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齒顎矯正治療成效評估之探討-以臺灣專科考試為例

2019-01-01T00:00:00Z

標題: 齒顎矯正治療成效評估之探討-以臺灣專科考試為例; Assessing orthodontic treatment outcomes: analysis with the Taiwan Board of Orthodontics objective grading system 作者: Yi-Jun Hung; 洪翊珺摘要: 摘要目的齒顎矯正醫師以改善病人齒列之美觀以及為病人建立理想咬合做為治療的目標，而許多因素會影響到矯正治療之成效，包含了病人初始牙齒狀況、病患配合程度、治療方式及不同的治療目標等。而監測矯正治療後成效對於治療品質的控制非常重要，鑑別出問題所在對於制定改善臨床結果的策略至關重要。除了需要暸解理想咬合之定義外，更需要有一套以合理且客觀的評分制度做為治療後成效的依據來評斷治療成效的好壞。本研究之實驗目的為藉由「中華民國齒顎矯正部定專科醫師口試病例審查評分標準」(Taiwan Board of Orthodontics Grading System, TBO-OGS)來評估矯正治療的成效，並分析此系統之評分信度。研究程序及方法從臺大醫院齒顎矯正科治療完成的病人中挑選三十六例，條件符合中華民國齒顎矯正學會專科醫師考試病例屬性且病歷資料完整。挑選九位一般醫師(General dentist)、九位受訓醫師(Graduate student)、以及九位專科醫師(Orthodontist)，總共二十七位醫師擔任本次研究之評分者，並請評分醫師依照TBO-OGS做兩次評分，時間間隔兩週。統計計算前後測差異分析及再測信度分析、整體評分者間信度、總分與不同資歷背景醫師之迴歸分析、各評分項目與不同資歷背景醫師之迴歸分析以及九種病例屬性評分間總分信度分析。結果本研究結果發現在不同資歷背景的醫師或不同屬性分類下，其評分前後測總分經paired t檢定皆未達統計上顯著差異。利用Pearson correlation進行分析，整體再測信度為高度相關(r=0.814)，表示其前後測一致性較高；以醫師資歷背景做分類去探討，三種資歷背景醫師的再測信度皆為高度相關。針對各評分項目之整體評分者間信度，各評分者間一致性較高之評分項目：垂直覆蓋；一致性中高之評分項目：鄰接面接觸、牙根平行度、中線、牙根吸收；一致性尚可之評分項目：水平覆蓋、臼齒關係、咬合接觸；一致性較低之評分項目：犬齒關係、邊緣脊、頰舌向牙齒傾斜、排列／旋轉。不同資歷背景醫師評分總分之分析，評分之總分不受評分者之資歷背景而有所影響。針對各項評分項目評分與不同資歷背景醫師之回歸分析，評分項目中僅在牙根吸收此項目受訓醫師相較於一般醫師給較高的分數機會是0.34倍，牙根吸收此項目專科醫師相較於受訓醫師給較高的分數機會是2.94倍。針對九種屬性總分之評分者間信度為尚可至中等(0.22-0.48)。結論 1. 整體而言，評分前後測之總分沒有差異，且前後測的分數相關性高。若以不同資歷背景來看，一般醫師、受訓醫師及專科醫師前後測數值皆為高度相關。若以不同屬性分類來看，Class I bimaxillary protrusion、Class II high angle、Class II div.2及anterior crossbite屬性前後測數值為中度相關性，其餘皆為高度相關。 2. 針對各個評分項目評分者間信度，高度一致性的為垂直覆蓋；中高度一致性的為鄰接面接觸、中線、牙根平行度及牙根吸收；一致性尚可的為水平覆蓋、臼齒關係及咬合接觸；一致性低的為犬齒關係、排列／旋轉、邊緣脊及頰舌向牙齒傾斜。 3. 針對不同資歷背景醫師評分總分之分析，評分之總分不受評分者之資歷背影而有所影響。 4. 對於大部分的評分項目，不同資歷背景醫師的各項評分沒有差異。而在牙根吸收項目，受訓醫師給的分數比一般醫師及專科醫師來得低。 5. 針對九種不同屬性類別的病例，其總分之評分者間信度為尚可至中等(0.22-0.48)。; Abstract Objective The orthodontists aim to improve the aesthetics of the patient's dentition and establish an ideal occlusion for the patient. Many factors including the initial dental condition of the patient, the degree of patient cooperation, the different treatment methods, and the different treatment goals etc., would affect the effectiveness of the treatment outcome. Monitoring treatment progress, final outcome and finding the problems for an orthodontic program are important for assuring quality control. In addition to understanding the definition of ideal occlusion, it is necessary to have a reasonable and objective scoring system as a basis for judging the effectiveness of treatment. In this study, we evaluated the treatment outcome of 36 cases, analyzed the results of the raters with