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系統識別號 U0007-1704200714494804
論文名稱(中文) 以激振方法分析人工牙根穩固度之相關性研究
論文名稱(英文) Excitation assessment for the stability of dental implants
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 林世芬
學號 M88040036
學位類別 碩士
語文別 中文
口試日期
論文頁數 75頁
口試委員 指導教授-林哲堂
指導教授-李勝揚
關鍵字(中) 人工牙根
穩固度
骨整合
共振頻率
關鍵字(英) dental implant
stability
osseointegration
resonance frequency
學科別分類
中文摘要 近年來,利用人工植體為缺牙患者進行口腔贗復的比例已逐漸增加,然直至目前為止,仍沒有一套簡單可靠的儀器可非侵入性地提供客觀量化的數值,以便臨床醫師能隨時有效地評估人工牙根植入後的骨整合或穩固程度。利用振動方法分析骨成長或流失的研究,於骨科醫學應用上已行之多年,而與骨頭同屬硬組織的牙齒包埋於齒槽骨中亦有類似的特性。若骨整合逐漸完成,植體周圍骨質的剛性會逐漸增加,其穩固度相對增加,共振頻率也隨之增加。但骨整合為軟組織逐漸轉變為硬組織的過程,植體周邊物質具有不等程度的黏彈性發展,若以不同外力推動植體,其移動度可能不與外力成正比,而表現出不同的剛性係數。為了能夠快速、精確地監測植體穩固度的改變,並符合臨床醫學需求,本研究發展出激振式人工牙根檢測儀,將振動裝置與訊號感測器合而為一,置於待測人工牙根上方,利用振動裝置激發待測牙根後,取激振後所輸出最大振幅頻率來觀察比較。當特定頻率振幅有變化時,表示植體與骨邊界間的穩固度有相對的變化。以體外模擬試驗來評估人工牙根振動頻率與三種手術條件(標準型、下端固定型、浮動型)及骨整合時間的關係,並於量測時改變檢測儀的控制電壓,以取得電壓與共振頻率之相對關係,藉以瞭解植體周邊物質於骨整合過程中之剛性係數變化。實驗結果顯示(1)單一控制電壓下,共振頻率會隨邊界物質剛性的增加而上升,共振頻率的上升曲線隨植床情況之不同而有差異,並分別在不同時間達到高原期(p<0.05)。(2)骨整合的過程中植體-骨邊界物質具有黏彈性,量測不同電壓下的剛性變化似乎更易區分植體穩固與否。因此,激振式人工牙根檢測儀有助於臨床醫師評估植體的骨整合或穩固程度,以達到縮短治療時間或提高成功率的效果。
英文摘要 The establishment of osseointegration following dental implant placement is a major contributing factor to the clinical success and long-term function of implant-retained prosthesis. The application of a simple, clinically applicable, noninvasive test to assess implant stability and osseointegration is considered highly desirable. Vibration methods have been widely used for many years to evaluate the mechanical performance and integrity of a structure. Many investigations have shown the technique capable of eliciting quantitative information related to implant stability and stiffness. Whereas, for osseointegrated and failure implants in which a non-bony layer exist at the bone-implant interface, there is the possibility of implant movement relative to bone, suggesting that a poorly integrated implant may show increased mobility through a limited range of motion. The investigation was designed to study the use of excitation analysis in search of the stability of the implant-tissue interface in vitro. Resonance frequency was measured when test implants were embedded in bakelites. There are three surgical models prepared in bakelites, which includes: standard type, immediate implantation type, and floating type. The change in stiffness observed during bone healing was modeled by embedding implants in gypsum during setting period. This research provides 4 main findings that may be value in studies of osseointegration. First, the starting resonance frequency under different surgery conditions can be measured by the self-designed diagnosis system, which can be used as the reference standard for implant following up. Second, there was an increase in resonance frquency related to stiffness increment during osseointegration (p<0.05). Third, due to variations from different surgical and bone conditions, the time needed for osseointegration would differ from one to the others. Finally, the range of stiffness in high and low voltage groups is correlated with implant stability. Excitation analysis technique is capable of eliciting quantitative information related to implant stability and stiffness. Using excitation frequency to evaluate osseointegration is benefit in clinical examination.
論文目次 中文摘要 …………………………………………………………… Ⅰ 英文摘要 …………………………………………………………… Ⅱ 第一章 研究動機與目的 …………………………………………… 1 第二章 文獻回顧 第一節 人工牙根穩固度 ……………………………………… 4 第二節 侵入性檢測 ………………………………………… 6 第三節 非侵入性檢測 ………………………………………… 8 第三章 研究材料與方法 第一節 人工牙根之黏彈模型 ………………………………… 11 第二節 激振式人工牙根檢測儀 ……………………………… 13 第三節 檢測儀之機械模型 …………………………………… 14 第四節 骨整合過程對共振頻率影響之模擬測試 …………… 16 第四章 結果 第一節 共振頻率與石膏硬化時間之關係 ……………………… 18 第二節 電壓改變之共振頻率變化百分率與石膏硬化時間的關係 ……………………………………………………… 19 第五章 討論 ………………………………………………………… 20 第六章 結論與建議 第一節 結論 ……………………………………………………… 24 第二節 應用與建議 …………………………………………… 25 參考文獻 …………………………………………………………… 26 圖表 ………………………………………………………………… 35 附錄 ………………………………………………………………… 54
參考文獻 Adell R, Lekholm U, Branemark P-I. Surgical Procedures. In: Branemark P-I, Zerb GA, Albrektsson T, ed. Tissue-integrated prosthesis: osseointegration in clinical dentistry. Chicago: Quintessence Publishing Co, 1985: pp. 211-232. Adell R, Lekholm U, Rockler B, Branemark P-I. A 15-years study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:137-416. Albrektsson T. Dental implants: A review of clinical approaches. APS Bull 1985;7-25. Albrektsson T. Bone tissue response. In: Branemark P-I, Zarb GA, Albrektsson T (eds). Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence 1985;129-143. Albrektsson T. On long-term maintenance of the osseointegrated response. Aust Pristhet J 1993;7:15-24 Albrektsson T, Sennerby L. State of the art in oral implant. J Clin Periodontal 1991;18:474-481. Berglundh T, Lindhe J, Ericsson I. The soft tissue barrier at implant and teeth. Clin Oral Implant Res 1991;2:81-90. Branemark R. A biomechanical study of osseointegration (thesis). Goteborg: Univ of Goteborg, 1996. Brunski JB. The influence of force, motion and related quantities on the response of bone to implants. In Fitzgerald (ed). Non-cemented Total Hip Arthroplasty. New York: Raven 1998:7-21. Brunski JB. Biomechanical factors affecting the bone-dental implant interface. Clin Mater 1992;10:153-201. Carlsson LV. On the Development of a New Concept for Orthopaedic Implant Fixation [thesis]. Goteborg: Univ of Goteborg, 1991. Carlson L, Rostlund T, Albrektsson B, Albrektsson T, Brnmark P-I. Osseointegrated of titanium implants. Acta Ortho Scand 1988;57:285-289. Caulier H, Naert I, Jansen A. The relationship of some histologic parameter, radiographic evaluations, and Periotest measurement of oral implants: An experimental animal study. Int J Oral Maxillofac Implants 1997;3:380-386. Chavez H, Ortman LF, DeFranco RL, Medige J. Assessment of oral implant mobility. J Prosthet Dent 1993;70:421-426. Derhami K, Wilfaardt JF, Dent M, Faulkner G, Grace M. Assessment of the Periotest device in baseline mobility measurements of ceaniofacial implamts. Int J oral Maxillofac Implants 1995;10:221-229. Donath K. Die Trenn-dunnschliff-Technik zur Herstellung histologischer Praparate von nicht schneidbaren Geweben und Materialien. Der Praparator 1988;34:197-206. Ericsson I, Johansson CB, Bystedt H, Norton MR. A histomorphometric evaluation of bone-to-implant contact on machine-prepared and roughened titanium dental implants. Clin Oral Implants Res 1994;5:202-206. Frigerg B, Jemt T, Kekholm U. Uearly failures in 4641 consecutively placed Branemark dental implants. A study from stage Ⅰ surgery to the connection of completed prostheses. Int J Oral Maxillofac Implants 1991;6:142-146. Frigerg B, Sennerby L, Roos J, Lekholm U. Identification of bone quality in conjunction with insertion of titanium implants. Clin Oral Implants Research 1995;6:213-219. Frigerg B, Sennerby L, Roos J, Johonsson P, Strid K-G, Lekholm U. Evaluation of bone density using cutting resistance measurements and radiography. Clin Oral Implants 1995 Frost HM. Bone remodeling dynamics. Springfield, IL: CC Thomas, 1963. Frost HM. Bone dynamics in osteoporosis and osteomalacia. Springfield, IL: CC Thomas, 1966. Heller JG, Bradley T, Estes MS, Diop A. Biomechanical study of screws in the lateral masses: Variables affecting pull-out resistance. J Bone Joint Surg [Am] 1996;78:1315-1321. Ho KN, Huang HM, Pan LC, Lee SY. Finite element analysis for noninvasive assessment of the dental implant stability. Oral engineering research & application symposium. May 27, 2000, pp.6. Huang HM, Pan LC, Lee SY, Chiu CL, Fan KH, Ho KN. Assessing the implant/bone interface by using natural frequency analysis. Oral Surg 2000;90(3):285-91. Huang HM, Chiu CL, Yeh CY, Lin CT, Lin LH, Lee SY. Early detection of implant healing process using resonance frequency analysis. Clin Oral Impl Res (in press). Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, et al. A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillofac Implants 1996;11:291-298. Johansson CB, Albreksson T. Integration of screw implants in the rabbit: A one-year follow-up of removal torque of titanium implants. Int J Oral Maxillofac Implants 1987;2:69-75. Kaneko T, Nagai Y, Ogino M, Futami T, Ichimura T. Acoustoelectric technique for assessing the mechanical state of the dental implant-bone interface. J Biomed Mater Res 1986;20:169-176. Kaneko T. Assessment of the interfacial rigidity of bone implants from vibrational signals. J Mater Sci 1987;22:3495-3502. Kaneko T. Comparison between acoustic and mechanical tapping methods for assessing the interfacial state of bone implants. J Mater Sci 1989;24:2820-2824. Kaneko T. Pulsed oscillation technique for assessing the mechanical state of the dental implant-bone interface. Biomaterials 1991;12:555-560. Kaneko T. Assessment of the dental implant-bone interface from a pulsed microvibration. J Mater Sci Lett 1991;10:185-187. Kirsch A, Mentag PJ. The IMZ endosseous two phase implant system: A complete oral rehabilitation treatment concept. J Oral Implant 1986;12:576-589. Laney WR. Selecting edentulous patients for tissue-integrated prostheses. Int J Oral Maxillofac Implants 1986;1:129-138. Lancy W.R., Jemt T, Harris D, Henry P.J., Krogh P.H.J., Polizzi G, Zarb G.A, Herrmann I. Osseointegrated implant for single-teeth replacement. Progress report from a multicenter prospective study after 3-years. International Journal of Oral and Maxillofacial Implants 1994;9:49-54. Lekholm U, van Seenberghe D, Herrmann I, Bolender C, Folmer T, Gunne J, Henry P, Higuchi K, Lancy WR, Linden U. Osseointegrated implants in the treatment of partially edentulous jaws. A prospective 5-year multicenter study. International Journal of Oral and Maxillofacial Implants 1994;9:627-635. Meredith N, Alleyne D, Cawley P. Quantitative determination of the stability of the implant-tissue interface using resonance frequency analysis. Clin Oral Implants Res 1996;7:261-267. Meredith N, Alleyne D, Cawley P, Shagaldi F. The application of resonance frequency measurements to study the stability of titanium implants during healing in the rabbit tibia. Clin Oral Implant Res 1997;8:234-243. Meredith N, Book K, Friberg B, Jemt T, Sennerby L. Resonance frequency measurements of implant stability in vivo. Clin Oral Implant Res 1997;8:226-233. Meredith N, Sennerby L. Resonance frequency analysis: measuring implant stability and osseointegration. Compendium 1998;19(5):493-502. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11(5):491-501. Muhlemann HR. Periodontometry, a method for measuring tooth mobility. Oral Surg Oral Med Oral Pathol 1951;4:1220-1233. Noyes DH, Solt CW. Measurement of mechanical mobility of human incisors with sinusoidal forces. J Biomechanics 1973;6:439-442. Oka H, Yamamoto T, Saratani K, Kawazoe T. Application of mechanical mobility of periodontal tissue to tooth mobility examination. Med & Biol Eng& Comput 1989;27:75-81. Okazaki M, Fukumoto M, Takahashi J. Damped oscillation analysis of natural and artificial periodontal membranes. Ann Biomechanical Eng 1996;24:234-240. Olive J, Aparicio C. The Periotest method as a measure of osseointegrated oral implanted oral implant stability. Int J Oral Maxillofac Implants 1990(4);5:390-399. Parfitt GY. Measurement of the physiological mobility of individual teeth in an axial direction. J Dent Res 1960;39:608-616. Persson R, Svensson A. Assessment of tooth mobility using small loads. J Clin Periodontol 1980;7:259-275. Piattelli A, Corigliano M, Scarano A, Costigliola G, Paolantonio M. Immediate loading of titanium plasma-sprayed implants: a histologic analysis in monkeys. Journal of Periodontology 1998;69:321-327. Ramp LC, Reddy MS, Jeffcoat RL. Assessment of osseointegration by nonlinear dynamic response. Int J Oral Maxillofac Implants 2000;15:197-208. Randow K, Ericosson I, Nilner k, Petersson A, Glantz P.O. Immediate functional loading of Branemark dental implants. An 18-month clinical follow-up study. Clinical Oral Implants Research 1999;10:8-15. Rao SS. Mechanical vibration. New York: Addisso-Wiley;1990:p.513-518. Rateritschak KH. Periodontology : Color atlas of dental medicine, New York, Thieme Med Pub, 2ed, pp.43-72. Salonen M, Oikarinen K, Virtanen K, Pernu H. Failures in the osseointegration of endosseous implants. Int J Oral Maxillofac Implants 1993;8:92-97. Schulte W. Was leister das Periotest verfahren heute? Dtsch Zahnarztl Z. 1985;40:705-706. Sennerby L, Thomsen P, Ericson LE. Early tissue response to titanium implants inserted in rabbit cortical bone. Part 1: Light microscopic observations. J Mater Sci Mater Med 1993;4:240-250. Sullivan DY, Sherwood RL, Collins TA, Krogh PHJ. The reverse-torque test. A clinical report. Int Oral Maxillofac Implants 1996;11:179-185. Sunden S, Grondahl K, Grondahl H-G. Accuracy and precision in the radiographic diagnosis and clinical instability in Branemark dental implants. Clin Oral Implants Res 1995;6:220-226. Thomson WT. Theory of vibration with applications. 3rd ed. Prentice-Hall, Inc. N.Y.

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系統識別號 U0007-1704200714494805
論文名稱(中文) 利用低溫電漿處理鈦金屬表面之蛋白質固定
論文名稱(英文) Protein Grafting on the Titanium Surfaces Using Glow Discharge
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 陳錦煜
學號 M88040045
學位類別 碩士
語文別 中文
口試日期
論文頁數 52頁
口試委員 指導教授-林哲堂
指導教授-李勝揚
關鍵字(中) 鈦金屬
低溫電漿
交鏈劑
第一型膠原蛋白
關鍵字(英) Titanium
glow discharge
cross-linking agent
TypeⅠcollagen
學科別分類
中文摘要 人工牙根植入後仍需三至六個月頗為漫長的癒合時間,且其骨整合程度經常不如預期,因此進行其鈦金屬之表面處理,以有效縮短骨癒合時間並強化骨整合,就變得格外重要。本研究利用低溫電漿來活化鈦金屬表面以連接第一型膠原蛋白。鈦金屬表面先以丙烯胺電漿處理,使附著上胺基(-NH2),再分別以不同濃度的交鏈劑BS3及戊二醛連接固定第一型膠原蛋白。而後以電子顯微鏡(SEM)觀察樣本的表面,以電子能譜儀(XPS)與顯微傅立葉轉換紅外線光譜儀(Microscopic-FTIR)作定性分析,並以元素分析儀(SEM-EDS)作定性分析與半定量分析,檢測蛋白質在不同濃度和種類的交鏈劑處理下在鈦金屬表面連接的情況。SEM結果可見,實驗組的鈦金屬上有球型或海綿狀類似膠原蛋白之披覆。FTIR則檢測出有C=O, OH, 醯胺Ⅰ鍵和醯胺Ⅱ鍵,可能為膠原蛋白本身結構中的醯胺鍵結,或是電漿處理後鈦金屬表面的醯胺鍵結。而XPS分析圖中也顯示有C、C=O、C-C、COOR、N、O等膠原蛋白的結構存在;並由SEM-EDS數據顯示,第一型膠原蛋白的量會隨著戊二醛或BS3濃度的升高而增加。經電漿與交鏈劑BS3或戊二醛的處理並固定第一型膠原蛋白後之實驗組類成骨細胞(MG 63)培養4小時後觀察,和對照組相比較,可見骨細胞伸出無數觸角延伸向有膠原蛋白纖維處,培養24小時後,可見骨細胞型態變為扁平並平鋪且深入具有膠原蛋白纖維處。本研究結果顯示,使用電漿處理技術可達成鈦金屬表面胺基化,加上交鏈劑BS3或戊二醛的處理後,可能使鈦金屬表面接上第一型膠原蛋白,且會隨著交鏈劑的濃度升高而增加,並可加速骨細胞生長。
英文摘要 One of the disadvantages for the dental implants is the six-month healing time. To shorten the healing time of osseointegration is an important issue for the dental implant development. Glow Discharge is a surface treatment to activate surface characters using gas plasma. Collagen is a key factor during the healing procedure and bone structuring. In this study, collagen connected titanium plates were evaluated in vitro. The titanium plates were treated by glow discharge with allylamine. Glow discharged titanium plates were connected with TypeⅠcollagen by amine cross-linking agents BS3 and Glutaraldehyde. The collagen-coated titanium plates were evaluated by their surface condition with scanning electron microscope-energy dispersive spectrometer (SEM-EDS) and microscopic FTIR and X-ray photoemission spectroscopy (XPS). There were collagen component elements C, S, N elements detected on the titanium surfaces. And collagen structural bonds C-N, C=O, C=C bonding were detected on the titanium surfaces by XPS and microscopic FTIR. The data proved that collagen were successful grafted on the titanium surfaces. The counts of collagen were increased with the increase of concentrations of BS3 or Glutaraldehyde detected on the titanium surfaces by SEM-EDS. Osteoblast-like cells (MG 63) were cultured on the treated titanium plates for 4 or 24 hours. The result showed the osteoblast-like cells spread radically after 4 hours, and they were almost flat after 24 hours. Therefore, collagens were successful grafted on the titanium plates by glow discharge technology. This method could improve the growth and spread of human osteoblasts.
