DOI:10.5125/jkaoms.2010.36.1.28 이주환 1 이인우 1 서병무 1,2,3,4 서울대학교치의학대학원 1 구강악안면외과, 2 치학연구소, 3 K 21, 4 치아재생공학연구실 bstract (J. Kor. Oral Maxillofac. Surg. 2010;36:28-38) Clinical analysis of early reoperation cases after orthognathic surgery Ju-Hwan Lee 1, In-Woo Lee 1, young-moo Seo 1,2,3,4 1 Department of Oral and Maxillofacial Surgery, Graduate School, Seoul National University, 2 Dental Research Institute, 3 K 21, 4 iotooth Engineering Lab The factors influencing the relapse and recurrence of skeletal deformity after the orthognathic surgery include various factors such as condylar deviation, the amount of mandibular set-back, stretching force by the soft tissues and muscles around the facial skeleton. The purpose of this report is to recognize and analyze the possible factors of reoperation after orthognathic surgery, due to early relapses. Six patients underwent reoperation after the orthognathic surgeries out of 110 patients from 2006 to 2009 were included in this study. In most cases, clincal signs of the insufficient occlusal stability, anterior open bite, and unilateral shifting of the mandible were founded within 2 weeks postoperatively. lthough elastic traction was initiated in every case, inadequate correction made reoperation for these cases inevitable. The chief complaints of five cases were the protruded mandible combined with some degree of asymmetric face and in the other one case, it was asymmetric face only. Various factors were considered as a major cause of post-operative instability such as condylar sagging, counter-clockwise rotation of the mandibular segment, soft tissue tension related with asymmetrical mandibular set-back, preoperatively existing temporomandibular disorder (TMD), poor fabrication of the final wafer, and dual bite tendency of the patients. Key words: Relapse, Orthognathic surgery, Reoperation, Mandibular set-back [ 원고접수일 2009. 11. 13 / 1 차수정일 2009. 12. 8 / 2 차수정일 2009. 12. 31 / 게재확정일 2010. 1. 22] Ⅰ. 서론 악교정수술후의재발및회귀현상은정도의차이는있지만거의대부분의증례에서일어나는현상이며이는어떠한술식이나고정방법을사용하더라도나타난다고알려져있다 1,2. 이러한회귀현상내지는수술후불안정성에영향을미치는요인은수술시잘못된하악과두의위치로인한과두의변위및처짐, 비대칭적인하악골의이동량및그것과관련된연조직및근육에의한견인등여러가지가보고되었다 3,4. 잘못된하악과두의위치와수술후불안정성과의관계는이미여러문헌에서보고된바가있다 5-7. 