surgery-the contribution of jaw rotation. J Korean Foundation for Gnatho-orthodontic research 2005;7:39-51. 16. Yang SD, Suhr CH. F-H to AB plane angle(faba) for assessment of anteroposterior jaw relationships. Angle Orthod. 1995; 65:223-31. 17. Kim KH, Choy KC, Kim HG, Park KH. Cephalometric Norms of the hard tissues of Korean orthognathic surgery. J Korean Oral Maxillofac Surg 2001;27:221-30. 18. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod 1983;84:1-28. 271