論文目次 致 謝 I 中 文 摘 要 II Abstract IV 目 錄 VI 圖表目次 IX 第一章 緒論 1 第一節 研究動機與其重要性 1 第二節 研究目的 2 第三節 名詞界定 3 第二章 文獻查證 5 第一節 鈦金屬 5 第二節 膠原蛋白 6 第三節 電漿基本原理 8 一 原理 8 二 電漿化學 10 三 電漿處理 12 第四節 氬氣電漿 14 第五節 丙烯胺電漿 14 第六節 交鏈劑 14 一 BS3 14 二 GA 15 第三章 研究材料和方法 16 第一節 實驗材料 16 第二節 實驗儀器 17 第三節 實驗步驟與方法 17 一 基本實驗流程 17 二 樣本分組 18 三 低溫電漿處理 18 四 蛋白質固定 19 五 樣品的表面性質檢測項目 20 六 類成骨細胞培養 20 第四章 分析與結果 21 第一節 電子顯微鏡觀察結果 21 第二節 元素分析觀察結果 21 第三節 電子能譜儀檢測結果 22 第四節 骨細胞培養結果 22 第五章 討論 24 第六章 結論與建議 29 參考資料 31 附錄 34
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Tissue ingrowth into titanium and Hydroxyapatite coated implants during stable and unstable mechanical conditions. Acta Orthop Scand, 64(sppl 225), 1992. 7. Boenig, H.V. Plasma science and technology. Cornell University Press, USA, pp. 16-35, 1982. 8. Taylor, Richard F. Protein immobilization: fundamentals and applications. New York: Marcel Dekker. 1991. 9. Ratner, B. D., A. S. Hoffman, F. J. Schoen, and J. E. Lemons. Biomaterials science: an introduction to materials in medicine. pp. 105-118. Academic Press. 1996. 10. Johansson CB. Hansson HA. Albreltsson T. Qualitative interfacial study between bone and tantalum, niobium or commercially pure titanium. Biomaterials. 11(4):277-80, 1990. 11. Steinemann SG. Titanium─the material of choice? [Review] [64 refs] Periodontology 2000. 17:7-21, 1998. 12. Kasemo B. Biocompatibility of titanium implants: Surface science aspects. J Prosthet Dent, 49:832,1983. 13. Ahmad M. Gawronski D. Blum J. Goldberg J. Gronowicz G. Differential response of human osteoblast-like cells to commercially pure (cp) titanium grades 1 and 4. Journal of Biomedical Materials Research. 46(1): 121-31, 1999. 14. Brånemark P-I., Rydevik Björn L., Skalak Richard. Osseointegration in skeletal reconstructure and joint replacement, second international workshop on osseointegration in skeletal reconstruction and joint replacement. Rancho Santa FE, California, October 27-29, 1994.chapter 2, History, Development, and Current Status of Osseointegration as Revealed by Experience in Craniomaxillofacial surgery. Philip Worthington. 25-44 15. Eugene P.L.,et al; International Dental Journal, 43: 245-253, 1993. 16. 黃玲惠。膠原蛋白生物技術。化工技術 4(7): 136-141, 1996. 17. Friess, W. Review article: collagen-biomaterial for drug delivery. European Journal of Pharmaceutics and Biopharmaceutics. 45: 113-136. 1998. 18. Biomaterials an introduction, second edition 19. J. Gross, “collagen.” Sci. Am. 204: 121-130, 1961. 20. Fujisawa R, Kuboki Y. [Bone matrix protein]. [Review] [10 refs] [Japanese] Japanese J. of clinical medicine. 122(1-2): 119-22,1998. 21. Fratzl P. Misof K. Zizak I. Rapp G. Amenitsch H. Bernstorff S. Fibrillar structure and mechanical properties of collagen. [Review] [8 refs] J. of Structure Biology. 122(1-2): 119-22,1998. 22. Takatsuka,M.. Jpn J Artif Organs 7 (1); 12, 1982. 23. J. E. Davies, B. Lowenberg,and A. Shiga. The bone-titanium interface in vitro. J of biomedical material research. 24: 1289-1306, 1990. 24. Nishimura k., [effect of extracellular matrix and serum components on cellular adhesion an growth in vitro and in vivo] [Japanese] Nichidai Koko Kagaku. 16(2): 237-60, 1990. 25. Boenig, H. V. Plasma science and technology. pp. 16-35. Cornell University Press. 1982 26. Ih-Houng Loh, ScD, “Plasma surface modification in biomedical applications’’ Advanced Surface Technology Inc., Billerica, Massachusetts. Medical Device technology. Jan/Feb issues (1999) 27. B. Chapman, Glow Discharge Processes — Sputtering and Plasma Etching, New York, Wiley pp.106-109, 1980. 28. Grill, A. Cold plasma in materials fabrication: from fundamentals to applications. pp. 151-179. IEEE Press. 1994. 29. 陳克紹。低溫電漿表面處理技術原理概述與應用簡介。低溫電漿表面處理技術於高分子材料上之應用研討會。於新竹市工研院化工所。5: 29-30, 1997. 30. B.-O. Aronsson. Glow discharge plasma treatment for surface cleaning and modification of metallic biomaterials. J. Biomed. Mater. Res. 35: 49-73, 1997. 31. Gogolewski S. Mainil-Varlet P. Dillon JG. Sterility, mechanical properties, and molecular stability of polylactide internal-fixation devices treated with low-temperature plasmas. J. Biomed. Mater. Res. 32(2): 227-35, 1996. 32. Hoffman, A. S. Adsorption and immobilization of proteins on gas discharge-treated surfaces. J. Appl. Polym. Sci.: Appl. Polym. Symp. 46: 341-359. 1990. 33. Jose G. Calderon, et al; J Biomed Mater Res. 42: 597-603, 1998. 34. Partis, M.D., et al; J. Prot. Chem. 2 (3): 263-277, 1983. 35. Timothy J. A. Johnson. Eur. J. Cell Biol. 45:160-169, 1987. 36. Billiau A, Edy V.G, Heremans H, Van Damme H, Desmyter J, Georgiades J.A, and De Somer P. Human iterferon: Mass production in a newly established cell line, MG-63, Antimicrob. Agents Chemother, 12: 11-15, 1977. 37. Peacock R. Ethylene oxide sterilization: the way ahead. Medical Device Technology. 10 (6): 24 - 6, 1999. 38. Solheim E., Pinholt E.M., Bang G., Sudmann E. Ethylene oxide gas sterilization does not reduce the osteoinductive potential of demineralized bone in rats. Journal of Craniofacial Surgery. 6(3):195-8, 1995. 39. M.A. Malik. Osteoblasts on hydroxylapatite, alumina and bone. Biomaterials, 13: 123-128, 1992. 40. Nishimura k. Effect of extracellular matrix and serum components on cellular adhesion an growth in vitro and in vivo. Nichidai Koko Kagaku. 16(2): 237-60, 1990. 41. J. M. Wozney. Growth factors influencing bone development. J Cell Sci, sppl 13: 149-156, 1990. 42. Arizono T. Iwamoto Y. Okuyama K. Sugioka Y. Ethylene oxide sterilization of bone grafts. Residual gas concentration and fibroblast toxicity. Acta Orthopaedica Scandinavica. 65(6):640-2, 1994 Dec. 43. Fujisawa, R., Mizuno, M., Nodasaka, Y., and Kuboki, Y. Attachment of osteoblastic cells to hydroxyapatite crystals by a synthetic peptide (Glu7-Pro-Arg-Gly-Asp-Thr) containing two functional sequences of bone sialoprotein. Matrix Biol. 16(1):21-8, 1997

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系統識別號 U0007-1704200714494806
論文名稱(中文) 人工牙根植體受重覆性疲勞負荷之破壞斷面分析
論文名稱(英文) Fracture Surface Analysis of Dental Implant after Repeated Loading Fatigue Failure
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 張正忠
學號 M88040063
學位類別 碩士
語文別 中文
口試日期
論文頁數 88頁
口試委員 指導教授-林哲堂
指導教授-李勝揚
關鍵字(中) 人工牙根
植體
疲勞
生物力學
斷面分析
關鍵字(英) dental implant
fatigue
biomechanics
surface analysis
學科別分類
中文摘要 雖然人工植牙的成功率很高,但植體失敗的機會仍時有所聞,而其中最常見的原因,則是植體的疲勞性斷裂以及螺釘鬆脫。儘管各家製造廠商在其植體系統中紛紛設計各種增強組件,但仍無法有效避免其發生的機會。當發生植體失敗時,簡單則只需要更換螺絲組件等,若無法如此解決,則常意味著要二次手術。 人工牙根鎖合螺釘發生疲勞斷裂,其原因可能是患者的特殊咀嚼習慣,若在第二次手術或重新更換鎖合螺釘時,手術者未能瞭解此特殊的情形,則重新裝入的鎖合螺釘依然會發生疲勞斷裂。但當人工牙根的鎖合螺釘發生疲勞破壞後,並沒有一個方法或指標,可以提供任何訊息給牙醫師,使其知道此鎖合螺釘已經承受了多少次與多大的重複性負荷以及病人的人工植體是否處於一個正常的受力狀態中。 因此本研究計劃利用動態材料試驗機,對植體的疲勞強度作一測試。首先進行緊配扭力檢測及靜態抗壓檢測,以求得適當的實驗參數,接著在負荷控制模式下進行動態疲勞測試,除提供斷裂試件以電子顯微鏡觀察植體破壞面的金相外,更利用有限元素分析描繪出受測人工牙根螺釘的疲勞限、S-N curve。 結果顯示,所受的負荷力量愈小或負荷次數愈多時,其連接體螺釘斷面的平滑面比例愈大,且彼此成線性關係。而其中又以斷面平滑區長度比例與負荷力量的相關性最高(R2=0.8506, p<0.01)。 有限元素的數值模擬,不但提供了內應力集中位置,更有效的計算出內應力大小。本研究希望藉此發展一套指標作為評估植體破壞的進程與原因的工具,並將分析所得的資料與臨床上的觀察作一比較,期提供植體設計與臨床應用一有用的資料。
英文摘要 Dental implants have become increasingly important in oral rehabilitation. However, implant treatments still fail frequently. The implant per se has to withstand stresses induced by intraoral forces. Abnormal loading, as well as fatigue under physiological loads, can lead to fractures of certain implant components. These problems are always complicated by cyclic fatigue. Fracture or loosening is most likely to occur in the screw. As for fracture problems, however, it is difficult to predict which component will suffer fatigue and the resulting effects on the entire system. Important aspects of implant design are related to biomechanics of implant systems and the different materials used for implants. However, a reliable method for dentist or manufacturer to evaluate the mechanisms of implant fracture was still unavailable. In this study proposal, a serious dynamic mechanical were carried out to assess the maximum dynamic loading and fatigue life of the implants. To provide the optimal testing parameters, preloading tests and static tests were performed first. After the pretests, dynamic tests were performed under the mode of loading control with a sinusoid force. To provide an indicator for assessing the fracture mechanisms of the fracture screw, the fracture surface of the failed screws were observed and recorded by SEM observation. The fatigue life as well as S-N curve of the sample implant were also obtained and further analyzed by numeric analysis with finite element method. The results showed the ratio of the length and area of the smooth portion on the fracture surface increased with decreased loading magnitude and increased loading cycles. It demonstrated linear relationships and the reliability is the highest between length ratio of the smooth area and loading magnitude (R2=0.8506, p<0.01). Besides, finite element analysis also demonstrated not only the stress concentrated area but the magnitude. The results obtained from this project will serve as important references for the future advance studies.
論文目次 目錄 頁數 致謝 I 中文摘要 II 英文摘要 IV 目錄 VI 圖表目次 VIII 第一章 緒論 1 第一節 研究動機與重要性 1 第二節 研究目的 2 第三節 研究假設 3 第四節 名詞界定 4 第二章 文獻查證 7 第一節 人工牙根 7 第二節 疲勞測試與斷面分析 11 第三節 有限元素模擬分析 14 第三章 研究材料與方法 17 第一節 研究設計與對象 17 第二節 研究測量與資料收集過程記錄 22 第三節 資料統計與分析 24 第四章 分析與研究結果 26 第一節 緊配扭力檢測 26 第二節 靜態抗壓測試 26 第三節 動態疲勞檢測 27 第四節 電子顯微鏡斷面分析 27 第五節 有限元素數值模擬 29 第五章 討論 31 第六章 結論與建議 39 第一節 結論 39 第二節 研究限制 40 第三節 應用與建議 40 參考文獻 42 附錄 48
參考文獻 Antheunis V, Tom WPK, Antonio CC (1999). Numerical analysis of a dental implant system preloaded with a washer. Int J Oral Maxillofac Implants 14:337-341. Balfour A, O'Brien GR (1995). Comparative study of antirotational single tooth abutments. J Prosthet Dent 73:36-43. Balshi T, Hernandez R, Pryszlak M, Rangert B (1996). A comparative study of one implant versus two replacing a single molar. Int J Oral Maxillofac Implants 11:372-378. Basten CH, Micholls JI, Daly CH, Taggart R (1996). Load fatigue performance of two implant-abutment combinations. Int J Oral Maxillofac Implants 11(4):522-528. Binon PP, McHuge MJ (1996). The effect of eliminating implant/abutment rotational misfit on screw joint stability. Int J Prosthodont 9(6):511-519. Boggan RS, Strong JT, Mish CE, Bidez MW (1999). Influence of hex geometry and prosthetic table width on static and fatigue strength of dental implants. J Prosthet Dent 82:436-40. Craig RG, editor (1993). Restorative Dental Materials. Mosby pp. 54-105. Gibbs CH, Mahan PE, Lundeen HC, Brehran K, Walsh EK, Holbrook WB (1981). Occlusal forces during chewing and swallowing as measured by sound transmission. J Prosthet Dent 46: 443-449. Gregory M, Murphy WM, Scott J, Watson CJ, Reeve PE (1990). A clinical study of the Branemark dental implant system. Br Dent J 168:18-23. Hass R, Mensdorff-Pouilly N, Mailath G, Watzek G. (1995). Branemark single implants: A preliminary report of 76 implants. J Prosthet Dent 73: 274-9. Ho MH, Lee SY, Chen HH, Lee MC (1994). Three-dimensional finite element analysis of the effects of posts on stress distribution in dentin. J Prosthet Dent 72(4): 367-372. Holmes DC, Grisby WR, Goel VK, Keeler JC (1992). Comparison of stress transmission in the IMZ implant system with polyoxymethylene or titanium intramobile element: A finite element stress analysis. Int J Oral Maxillofac Implants 7:450-458. Holmes DC, Haganman CR, Aquilino SA (1994). Deflection of superstructure and stress concentration in the IMZ implant system. Int J Prosthodont 7:239-246. Holmes HM, Loftus JT (1997). Influence of bone quality on stress distribution for endosseous implants. J Oral Impl 23: 104-111. Huang HM, Chang CC, Lee LY, Fan KH, Ho KN, Ma LH, Lin CT, Shiau YY, Lee SY (2002). Vibration Assessment of the Stability of Root Keeper. Chinese Dent J(In Press) Jemt T, Lekholm U, Gröndahl K (1990). A 3-year follow up study of early single implant restorations ad modum Brånemark. Int J Periodont Res 10:340-349. Jemt T (1991). Failure and complications in 391 consecutive inserted fixed prostheses supported by Brånemark implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual checkup. Int J Oral Maxillofac Implants 6:270-276. Jemt T, Linden B, Lekholm U (1992). Failures and complications in 127 consecutively placed fixed partial prostheses supported by Branemark implants: From prosthetic treatment to first annual checkup. Int J Oral Maxillofac Implants 7:40-44. Jemt T, Lekholm U (1995). Implant treatment in edentulous maxillae: A 5-year follow-up report on patients with defferent degrees of jaw resorption. Int J Oral Maxillofac Implants 10:303-311. Kelly JR, Campbell SD, Bowen HK (1989). Fracture-surface analysis of dental ceramics. J Prosthet Dent 62:536-41. Lekholm U, Steenberghe D, Herrmann I, Bolnder C, Folmer T, Gunne J, Henry P, Higuchi K, Laney R W, Linden U (1994). Osseointegrated implants in the treatment of partially edentulous jaes: A prospective 5-year multicenter study. Int J Oral Maxillofac Implants 9:627-635. Lewinstein I, Bank-Sills L, Eliasi R (1995). Finite element analysis of a new system (IL) for supporting an implant-retained cantilever prosthesis. Int J Oral Maxillofac Implants 10: 355-366. Lloyd CH, Scrimgeour SN (1993). Dental Materials: 1993 literature review, J Dent 2(23):67-93. Mecholsky JJ (1995). Fracture mechanics principles. Dent Mater 11:111-112 Mecholsky JJ. Fractography (1995). Determining the sites of fracture initiation. Dent Mater 11:113-116. Meijer HJ, Starmans FJ, Steen WH, Bosman F (1993). A three-dimensional finite-element analysis of bone around dental implants in edentulous human mandible. Arch Oral Biol 38:491-496. Misch CM, Ismail YH (1993). Finite element analysis of tooth-to-implant fixed partial denture designs. J Prosthodont 2:82-92. Misch CE, editor (1999). Contemporary Implant Dentistry. Mosby pp. 303-316. Morgan MJ, James DF, Pilliar RM (1993). Fractures of the fixture component of an osseointegrated implant. Int J Oal Maxillofac Implants 8:409-414. Naert I, Quirynen M, van Steenberghe D, Darius P (1992). A study of 589 consecutive implants supporting complete fixed prostheses. Part II: Prosthetic aspects. J Prosth Dent 68: 949-956. Palmqvist S, Soderfeldt B, Arnbjerg D (1991). Subjective need for implant dentistry in a Swedish population aged 45-69 years. Clin Oral Impl Res 2:99-102. Piattelli A, Piattelli M, Scarano A, Montesani L (1998). Light and scanning electron mocroscopic report of four fractured implants. Int J Oral Maxillofac Implants 13:561-564. Piattelli A, Scarano A, Piattelli M, Vaia E, Matarasso S (1998). Hollow implants retrieved for fracture: A light and scanning electron microscope analysis of 4 cases J Periodontol 69:185-189. Patterson EA, Johns RB (1992). Theoretical analysis of the fatigue life of fixture screws in osseointegrated dental implants. Int J Oral Maxillofac Implnats 7:26-34. Rangert B, Krogh P, Langer B, Roekel N (1993). Bending overload and implant fracture: A retrospective clinical analysis. Int J Oral Maxillofac Implants 10:326-334. Sakaguchi RL (1995). Nonlinear contact analysis of preload in dental implant screw. Int J Oral Maxillofac Implants 10(3):295-302. Thompson JY, Anusavice KJ, Naman A, Morris HF (1994). Fracture surface characterization of clinically failed all-ceramic crowns. J Dent Res 73(12):1824-1832. Vallittu PK, Kokkonen M (1995). Deflection fatigue of cobalt-chromium, titanium, and gold alloy cast denture clasp. J Prosthet Dent 74:412-9. Vallittu PK (1996). Fracture surface characteristics of damaged acrylic-resin-based dentures as analysed by SEM-replica technique. J of Oral Rehab 23:524-529. Vallittu PK (1997). Brazing joints of gold alloy used un porcelain-fused-to-metal restorations and their resistance to deflection fatigue. J of Oral Rehabilitation 24:444-448. Wiskott HA, Nicholls JI, Belser UC (1995). Stress fatigue: Basic principles and prosthodontic implications. Int J Prosthodont 8:105-116. Zarb G A, Schmitt A (1990). The longitueinal clinical effectiveness of osseointegrated dental implants: The Toronto study. Part I: Surgical results. J Prosthet Dent 63:451-457. Zarb GA, Schmit A (1990). The longitudinal effectiveness of osseointegrated dental implants: the Toronto study. Part III: Problems and complications encountered. J Prosthet Dent 64:185-94.