different training background, and assessed the reliability of the Taiwan Board of Orthodontics Grading System. Material and methods Nine general dentists, nine graduate students under orthodontic training, and nine certificated orthodontists, total twenty-seven raters, were recruited into the study. We randomly selected 36 patients who completed orthodontic treatment in National Taiwan University Hospital. The case should meet the case assessment form for the board exam of the Taiwan Board of Orthodontics. Paired t test and Pearson correlation, repeated linear regression model, Gwet’s AC2, repeated ordinal logistic regression, and mixed model calculate ICC (intra-class correlation) were used to analyze the data. Results There is no significant difference between pre-test and post-test, and data of pre-test and post-test have high correlation(r=0.814). That reveals that the interrater reliability is good. Categorized by different training background, there is no significant difference in the pre-test and post-test data which have high correlation. Categorized by different grading items, the analysis report reveals that raters reach the almost perfect strength of agreement in overbite item; substantial strength of agreement in interproximal contacts, root parallelism, midline, and root resorption items; fair strength of agreement in overjet, molar relationship, and occlusal contacts items; slight strength of agreement in canine relationship, marginal ridge, buccolingual inclination, and the alignment/rotation items. There is no significant difference on the total scores by raters with different training background. Based on the outcome of repeated ordinal logistic regression, the graduate students would give the higher scores of root resorption item is 0.34 times than general dentists. The orthodontists would give the higher scores of root resorption item is 2.94 times than graduate students. Based to the nine different categories, the inter-rater reliability is fair to moderate (0.22-0.48). Conclusion 1. There is no significant difference between pre-test and post-test, and data of pre-test and post-test have high correlation. 2. Based on the different items, the overbite, inter proximal contact, root parallelism and the root resorption have the better inter-rater reliability. 3. The training background of the examiners does not affect the total scores. 4. Based to the different categories, the inter-rater reliability is fair to moderate (0.22-0.48). 5. Intra-rater & inter-rater reliability of TBO-OGS is good.