과두의처짐이란계획된교합상태에서하악과두와과두와의관계가부적절한것을말하며이는과두의하방, 측방, 또는전후방변위 서병무서울시종로구창경궁로 62-1 서울대학교치의학대학원구강악안면외과 young-moo Seo Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University, 62-1 Changgyounggungg-no Jongno-gu, Seoul, Korea Tel: +82-2-2072-3369 Fax: +82-2-766-4948 E-mail: seobm@snu.ac.kr 로나타난다. 과두의처짐은악간고정을제거한후의불안정한교합을야기하며이는곧술후불안정성과직결된다 8. 과두의위치뿐만아니라골절단후의근심골편의위치변화자체도회귀현상을일으킬수있다. 특히근심골편에의한회귀현상은원심골편에비해조기에재발을일으키는주요인으로알려져있다 9. 근심골편에포함된익돌교근띠는수술후새로운위치에적응하면서견인력을발휘하고새롭게후하방위치된하악각부위의교근또한수술후 8 주동안이나상당한견인력을발휘하여회귀현상을일으키는것으로보고되었다 10,11. 골절단후원심골편의위치변화는구강악안면계의생역학적인불균형을초래할수있다. 원심골편의후방이동은내측익돌근의위치와길이를변화시키며이의전방이동은상설골근육의견인을야기하며근육이외의피부, 결합조직들의탄력성또한회귀현상을일으킬수있는견인력을발생시키는것으로밝혀져있다 11,12. 이러한회귀현상이조기에나타나거나그정도가심할수록기능적, 심미적으로바람직하지못한결과를가져올수있으며증례및술자의선택에따라재수술이시행되기도한다. 28
장기적인추적조사의결과에서 Chow 등은 15 년간총 1,294 명의환자에서악교정수술시행후수술자체와관련된합병증 9.7% 를보고하였으며그중 12 예에서재수술을시행하였음을발표하였고 13, MacIntosh 는 13 년간총 236 명의환자에서시상분할하악지골절단술을시행한후평균 2 년간경과관찰시 12% 의환자에서뚜렷한재발을보였으며 4 명의환자에서재수술을시행하였다고보고하였다 14. 본연구는동일한술자에의해악교정수술이시행된후조기회귀현상이일어나재수술을시행한증례들의분석 을통해수술후의불안정성및회귀현상을일으킨요인들을알아보고자하였다. Ⅱ. 연구대상및연구방법 환자는총 6 명으로 2006 년부터 2009 년 6 월사이에서울대병원구강악안면외과에내원하여악교정수술을시행했던 110 명중에수술기록상으로조기재수술을시행하였던환자를선별하였다. 나이는 20 세부터 29 세까지였으며남 Table 1. Patients data. No. Sex ge Type 1st Operation 2nd Operation Maxilla Mandible Time Maxilla Mandible MP IVSRO setback 1 M 29 + - - Rt.: 9 mm 22 days - Refixation O - Lt.: 8.5 mm 2 F 20 LF I - #11,21 IVSRO setback IVSRO setback MP ; 3 mm advancement - Rt.: 7 mm - Rt.: 1.5 mm + - #13 - Lt.: 16 mm 4 months - - Lt.: 2.5 mm F ; 1 mm elongation Genioplasty ngle reduction - #23-4 mm setback ; 1 mm impaction IVSRO setback 3 M 25 - Rt.: 5 mm MP - Lt.: 9 mm + - Genioplasty F - 4 mm advancement 2 months - Refixation ngle reduction (Rt.) LF I + SO MP - #11, 21 IVSRO setback 4 F 21 + ; 1 mm setback. - Rt.: 10 mm 42 days - Refixation F ; 1 mm left shift - Lt.: 0 mm ; 10 elongation High LF I IVSRO setback MP - #11, 21 - Rt.: 17 mm 5 M 20 + ; 4 mm advancement - Lt.: 10 mm 24 days - Refixation F - #16 Genioplasty ; 1 mm impaction - 4 mm advancement LF I 6 M 21 F - #11, 21 IVSRO advancement ; 1 mm elongation LF I - Rt.: 0.5 mm IVSRO setback ; 3 mm shift to Rt. - #11, 21 - Lt.: 1.5 mm 5 months - Rt.: 3 mm - #16 ; 3 mm advancement Genioplasty - Lt.: 1 mm ; 0.5 mm impaction - 2 mm advancement - #26 ; 3.5 mm impaction (M: male, F: female, MP: mandibular prognathism, O: anterior openbite, F: facial asymmetry, LF I: Le Fort I osteotomy, IVSRO: intraoral vertico-sagittal ramus osteotomy, Rt.: right, Lt.: left, TMD: temporomandibular joint disorder, CR: centric relation) 29