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系統識別號 U0007-1704200714494807
論文名稱(中文) 成人之下顎運動速度與顱顏齒列形態的關係
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 官儀妍
學號 M88040081
學位類別 碩士
語文別 中文
口試日期
論文頁數 88頁
口試委員 指導教授-蔡吉陽
指導教授-吳慶榕
關鍵字(中) 下顎運動速度
顱顏齒列形態
學科別分類
中文摘要 下顎運動速度是評估口顎系統動態運動功能的指標之一,但個體間的差異變化相當大。影響下顎運動速度表現的原因,除了咀嚼肌本身的差異外,其周圍的骨骼系統、支配的神經系統均扮演重要角色。本研究的目的希望藉由下顎運動軌跡記錄系統(mandibular kinesiography)觀察不同顱顏形態之成年人的下顎運動速度表現,以瞭解下顎運動速度與顱顏齒列型態的相關性。實驗對象為無顱顏畸形及下顎運動障礙之127位成年人,其中男性84位,女性43位,年齡分布21至26歲。受測者接受測顱X光攝影及齒列模型製作以分析顱顏齒列型態,並利用下顎運動軌跡記錄器記錄開口、閉口時的最大及平均速度和閉口末端接觸速度,所得的各變項值再進行相關性的統計分析。 結果顯示個體本身之開口、閉口速度間相關性很高(p<0.001),但個體間的開口、閉口速度存在明顯差異;性別間亦存在明顯差異(p<0.01),男性之開、閉口速度均大於女性。與顱顏齒列形態的相關性並不明顯,僅男性的閉口速度會受上顎門齒之萌出度、傾斜度及與下顎門齒之垂直覆蓋量影響(p<0.05);男女之閉口末端接觸速度會隨顱顏開展度增加而增大(p<0.05)。所以,造成下顎運動速度個體差異的原因,顱顏齒列形態差異造成的影響並不大。
英文摘要 The relationship between the morphologic characteristics of facial skeleton and the function of the masticatory system has been studied extensively. Mandibular movement velocity is one of the parameters used to evaluate the mandibular function. However, the interaction between dentofacial morphology and mandibular movement velocity is unclear. The aims of this study were to investigate the mandibular movement velocity in different dentofacial morphology of young adults and observe the association between different characteristics of the dentofacial morphology and the velocity of mandibular movement. One hundred twenty seven young adults (84 males, 43 females, age ranged from 21 to 26 years) were observed by using Myotronics Kinesiograph K-6 model for the measurement of jaw motion velocity. Five consecutive open-close strokes were recorded for evaluating the following parameters. (1) the maximal opening and closing velocity, (2)the average opening and closing velocity, and(3)the maximal velocity of terminal tooth contact. Dentofacial morphology was evaluated with conventional lateral cephalometric radiographs and dental cast. Analysis of data indicated that the correlation between the opening and closing velocity among individual was high (p<0.01), but there existed large interindividual variation. Only the maximum and average closing velocity of the male subjects had the significant association with the position of upper incisor (p<0.05). It could be concluded that there existed weak correlation between the velocity of mandibular movement and dentofacial morphology.
論文目次 目錄 第一章 緒論 ------------------------------------------- 1 第二章 文獻回顧 第一節 骨骼肌的基本運動特性 ----------------- 5 第二節 咀嚼肌與顱顏型態的關係 -------------- 9 第三節 下顎的動態運動記錄 ------------------ 18 第三章 材料與方法 第一節 研究對象 --------------------------------- 23 第二節 顱顏齒列型態之測量 ------------------ 24 第三節 下顎運動速度之記錄 ------------------ 30 第四節 統計分析 --------------------------------- 32 第四章 結果 ------------------------------------------ 35 第五章 討論 ------------------------------------------ 43 第六章 結論 ------------------------------------------ 54 第七章 參考文獻 ------------------------------------ 57 圖表 ------------------------------------------------------ 64 表目錄 表一 顱顏形態測量項目之分類 -------------------------------------- 64 表二 所有樣本基本資料分布狀況 ----------------------------------- 65 表三 下顎運動速度各測量值之描述性統計 ----------------------- 66 表四 下顎運動速度各測量值之統計結果與性別差異檢定 ----- 67 表五 男性下顎運動速度各測量值之相關性分析 ----------------- 68 表六 女性下顎運動速度各測量值之相關性分析 ----------------- 69 表七 男性顱顏齒列形態測量值之描述性統計 -------------------- 70 表八 女性顱顏齒列形態測量值之描述性統計 -------------------- 71 表九 顱顏齒列形態各測量值之統計結果與性別差異檢定 ----- 72 表十 開口運動速度與顱顏齒列形態之相關性分析 -------------- 73 表十一 閉口運動速度與顱顏齒列形態之相關性分析 -------------- 75 表十二 閉口末端接觸速度與顱顏齒列形態之相關性分析---------- 77 表十三 男性的安格氏異常咬合各組下顎運動速度測量值之統計結 果與差異檢定------------------------------------------------------- 78 表十四 女性的安格氏異常咬合各組下顎運動速度測量值之統計結果與差異檢定 ------------------------------------------------------79 表十五 男性的安格氏異常咬合分組顱顏齒列形態各測量值之統計結果與差異檢定 -------------------------------------------------- 80 表十六 女性的安格氏異常咬合分組顱顏齒列形態各測量值之統計結果與差異檢定 -------------------------------------------------- 81 圖目錄 圖一 顱顏界標(cephalometric landmarks)--------------------------- 82 圖二 測顱線與測顱平面(cephalometric lines and planes)-------- 83 圖三 線性測量項目(linear cephalometric measurements)--------- 84 圖四 角度測量項目(angular cephalometric measurements)------- 85 圖五 感應磁鐵固定於口內之狀況 -------------------------------------- 86 圖六 感應器固定於受測者頭部之位置 -------------------------------- 87 圖七 顯示器上所顯示之K-6系統的第二圖表 ----------------------- 87
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系統識別號 U0007-1704200714494808
論文名稱(中文) 磨牙症患者在咬合板治療下的夜間咬肌肌電圖變化
論文名稱(英文) The Nocturnal EMG Activity of Masseter Muscle on Bruxers during Splint Treatment
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 趙文瑄
學號 M88040090
學位類別 碩士
語文別 中文
口試日期
論文頁數 114頁
口試委員 指導教授-蔡吉陽
指導教授-周孫隆
關鍵字(中) 磨牙症
咬合板
可攜帶式肌電圖
關鍵字(英) Bruxism
Splint
Portable EMG
學科別分類
中文摘要 磨牙症是屬於下意識的口腔異常功能性(parafunctional)運動,由於具有強烈的肌肉收縮,長期下來往往對於牙齒、牙周、肌肉以及顳顎關節產生傷害。其致病因素為多因子,一般相信與壓力和咬合以及中樞神經系統相關。臨床上最普遍採用的治療方式為咬合板治療,因此本實驗的目的在於探討咬合板治療在短期內(19天) 對於磨牙症患者的夜間咬肌活性之影響。實驗方法使用可攜帶型肌電圖系統(portable EMG) ,長程記錄10位磨牙症患者在平時所習慣的睡眠環境下之夜間咬肌活性。分別於咬合板配戴前(pre-1;pre-2) 、配戴中第一星期(S-6; S-7) 、配戴中第二星期(S-13; S-14) 、咬合板配戴後第一、二天(po-1; po-2) 及二個月之後追蹤(F/U-1; F/U-2)共10天夜間測量。每晚記錄肌電圖時並以「每日壓力感受量表」(Daily Stress Inventory, DSI)和受測者自覺壓力分數來評量受測當日之壓力指數。 統計分析先以Friedman two way analysis of ranks和 Wilcoxon match-pairs ranks test檢驗配戴咬合板前、中、後、追蹤四組咬肌活性的差異;再分別以General Estimating Equations (GEE)分析同時以性別及壓力和咬合板的配戴作為共同影響因素時對於咬肌活性的影響。 實驗結果顯示咬合板治療結束後(po-1; po-2)所測得的肌肉活性最低。而咬合板的配戴使得2位受測者的咬肌活性降低,2位升高,6位無明顯變化;磨牙型態較偏向於有強烈收縮的緊咬(clenching)以及沒有側方干擾的磨牙症患者,對於咬合板的治療效果較好;男性的肌肉活性較女性為強,且受測者日間承受的情緒壓力度與夜間磨牙頻率成正相關。 我們可以說磨牙症是由中樞神經系統主導的一種病症,與情緒壓力很有關連;咬合板治療並不能停止或改變夜間磨牙,但它可以使得原本肌肉活性特別強烈的患者有一定程度的改善。本實驗將性別,壓力等可能影響肌肉活性的因素一起考量,對於評估咬合板的治療效果會有較完整的呈現。
英文摘要 Bruxism was a mandibular parafunctional behavior and had excessive occlusal forces, the long-term effects of it were injury to the teeth, PDL, muscles and TMJ. The etiology was multifactorial and was believed to be emotional stress, occlusal factors and CNS problems. The most common treatment regime of it was splint therapy, so we wanted to know how the nocturnal masseter muscle activity was influenced by it. We used portable EMG system to record bilateral masseter muscle activity of 10 bruxers under their usual sleeping environment. The recording was performed before splint treatment (pre-1; pre-2), during the first week of treatment (S-6; S-7), the second week of treatment (s-13; S-14), and immediately after the splint treatment (po-1; po-2). After 2 months taking-off the splint, the recording was performed as follow-up period (F/U-1; F/U-2). All ten recording nights before sleep, the subjects were asked to evaluate their daily stress amount by answer the “Daily Stress Inventory; DSI” and scale their subjective feelings from 0 to 10. The special stress events were also recorded. Friedman two way analysis of ranks and Wilcoxon match-pairs ranks test were used to evaluate the muscle activity changed before, during, after splint and follow-up period. General Estimating Equations (GEE) was used to evaluate whether the sex, stress and splint may influence the nocturnal masseter muscle activity. It revealed that: 1. The lowest muscle activity was detected immediately after the splint treatment (po-1; po-2); 2. The muscle activity of male was stronger than female; 3. The subjects’ daily emotional stress was positive correlated with the nocturnal muscle activity; 4. Nocturnal EMG values were reduced during use of splints in two subjects (both male), six subjects (3 male, 3 female) had no change and two (both female) had increase in nocturnal EMG values. It seemed to have better treatment result on bruxers with extreme clenching and without balancing side interference. We can conclude that the bruxism was mainly controlled by CNS and highly related with emotional stress. The effect of splint therapy was varied from one to one and it may even increase the muscle activity in some subjects. Our study put sex, stress, and splint treatment together to evaluate the change of muscle activity could have a more complete result.