齒源性角化囊腫及含齒囊腫中之蘭格罕氏細胞數目及其與臨床病理參數之相關性

2017-01-01T00:00:00Z

標題: 齒源性角化囊腫及含齒囊腫中之蘭格罕氏細胞數目及其與臨床病理參數之相關性; Langerhans cell counts in odontogenic keratocysts and dentigerous cysts and their correlations with clinicopathological parameters 作者: Chun-Han Chang; 張君涵摘要: 背景：蘭格罕氏細胞是主要存在於上皮內的抗原呈遞細胞，本研究評估齒源性角化囊腫(OKC)及含齒囊腫(DC)中之蘭格罕氏細胞(LC)數目。方法：本研究主要利用anti-CD1a及anti-S100蛋白質免疫組織化學染色法，評估於60例OKC標本及80例DC標本中之蘭格罕氏細胞數目及其與臨床病理參數之相關性。於60例OKC標本中，評估60個無發炎部位，39個輕度或中度發炎部位，13個重度發炎部位之蘭格罕氏細胞數目；於80例DC標本中，評估80個無發炎部位，33個輕度或中度發炎部位，9個重度發炎部位之蘭格罕氏細胞數目。結果：60例OKC樣本中，在內襯上皮和上皮下方結締組織中之平均CD1a陽性或S100陽性之LC細胞數目，從無發炎部位至輕度/中度發炎部位，及至重度發炎部位，其蘭格罕氏細胞數目皆逐步顯著增加（P值皆< 0.001）。有發炎之OKC部位比無發炎之OKC部位，具有較厚之內襯上皮。此外，在厚內襯上皮（> 100 μm）組之OKCs中，內襯上皮和上皮下結締組織中之平均CD1a陽性或S100陽性之LC細胞數目，皆明顯高於薄內襯上皮（≤ 100 μm）組之OKCs (P值皆< 0.001）。於80例DC樣本中，也可發現在內襯上皮和上皮下方結締組織中之平均CD1a陽性或S100陽性之LC細胞數目，從無發炎部位至輕度/中度發炎部位，及至重度發炎部位，其蘭格罕氏細胞數目皆逐步顯著增加（P值皆< 0.001）。有發炎之DC部位比無發炎之DC部位，具有較厚之內襯上皮。此外，在厚內襯上皮（> 50 μm）組之DCs中，內襯上皮和上皮下結締組織中之平均CD1a陽性或S100陽性之LC細胞數目，皆明顯高於薄內襯上皮（≤ 50 μm）組之DCs (P值皆< 0.001）。結論：本研究發現發炎之等級與OKC中之LC數量，有顯著相關。在無發炎OKC的內襯上皮中，只可發現極少量之LC，此表示OKC內襯上皮細胞之免疫監視能力明顯喪失，這可解釋為什麼OKC具有強大臨床侵犯性、強大細胞增殖潛力和高的復發率。此外在DC研究中，LC數量之增加與高發炎程度和厚內襯上皮有顯著相關。在無發炎DC之內襯上皮中，只發現極少數之LC，也表明DC患者之內襯上皮細胞免疫監視能力明顯下降。然而，需要進一步研究來確認上皮免疫監視能力之降低和DC之囊腫增大是否有關。; Background/Purpose: Langerhans cells (LCs) are antigen-presenting cells that reside mainly within the epithelium. This study assessed the LC counts in odontogenic keratocysts (OKCs) and dentigerous cysts (DCs). Methods: This study used anti-CD1a and anti-S100 protein immunostains to assess the LC counts in 60 OKCs and 80 DCs and the correlations of LC counts with clinicopathological parameters of 60 OKCs and 80 DCs. The LC numbers in the lining epithelia and subepithelial connective tissues were counted at 60 OKC sites without inflammation, 39 OKC sites with mild/moderate inflammation, and 13 OKC sites with severe inflammation from 60 OKC specimens as well as at 80 DC sites without inflammation, 33 DC sites with mild/moderate inflammation, and 9 DC sites with severe inflammation from 80 DC specimens. Results: For 60 OKC cases, the mean CD1a-positive or S100-positive LC counts in the lining epithelia and subepithelial connective tissues increased significantly from no inflammation through mild/moderate inflammation to severe inflammation OKC sites (all P-values < 0.001). OKC sites with inflammation had thicker lining epithelia than those without inflammation. Moreover, the mean CD1a-positive or S100-positive LC counts in the lining epithelia and subepithelial connective tissues of OKCs were significantly higher in the thicker lining epithelium (> 100 μm) group than in the thinner lining epithelium (≦ 100 μm) group (both P-values < 0.001). For 80 DC cases, the mean CD1a-positive or S100-positive LC counts in the lining epithelia and subepithelial connective tissues also increased significantly from no inflammation through mild/moderate inflammation to severe inflammation DC sites (all P-values < 0.001). DC sites with inflammation had thicker lining epithelia than those without inflammation. Moreover, the CD1a-positive or S100-positive mean LC counts in the lining epithelia and subepithelial connective tissues of DCs were significantly higher in the thicker lining epithelium (> 50 μm) group than in the thinner lining epithelium (≦ 50 μm) group (both P-values < 0.001). Conclusion: A significant association of inflammation grade with the number of LCs in OKCs is found in this study. The finding of scare LCs in the lining epithelia of OKCs without inflammation indicates the loss of immunosurveillance ability against the OKC lining epithelial cells; this can explain why OKCs have aggressive clinical behavior, a great growth potential, and a high recurrence rate. Moreover, the increased LC number in DCs is also associated with high-grade inflammation and thick lining epithelium. The finding of few LCs in the lining epithelia of DCs without inflammation also indicates the reduced immunosurveillance ability against DC lining epithelial cells in DC patients. However, it needs further studies to confirm the role of reduced lining epithelial cell immunosurveillance in the enlargement of the DC.