대구외지 2010;36:28-38 자 4 명, 여자 2 명의분포를보였다. 5 예는모두하악골의돌출이주소로써안면비대칭이동반된 4 예에서는상악골의동반수술을포함한구강내수직시상하악지분할골절단술 (intraoral vertico-sagittal ramus osteotomy, IVSRO) 에의한하악골의후퇴술이시행되었다. 다른한증례의환자는안면비대칭이심한증례로상, 하악골의악교정수술을시행하였다. 모든증례에서수술후 2 주이내에불안정한교합양상을보여수술후 2 주에서 5 개월사이에하악골의재고정또는상, 하악의재수술을시행하였다.(Table 1.) 환자의분석은술전방사선사진과술후방사선사진, 그리고임상사진을토대로시행하였으며술후추적기간은최소 6 개월에서 1 년까지였다. Ⅲ. 연구결과 전체 110 명의 1 차수술대상중조기재발로재수술을시행하였던환자는 6 명으로 5.45% 의발생빈도를보였으며상악골수술을동반한경우가 4 예, 하악골만수술한증례가 2 예였다. 각각의원인들을제거한경우안정적인교합을이루었으나일부증례에서는장기적인회귀현상을보였다. 좌우이동량의차이가 7 mm 이상인경우가 3 예이며이는좌우비대칭적인하악의후퇴가재수술을촉발하는하나의원인으로볼수있다. 그러나나머지 3 예에서는좌우이동량의편차가크지않아이를제외한다른원인을고려할수있다. 분석결과하악과두의위치부정이 1 예, 그리고이중교합상태가 1 예로분석된다. 또한술전교정시상하악궁의부조화가있는경우이를해소하지못한것도 1 예가된다. 좌우비대칭적인후퇴에있어서 1 예는최종스플린트의과오제작도겹쳐서조기재발의원인이되었다. 이른시기에재수술을고려하는경우가많은데 1 개월이내는 2 명, 2 개월이내 2 명, 나머지는 4 개월그리고 5 개월째재수술을시행하였다. 1. 하악과두의하방전위증례 29 세의남자환자로하악골의돌출을주소로내원하였고안모의횡적부조화는뚜렷하지않았으나골격적 3 급부정교합및약 2 mm 의전치부개방교합의소견을보이고있었다.(Fig. 1..) 술전교정후에하악골단독수술을계획하였다. 하악골의 IVSRO 를통해우측은 9 mm, 좌측은 8.5 mm 의후방이동을시행하였다. 술후 1 일째, 경두개방사선사진상양쪽하악과두가술전보다전하방위치된소견이보였다.(Fig. 1. C, D.) 술후 2 일째부터전치부에고무줄을이용한견인, 교합유도를시행하였다. 술후 16 일째전치부의개방교합이재발되고하악이좌측으로변위된양상이관찰되어재수술에의한하악골의재고정을계획하였다.(Fig. 1..) 재고정술을시행한후별다른재발의소견없이교합의유도및하악골의위치는안정화되었다.(Fig. 1. E.) 술후방사선사진상에서도과두의처짐이발견된것으로보아본증례는잘못된근심골편의고정위치에의한과두의처짐으로인해안정위 (centric relation) 상태에서구치부의조기접촉이일어나전치부개방교합을일으킨전형적인증례로여겨진다 6,15,16. 2. 하악의비대칭적인후퇴술의증례 20 세의여자환자로하악골의돌출및안면비대칭을주소로내원하였다. 임상적, 방사선학적검사상골격적 3 급부정교합및상악중절치의중앙선에비해하악중절치의중앙선이우측으로의 4 mm 변위및그와동반된하악골의우측변위소견을보였다.(Fig. 2..) 술전교정후상악골및하악골동시수술을계획하였다. 제 1 형르포씨골절단술에의해전체적인상악골의 3 mm 상방이동및우측상악견치첨단을 1 mm 하방, 좌측상악견치첨단을 1 mm 상방이동하였다. 하악골은 IVSRO 에의해우측은 7 mm, 좌측은 16 mm 의후방이동을시행하였고추가로이부성형술을시행하여이부의 4 mm 후방이동을시행하였다. 술후시행한방사선사진상특이소견은없었으나최종교합장치의수동적적합에어려움이있었고하악골은우측변위양상을보여고무줄에의한견인을시행하였다. 술후 5 일째최종교합장치를제거하고고무줄견인을지속하기로하였다. 이후술후교정을시작하면서교합은어느정도안정되는양상을보였으나술후 4 개월째환자가안면비대칭의잔존을호소하였고하악골이전방이동되는회귀현상을보여재수술을시행하기로계획하였다.(Fig. 2..) 2 차수술시하악골주변에부착된근육및연조직의박리를충분히시행하면서 IVSRO 에의해우측은 1.5 mm, 좌측은 2.5 mm 의추가적인후방이동이시행되는만큼의원심골편의근심부를절제하였다. 그리고하악각절단술이추가로시행하였다. 재수술후안모의비대칭이해소되었고안정된교합이유지되는것을관찰할수있었다. (Fig. 2. C.) 본증례에서는하악골의과도한후퇴에따라원심골편의근심부가후방의연조직에가한압력및좌, 우측후퇴량이큰차이 (9 mm) 로인한골편간의간섭및연조직의견인력이재발및회귀현상을일으킨주요인이었을것으로분석된다 17. 3. 술전교정에서상하악궁의폭경차가해소되지않고잔존한증례 25 세의남자환자가술전교정이진행된상태에서하악골의돌출을주소로내원하였다. 임상적, 방사선학적검사상골격적 3 급부정교합및왼쪽에비해우측하악각이더 30