論文目次 目 錄 致謝……………………………………………………………………I 中文摘要...……………………………………………………..II 英文摘要……………………..………………………………...IV 目錄…..…………………………………………………………VII 表目錄………………………...………………………………………...X 圖目錄…………………………………………………….…….XI 第一章 緒論………………………………………………………………..1 第一節 研究目的……………………………………………………….1 第二節 研究假設……………………………………………………….2 第二章 文獻回顧………………………………………………………….3 第一節 磨牙症………………………………………………………….3 第二節 肌電圖應用測量磨牙症病人的肌肉活性……………………12 第三章 材料與方法…………………………………....19 第一節 樣本之取樣…………...…..........................19 第二節 咬合板治療………...…...............................20 第三節 可攜帶型肌電圖系統....................................21 第四節 肌電圖分析系統.......................................................22 第五節 實驗方法.........................................................23 第六節 臨床檢查及問卷........................................26 第七節 壓力測量.............................................27 第八節 統計方法..............................................28 第四章 研究結果………………………………………………………...31 第一節 各電位平面大小……………………………………………...31 第二節 咬合板治療前、中、後及追蹤期之咬肌活性比較………...31 第三節 性別及咬合板的配戴對於咬肌活性的影響………………...34 第四節 壓力及咬合板的配戴對於咬肌活性的影響………………...37 第五節 性別、壓力及咬合板的配戴對於咬肌活性的影響…….......40 第六節 咬合板治療前及追蹤期的夜間咬肌活動情形...............42 第五章 討論…………………………………………………………….44 第一節 各電位平面大小……………………………………………....44 第二節 咬合板的配戴對於夜間咬肌活性的影響…………………....45 第三節 性別對於夜間咬肌活性的影響……………………………....48 第四節 壓力對於夜間咬肌活性的影響……………………………....48 第五節 咬合板治療前及追蹤期的夜間咬肌活動情形……………....49 第六節 以圖表示各受測者的情形……………....................51 第六章 結論與建議…………………………………………………………58 第一節 結論……………………………………………………………58 第二節 研究限制………………………………………………………59 第三節 應用與建議……………………………………………………60 參考文獻…………………………………………………………………...61
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系統識別號 U0007-1704200714494809
論文名稱(中文) 顳顎關節障礙患者的精神輪廓
論文名稱(英文) Psychological profile of temporomandibular disorder patients
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 施滿祝
學號 M88040107
學位類別 碩士
語文別 中文
口試日期
論文頁數 40頁
口試委員 指導教授-周孫隆
關鍵字(中) 精神
顳顎關節障礙
診斷分類
心身症
關鍵字(英) Psychological
temporomandibular disorder
diagnosis classification
psychosomatic disorder
學科別分類
中文摘要 顳顎障礙的形成是多因性的,即是包含許多形成因素。 許多研究顯示TMD患者比對照組健康人有較多焦慮傾向。因此Engel在1977年首度對TMD / orofacial pain提出Biopsychosocial model。本研究利用精神症狀量表BSRS探討TMD患者10種精神症狀分類、分佈情形,並與正常值比較。 研究假說(hypothesis)為:某類顳顎障礙患者有特殊精神症狀 ? 研究動機:比較顳顎障礙患者在精神輪廓是否與正常人有所不同? 本研究目的即在使用精神症狀量表,探討不同類型TMD患者的精神症狀,瞭解那些症狀特別明顯,並據以簡化精神問卷。 研究目標: 1. 探討四類顳顎障礙患者10種精神症狀差異程度。 2. 與一般牙科患者比較,差異程度如何? 本研究選取台北醫學大學附設醫院顳顎障礙特別門診就診之新病患。診察內容包括病人基本資料、全身健康情況、主訴、發病至就診時的間距。填寫顱顎機能障礙問卷及簡式症狀表(BSRS)。使用臨床檢查表,記錄檢查結果。 統計整理270份樣本資料,即為本研究實驗組材料。 選取台北市內湖區某基層牙醫診所,選取全口牙結石清除(洗牙)及牙體復形(補牙)的就診病患(就醫時皆無疼痛的因素),經臨床檢查無關節及肌肉症狀,非TMD病患作為本研究的對照組。 研究結果為頭-臉-頸肌肉疼痛患者,10種精神向度明顯與其他顳顎障礙患者及對照組不同,並且各項向度數值均大於其他顳顎障礙患者及對照組。 以 T-SCORE 計算其差異程度,大於一倍標準差者為:身體化症狀、強迫性症狀、憂鬱、焦慮、敵意、附加症狀六種精神分項症狀。與精神科、家醫科、外科患者比較,頭-臉-頸肌肉疼痛患者及精神科患者明顯與其他六科不同,並且各項數值均大。本研究顯示若將頭-臉-頸肌肉疼痛獨立為一特別診斷分類,則可發現頭-臉-頸肌肉疼痛的精神分項迥異於其他顳顎障礙患者及對照組。因而証實研究假說:某類 TMD患者有特殊精神症狀。
英文摘要 The purpose of this study is to identify the psychological profile of temporomandibular disorder (TMD) patients. The authors applied one of the self-report models of psychological measurement, Brief Symptom Rating scale (BSRS). The experiment group was 270 temporomandibular disorder patients who visited TMJ center, Taipei Medical University Hospital. Patients were divided into four subgroups (Disc derangement with reduction, TMJ arthralgia and arthritis, head-face-neck myalgia, and local myalgia) according to chief complain and clinical examination. The control group was non-TMD patients who visited local dental clinic for cavity restoration or scaling. There is no pain complained during visits. Significant psychological profiles difference was uncovered when head-face-neck myalgia subpopulation was compared with the other three groups and control group. Significant difference exists in Somatization, Obsession, Depression, Anxiety, Hostility and Addition in terms of T-score. It is also noteworthy, from a treatment-planning perspective, which up to 27 % of TMD patients may have severe emotional distress to the point of appearing psychopathological on screening measures. The combination of supportive psychotherapy may be necessary for the optimal treatment outcome and it also illustrate the importance of consultation-liaison psychiatry in the dental field.
論文目次 目 錄 頁 數 致 謝 ………………………………………………………. I 中文摘要 ………………………………………………………. II 英文摘要 ………………………………………………………. III 目 錄 ………………………………………………………. IV 圖表目次 ………………………………………………………. V 第一章 緒論 1 第二章 文獻查証 4 第三章 研究材料與方法 9 第四章 分析與結果 18 第五章 討論 22 第六章 結論與建議 26 參考資料 中文部份 ……………………………………… 28 英文部份 ……………………………………… 29 附錄 31
參考文獻 中文參考資料: 王若松*林立德*洪志遠*蔡宗一*林俊彬*李萬萱*蕭裕源* 顳顎障礙分類中單項與多項診斷族群間之差異 Dent J (中華牙誌)18(3):207-216 September 1999 李明濱 情緒與疾病 臺灣大學醫學院1998 李明濱 實用精神醫學臺灣大學醫學院1999 李明濱 精神官能症 橘井1989 李明濱 精神官能症之行為治療健康1998 徐斌 王效道 心身醫學 合記2000 英文參考資料: Charles S. Greene The etiology of temporomandibular disorders: Implications for treatment Journal of orofacial Pain (2001);15:93-103 Daniel M. Laskin Etiology of the pain-dysfunction syndrome JADA 51 (1969);147-153 Elliot. N. Gale Psychological Characteristics of Long-Term Female Temporomandibular Joint Pain Patients journal of Dent Res 57(March 1978);481-483 Franco Mongini Psychological Factors Headache and Facial Pain (1999); 92-99 Jere Butterworth, William W. Deardorff Psychometric Profiles of Cranilmandibular Pain , Patients Identifying Specific Subgroups Journal of Craniomandibular Practice (July 1987); V5:226-232 Jeffrey P. Okeson orofacial pain : guidelines for assessment, diagnosis, and management Quintessence 1996 John D. Rugh Psychologicl Factors in TMD Current Controversies in TMD by Charles mcNeill 1992 John D. Rugh and Lars Dahlstrom Behavioral and Psychological Mechanisms Temporomandibular joint and masticatory muscle disorders mosby1995 L. Laszlo Schwartz Pain associated with the temporomandibular joint JADA 51 (1955); 394-397 L. Laszlo Schwartz Temporomandibular Joint Syndromes J. Pros. Den. (July 1957); 489-499 L.R. Eversole, Constance E. Stone,Douglas Matheson,Herman Kaplan Psychometric profiles and facial pain Journal of Oral surgery (1985);V60;269-274 Lars Dahlstrom Psychometrics in temporomandibular disorders ACTA ODONTOL SCAND 5I (1993); 339-352 M. M. Ash Current Concepts in the aetiology , diagnosis and treatment of TMJ and muscle dysfunction Journal of Oral Rehabilitation (1986); V13:1-20 29 Molin Carl Studies in Mandibular Pain Dysfunction Syndrome Swedish Dental Journal (1973);V66:Suppl. No.4 Robert A. Moss and James C. Garrett Temporomandibular joint dysfunction syndrome and myofascial pain dysfunction syndrome: a critical review Journal of Oral Rehabilitation (1984);11:3-28 Rugh JD, Woods BJ, Dahlstrom L Temporomandibular disorders: assessment of psychological factors Adv Dent Res (1993 Aug.);127-136 Samuel F. Dworkin, DDS,PhD Psychosocial Issues Orofacial Pain Quintessence2001 p.115-127 Samuel F. Dworkin, DDS,PhD Research Diagnostic Criteria For Temporomandibular Disorders:Review, Criteria,Examinations, and Specifications, Critique Journal of Craniomandibular Disorders Facial and Oral Pain (1992);V6:302-355 Shang-Ying Tsai, Chiao-Chicy-Chen,Eng-Kung Yeh Alcohol problems and long-term psychosocial outcome in chinese patients with bipolar disorder Journal of affective Disorders (1997);1-8 Steven A. King Psychologic Aspects Temporomandibular disorders:Diagnosis and treatment byKaplan And Assael 1991 Young Ok Lee, Sung Woo Lee, A Study of the Emotional Characteristics of Temporomandibular Disorder Patients Using SCL-90-R Journal of Craniomandibular Disorders Facial and Oral Pain (1989); V3:25-34

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系統識別號 U0007-1704200714494810
論文名稱(中文) 口腔超音波網路教學系統之建立與評估
論文名稱(英文) Establishment and evaluation of a Web Based Oral Ultrasound Teaching System
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 林郁馨
學號 M88040152
學位類別 碩士
語文別 中文
口試日期
論文頁數 0頁
口試委員 指導教授-彭建綸
指導教授-林哲堂
關鍵字(中) 口腔超音波
全球資訊網
電腦輔助教學
多媒體
舌運動功能
關鍵字(英) Oral ultrasonography
Computer-aided learning system
Tongue function
Multimedia
Internet
學科別分類
中文摘要 診斷用超音波在臨床醫學使用相當經濟方便,它可以即時(real time)展現舌部運動的狀況,而且對人體無害;此外,可將超音波影像經由錄影設備儲存,方便進一步的觀察分析。因此,超音波已成為近年來研究舌部運動功能的重要工具。 今日電腦數位科技及網際網路技術一日千里,對我們生活各個層面都有著極大的影響。而資訊與醫學的結合應用也相當受矚目,例如:網路門診系統、遠距會診及醫學多媒體教學等,都有很高的學術和應用價值。 有鑑於此,本研究以網際網路架構為基礎,發展口腔超音波網路教學系統,以台北醫學大學牙醫學系四年級學生,共61人為對象,擷取其口腔超音波影像並建置網路教學系統,讓學生透過網路學習超音波課程。架構中以提供學生線上超音波儀器模擬操作系統為特色,讓學生可以不必親自到超音波室上機學習操作,而可以在家學習使用超音波儀器。同時導入多媒體的優點,讓過去傳統教學的靜態超音波畫面,可以在線上以動畫影音展示,增強學習效果。此外也用Flash技術,讓同學以像看電影的方式,來了解課程大綱。在系統教學使用的評估上,我們特別以問卷的方式來瞭解學生的使用情形,結果顯示超過九成的同學對本系統抱持正面肯定,認為可以提升其對超音波課程學習的效果;尤其是針對動態影像展示的部分,比平面靜態資料確實可以輔助學習。未來希望藉由網路科技持續的發展,讓本系統可以更活潑生動,同時也期待以此研究為起點,未來在牙科教育上導入更多的網路學習課程,讓學生在學習上能更多元化、高效率化。
英文摘要 Diagnostic Ultrasonography has advantage of being noninvasive. It shows real-time images and can be applied easily and repeatedly on patients. Quantitative measurement of tongue movement with ultrasound had also been reported these years. Therefore, ultrasonography has become a valuable tool for study tongue morphology as well as tongue functions. In the present development of broadband networking today, it is technological advances an aspects of our lives. There are many applications of word wide web in medical field have been reported, such as, on-lined outpatient service system, distance consultation, and multimedia teaching system. It was the purpose of this study, to set up an oral ultrasound teaching system on World Wide Web, and to provide a better learning for our students. Sixty-one volunteers were chosen from dental students at Taipei Medical University. All images used in this study were taken from these students. This teaching system provides on-line simulation of ultrasound machine. Students can learn any time and anywhere through Internet. With the use of multimedia technology, sound based dynamic ultrasound images can display through Internet so as to enhance the learning efficiency on tongue movements during swallowing and phonation. Furthermore, we applied flash technique to provide students a movie styled introduction of the teaching program. In addition, a questionnaire was designed to evaluate the learning effect of this system. The result demonstrated that over 90% of the students held positive to this teaching system and agree with that it helps enhancing their learning on oral ultrasonography. In the future, we hope to enrich the content and apply more advanced multi-media technologies to improve our teaching system. Widely application of such web-based teaching system on Internet in other fields of dental education and research are strongly suggested.
論文目次 第一章 緒 論 第一節 研究背景與動機 第二節 文獻回顧 第三節 舌功能的重要性 第四節 其他研究舌部運動之方法 第五節 超音波的簡介 第六節 數位影像之簡介 第二章 研究目的 第三章 研究材料與方法 第一節 口腔超音波之擷取 第二節 教學系統之建置 第三節 系統評估問卷之設計及量化 第四章 結果 第一節 學生介面之設計 第二節 教師模式系統展示 第三節 問卷調查結果 第五章 討論 第一節 提升學習效果 第二節 製作技術上之檢討 第三節 未來網路多媒體應用之探討 第六章 未來展望
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Anthony Parker, Kevin J. Donohoe,Gerald M. Kolodny, “The All-Digital Department Moves to the Web” (http://ej.rsna.org/EJ_0_96/0006-96/home.htm) [26] Laboratorio de Imagen, UDIAT CD - Nuestro PACS, (http://www.cspt.es/webcspt/labimg/pacs_udiatang.htm) [27] 王安宇,網路多媒體醫學教學輔助系統之研究,國力台灣大學電機工程學研究所碩士,1997年6月 [28] Stanford University medical center (http://www.med.stanford.edu/medcenter/) [29] Virtual hospital images (http://amesnews.arc.nasa.gov/releases/1999/99images/virtualhospital/virhospx.html) [30] Virtual Hospital , (http://taiwan.vh.org/International/taiwan.html) [31] 黃文科,以WWW及軟體元件技術為基礎之主從式互動醫學教學系統,國立成功大學電機工程學系碩士論文,1999年6月 [32]中央虛擬教室(http://dbweb.csie ntu.edu.tw/~ncuve) [33]東華遠距教學(http://dlearn.ndhu.edu.tw/) [34]交通大學多媒體學網(http://inforscience.nctu.edu.tw/index_new.htm) [35]北醫的遠距教學網(http://video.tmu.edu.tw/) [36] 簡綜男,互動式多媒體輔助教材在電腦輔助教學之學習成效影響研究,國立成功大學資訊管理學系碩士論文,1999年6月 [37] 陳明溥,「CAI之發展趨勢─多媒體電腦輔助教學」,1999,(http://www.edu.tw/information/docs/iecai52/ba006.htm ) [38] 語音學大綱,中國語文叢刊,台灣學生書局印行 [39] Curie I and Curie P. D?veloppement par pression de l?lectricit? polare dans les cristaux h?mi?dres a faces inclin?es. C.R. 91: 294-295, 1880. [40] Ludwig GD, Struthers FW. Considerations underlying the use of ultrasound to detect gallstones and foreign bodies in tissue. Naval Medical Research Institute, Project NM. 004001, report No.4, 1949. [41] Howry DH and Bliss WR. Ultrasonic visualization of soft tissue structures of the body. J Lab Clin Med. 40: 579-592, 1952 [42] Donald I, MacVicar J and Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet. 1: 1188-1195, 1958. [43] Kikuch Y, Uchida R, Tanaka K and Wagai T. Early cancer diagnosis through ultrasonics. J Acoust Soc Am. 29: 824-833, 1957. [44] Minifie FD, Kelsey CA and Hixon TJ. Measurement of vocal fold motion using an ultrasonic Doppler velocity monitor. J Acoust Soc Am. 43: 1165-9, 1968. [45] Beach JL and Kelsey CA. Ultrasonic Doppler monitoring of vocafold velocity and displacement. J Acoust Soc Am. 46: 1045-7, 1969. 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系統識別號 U0007-1704200714494812
論文名稱(中文) 口腔黏膜下纖維化症之超微結構研究
論文名稱(英文) Ultrastructural Findings of Oral Submucous Fibrosis
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 林敬修
學號 M85040088
學位類別 碩士
語文別 中文
口試日期
論文頁數 77頁
口試委員 指導教授-郭倍榮博士
指導教授-謝虢錚博士
關鍵字(中) 口腔黏膜下纖維化症
穿透式電子顯微鏡
掃瞄式電子顯微鏡
關鍵字(英) Oral submucous fibrosis
TEM
SEM
學科別分類
中文摘要 口腔黏膜下纖維化症(Oral submucous fibrosis,簡稱OSF)之病人有口腔黏膜灼燒感、張口困難以及對冷熱和辛辣食物特別敏感的現象;本實驗針對口腔黏膜下纖維化症病人之口腔黏膜組織(包括上皮、結締組織、肌肉、血管和神經組織)在超微結構下,做一研究探討。20例取自口腔黏膜下纖維化症病人的頰黏膜組織,做電子顯微鏡觀察。發現上皮組織大多呈現退化的現象,細胞間隙水腫,基底膜變得不規則,可見缺損、變多層;上皮的分層變得不規則,細胞核變多型。在結締組織上可見透明均質化的顆粒,OSF的膠原纖維是細且多(不成熟的);OSF病人張口困難,不只是因為黏膜下纖維化,連肌肉組織都有受影響。肌細胞呈現不等程度的退化,細胞膜的破損。肌肉中的血管可見內皮細胞損壞的現象。在神經的變化上,以往的文獻沒有提到。末稍神經呈現退化現象。神經周圍細胞(perineural cell) 兩側的基底板增厚且不完整;微纖維散亂地分佈在神經的周圍且呈被壓縮的狀態。神經內的膠原纖維緊密的集中在神經纖維旁邊。許旺細胞鞘被明顯增厚的基底板所包圍住。軸突呈現退化的狀態,粒線體腫脹而且細胞質透明化。透明化的軸突常可在神經細胞的遠心端看到。此神經變化可能和病人感覺改變有關。
英文摘要 Oral submucous fibrosis(OSF)is characterized by symptoms such as intolerance to spicy food, burning seasation, altered salivation, progressive difficulty in opening the mouth. The purpose of the present investigation is to describe the ultrastructural findings(TEM & SEM)of the oral epithelium , subepithelial connective tissue, muscle, vessels and nerve of OSF. Biopsies were taken from the buccal mucosa of 20 cases of typical OSF. Routine EM procedures were done and sections were examined by TEM and SEM.The epithelium showed degeneration. The intercellular spaces of cells were edematous. The basal lamina appeared branched, thickened and duplicated in almost all the lesions. The cells showed pleomorphism. There were hylinized homogenous granules in the connective tissue. The collagen fibers of OSF tissue were excessive and fine (immature).The muscle was involved as well as submucous layer in OSF. Muscle fibers underwent degeneration and plasma membrane was vacuolization and hyalinization. The endothelial cells of vessels in muscle showed degeneration. Peripheral nerve also showed degeneration. The basal laminae on each side of perineural cells were thickened and incomplete. Microfibrils were compressed and scattered at the periphery of the nerve. Endoneural collagen fibrils were also compacted and concentrated around nerve fibers. The Schwann cell sheaths were invested with remarkably thickened basal lamina. The axons appeared degenerated with swollen mitochondria and hyalinized cytoplasm. The hyalinized axons were frequently observed at the distal portion of nerves. The disorganized changes of neural tissues in OSF were not previously reported and might be one of the factors resulting in the intolerance to spicy food and the burning sensation of the mouth.