齒槽骨維持術的臨床表現統合分析

2014-01-01T00:00:00Z

標題: 齒槽骨維持術的臨床表現統合分析; Meta-analysis of clinical performance of Alveolar ridge preservation 作者: Wei Chiang; 蔣蔚摘要: 臨床上我們很常會面對到拔牙後齒槽骨縮減狀況。所以我們希望能夠集結許多臨床試驗，利用統合分析(meta-analysis)，找出科學證據來：（1）評估齒槽骨維持術與拔牙後自然癒合的預期結果差別（2）比較各式齒槽骨維持術方法的同異與效益和（3）評估施行齒槽骨維持術後對於將植體植入理想位置的價值。做出一個統整。希望能幫助臨床醫師訂定及執行後續的治療計畫。我們利用電子資料庫MEDLINE，Scopus Elsevier，Cochrane Library，全國期刊聯合資料庫，中國知識資源總庫、全國博碩士論文資訊加值網、華藝線上圖書館，及Google學術搜尋，全面系統性的搜尋了從西元1990到2014年4月與齒槽骨維持術相關的隨機對照試驗(Randomized controlled trial)，橫段式研究（cross-sectional study），病例-對照研究（case-control study），世代追蹤研究法（cohort study），及有治療組、對照組，兩組以上互相比較的病例系列報告(case series)。然後用統合分析方式比較齒槽骨維持術使用不同材料及方法其臨床表現的優劣。我們最後篩選出18篇文章。統合分析結果顯示，有做齒槽骨保存術的組別比未做齒槽骨保存術的組別在拔牙後有更少的骨嵴高度減少（加權平均差異，WMD = 1.074±0.291 mm(p<0.05))。更少的骨嵴寬度減少（加權平均差異，WMD = 1.981±0.24 mm(p<0.05))。用再生膜(Membrane) (p<0.001)，異體骨(Xenograft) (p<0.001)，以及島瓣一級縫合(primary closure) (p<0.001)等皆可降低拔牙後骨嵴高度減少。明顯有利於齒槽骨保存。至於在齒槽骨維持術治療對植牙治療長期成果的好處，並沒有足夠資料可用來得出結論。本研究論證了齒槽骨維持術治療的重要性。但無法明確提供齒槽骨維持術使用的生物材料的類型，或手術過程清晰的指引。; Objective: This systematic review aims to the effect of socket preservation following tooth extraction in humans as compared with natural healing ,to evaluate the scientific evidence on the efficacy in the surgical protocols designed for preserving the alveolar ridge after tooth extraction and to evaluate how these techniques affect the placement of dental implants and the final implant supported restoration. Material and methods: A thorough search in MEDLINE via Pubmed, Scopus Elsevier , MEDLINE (OvidSP), Cochrane Library, STICNET in Taiwan, NDLTD in Taiwan, Airiti library in Taiwan, CNKI in China and hand-searched the relevant journals from 1990 to April 2014. Randomized controlled trial, cross-sectional study. case-control study ,cohort study with a follow-up of at least 4 months reporting changes on both the hard and soft tissues (height and/or width) of the alveolar process (mm or %) after tooth extraction were considered for inclusion. Results: The screening of titles and abstracts resulted in 18 publications meeting the eligibility criteria. Results from the meta-analyses showed a statistically significant greater ridge reduction in bone height & width for control groups as compared to test groups Meta-regression analyses was based on the surgical protocol used for the ridge preservation (Membrane(Yes vs. No); Membrane (Yes(artifical) vs. No); Membrane (artificial vs autogenous); Xenograft (Yes vs. No); Graft (Yes vs. No); Flap (Yes vs. No); Primary Closure(Yes vs. No); Membrane(Yes)+Graft(Yes) vs. Membrane(Yes)+Graft (No)) and on the measurement method utilized to evaluate morphological changes. Meta-regression analyses demonstrated a statistically significant difference favoring the Membrane(Yes), Xenograft (Yes ) Primary Closure (Yes ) subgroup in terms of bone height & width . Conclusions: The potential benefit of socket preservation therapies was demonstrated resulting in significantly less vertical and horizontal contraction of the alveolar bone crest. The scientific evidence does not provide clear guidelines in regards to the type of biomaterial, or surgical procedure, There are no data available to draw conclusions on the consequences of such benefits on the long-term outcomes of implant therapy.