큰골격적문제로인한안면비대칭의소견을보이고있었다.(Fig. 3..) 교합상태를확인한결과좌측구치부에서반대교합을보이고있었다. 이는술전교정에서악궁의폭을조절되지않은원인으로생각된다. 하악골단독수술에의한후방이동을계획하였으며 IVS- RO 에의해우측은 5 mm, 좌측은 9 mm 의후방이동을시행하였고추가로우측하악각절제술및이부성형술에의한이부의 4 mm 전방이동을시행하였다. 수술전제작한최종교합장치를적합시하악골의변위가나타나장치를적합시키지않고하악골편간의고정술을시행하였다. 술후 1 일째시행된방사선사진상특이소견은없었으나이상적인교합유도의어려움및전치부의피개교합의부족의소 견을보여고무줄에의한견인을시행하였고이를지속하였다. 술후 10 일째에도전치부피개교합의부족현상을보여조기에술후교정을시작하기로하였다. 술후 52 일째경과관찰시구치부의우측편측저작및교합시슬라이딩, 하악의우측변위등의불안정한양상을보여재수술을시행하기로계획하였다.(Fig. 3..) 최종교합장치를재제작한후하악골의재고정을시행하였다. 술후 9 일째교합유도시환자스스로전방으로내미는소견을보여최종교합장치를제거하고고무줄에의한견인을시행하였으며이후안정된교합양상을보였다. (Fig. 3. C.) C D E Fig. 1. patient with condylar sagging.. Pre-operative intraoral photograph shows anterior openbite and crossbite.. Intraoral photograph after 1st operation shows remained anterior openbite. C. Pre-operative transcranial radiographs show normal relation between mandibular condyle and articular fossa. D. Transcranial view after 1st operation shows antero-inferiorly positioned condyle: condylar sagging. E. Intraoral photograph after reoperation shows stable occlusion. 31
대구외지 2010;36:28-38 4. 하악의후방회전을일으키는부적절한수술용스플린트의적용증례 21 세의여자환자로하악골의돌출및안면비대칭을주소로내원하였다. 임상적, 방사선학적검사상골격적 3 급 부정교합및하악치열및악골의좌측변위의안면비대칭이동반되어있었다.(Fig. 4..) 술전교정후상악골및하악골동시수술을계획하였다. 제 1 형르포씨골절단술에의한중절치의 3 mm 전방위치및좌측으로 1 mm 이동, 제 1 소구치의발거와함께전방분 C Fig. 2. patient with large and asymmetric mandibular set-back. (Soft tissue tension increased post-operative instability.). Pre-operative photographs show anterior crossbite with deviation of lower dental midline to right side.. Post-operative photographs after 1st operation show remained facial asymmetry. C. fter reoperation, facial symmetry and stable occlusion were maintained. 32
절골절단술을통해중절치의 4 mm 후방이동및 10 직립을시행하였다. 하악골은 IVSRO 에의해우측은 10 mm, 좌측은 0 mm 의후방이동을시행하였다. 술전환자의하악골의변위가심하여비대칭적인하악골의회전이동이예상되었고이에따른골편간의간섭이초래되었다. 상악골의분절골절단을시행하고최종교합장치를적합하였을때는하악의골절단이이뤄지지않아최종하악골의위치를파악하지못하였으나골전단완료후하악골을최종위치시켰을때하악골의더욱심한변위가관찰되었고이는하악후방부의수평적회전이더심한상태로장치가잘못제작되었기때문이었다. 술후 1 일째촬영한방사선사진 상좌측하악과두가과두와에서외측으로변위된소견이발견되었다. 술후 7 일째교합유도시하악이전방으로변위되는양상이보여고무줄에의한강한견인을시행하였다. 이후로경과관찰도중술후 24 일째면비대칭이해소되지않은양상을확인하고재수술을계획하였다.