論文目次 第一章 緒論 第二章 文獻查證 第一節 口腔黏膜下纖維化症(OSF) 1、 OSF的臨床症狀 2、 OSF的盛行率 3、 OSF的組織病理特徵 4、 OSF的治療 5、 OSF的病因 6、 OSF患者之免疫學研究 7、 OSF與口腔癌之關係 第二節 OSF之超微結構 1、 口腔黏膜上皮組織 2、 肌肉及血管組織 3、 膠原纖維 第三節 相關疾病之研究 1、 口腔黏膜白斑症 2、 鱗狀細胞癌 第三章 研究材料與方法 第四章 結果 第五章 討論 第六章 結論 第七章 參考文獻
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Community Dent Oral Epidermiol, 25:377-383,1997. 第一章 緒論 口腔黏膜下纖維化症(Oral submucous fibrosis,OSF),首先由Joshi(1953)提出,是口腔內的慢性疾病;病人通常覺得口腔黏膜灼燒感,唾液分泌改變,不能忍受辛辣食物,張口漸漸困難。 在口腔黏膜上,可見到長水泡、潰瘍、白斑,黏膜變得較堅硬。在舌頭可見味蕾消失(depapillation)和移動能力的改變;這些變化主要是由於固有層(lamina propria)及深層結締組織廣泛的纖維化(fibroelastic scarring)。在上皮下(subepithelial)通常可發現不同程度的漿細胞和淋巴球聚集(plasma cell and lymphocytic infiltration)(Pillai & Redediar, 1992)。 這些病理上的變化,可能和外物直接剌激,例如檳榔鹼,或者是和自體的免疫反應引起的組織抗原性(tissue antigenicity)有關。在印度,口腔癌的盛行率高和嚼檳榔的習慣有關(Singh & von Essen 1966, Samuel et al. 1969 , Khadim 1977)。檳榔是口腔癌的致病因子(Binnie et al 1983 )。嚼檳榔的習慣和口腔黏膜下纖維化的形成有關(Canniff & Harvey 1981)。在口腔黏膜下纖維化的病人中,十七年內約有7.6﹪的人會變成口腔癌(Pindborg 1965 , Pinborg et al. 1969)。因此OSF被定義為口腔癌前狀態(pre-cancerous condition)。 在組織學上,上皮明顯的萎縮(atrophy)和異形(atypia)(Pinborg et al. 1970);在結締組織中,有緻密的膠原蛋白(collagen)沈澱(Mani 1977)。在電子顯微鏡方面,口腔黏膜下纖維化的研究,主要集中在上皮(Cohen et al. 1971)或是在其下的結締組織(Binnie & Cawson 1972)。超微結構下的研究,可能可找出早期的退化現象。 第二章 文獻查證 第一節 口腔黏膜下纖維化症 (Oral Submucous Fibrosis) OSF是一種慢性進行性的口腔黏膜病變,可侵犯口腔內任何部位的黏膜,在有的病例中甚至擴散到咽喉和食道,其主要特性為口腔黏膜下膠原蛋白異常堆積。病變區早期出現水泡並在固有層與上皮鄰接處有發炎反應,接著發生纖維彈性變化(fibroelastic change)及上皮萎縮(epithelial atrophy),進而導致病人口腔黏膜僵硬(stiffiness)、張口困難(trismus)、吞嚥困難(dysphagia)(Pindborg et al. 1964)。 (一) OSF的臨床症狀 (1)灼燒感:由於口腔黏膜的病變,使其黏膜層變薄,感覺變敏感,所以患者在進食過泠、過熱或辛辣食物時,會有灼熱疼痛的感覺(Pindborg et al. 1964)。 (2)水泡、潰瘍:軟腭、頰黏膜、唇黏膜表面長水泡,水泡隨即破掉留下潰瘍的痕跡,組織學的檢查發現水泡是由於上皮下的固有層的發炎反應引起上皮下的液體堆積所造成的。(Pindborg et al. 1966) (3)口腔黏膜顏色變白,出現白色的纖維帶,舌頭變小且移動性變差,而由於膠原蛋白的圍繞,使唇扭曲變形(Pillai et al. 1992)。 (4)張口限制:嚴重的病患會有牙關緊鎖(trismus)的情形,黏膜完全變為無彈性的狀態。由於無彈性的纖維組織與退化的肌肉組纖堆積在口腔黏膜上皮附近,限制了張口程度,阻礙下顎的移動,並影響咀嚼及說話等能力。 (5)吞嚥困難:當口腔黏膜下纖維化情形由口腔擴散到咽喉、食道等區域之後,會影響吞嚥功能,造成吞嚥困難。 (6)聽力減退:當口腔黏膜下纖維化情形由口腔擴散到咽喉的時候,纖維化情形會使耳咽管(eustachian tube)開口處變狹窄或阻塞,使聽覺的敏銳度受損,有的人會感覺到耳朵疼痛。 (二) OSF的盛行率 OSF的患者多見於印度(Pindborg et al. 1966),還有台灣(Shiau&Kwan 1979)、南非(Lemmer J & Shear M 1967)、歐洲(Simpson W 1969)等地的亞洲移民及其後裔。在印度約0.5﹪的人口罹患此疾病,此疾病可發生於任何年齡,而多見於20-40歲患者(Pindborg et al. 1984)。在台灣,OSF最常發生於30-50歲患者,大多數發生於男性,僅偶而發生於女性,和嚼食檳榔有關係,與抽菸、飲酒、嗜食辛辣食物則無明顯相關(Shiau&Kwan 1979;Chiang et al. 2000)。 (三) OSF的組織病理特徵 OSF的組織病理學特徵是上皮和固有層交界處的發炎反應和固有層及黏膜下層的進行性纖維化。其表現包括:(1)纖維母細胞(fibroblast)數目減少,且在結締組織中有輕度到中度的慢性發炎現象(2)固有層和黏膜下層的血管變少,並且呈現膠原纖維的堆積和透明變性(3)上皮萎縮及不等程度的上皮變異(dysplasia)。(Pillai et al 1992;Regezi & Sciubba 1993)。 有多量的膠原纖維堆積於固有層、黏膜下層及肌肉表層。在電子顯微鏡觀察下發現膠原纖維的數量增加,以第一型膠原蛋白(type I collagen)為主,且纖維變細,形狀碎裂而彎曲(Binnie & Cawson 1972)。 Pindborg等人(1966)以結締組織的變化在HE (hematoxylin and eosin)stain下所見,將OSF分成4個時期:(1)最早期(very early stage ):結締組織水腫,其中散佈許多細小不成束的膠原纖維,可見很多年輕的纖維細胞(fibrocyte);血管通常是呈擴張且充血的狀態,偶而可見正常的血管。可見到很多發炎細胞,以多形核白血球(leukocyte)為主有少數的嗜酸性球(eosinophil)。(2)早期(early stage):上皮和結締組織交界處呈現早期的透明化現象;結締組織可見成束增厚的膠原纖維,和許多的發炎細胞,以單核白血球和嗜酸性球為主,偶而可見漿細胞(plasma cell);血管擴張充血。(3)中期(moderately advanced stage):膠原纖維中度透明化;上皮交界處的基底膜開始有無形的變化(amorphous change);可見到較多成熟的纖維細胞;血管呈收縮(因為環繞的膠原纖維變多)或不收縮狀態,可見許多發炎細胞,主要是淋巴球(lymphocyte)和漿細胞,偶而可見嗜酸性球。(4)後期(advanced stage):膠原纖維完全透明化,看不出一束一束,水腫的情況不復存在,透明化的膠原纖維幾乎完全佔滿了黏膜下層,幾乎看不到纖維母細胞;血管狹窄或是堵塞,發炎細胞以淋巴球和漿細胞為主。 (四) OSF的治療 目前OSF的治療方式包括:(1)拉張運動(Stretching exercise)並配合使用在病變區的類固醇注射。(2)以手術切除纖維帶並局部注射chymotrypsin、hyaluronidase和dexamethasone等藥物,來減輕病人張口受限的情況。但由於OSF是一種不可逆的病變過程,所以這些治療所能提供的實質幫助也極為有限(Regezi & Sciubba 1993)。近來國內有使用手術切除纖維帶,並輔以羊膜移植來改善OSF患者的張口程度(賴德榮 et al. 1993)。 OSF具有癌前病變的性質。在Gupta、Pindborg及Murti等人的研究,發現經10年、15年及17年的追蹤,OSF轉變成口腔癌的比例分別是2.3﹪,4.5﹪和7.6﹪。顯示了時間愈長,OSF惡性轉變的比例愈高。一般約在診斷為OSF後3到16年間發展成口腔癌(Paymaster 1956;Pindborg et al. 1984;Murti et al. 1985)。 (五) OSF的病因 目前OSF的病因仍不清楚,研究顯示OSF患者絶大多數皆有嚼食檳榔的習慣(Canniff et al. 1986),Maher等人(1994)的研究顯示嚼食檳榔是產生OSF的重要因子,更有研究顯示所有OSF患者皆有嚼食檳榔的習慣(黃湧澧 1990;郎明蓁1994;Chiang et al. 2000)。在印度,OSF患者中約有52﹪有嚼食檳榔的習慣,而一般族群中只有2.1﹪有嚼食檳榔的習慣(Mehta et al. 1972)。在台灣,所有的OSF患者都有嚼食檳榔的習慣(Chiang et al. 1999)。然而,造成OSF發生的最好解釋還是各種影響因子的聯合作用所致(Pillai & Reddiar 1992)。 歸納文獻報告我們可由下列幾方面來探討OSF發生的原因: (1)、具高膠原纖維合成能力之纖維母細胞的選擇性增殖:檳榔嚼塊中的成份,如來自檳榔子的檳榔素(arecoline)和檳榔次鹼(arecaidine)以及來自老藤(inflorence of piper betel)的黃樟素等皆具有細胞毒性,可以造成細胞DNA的斷裂或細胞的死亡(謝天渝1990;Jeng et al.1994)。所以嚼食檳榔會造成組織的壞死與發炎反應,而參與修復過程的纖維母細胞可能是具較高膠原纖維合成能力的經選擇後的纖維母細胞。Meghji 等人(1987)的研究發現OSF纖維母細胞的基礎膠原纖維合成率略高於正常纖維母細胞,其值為1.15:1。這些具膠原纖維合成能力的纖維母細胞參與組織修復可能使得上皮下方的結締組織因過多的膠原纖維堆積而產生變性。 (2)、因檳榔中成分的刺激使得纖維母細胞產生較多的膠原纖維:Harvey等人(1986)的研究,利用檳榔子萃取物刺激人類頰黏膜的纖維母細胞,發現檳榔子萃取物中的檳榔素和檳榔次鹼都會刺激纖維母細胞的增生及增加膠原纖維的合成。 (3)、膠原纖維的分解減少:膠原纖維於組織中的含量是動態平衡的狀態,纖維母細胞會形成膠原纖維,另一方面纖維母細胞也會分泌膠原蛋白酶(collagenase)或吞噬膠原纖維,再利用溶解體中之酵素如組織蛋白酶(cathepsin)來分解膠原纖維,以維持組織中膠原纖維恆定的替換。謝天渝等人(1992)的研究發現OSF病變處的口腔黏膜之膠原蛋白酶比正常口腔黏膜中的膠原蛋白酶低甚多。此外,馬瑞宏等人(1995)的研究也發現OSF纖維母細胞對膠原纖維的吞噬能力明顯地低於正常纖維母細胞,且檳榔次鹼也具有使纖維母細胞吞噬膠原纖維能力降低的作用。所以,OSF纖維母細胞所分解的膠原纖維較正常的纖維母細胞少也是造成OSF病變處的膠原纖維堆積的原因之一。 (4)、形成結構更穩定的膠原纖維:在OSF纖維母細胞的膠原纖維之生物合成研究上,發現第一型膠原纖維三倍體結構α1(I)3的產生,這種結構的膠原纖維非常穩定至可以抵抗膠原蛋白酶的分解(陳信銘1992)。Scutt等人(1987)的研究發現發現膠原纖維以檳榔萃取物中的鞣酸(tannin)或兒茶素(catechin)處理後抵抗人類及細菌產生的膠原蛋白酶的能力較強。因此,OSF的膠原纖維較正常組織中的膠原纖維不容易被膠原蛋白酶分解。 (5)、發炎細胞所分泌之致纖維化細胞素(fibrogenic cytokine)之刺激:組織環境,細胞與細胞之間的交互作用常藉著分泌細胞素,以自體分泌(autocrine)或旁體分泌(paracrine)方式來調控。在受傷組織的修復過程,巨噬細胞和淋巴細胞等發炎細胞會產生一些細胞素來促進纖維母細胞的增生和膠原纖維的合成。其中最主要的是第一型介白質(IL-1)、轉形生長因子-β(transforming growth factor-β,TGF-β)和血小板源生性生長因子(platelete-derived growth factor,PDGF)(Kovacs 1991)。OSF是一種慢性發炎病變,其纖維化的過程中,發炎細胞所分泌的致纖維化細胞素也可能參與其中的反應。OSF病程發展的變化,起先為上皮下方的固有層的發炎反應,導致結締組織破壞,而啓發了細胞的修復作用;然而,反復不斷的發炎反應和修復作用,造成了上皮下方的固有層及黏膜下層異常地過度堆積膠原纖維,血管內皮破壞,血管數量減少。由於血液供應的降低造成營養的不足,因而造成表層上皮的萎縮,使得上皮的通透性愈來愈高,食物中較刺激的成份更容易穿透上皮,引起患者對辛辣食物的灼熱疼痛,可能也會進一步刺激結締組織,使其纖維化的情況更加地惡化。 (6)、某些營養素缺乏:有很多的研究發現,缺乏鐵以及維生素B群可能與OSF的發生有關連(Ramanathan et al. 1956; Jacobs et al. 1968; Harrison et al. 1971; Rennie et al. 1982; Prime et al. 1983)。在血液學方面的研究則顯示,30﹪OSF患者血液中血紅素及鐵質含量比正常人低,但總鐵結合能力(total iron binding capacity,TIBC)比正常人高(Canniff et al. 1986)。又OSF患者血液中銅和鋅的濃度比正常人低,但銅/鋅比值卻比正常人高(Varghese et al. 1987);此外,OSF患者之全血蛋白、血清蛋白和球蛋白含量均有升高的趨勢,但白蛋白/球蛋白(albumin/globulin)比值及抗壞血酸濃度則均有顯著地降低(Varghese et al. 1987; Anuradha et al. 1993),由此推知,OSF患者血液成份的變化可能與膠原蛋白合成量增加有關。由於OSF和Plummer-Vinson症候群(或稱缺鐡性吞嚥困難症候群)(Hoffman et al. 1995)在臨床症狀或預後上都非常類似,因此有學者認為OSF為亞洲型的Plummer-Vinson症候群(Ramanathan et al. 1956)。 (六) OSF患者之免疫學研究 OSF為在光學顯微鏡下觀察時,通常可見到不等程度的發炎細胞浸潤,多半為淋巴細胞。由一些關於OSF的免疫學研究顯示,在體液免疫方面,OSF患者之血清中的IgG、IgA、IgD和IgE都有報告表現增加的現象(Phatak & Gosavi 1975;Rajendran et al. 1986)。關於循環免疫複合體(circulating immune complex, CIC)方面,OSF患者以及大量嚼食檳榔者,其血中CIC濃度皆較未嚼食檳榔者偏高(Remani et al. 1988;Balaram et al. 1987),OSF患者這些免疫球蛋白及免疫複合體偏高的異常現象在口腔癌患者也有類似的發現(Rajendran et al. 1986)。 在細胞媒介免疫方面的研究,Phatak(1975)的研究發現OSF患者的細胞免疫功能明顯的較正常人低。Pillai等人(1987)也發現OSF患者周邊血液中T淋巴細胞次群明顯地較正常人的量來得低,其中幫助者T細胞能促進B淋巴細胞成熟和釋出第二型介白質(interleukin-2,IL-2),IL-2會刺激T淋巴細胞和間接導致B淋巴細胞的增生,IL-2釋出量降低,就會造成細胞媒介免疫反應以及體液免疫反應的降低(Pillai & Reddiar 1992)。在OSF及其他癌前病變的研究顯示,OSF患者的自然殺手細胞(natural killer cells,NK cells)的活性明顯地比正常人的低(Pillai et al. 1990)。由以上研究結果顯示OSF患者在體液免疫反應以及細胞媒介免疫反應都存在某種程度的缺陷。 (七) 口腔黏膜下纖維化與口腔癌之關係 口腔癌的癌前病變包括了口腔白斑病(leukoplakia)及紅斑病(erythroplakia)。而口腔黏膜下纖維化為口腔癌前狀態之一(Tang et al. 1997; Zain et al. 1997; Gupta et al. 1998)。Tang 等(1997)的研究發現在中國口腔黏膜下纖維化的患者約有1.19﹪會轉變成口腔癌。Pindborg(1967)等人的研究也發現上皮異形經常在OSF患者的鱗狀細胞癌的旁邊被發現。在印度,則有7.6﹪的口腔黏膜下纖維化患者會轉變成口腔癌(Pindborg et al.1969)。由此可知,口腔黏膜下纖維化患者是口腔癌發生的高危險群。 第二節 口腔黏膜下纖維化症之超微結構 (一) 口腔黏膜上皮組織 口腔頰黏膜上皮屬於非角化上皮,依形態之不同分為三層:表面細胞層(surface cell layer),中間層(intermediate layer),及基底層(basal layer)。其超微結構之表現在表面細胞為紡綞形的細胞,有凝縮的核,其表面有細長的微絨毛狀的細胞突起,細胞質以張絲為主,含脂質顆粒,細胞因含有多量ribosome而濃染,顯現dark cell的形態,細胞間隙較窄,胞橋小體中等至偏少。中間層之細胞其形狀為圓形或橢圓形,細胞核大而發逹含有一至數個明顯而發逹的核仁。細胞質內含有中等量的張絲,粒線體等胞器。細胞間隙較表面細胞層寛,各個細胞的細胞突起互相交錯形成interdigitation的連接,並可見多量的胞橋小體。基底層的細胞呈圓形或多邊形,細胞核有倒凹(indentation),但是以圓形為主,有一至數個核仁,hetrochromatin較少故細胞核看起來較明亮。細胞質含多量的張絲及粒線體,張絲常環繞細胞核形成一圈濃染的細纖維,其它部份則呈現明亮的細胞質。 Pindborg (1970)對OSF口腔上皮的超微結構的觀察發現OSF的上皮呈萎縮,萎縮的上皮的epithelial ridges 消失。正常的頰黏膜上皮是非角化上皮;OSF的口腔黏膜上皮:有26﹪是ortho- or hyperorthokeratosis,有22﹪是para- or hyperparakeratosis,有26﹪是非角化上皮。Cohen 等人(1971)以及Sirsat & Daftary(1974)對OSF的口腔黏膜上皮的超微結構觀察發現OSF的口腔黏膜上皮有上皮異型(epithelial atypia)的現象:特徵包括有上皮不規則的分層、上皮細胞中細胞分裂的數目較正常的上皮多、多形的細胞核、染色質過多(hyperchromatism)、細胞的極性消失等現象;細胞間隙水腫尤其是接近基底層的細胞。 (二) 肌肉及血管組織 El-Labban 等人(1985)對有張口受限的情形的OSF病患的組織中的肌纖維的超微結構觀察中,發現肌纖維大部份呈退行性變化。肌纖維中有大片的均質的物質;這些物質和肌纖維之間的結締組織水腫的液體相似。有些肌小節(sarcomeres)被聚集的絲狀物體取代,這些絲狀物體周圍有均勻的液態物質包圍。粒線體退化或消失;有的肌纖維中可見像鬼影子一般的(ghost-like)粒線體且有電子緻密物質。細胞核呈現不等程度的退化,從異染色質的聚集到完全喪失核膜的都有;喪失核膜的細胞核內的染色質分散到肌纖維的周圍。常可見到細胞膜破裂的細胞,特別是在液體狀物的周圍。有些肌細胞已經完全喪失了細胞膜,細胞的外型由完整的基底膜維持。肌纖維常由水腫液體及紅血球包圍。血管擴張內皮變薄,常可見血管破裂,破裂處可看到血小板聚集。 (三) 膠原纖維 Binnie 等人(1972)對OSF的結締組織纖維的研究,在穿透式電子顯微鏡下觀察正常結締組織的纖維是統一大小的纖維(49.7 nm),而且聚集成束;OSF的結締組織纖維是不成熟的、多且細(36.2 nm)且不成束的纖維。正常的結締組織纖維的密度是170 ~180 fibrils /μm2,OSF的結締組織纖維的密度是210 ~ 240 fibrils /μm2。比較OSF和正常的結締組織纖維可發現三個主要差異: (1)OSF的結締組織纖維沒有真正的成「束(bundle)」:細小的纖維散佈在基質(ground substance)中,纖維之間的空隙比正常的結締組織纖維大,但是大小不均。 (2)OSF的結締組織纖維的直徑變化較正常的纖維大,但總體而言,OSF的結締組織纖維的直徑較正常者細:正常的纖維的平均直徑是49.7 nm,95﹪的纖維直徑在35.5 nm ~ 59 nm之間。OSF的纖維的平均直徑是36.2 nm,95﹪纖維的直徑在17 nm ~ 53 nm之間。 (3)OSF的結締組織纖維和纖維之間的空隙較正常者大。 Mani(1977)的研究發現OSF結締組織的變化和風濕性關節炎、硬皮病及其他結締組織異常的疾病類似。電子顯微鏡下可見不正常膠原纖維片段及不定型物質。血管的數量較正常減少,在結締組織及上皮間有發現空泡(vesicle)。 Sirsat & Pindborg 的研究發現,隨著OSF的惡化,水腫減少但纖維細胞活性增加,膠原合成增加。 Van(1990)的研究發現OSF的固有層中膠原纖維的數量較正常者增加很多,尤其是type I collagen fiber。 第三節 相關疾病之研究 (一) 口腔黏膜白斑症 在Hashimoto等人(1968)對口腔黏膜白斑症的超微結構的研究發現,粒線體增加,具多形性。正常和病變的角質層的差異在於基底細胞質凸起在病變組織較短。 Silverman(1967)的觀察發現基底膜成多層且不連續;細胞胞器增加。在棘狀層的上部可見條紋狀的(striated)顆粒。角質顆粒出現在不常出現的地方。胞橋小體在角化及非角化上皮上沒有差異。 在Banoczy 等人(1979)對12個白斑症病例的研究,把白斑症分三類: (1)Leukoplakia simplex:有上皮增生,接近基底層的細胞增生(acanthosis),以及高度角化(hyperorthokeratosis)的現象。顆粒層發育良好,結締組織有少許發炎的現象,上皮和結締組織交界清楚。 (2)Leukoplakia verrucosa:上皮增生,接近基底層的細胞增生(acanthosis),部分有角化不全(hyperparakeratosis)的現象,部分有高度角化(hyperorthokeratosis)的現象,結締組織有少許的發炎現象,有一例有輕微的上皮異形現象,上皮和結締組織的交界尚存。 (3)Leukoplakia erosiva:上皮增生,表面有潰瘍的症狀,上皮有角化不全(parakeratosis)的現象,結締組織有中等至重度的發炎,上皮和結締組織的交界不清楚。 基底膜在leukoplakia simplex 和leukoplakia verrucosa是完整的,部份的地方有增厚、變多層以及基底細胞間隙擴大的現象。在leukoplakia erosiva可見基底膜斷裂。 基底層的細胞藉由細胞的指狀突起(interdigitations)相連,在leukoplakia verrucous 和 leukoplakia eorsiva ,這種相連有鬆動的現象;而且leukoplakia erosiva的基底層的半胞橋小體的數目減少。 接近基底層的細胞的細胞間隙在leukoplakia simplex 和leukoplakia verrucosa輕微的擴大;在leukoplakia erosiva擴大的情形較前兩者明顯許多,而且胞橋小體已經破壞,細胞之間的相連有部份已經消失。leukoplakia simplex的核糖體平均分佈在細胞質中;leukoplakia erosiva的核糖體聚成一團團的像薔薇花飾(rosette-like groups),粒線體有嵴溶解(cristolysis)和破裂(rhexis)的現象,大部份的粒線體已經破壞了,可看到類脂質的顆粒(lipoid granules),有的細胞的核糖體變多形成dark cell,有的細胞的核糖體很少形成clear cell。 接近表層的細胞在leukoplakia simplex 和leukoplakia verrucosa 可看到有的細胞內有角質層透明質顆粒(kerato-hyalin granules)有的細胞內則無;角質層透明質顆粒在leukoplakia erosiva 則很少看到。 (二) 鱗狀細胞癌 Firthiof(1969)觀察癌病變的上皮的基底膜發現基底膜較其他角化或非角化上皮薄,此外他還發現在癌侵入的地方的基底膜破壞、不連續、甚至消失。基底層細胞的凸起伸入下方的結締組織中。 Chen SY 等人(1977)對16個口腔鱗狀細胞癌病例做超微結構觀察發現: (1)光學顯微鏡的觀察:上皮的分層不規則,細胞核較大而且有hyperchromatic的現象,核體非常明顯;可以見到很多正常和不正常的細胞分裂。鬆散的結締組織中有許多淋巴細胞、漿細胞,還有少許的中性球。 (2)電子顯微鏡的觀察:環繞癌細胞群(cancer cell islands)的纖維結締組織由中度的電子緻密性(electron dense)的基質組成,其中散佈著不成束的膠原纖維和小束的膠原纖維。癌細胞是多形的,大多數呈橢圓形,比正常的上皮細胞大;在癌細胞群邊緣和結締組織接觸的地方有一層薄的基底膜,厚度大約580 Å。許多有偽足狀或微纖維狀的細胞質突起的地方沒有基底膜;但有某些地方的基底膜變複層。作者認為基底膜變複層可能是癌細胞移動的結果。和基底膜相連的細胞膜上有一些半胞橋小體,數量上比正常上皮的基底層細胞少很多。癌細胞之間以少量的胞橋小體相連,細胞膜的皺褶很多,而且有很多微纖維狀的細胞質突起。 Kannan 等人(1996)對15個口腔鱗狀細胞癌旁邊的上皮的超微結構所作的觀察發現: 所有的病例的上皮的接近基底層的細胞的胞橋小體的數目和大小都顯著地的減少;基底細胞的細胞質突起數目顯著變少、半胞橋小體的數目顯著變少,基底細胞的細胞核呈多形、奇形怪狀、且擴大的,核裡面有很多異染色質;基底膜變薄以及基底細胞間隙水腫的情況在大多數的病例都可見到。 和正常的黏膜以及良性的白斑(benign leukoplakia)比起來,中間層的細胞的張絲和角質明顯的減少。中間層的細胞間隙水腫以及角化不良的情形在大多數的病例都可見到。表層的細胞間隙有些微的水腫。除此之外表層細胞無其他明顯的變化。他們認為在上皮細胞癌化的過程中,初期的轉變是發生在基底層,到後期才漸漸連表層也受到影響。 Pierce & Nakane 認為基底膜變厚變複層可能是因為在上皮異形的過程中基底細胞所分泌的產物(cellular or extracellular)所致。他們也在鱗狀細胞癌的超微結構中看到變複層或是不連續的基底膜;Kannan等人認為在上皮的癌化過程中基底膜變薄可能是初期,後期基底膜就變成不連續了。基底膜的形態是判定上皮的惡性轉變的重要指標。 某些研究指胞橋小體或是細胞間橋(intercellular bridges)的喪失是惡性轉變的特徵之一(Frithiof 1969;Chen 1977)。 Kannan 等人(1994)對25口腔鱗狀細胞癌所做的超微結構的研究:Invasive SCC的上皮的基底膜斷斷續續的不明顯,Carcinoma in situ(CIS)的上皮的基底膜緻密且連續、有些地方增厚變複層。CIS的基底細胞的半胞橋小體很多,某些地方有減少,Invasive SCC的半胞橋小體很少,且發育不良。 Ramaesh 等人(1998)對正常的、有白斑病的以及有SCC的口腔上皮的刮屑(squames)的細胞做細胞直徑和細胞核直徑測量,再做統計分析:正常的口腔上皮和無上皮異型的病變上皮的細胞核直徑愈大,細胞愈大,呈正相關;有上皮異型的病變上皮和SCC的上皮的細胞核直徑和細胞直徑則沒有相關。細胞直徑最大的是正常上皮細胞最小的是SCC上皮細胞,依序是:正常上皮細胞>無異型的病變上皮>有異型的病變上皮>SCC。正常上皮和無異型的病變上皮的細胞核直徑差不多,且大於有異型的病變上皮和SCC上皮。作者認為此種細胞直徑變小、細胞核直徑變大(核 / 質比變大)的現象可以做為早期診斷惡性轉變的指標。 第三章 研究材料與方法 一、材料 標本①(20個)取自典型口腔黏膜下纖維化病人之頰黏膜。 在這些典型OSF病人頰部可見蒼白色的頰黏膜,而且可摸到fibrous band。 標本②(2個)取自正常無纖維化之頰黏膜,做為對照組。 二、方法 手術取出標本後,分成兩組,一組做掃瞄式電子顯微鏡,一組做穿透式電子顯微鏡的觀察。 穿透式電子顯微鏡這一組的標本切成1㎜的小塊,放入冰的2﹪cacodylate-buffered glutaraldehyde(pH 7.4)1天,反復以cacodylate buffer pH7.4沖洗。 以1﹪osmium tetroxide 後固定2小時,連續提昇酒精濃度脫水,以Epon 812R樹脂包埋。切片機切片,厚片以toluidine blue 甲苯胺藍染色觀察,薄片以銅網固定,用uranyl acetate 和lead citrate 染色。 然後用穿透式電子顯微鏡Hitachi H-600觀察。 另外一組標本以Malick and Wilson(1975)的方法製備,以Hitachi S-2000掃瞄式電子顯微鏡觀察。 第四章 結果 OSF頰黏膜上皮的表層細胞(SC:surface cell),此層有完全角質化的扁平狀細胞,其細胞可見均質化的細胞質、中等量的脂質顆粒,以及變窄的細胞間隙。(圖1) 在口腔黏膜下纖維化症的頰黏膜上皮大多呈現退化的現象,角化層的細胞殘餘的胞器主要是以多量的張絲(tonofilament)為主(圖2)。 在最表面的角質細胞一般有1至2層,其外型呈紡綞狀,外表平滑,並可觀察到短小的細胞突起;偶而可看到有些纖維狀物嵌入分開的上皮細胞之間(圖3)。 正常頰黏膜最表面的角質細胞,可見到4-5層的細胞,還有明顯的細胞間隙(圖4)。 中間層接近表面的細胞,常見擴大的細胞間隙,含細長的微絨毛(microvilli)。細胞質內可觀察到多量含有膜狀構造之空泡(membrane bound vesicles),及無明顯膜構造之空泡(圖5)。兩者皆含有多量細粒狀物質。 有時可發現其細胞質內較大的囊狀空泡把細胞核擠到細胞的一邊,呈現指環細胞(signet ring cell)的形態;有些空泡內有微絨毛,此外細胞質內之粒線體亦顯現腫脹(swelling)及凝縮(condensation)的狀態(圖6),細胞質內亦可見到中等量的脂質顆粒及偶而可見之細胞內胞橋小體(intracytoplasmic desmosomes)。 正常頰黏膜中間層內的細胞,細胞呈圓形或卵圓形,細胞核亦為圓形,邊緣稍帶鋸齒狀。有明顯的核仁,中等量的張絲及少量粒線體。細胞間隙正常。還有多量的胞橋小體(圖7)。 頰黏膜中間層接近基底層的角質細胞為橢圓形,胞橋小體(desmosome)相當多,而且大部份胞橋小體中有張絲(tonofilament)插入。核糖體平均地分佈在細胞質中,有些細胞並可觀察到黑色素體(melanosomes)。大部份的粒線體呈現嵴溶解(cristolysis)的現象,其內嵴(cristae)已消失。有時可發現具有鋸齒狀細胞核之細胞,含有1至2個發育良好之核仁,張絲常環繞於細胞核周圍(圖8)。 頰黏膜中間層接近基底層內的角質細胞。胞橋小體相當多,而且大部份胞橋小體中有張絲插入。核糖體平均地分佈在細胞質中。大部份的粒線體已破壞掉。可見到細胞核有皺摺,細胞核與細胞質間有間隙(perinuclear space)。(圖9) 基底層的細胞有指狀突起(interdigitation)以及多數細長的微絨毛,其細胞間隙是擴大的,細胞外形是多形性的,細胞的核 / 質比很大,細胞核通常具有一至數個發育良好的核仁。染色質被壓縮的程度很高,可以從明顯的邊緣的異染色質看出來。在細胞核內,可見到有很多內染色質(inter-chromatin)和周圍染色質顆粒 (perichromatin granules)。基底細胞的細胞質內有很多的張絲及多量的粒線體,同時摻雜著黑色素細胞(圖10)。胞橋小體構造正常但數量較少。在基底細胞面向基底膜一側的細胞膜上有許多構造正常的半胞橋小體(hemidesmosome)。有許多細而長的細胞突起(cyto-plasmic process)伸入上皮下基質(subepithelial stroma)中。這些突起內含許多張絲。在大多數的區域內基底膜看起來呈分枝狀、增厚而且變複層。同時在結締組織中可看到很多類似基底膜構造的斷片,其周圍伴隨著reticulin fibers(圖11)。 正常頰黏膜基底層細胞可見較多量的粒線體(M:mitochondria),細胞核呈圓形有明顯的鋸齒狀,可看到2到3個核仁;還有中等量的張絲。可見短小的細胞質突起(P:cytoplasmic process),和連續的基底板(Arrow:basal lamina),基底板基本上是一層,有時可見兩層,有可能是切面的關係。面向基底膜一側的半胞橋小體很明顯(圖12)。 頰黏膜固有層中不規則地排列的膠原纖維,這些膠原纖維平均直徑35.2nm,95﹪的纖維直徑在16~50nm之間。在這些膠原纖維中有微絲(microfilaments)構成的不尋常團塊(圖13)。正常的頰黏膜固有層中的膠原纖維排列規則,平均直徑是47.3nm,95﹪的纖維直徑在35.5~50nm之間。(圖14)在接近血管的部位可見到有壞死的區域,並有不同程度淋巴球浸潤。 頰黏膜下深層組織,可見部份肌纖維的壞死變性(圖15)。在已破壞的肌原纖維之間可見到均質的物體聚集。粒線體有凝縮的現象。肌纖維之間的微血管也有受到影響;微血管的內皮細胞增厚,細胞質的密度也有變化。有些地方,包圍內皮的基底板變得不規則而且斷斷續續的。 頰上皮下組織內的神經纖維的超微結構;可見神經周圍細胞(perineural cell) 兩側的基底板增厚且不完整,有許多微纖聚集。同時微纖也散亂地分佈在神經的周圍及纖維母細胞附近且呈被壓縮的狀態。神經內的膠原纖維緊密的集中在神經纖維旁邊。在神經內,有一些由膜包圍的構造,這些構造大小不一。許旺細胞鞘被明顯增厚的基底板所包圍,但許旺細胞本身並無太大變化。有些有髓鞘的軸突內包含有髓鞘物體(myelinated bodies)的空泡。軸突呈現退化的狀態,脂肪變性,粒線體腫脹而且細胞質透明化;透明化的軸突常可在神經細胞的遠心端看到,此處的軸突並沒有完全被神經周圍細胞包住(圖16)。 掃瞄式電子顯微鏡下的頰黏膜上皮的表面細胞呈頁狀,有些可看到纖維狀物質附著在其表面(圖18)。其表面型態有兩個特徵:微嵴(microridges)和微絨毛(micro-villi);這些突起的密度在每一個細胞都不相同。有些部份當表面細胞剥落時可見到其內面充滿微絨毛(圖19)。在某些細胞並可觀察到同一平面上同時存在微嵴和微絨毛(圖20)。 有些表面細胞的形態有明顯的改變,可見到短而粗、大小不同的皰(bleb)(圖21AB)。 正常的表皮細胞上的微絨毛大小均一,可見微嵴和微絨毛(圖22)。 圖1 OSF頰黏膜上皮的表層細胞(SC:surface cell),此層有完全角質化的扁平狀細胞,可見均質化的細胞質,細胞中殘餘的胞器主要是張絲(Arrow:Tonofilament),還有中等量的脂質顆粒(L:lipid granules),以及變窄的細胞間隙。(bar =5μm) 圖2 OSF頰黏膜上皮的表層細胞,細胞中殘餘的胞器主要是張絲(Arrow:Tonofilament),可見變窄的細胞間隙。 (bar =2μm) 圖3 OSF頰黏膜的口內面。可見到最表面的角質細胞其外表平滑。有些纖維狀物(FLM:fibrous like materials)伸入分開的鱗狀上皮之間。角化層的細胞常有小而緊密而皺縮的細胞核。(bar = 4μm) 圖4 正常頰黏膜最表面的角質細胞,可見到4-5層的細胞,還有明顯的細胞間隙(S:intercellular space)。(bar=5µm) 圖5 OSF頰黏膜上皮,中間層的細胞(intermediate cell layer)。 細胞質內可觀察到多量含有膜狀構造之空泡(V:membrane bound vesicles)並且充滿細粒狀物質(Arrow:granular materials)。粒線體(M:mitochondria)顯現凝縮的型態。 T:tonofilaments (bar = 2μm) 圖6 OSF頰黏膜上皮,中間層接近表層的細胞。 細胞質內有大的囊狀空泡把細胞核擠到細胞的一邊,呈現指環細胞(S:signet ring cell)的形態;空泡內有微小的微絨毛(Arrow head:microvilli)。D:desmosome Arrow:granular materials (bar = 5μm) 圖7 正常頰黏膜中間層內的細胞,細胞呈圓形或卵圓形,細胞核亦為圓形,邊緣稍帶鋸齒狀。有明顯的核仁(N:Nucleolus)中等量的張絲及少量粒線體(M:mitochondria)。細胞間隙正常。還有多量的胞橋小體(D:desmosome)。(bar = 5μm) 圖8 OSF頰黏膜中間層接近基底層的細胞。此層的細胞是多形性的;細胞核變大而且具有多種形態,細胞核(N:nucleus)內有發育良好的核仁(No:nucleoli),核體通常可以看到。還有稍多量的緻密染色質。M:mitochondria (bar = 5μm) 圖9 頰黏膜中間層接近基底層內的角質細胞。 胞橋小體(D:desmosome)相當多,而且大部份胞橋小體中有張絲(Arrow:tonofilament)插入。核糖體平均地分佈在細胞質中。大部份的粒線體(M:mitochondria)已破壞掉。可見到細胞核有皺摺(folded),細胞核與細胞質間有間隙(perinuclear space)。