齒槽骨再生之大鼠動物模型

2020-01-01T00:00:00Z

標題: 齒槽骨再生之大鼠動物模型; A Novel rat Model Design for Alveolar Bone Regeneration-related Research 作者: Ching-Hung Li; 李慶宏摘要: 目的儘管沒有動物模型能夠完美地模擬臨床狀況，但我們應根據臨床可能的適應症建立動物模型。而且與骨再生相關的大鼠動物模型，比較沒有是在上顎部位的骨缺陷實驗設計。通常與上顎有關的骨缺陷設計是討論顎裂疾病相關，而且也鮮少有關於上顎骨臨界尺寸的骨缺損討論。所以我們試圖比較兩種拔牙模式之齒槽骨寬度二維量值大小，軟組織高度二維量值大小以及齒槽骨邊界體積(alveolar bone contour volume)的差異，藉此找尋適當的實驗時間點，以利於後續骨再生相關手術實驗中骨缺陷的製作，也有利於之後對於大鼠上顎齒槽骨骨缺損臨界尺寸大小的探討。研究程序及方法隨意分配不同時間點犧牲之大鼠上顎某側僅先磨除第一大臼齒牙冠作為實驗側（組），同一隻大鼠上顎另一側為拔除第一大臼齒為對照側（組），為一分口(split-mouth)實驗設計。使用micro-CT影像重組，其冠狀面切面影像測量軟組織的高度，軸向面切面影像測量齒槽骨寬度。在三維重組影像上，針對感興趣區(Region of interest)，計算區間內齒槽骨邊界體積(alveolar bone contour volume)。結果在實驗側可見第一大臼齒牙根尖頂點的軸向切面上，分別測量實驗側第ㄧ大臼齒近心牙根，中央牙根以及遠心牙根處位置的齒槽骨寬度以及對照側相對應位置的齒槽骨寬度。發現實驗側與對照側在這三個位置上皆有統計上顯著差異，實驗側齒槽骨寬度比對照側大。實驗側與對照側的軟組織高度在第一大臼齒中央處和近心牙根處的兩側比較，皆有統計上顯著差異，實驗側軟組織高度比對照側高。細分不同時間點犧牲的大鼠，發現僅術後十四週大鼠在第一大臼齒中央處軟組織高度在實驗側顯著大於對照側。而在近心側牙根處的軟組織高度研究分別就術後兩週，六週以及十週的實驗側顯著大於對照側。實驗側比對照側有較多的齒槽骨邊界體積，且達到統計上顯著差異。但若細分不同時間點犧牲大鼠，發現術後兩週，六週以及十四週的大鼠，兩側齒槽骨邊界體積有達到統計上顯著差異，實驗側比對照側有較多的齒槽骨邊界體積。且在實驗側部分，術後十四週大鼠的骨頭體積與其他三個時間點的實驗側相比，有較多的齒槽骨邊界體積，統計上有顯著差異。結論實驗側（僅先磨除牙冠）可以保有較多的齒槽骨邊界體積(bone contour volume)，以及在根尖處齒槽骨寬度得以維持，有利於後續骨缺陷的製作。 ; Objective Although no animal model can perfectly simulate clinical conditions, we should establish animal models based on possible clinical indications. Moreover, compared with the rat animal model related to bone regeneration, there were few experimental designs of bone defects in the upper jaw. Usually the designs of bone defects related to the upper jaw were related to the discussion of cleft palate disease, and there were few discussions about bone defects of the critical size defect of the maxilla. Therefore, we compared the dimension of the upper first molar alveolar bone after extraction and just the crown removed respectively with two different protocols. The difference in alveolar bone contour volume could be used to find the appropriate experimental time point for subsequent bone regeneration surgery experiments, and also help the subsequent evaluation of the critical size of the rat maxillary alveolar bone defect. Material and methods The rats sacrificed at different time points were assigned randomly that the upper first molar crown was removed first as the experimental side (group), and the other side of the same rat’s upper first molar was extracted as the control side (group). Using micro-CT image reconstruction, we measured the height of the soft tissue and the alveolar bone width in the coronal and trans-axial slices respectively. On the three-dimensional reconstructed image, we calculated the alveolar bone contour volume in the Region of interest. Results The width of the alveolar bone at the mesial, middle and distal roots of the first molar on the experimental side and the alveolar at the corresponding position on the control side were measured. It was found that between the experimental side and the control side there were statistically significant differences in these three positions at the root apex; the widths of the alveolar bone on the experimental side were larger than the ones on the control side. There were statistically significant differences in the soft tissue height between the experimental side and the control side in the middle of the first molar and the mesial root. The soft tissue height on the experimental side was higher. The experimental group had more alveolar bone contour volume than the control group, and reached a statistically significant difference. Among the experimental sides, the bone volume of the rat at fourteen weeks after the operation was statistically significant larger than the other three time points. Conclusion The experimental side can retain more bone contour volume, and the width of the alveolar bone at the root apex can be maintained, which is beneficial to the production of subsequent bone defects.