(Fig. 4..) 재수술시기존의최종교합장치를제거하고양측하악의고정나사를모두제거한후수술용스플린트없이가장이상적인교합상태로하악을재위치시킨후하악골편간의고정을시행하였다. 술후환자는안정된교합및안모를보였다.(Fig. 4. C.) C Fig. 3. patient with unsolved transverse arch discrepancy.. Pre-operative photographs show anterior crossbite with lager mandibular angle on the right side. lso Lateral cossbite is recognizable in the left side.. Post-operative photographs after 1st operation show occlusal shifting and instability. C. fter refixation, stable occlusion were maintained. 33
대구외지 2010;36:28-38 5. 하악과두의불안정한위치와비대칭적인하악후퇴증례 20 세의남자환자로하악골의돌출및안면비대칭을주소로내원하였다. 임상적, 방사선학적검사상골격적 3 급부정교합및하악골의좌측변위를보였다. 술전양쪽측두하악관절부의핵의학뼈스캔검사상에서진한섭취가된소견을보였다.(Fig. 5..) 술전교정후상악골및하악골동시수술을계획하였다. 상방위치형제 1 형르포씨골절단술에의한중절치의 4 mm 전방위치및우측제 1 대구치의 1 mm 상방이동을시 행하였다. 하악골은 IVSRO 에의해우측은 17 mm, 좌측은 10 mm 의후방이동을시행하였다. 이에추가로이부성형술에의해이부의 4 mm 전진이동을시행하였다. 술후 1 일째시행된방사선사진상특이소견은없었으며술후 10 일째교합유도시수조작에의해서는하악이원하는위치로유도가되었으나환자스스로는하악을올바르게위치시키는데어려움이있어전치부에고무줄에의한견인을시행하였다. 술후 16 일째고무줄을제거시전치부개교합의소견을보여술후 20 일째재수술을시행하기로결정하였다. C Fig. 4. patient of posterior mandibular rotation combined with poor final wafer fabrication.. Pre-operative photographs show facial asymmetry, anterior crossbite with deviation of lower dental midline to left side.. Post-operative photographs after 1st operation show unsolved facial asymmetry and poor occlusal adaptation to the final wafer. C. fter refixation, facial symmetry and stable occlusion were maintained. 34
하악골의재고정시좌측에는 2 개의금속판과나사로고정을시행하고우측은 3 개의긴나사로두개의골편을고정하였다. 재수술이시행되고 24 일째불안정한교합및이중교합의소견을보였고 3 개월째경과관찰시에하악전방변위및전치부개교합이재발되는소견을보였다.(Fig. 5..) 본증례는술전뼈스캔검사상진한섭취를보이는측두하악관절의이상소견이있었고하악골의큰후방이동량, 비대칭적인후퇴및그로인한골편간섭과연조직견인력의작용그리고이중교합이술후회귀현상을일으켰을것으로여겨진다 17,18. 추후환자에대한추가적인수술을권유하였으나환자가거부하여추가적인수술없이종료하였다. Fig. 5. patient of large and asymmetric mandibular setback combined with temporomandibular joint instability.. Pre-operative bone scintigraphy shows increased uptake on both TMJ.. Even after re-operation, persistent unstable occlusion with relapse tendency was noticed. Fig. 6. patient of centric relation-centric occlusion (CR-CO) discrepancy with dual bite.. Pre-operative intraoral photographs show several missing teeth and poor occlusion with deviated dental midline.. Post-operative photographs after 1st operation show no improvement of the occlusion. 35