(bar = 4μm) 圖10 OSF頰黏膜基底層的細胞。基底細胞(B:basal cell)有指狀突起(interdigitation)以及多數細長的微絨毛,其細胞間隙是擴大的,細胞外型是多形性的,細胞的核 / 質比很大,細胞核通常具有一至數個發育良好的核仁。染色質被壓縮的程度很高,可以從明顯的邊緣的異染色質看出來。在細胞核內,可見到有很多內染色質(inter-chromatin)和周圍染色質顆粒 (perichromatin granules)。基底細胞的細胞質內有很多的張絲及多量的粒線體,同時摻雜著黑色素細胞(M:melanocyte)。 圖11 OSF頰黏膜基底層的細胞。基底細胞的細胞質內有很多的張絲。胞橋小體構造正常但數量很少。在基底細胞的面向基底膜一側的細胞膜上有許多構造正常的半胞橋小體(hemidesmosome)。有許多細胞質突起(CP:cytoplasmic process)伸入上皮下基質(subepithelial stroma)中,這些突起內含許多張絲。在大多數受傷的區域內的基底板(Arrow:basal lamina)看起來呈分枝狀、增厚而且變複層。(bar = 5μm)。 圖12 正常頰黏膜基底層細胞。 可見較多量的粒線體,細胞核呈圓形有明顯的鋸齒狀,可看到2到3個核仁;還有中等量的彈性纖維。可見短小的細胞質突起(P:cytoplasmic process),和連續的基底板(Arrow:basal lamina),基底板基本上是一層,有時可見兩層,有可能是切面的關係。面向基底膜一側的半胞橋小體很明顯。(bar = 5μm) 圖13 OSF頰黏膜固有層中不規則地排列的膠原纖維(CF:collagen fiber)。這些膠原纖維粗細不一。在這些膠原纖維中有微絲(MF:microfilament)構成的不尋常團塊。(bar = 1μm) 圖14 正常的頰黏膜固有層中排列規則的,粗細均一的膠原纖維(CF:collagen fiber)。(bar = 5μm) 圖15 OSF頰黏膜下深層組織。可見部份肌纖維(M:muscle)的退化。在已破壞的肌原纖維之間可見到均質的物體的聚集。肌纖維之間的微血管(V:blood vessel)也有受到影響;微血管的內皮細胞增厚,細胞質的密度也有變化,包圍內皮的基底板變得不規則而且斷斷續續的。(bar = 3μm) 圖16 OSF頰上皮下組織內的神經纖維的超微結構。 神經周圍細胞(PC:perineural cell) 兩側的基底板增厚且不完整,尤其是在內側;在此有許多微纖(MF:microfibrils )聚集。這些微纖也聚集在神經內的纖維母細胞附近。其它的微纖散亂地分佈在神經的周圍且呈被壓縮的狀態。神經內的膠原纖維緊密的集中在神經纖維旁邊。在神經內,有一些由膜包圍的構造,這些構造大小不一,來源未知,其中含有豐富的微纖。許旺細胞鞘被明顯增厚的基底板所包圍;這些基底板的厚度大約等於神經內膠原纖維的直徑。許旺細胞的細胞質有較多的微纖,偶而也有含有髓鞘的物體(MB :myelinated bodies)的空泡。在電子顯微鏡下可見不一密度的細胞質,有些呈現異常的電子穿透性,和軸突相似。軸突呈現退化的狀態,粒線體腫脹而且細胞質透明化。 透明化的軸突常可在神經細胞的遠心端看到,此處的軸突並沒有完全被神經周圍細胞(perineural cells)包住。 Fb:fibroblast Cf:collagen fiber(bar = 20μm) 圖17 掃瞄式電子顯微鏡下的OSF頰黏膜上皮的游離面。表面的細胞呈扁平的多邊形。可以見到個別細胞的重疊和脫落。 圖18 在更高倍放大下觀察OSF頰黏膜上皮的表面細胞。 這些細胞的表面型態有兩個特徵:微嵴(microridges)和微絨毛(microvilli);這些突起的密度在每一個細胞都不相同。 圖19 電子顯微鏡下的部份剝落的OSF頰黏膜表面細胞。細胞的內面有許多的微絨毛(microvilli)。 圖20 電子顯微鏡下的OSF頰黏膜表面細胞的一面上的微絨毛(MV:micro-villi)和微嵴(MR:microridge)。此細胞顯示出一過渡的區域,在此區中同時有微嵴和微絨毛。(bar = 5μm) 圖21A 電子顯微鏡下觀察OSF頰黏膜上皮表面細胞。表面細胞的形態有明顯的改變,可見到短而粗、有皰(B:bleb)的突起。(bar = 5μm) 圖21B 電子顯微鏡下觀察頰黏膜上皮中最嚴重的病變的區域。在表面細胞可發現許多大小不同的皰(B:bleb)。 圖22 正常的表皮細胞上的微絨毛大小均一,可見微嵴和微絨毛。 第五章 討論 臨床上,常見OSF 病人口腔黏膜上附著褐色的斑塊,同時在超微結構的觀察中亦可見纖維狀物嵌入分開的鱗狀上皮中,這些纖維狀物質可能是檳榔的纖維。若是如此,檳榔不單是在嚼食過程中,且在不嚼食的時間也會因嵌入上皮內的檳榔纖維而終日刺激上皮組織。進一步分析此種嵌入物的性質及是否含有致癌物質是必要的。 中間層細胞的細胞間隙水腫在Cohen等人(1971),Sirsat & Daftary(1974)的研究也有觀察到,同時在Banoczy 等人(1980)對口腔黏膜白斑病的觀察中亦提及三種形態的白斑病皆有細胞間隙水腫變寛的現象,尤其是在erosive leukoplakia,他們(Banoczy等人)認為這種現象是形成前癌(precancerous)及癌病變(cancerous lesion)的變化之一。與上皮細胞失去或減低細胞間接合力有關。且OSF亦有此種現象,可推測其亦有形成前癌或癌病變之潛能。 在中間層細胞還可觀察到含有細粒狀物質的囊狀空泡,這些空泡有時大到把細胞核擠到細胞邊緣而形成指環細胞之現象。觀察這些空泡有些部位在內腔有微絨毛,顯示這些部份是屬於細胞外側。其它部位則又顯示這些部份在細胞質內。這些空泡應該是smooth ER及rough ER(滑面及粗面內質網)的空泡化。細胞在初期受到傷害時,最初期及最一致性的變化為內質網的擴大(Diagnostic Transmission Electron Microscopy of Tumors p99)。同時水份亦進入其內,故內容物之電子透過性高呈透明狀。固然在上皮異形或癌組織中亦可觀察到內質網的空泡化,但在那種情況下,因細胞性質的改變,導致蛋白質合成能力改變,一般來說,其內容物電子密度較高或形成特殊的形態(Ultrastructure Patho of Cell and Matrix p336)。故OSF的此種變化應屬於細胞受到傷害所引起的反應。 在超微結構上,OSF可發現細胞質凸起伸入上皮下基底層(subepithelial stroma)。在白斑病的觀察中也有此現象被報告(Banoczy et al. 1980),但其形態為不含張絲的細胞突起而非如本研究所見是一種含有張絲的真正的細胞突起。同時基底板(basal lamina)變得不規則,可見缺損、變多層,相似的情況也在以前的研究被提及(Cohen et al. 1971,Sirsat & Daftary 1974);Banoczy (1980)等人對口腔黏膜白斑的電顯研究也有類似的發現。另外在鱗狀細胞癌(Chen et al. 1977)、疣狀癌(Prioleau et al. 1980)甚至於其他器官之慢性疾病及糖尿病亦有基底板增厚變多層等變化被觀察到。顯示基底板的變化,應非單純與惡性化或前癌化有關。基底板是由上皮細胞由來之物質,其功用之一為連結皮下組織,也有影響連接它的上皮細胞的分化與增殖的功能,基底板的變化,可能與檳榔的磨擦有關。在超微結構下上皮組織與其下之結締組織相接處有兩種變化最為明顯。一為基底的變厚,不規則及變多層,另一為細胞質突起伸入上皮下基質(subepithelial stroma)中。 基底膜的增厚,經常是因為細胞受到傷害而引起的一種保護反應,增厚的基底板膜形成一種障壁(barrier),使得減少或阻止毒素(toxin)侵入(Ultrastructural Pathobiology p53)。 在OSF的情況,可能是檳榔?所含的毒素對基底細胞引起刺激造成基底板變厚,形成障壁以避免毒性物質侵入上皮下組織。同時因為基底膜有連結皮下組織之功用,當不斷食用像檳榔般的硬物。上皮與其下結締組織受到檳榔較大的磨擦力而撕裂進而修復,尤其是在黏膜下組織纖維化後更沒有彈性的狀況下。故基底膜上可見破損以及多次增生的證據。同時也可解釋基底細胞的突起向固有層延伸變長以增加其接著力的功能性的表現。 正常的上皮下的結締組織的纖維是排列整齊、大小均一、聚集成束的;但在OSF的纖維則是排列混亂,在這些膠原纖維周圍可觀察到多量的細小,不成束的纖維(Binnie 1972)。這些纖維在電子顯微鏡觀察下非常類似reticulin fibers,應是伴隨基底板增生屬於黏膜下組織來源的reticulin fibers,它們的增生,也應該是如同基底板屬於抗摩擦的代償作用的結果。 OSF病人張口困難,不只是因為黏膜下纖維化,連肌肉組織都有受影響。肌細胞呈現不等程度的退化甚至壞死。 肌肉中的血管可見內皮細胞損壞的現象。肌肉的壞死,可能和局部缺血有關。 Mani (1977)的研究:OSF頰黏膜的血管數量減少。微血管周圍有較多的膠原纖維包圍住。供應肌肉的養分減少,和肌肉的壞死應有相關。由肌肉壞死的性質來看,在臨床上,單純切除纖維帶,治療張口困難,因為深層的肌肉組織也受到波及,可預見其效果是有限的。 在神經的變化上,以往的文獻沒有提到。末稍神經呈現退化現象,神經周圍細胞兩側基底板不完整。但主要的變化在軸突上,軸突或呈現透明化或形成空泡,這些空泡有些是粒線體的腫脹,有些則來源不明,可能是軸突本身的空泡化。這些變化很可能是一種急性發炎性神經病變(acute inflammatory neuropathies)(Diagnosis Ultrastructure of Non-Neoplastic Diseases p584-588)。在有髓鞘內軸突周圍的有髓鞘物體,可能是經由脫髓鞘反應(demyelination)所產生的產物(Diagnostic Electron Microscopy volII p309-350)。 在OSF的黏膜下組織可發現很多炎症細胞,這些炎症細胞當然可能與神經末稍產生neurogenic inflammation,但是除了這些細胞的作用以外,神經末稍的變性是否也是與病人不能忍受辛辣食物有關。這方面的研究在過去的報告並未見到,應是未來對OSF的研究的重點之一。這些神經變性的現象可能和病人不能忍受辛辣食物有關。 在掃瞄式電子顯微鏡下所觀察到的細胞表面,大部份與正常細胞的表面類似,但有少數細胞在形態上有相當大的差異,有類似癌細胞表面可觀察到的『皰』現象,但這種現象在細胞受到傷害後的恢復期也可觀察到,細胞在復原時,細胞形成大小不同的皰,其中包含被損害胞器,同時漸漸的在基部斷離而離開細胞。在穿透式電顯因為未觀察到此一現象,故可能只存在少數細胞表面,至於是癌化或受到傷害的恢復則無法確定。(Diagnosic Ultrastructure of Non-Neoplastic Diseases p66) 第六章 結論 1. OSF的口腔黏膜上皮組織的變化可見空泡、細胞間隙水腫、粒線體腫脹、基底板變複層。 2. 黏膜下纖維化的頰黏膜上皮的形態的改變,在穿透式及掃瞄式電子顯微鏡皆可觀察到,在掃瞄式電子顯微式鏡中,我們觀察到特殊現象是細胞的blebing,這種現象在癌細胞常被觀察到,是否為癌化的指標,需進一步的觀察。 3. 超微結構的研究發現,纖維化的現象不只是發生在基質,在神經以及肌肉組織中也有發現。上皮以下的組織廣泛的纖維化以及肌肉的變性造成了張口困難和口腔黏膜的堅硬無彈性。 4. 黏膜下層的膠原纖維在正常組織中的大小較均一;在OSF中則是細且多的不成熟膠原纖維。 5. 肌肉、神經和血管都有受傷的變化,尤其是神經的變化,主要在軸突上,許旺氏細胞並無變化。 6. 在OSF中,神經組織的變化(disorganized change)在以往的文獻中並沒有提到;這可能和患者不能忍受辛辣食物及口腔灼燒感有關。

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系統識別號 U0007-1704200714494813
論文名稱(中文) 鐵弗龍人工膜片與膠原蛋白膜於傷口癒合時細胞黏合現象與細胞激素表現之觀察與比較
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 柯孟宗
學號 M87040078
學位類別 碩士
語文別 中文
口試日期
論文頁數 0頁
口試委員 指導教授-呂炫堃
關鍵字(中) 黏合分子
細胞激素
牙周再生
膠原蛋白膜
鐵弗龍膜片
學科別分類
中文摘要 在經過牙周病治療後,我們希望能以牙周再生的技術以重建牙周組織的功能。在牙周手術上被廣為採用的,便是以ePTFE (expanded polytetrafluoroethylene)製成的GORE-TEX® (Goretex)膜片,但是使用此種再生膜卻有需要二次手術及容易產生膜片外露而造成感染的困擾。Biomend Extend™ (Biomend)則是一種可吸收性的膠原蛋白膜片,在臨床使用上也有良好的效果;而我們實驗室所製備的豬皮膠原蛋白膜(porcine dermal collagen membrane; PDCM),則是採取豬的真皮層所精製的一種可吸收性膠原蛋白膜片,根據研究顯示具有良好的生物相容性。由於膜片與組織之間的組織整合作用與免疫反應趨向仍未完全明瞭,本實驗以SD rat為實驗對象,將PDCM, Biomend與Goretex膜片植於實驗動物皮下,目的將觀察三種膜片與組織交界面的黏合分子表現,並以一套強度檢定系統,經Kruskal-Wallis檢定與Mann-Whitney多重比較後,分析三種人工膜片的免疫反應趨向。結果發現,在三種膜片中,Goretex膜片表面的黏合分子在上皮組織有較強的α2反應與較弱的β4表現,表現出較高有利上皮細胞移動的趨勢,可能導致臨床之Goretex膜片容易於術後暴露的情況;而在結締組織與膜片交界部份只有PDCM可以發現有α5的反應。而於第7天、第10天、第14天時觀察膜片與組織介面之間所產生的免疫反應趨向,分析結果發現三種膜片中,各時期interleukin-2 (IL-2)的表現並無統計上的顯著差異,而interferon-γ(INF-γ)在三種膜片中的表現也沒有明顯的差別。而PDCM膜片於各時期中所引發Th2型之interleukin-4 (IL-4)、 interleukin-10 (IL-10)與interleukin-13 (IL-13)的表現均低於其他兩種膜片,尤其以第7天到第14天時都顯著低於Goretex的表現(P < 0.05)。比較IL2/IL4 ratio,發現PDCM膜片一直與控制組有較相似的表現;而Goretex則顯著低於控制組(P < 0.01),如此顯示Goretex於組織中所引起的Th1/Th2反應,導致於GTR技術中趨向於組織破壞。本研究中顯示:Goretex膜片有較高引起上皮移動的趨勢,可能是造成在牙周臨床GTR技術應用時導致膜片暴露的原因,在結締組織中則以PDCM有α5的反應;分析PDCM膜片於傷口中所引發的細胞激素表現,比Biomend與Goretex膜片較趨向Th1細胞激素之表現,應可引導組織朝修復的狀態發展。
論文目次 致謝……………………………………………………………… I 中文摘要………………………………………………………… III 英文摘要………………………………………………………… V 目錄……………………………………………………………… VII 圖表目次………………………………………………………… VIII 第一章 緒論…………………………………………………… 1 第一節 研究動機與重要性……………………………….. 1 第二節 研究目的………………………………………….. 2 第三節 研究假設………………………………………….. 3 第二章 文獻查證………………………………………………. 4 第三章 研究材料與方法………………………………………. 15 第四章 研究結果………………………………………………. 21 第五章 討論……………………………………………………. 33 第六章 結論……………………………………………………. 48 參考資料………………………………………………………….. 62
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系統識別號 U0007-1704200714494814
論文名稱(中文) 以超音波觀察不同齒顏面形態成年人的舌頭吞嚥功能
論文名稱(英文) Ultrasound Investigation of the Tongue Function during Swallowing in Different Dentofacial Forms
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 鄭佳芬
學號 M87040096
學位類別 碩士
語文別 中文
口試日期
論文頁數 101頁
口試委員 指導教授-蔡吉陽
指導教授-彭建綸
關鍵字(中) 超音波
吞嚥
齒顏面形態
關鍵字(英) ultrasound
swallowing
dentofacial forms
學科別分類
中文摘要 為了瞭解舌頭在咬合發展所扮演的角色,本實驗使用超音波、傳統測顱X光片及牙弓模型為測量工具,檢測舌頭吞嚥功能與齒顏面形態的相關性。選取112名健康的成年志願者為受測對象(男性74位,女性38位,平均年齡為22歲),以電腦輔助B模式結合M模式口腔超音波防震掃描技術評估吞嚥時舌頭的運動情形,計算舌頭在不同吞嚥分期的運動持續時間、運動振幅以及速度,並以簡單相關分析法求得與齒顏面形態的相關性。 結果顯示:舌頭吞嚥運動與齒顏面形態間是有相關的,尤其以早期終止期(Phase IIIa)的運動振幅和齒顏面形態的相關性最為顯著,而運動持續時間及速度與齒顏面形態間較無相關。在齒顏面形態方面,以上下顎骨垂直關係及下顎第一大臼齒萌出度,和舌頭吞嚥運動的相關性最為顯著,但在離舌頭較遠處的顱底以及上顎骨的前後、垂直與旋轉關係,與舌頭吞嚥運動較無關聯;隨著牙弓長度的增加,在晚期終止期的吞嚥持續時間會延長。 由本實驗可知,不同齒顏面形態的個體的舌頭吞嚥功能是有差異的;使用電腦輔助B模式結合M模式口腔超音波防震掃描技術,來評估吞嚥時舌頭運動功能和齒顏面形態之間的關係時,是一種簡單、方便且值得推薦的研究工具。