대구외지 2010;36:28-38 6. 중심위와중심교합위의상이한관계로이중교합을갖는증례 21 세의남자환자로술전교정을완료한상태로안면비대칭을주소로내원하였다. 임상및방사선검사상상악교합평면의경사를동반한하악골의우측변위를관찰할수있었다. 다수의상실치와치아의배열이좋지않아수술계획을세우는데있어어려움이있었다.(Fig. 6..) 특히상악중절치는교두간섭을일으키며최종적인교합위치를설정하는데방해가되었다. 상악골은제 1 형르포씨골절단술에의하여상악중절치를기준으로 3 mm 전방이동을시행하였다. 하악골은 IVS- RO 에의해우측은 0.5 mm, 좌측은 1.5 mm 의전방이동을시행하였다. 이에추가로이부성형술에의해이부의 2 mm 전진이동을시행하였다. 술후 1 일째시행된경두개방사선사진상양쪽하악과두의전방이동소견을보였으나당시의교합은안정된양상을보였다. 술후 13 일째양측측두하악관절의불편감을호소하였고불안정한교합을보였으나고무줄에의한견인후 16 일째는다시안정된교합을보였다. 술후 20 일째전치부개교합양상이나타났고하악과두의지속적불편감을호소하여재수술을시행하기로결정하였다.(Fig. 6..) 재수술시상악은제 1 형르포씨골절단술에의한중절치의 2 mm 우측이동및 1 mm 하방이동, 우측제 1 대구치의 0.5 mm 상방이동과좌측제 1 대구치의 3.5 mm 상방이동을시행하였다. 하악골은 IVSRO 에의해우측은 3 mm, 좌 측은 1 mm 의후방이동을시행하였다. 이때하악의골편간의고정을시행하지않고상, 하악악간고정을강선을이용하여시행하였다. 재수술직후방사선사진상하악의골편간에큰간극이관찰되고과두의하전방이동이나타났으며교합유도에어려움이있어스크류를이용한재고정을시행하였다. 본증례에서는불충분한술전교정상태와 centric relation-centric occlusion (CR-CO) 간에상이한위치를보이는이중교합의소견을보여이로인해술후의불안정한교합을일으켰을뿐아니라안모비대칭을해결하기위한치료계획수립에도착오를일으킨것으로판단된다. 추가적으로지속적인교정시에도안정적이지못한교합상태를지속적으로보이고있으나추가적인수술을시행하지않았다. Ⅳ. 고찰 이상과같은증례들에서는악교정수술후조기회귀현상이일어난총 6 명의환자에서재수술을시행하여 4 명의환자에서는이후안정적인결과를얻었고나머지 2 명의환자에서는지속적인악골의불안정한위치및부정교합의소견을보였다.(Table 2.) 과두의처짐이재발의주요인이되었던증례를통해알수있듯이수술시계산착오등으로인해근심골편이잘못위치되어하악골의고정이이루어지게되면하악과두가생리적인위치에서벗어나악골간고정을제거한직후에불안정한교합및하악골의불안정성을야기할수있다 5-7. Table 2. Case analysis. No. Early findings of post-op instability Possible causes lternative solutions 1 nterior open bite Condylar sagging Condylar positioning devices 19 Navigation surgery 20,21 Intraoperative awakening 22 2 Shifting of mandible to Rt. side Large & asymmetric mandibular setback Short lingual technique 25-27 Remained asymmetry -> Distal cutting technique 28 Soft tissue tension Secondary osteotomy 29 3 Unstable occlusion Transverse discrepancy Palatal osteotomy 30 Shifting of mandible to Rt. side 4 Unstable occlusion Poor final wafer Computer-assited planning 31 Remained asymmetry -> Rotation of posterior mandible to Lt. side 5 nterior open bite Large & asymmetric mandibular setback Short lingual technique 25-27 Shifting of mandible anteriorly -> Distal cutting technique 28 Soft tissue tension Secondary osteotomy 29 Temporomandibular joint instability 6 Unstable occlusion Dual bite Computer-assited planning 31 nterior open bite Remained asymmetry CR splint (Rt.: right, Lt.: left, CR: centric relation) 36
따라서수술중근심골편을올바르게위치시키기위한여러연구들이있어왔다. 이중 Leonard 등 10 은상악치열의선부자에연결된장치를, Luhr 32 등은관골체에부착시킨장치를사용하여근심골편이술전과같은위치를유지하도록하는방법을고안하였다. 이러한과두위치장치 (condylar positioning device) 는고정시하악과두의처짐을방지할수있도록하는한가지방법이될수있다. 그러나최근의한연구에따르면수조작에의해근심골편을위치시키는것에비해과두위치장치를사용하는것이뚜렷한과학적근거가없고논란의여지가있다고하였다 19. 또한초음파를이용하여과두의위치를확인하거나컴퓨터를이용한항법수술 (navigation surgery) 로수술중과두를정확히위치시키려는방법이소개되기도하였으나이는부가적인장비와피부관통절개가필요하며추가적인시간이소요되는단점이있다 20,21. Politi 등은환자가마취된상태에서는하악의움직임에따른근육의긴장및환자의실제의개, 폐구를재현하기어렵다는가정하에수술중환자를각성시켜하악과두의위치를정하는방법을고안하여보고하기도하였다 22. 그러나이술식의안정성및환자가느끼는불편감등과관련하여더심도있는연구가필요할것으로보인다. 하악의골절단후일어나는원심부의이동은앞서위에서언급한바와골편간의간섭및연조직의견인력으로인해술후재발및회귀현상을일으킬수있다 11,12,23. 특히근육에의한견인력이하악골을후퇴시킨후에재발을일으키는가장큰요인이라고보고되기도하였다 24. 본연구에서도과도한양의하악골의후퇴이동에따라조기회기현상이일어난증례들이있었다. 따라서하악골절단시내측의수평적골절단을소설직상방및직후방까지만연장하게되면원심골편의후방부길이를줄여줄수있고골편의간섭및내측익돌근의부착에의한견인을최소화하여회귀현상을줄이는데도움이될수있을것이다 25-27. 또는원심골편의후방부를하악공후방에서하악각부터과두하까지골절단한후에이를제거하는방법을통해서도돌출되는원심골편을없애재발을줄여주는것으로보고되었다 28. 비대칭적인하악골의이동또한위여러증례에서보여지듯고정시골편간의수동적인적합을어렵게하여재발및불안정한악골의위치를야기할수있다. 따라서 Ellis 가제시한것처럼원심골편의후방부에수직적인골절단을가한후이를내측으로회전시켜근심골편과원심골편간의간극을줄여주고수동적인접합을꾀할수있을것이다 29. 상, 하악의횡적부조화가술후의불안정성을야기한위증례에서는수술전이나수술과동시에상악구개측의골절단을통해서횡적부조화를해결하였다면조기회귀현상을예방할수있었을것이라여겨진다 30. 또한컴퓨터를이용하여환자의진단과수술계획을수립하는방법이더욱발전하게된다면 CR-CO 상이함등으로인한수술계획 의오차를줄일수도있고보다정확한교합장치의제작도가능해져예측가능성이높고안정적인수술계획및술식이앞으로이뤄질수있을것으로기대된다 31. 참고문헌 1. Paulus GW, Steinhauser EW. comparative study of wire osteosynthesis versus bone screws in the treatment of mandibular prognathism. Oral Surg Oral Med Oral Pathol 1982;54:2-6. 2. Phillips C, Zaytoun HS Jr, Thomas PM, Terry C. Skeletal alterations following TOVRO or SSO procedures. Int J dult Orthodon Orthognath Surg 1986;1:203-13. 3. Komori E, igase K, Sugisaki M, Tanabe H. Cause of early skeletal relapse after mandibular setback. m J Orthod Dentofacial Orthop 1989;95:29-36. 4. Kobayashi T, Watanabe I, Ueda K, Nakajima T. Stability of the mandible after sagittal ramus osteotomy for correction of prognathism. J Oral Maxillofac Surg 1986;44:693-7. 5. Will L, Joondeph DR, Hohl TH, West R. Condylar position following mandibular advancement: its relationship to relapse. J Oral Maxillofac Surg 1984;42:578-88. 6. Van Sickels JE, Larsen J, Thrash WJ. Relapse after rigid fixation of mandibular advancement. J Oral Maxillofac Surg 1986;44:698-702. 7. Epker N, Wessberg G. Mechanisms of early skeletal release following surgical advancement of the mandible. r J Oral Surg 1982;20:175-82. 8. Reyneke JP, Ferretti C. Intraoperative diagnosis of condylar sag after bilateral sagittal split ramus osteotomy. r J Oral Maxillofac Surg 2002;40:285-92. 9. Stella JP, strand P, Epker N. Patterns and etiology of relapse after correction of Class III open bite via subcondylar ramus osteotomy. Int J dult Orthodon Orthognath Surg 1986;1:91-9. 10. Leonard MS, Ziman P, evis R, Cavanaugh G, Speidel MT, Worms F. The sagittal split osteotomy of the mandible. Oral Surg Oral Med Oral Pathol 1985; 60:459-66. 11. Yellich GM, McNamara J Jr, Ungerleider JC. Muscular and mandibular adaptation after lengthening, detachment, and reattachment of the masseter muscle. J Oral Surg 1981;39:656-65. 12. Ellis E 3rd, Carlson DS. Stability two years after mandibular advancement with and without suprahyoid myotomy: an experimental study. J Oral Maxillofac Surg 1983;41:426-37. 13. Chow LK, Singh, Chiu WK, Samman N. Prevalence of postoperative complications after orthognathic surgery: a 15-year review. J Oral Maxillofac Surg 2007;65:984-92. 14. MacIntosh R. Experience with the sagittal osteotomy of the mandibular ramus: a 13-year review. J Maxillofac Surg 1981;9:151-65. 15. Singer RS, ays R. comparison between superior and inferior border wiring techniques in sagittal split ramus osteotomy. J Oral Maxillofac Surg 1985;43:444-9. 16. Kundert M, Hadjianghelou O. Condylar displacement after sagittal splitting of the mandibular rami. short-term radiographic study. J Maxillofac Surg 1980;8:278-87. 17. ell WH, Jacobs JD. Tridimensional planning for surgical/orthodontic treatment of mandibular excess. m J Orthod 1981;80: 263-88. 18. Link JJ, Nickerson JW Jr. Temporomandibular joint internal derangements in an orthognathic surgery population. Int J dult Orthodon Orthognath Surg 1992;7:161-9. 19. Costa F, Robiony M, Toro C, Sembronio S, Polini F, Politi M. Condylar positioning devices for orthognathic surgery: a literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:179-90. 20. Gateno J, Miloro M, Hendler H, Horrow M. The use of ultrasound to determine the position of the mandibular condyle. J Oral 37
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