英文摘要 To understand the role of tongue in the development of occlusion, the relationship between tongue movements during swallowing and dentofacial morphology was examined by ultrasonography, cephalometric radiography and dental casts. The computer-aided B+M-mode ultrasonography was used to assess their tongue movements. Duration, magnitude and speed of tongue movements in different swallowing phase were measured from 112 healthy adult volunteers and compared with their dentofacial morphology using a simple correlation analysis. The results show that the movements of tongue during swallowing are related to the dentofacial morphology especially in the motion magnitude of the early final phase (phase IIIa), while only few correlations are found when analyzing the duration and speed of swallowing. The results also present that the intermaxillary vertical relation has significantly positive relation with the motion magnitude of the tongue movements; however, the cranial base (component 1) and the maxilla (component 2-4), except the palatal depth, show no correlation to swallowing. Furthermore, arch length is found increased with prolonged duration of swallowing. This study also elucidated that the computer-aided B+M-mode ultrasonography in combination with the cushion-scanning technique serves as a valuable tool for investigation of the relationship between tongue movements during swallowing and dentofacial forms.
論文目次 致謝 I 中文摘要 II 英文摘要 IV 目錄 VI 附圖目錄 VIII 附表目錄 X 第一章 緒論 1 第二章 文獻回顧 4 第一節 舌頭與齒顏面型態的關係 5 第二節 研究舌頭位置及運動的方法 9 第三節 口腔超音波的簡介及發展 13 第四節 研究目的 21 第三章 材料與方法 22 第一節 研究對象 23 第二節 舌頭吞嚥運動的測量 24 第三節 齒顏面形態的測量 30 第四節 實驗誤差估計與再現性的評估 32 第五節 統計方法 35 第四章 結果 38 第一節 變相的分布性質 39 第二節 齒顏面形態的測量及分析結果 40 第三節 舌頭吞嚥運動的測量及分析結果 42 第四節 齒顏面形態與舌頭吞嚥運動之相關性 43 第五節 齒顏面形態測量變項分組與吞嚥運動之相關性 45 第六節 齒顏面形態與舌頭吞嚥運動相關性之性別差異 48 第五章 討論 50 第一節 齒顏面形態測量變項之分析 51 第二節 舌頭吞嚥運動測量變項之分析 52 第三節 齒顏面形態與舌頭吞嚥運動之相關性 55 第四節 齒顏面形態與舌頭吞嚥運動相關性之性別差異 59 第五節 臨床應用及未來展望 61 第六章 結論 63 參考文獻 66 圖表附錄 73
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Proffit WR. Equilibrium theory revisited: factors influencing position of the teeth. Angle Orthod 1978; 48: 175-86. 31. Alexander S, Sudha P. Genioglossis muscle electrical activity and associated arch dimensional changes in simple tongue thrust swallow pattern. J Clin Pediatr Dent 1997; 21(3): 213-222. 32. Fujiki T, Takano-Yamamoto T, Noguchi H, Tamashiro T, Guan G, Tanimoto K. A cineradiographic study of deglutitive tongue movement and nasopharyngeal closure in patients with anterior open bite. Angle Orthod 2000; 70: 284-289. 33. Melson B, Attina L, Santuari M, Attina A. Relationships between swallowing pattern, mode of respiration, and development of malocclusion. Angle Orthod 1987; April: 113-119. 34. Hanson ML, Barnard LW, Case JL. Tongue-thrust in preschool children. Part II: Dental occlusal patterns. Am J Orthod 1970; 57: 15-22. 35. Fröhlich K, Ingervall B Schmoker R. Influence of surgical tongue reduction on pressure from the tongue on the teeth. 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Computed tomographic measurements of tongue volume relative to its surrounding space. Am J Orthod 1982; 81:172-188. 43. Lauder R, Muhl ZF. Estimation of tongue volume from magnetic resonance imaging. Angle Orthod 1991; 61: 175-184. 44. Murakami E, Takada K, Fuchihata H, Sakuda M. Tongue volume in human female adults with mandibular prognathism. J Dent Res 1996; 75: 1957-1962. 45. Minifie FD, Kelsey CA, Zagzebski JA, King TW. Ultrasonic scans of the dorsal surface of the tongue. J Acoust Soc Am 1971; 49: 1857-1860. 46. Watkin KL, Zagzebski JA. On-line ultrasonic technique for monitoring tongue displacements. J Acoust Soc Am 1973; 54: 544-561. 47. Mettler FA, Schultz K, Kelsey CA. Gray-scale ultrasonography in the evaluation of neoplastic invasion of the base of the tongue. Radiology 1979; 133: 781-789. 48. Schuette WH, Shawker TH, Whitehouse WC. Television synchronization of a real-time ultrasonic sector scanner. J Clin Ultrasound 1978; 6: 16-18. 49. 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Findly IA, Kilpatrick SJ. An analysis of myographic records of swallowing in normal and abnormal subjects. J Dent Res 1960;39:629-35. 63. Peng C-L, Jost-Brinkmann P-G, Miethke R-R, Lin C-T. Ultrasonographic measurement of tongue movement during swallowing. J Ultrasound Med 2000;19:15-20.

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系統識別號 U0007-1704200714494815
論文名稱(中文) 矯正疼痛對下顎運動速度之影響
論文名稱(英文) The Effect of the Orthodontically Induced Pain on the Mandibular Movement Velocity
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 蕭慧貞
學號 M87040102
學位類別 碩士
語文別 中文
口試日期
論文頁數 86頁
口試委員 指導教授-蔡吉陽
指導教授-吳慶榕
關鍵字(中) 矯正疼痛
下顎運動速度
齒間分離器
關鍵字(英) orthodontically pain
mandibular velocity
separator
學科別分類
中文摘要 中文摘要 因為矯正治療中牙齒的移動,可能會引起牙齒的不適與疼痛而影響到正常的下顎功能,本研究是討論此矯正疼痛是否已經影響到正常的下顎功能。本研究在三十位成年受測者之單側第一大臼齒的近心側及遠心側各置放一條齒間分離器 ( separator )來當做矯正疼痛的引發工具,然後用下顎運動圖Mandibular Kinesiograph (MKG)來測量下顎三度空間未置放齒間分離器與放置後五天內下顎運動速度之變化。疼痛的評估以視覺類比尺度(VAS)來作記錄,K6測量的項目包括了疼痛程度與平均張口速度、最大張口速度、平均閉口速度、最大閉口速度及最終閉口瞬間速度之關係。 結果發現大部份的受測者會因齒間分離器而產生不同程度的疼痛,且疼痛高峰期會出現在後牙齒間分離器置放後的第二天與第三天間;但在疼痛程度與下顎運動速度之變化方面,其相關性並不高,約有一半以上的受測者因放置後牙齒間分離器所產生之疼痛對下顎運動速度的影響並不大,僅呈現低度相關,故齒間分離器所產生之疼痛並不至於造成下顎之運動速度之改變。齒間分離器的放置,可能的確使牙齒產生移位,因而使牙齒的咬合狀態產生改變,所以使得下顎最大閉口速度發生變化,但就整體下顎運動速度來說其變化是極為小的。
英文摘要 ABSTRACT The fear of pain is one of the key factors that discourage a patient from seeking orthodontic treatment . Orthodontic pain will decrease the muscular activity in EMG studies . Changes in masseter muscle activity during orthodontic treatment were probably due to discomfort , pain or alteration in occlusal relationship produced by tooth movement . But , we still do not understand that the pain due to orthodontic appliances will affect the function of jaws movement or not . The purpose of this study is to determine the effect of orthodontic pain on the velocity of mandibular movement on thirty subjects . The subjects ( 18 males and 12 females , ranging from 32 to 23 years old ) were observed by using a Myotonics Kinesiograph K-6 Model for the measurement of jaw motion velocity before and after the insertion of orthodontic posterior separators first day , second day , third day , fifth day , and fifth day after the separators was removed . The continuous opening — closing strokes five times were recorded and processed to evaluate the following parameters : 1. the maximal opening and closing velocity , 2. the average opening and closing velocity ,and 3. the maximal velocity before tooth contact . The measurement of orthodontic pain were evaluated by visual analog scales ( VAS ) . Average velocity of five consecutive mandibular movement strokes of the five days were compared with VAS by Pearson Correlation . Neither the opening velocity nor the closing velocity were affected by inserting separators . The maximal closing velocity of fifth day , and after the separators were removed were different from the first day just before the separators were placed ( p — level < 0.05 ) . In conclusion , the mandibular opening velocity , closing velocity , and the maximal velocity before tooth contact were not affected by orthodontic posterior separators .
論文目次 目 錄 中文摘要 英文摘要 第一章 緒論 1 第二章 文獻回顧 5 第一節 矯正治療之疼痛 6 1 — 1 疼痛之定義 6 1 — 2 矯正治療期間之疼痛的原因及機轉 7 1 — 3 矯正治療時之疼痛變化及影響因子 10 第二節 疼痛之測量方法 13 第三節 Mandibular Kinesiograph 之文獻回顧 16 第四節 疼痛對下顎運動速率之影響 18 第三章 研究材料與方法 19 第一節 受測者之選擇 20 第二節 製造疼痛之方法 21 第三節 疼痛之測量方法 22 第四節 下顎運動速度之測量 22 4 — 1 Model K6 Diagnostic System之裝置方法 23 4 — 2 測量時機 25 第五節 受測者誤差估計與統計方法 27 5 — 1 VAS評估表之誤差估計 27 5 — 2 下顎運動速度紀錄之準確性估計 27 5 — 3 疼痛程度與下顎運動速度間之相關性統計 28 5 — 4 下顎運動速度於置放後牙齒間分離器後之變化 28 第四章 實驗結果與分析 29 第一節 實驗誤差之估計 30 1 — 1 視覺類比尺度評估表(VAS)線段測量值之誤差估計 30 1 — 2 下顎運動速度紀錄之準確性估計 30 第二節 矯正疼痛評估結果之分析 31 第三節 矯正疼痛與下顎運動速度間之相關性 32 3 — 1 個別之疼痛值與下顎運動速度間之相關性 32 3 — 2 疼痛值與下顎運動速度比例間之相關性 33 3 — 3 疼痛高峰期與下顎運動速度降低程度之關係 33 第四節 下顎運動速度變化之比較 34 4 — 1 下顎平均張口速度 34 4 — 2 下顎最大張口速度 35 4 — 3 下顎平均閉口速度 36 4 — 4 下顎最大閉口速度 38 4 — 5 下顎最終閉口瞬間速度 39 第五章 討論 41 第一節 實驗之設計 42 1 — 1 矯正疼痛之製造 42 1 — 2 實驗紀錄之天數 42 1 — 3 疼痛之計測 43 第二節 疼痛高峰期之比較 43 第三節 矯正疼痛與下顎運動速度間相關性之探討 44 第四節 下顎運動速度變化之探討 46 第五節 疼痛之探討 47 第六節 下顎運動速度之探討 49 第 六 章 結 論 與 建 議 50 第 七 章 參考文獻 53 附錄 一 表 目 錄 表一 表二 表三 表四 表五 表六 表七 表八 表九 表十 表十一 表十二 表十三 表十四 表十五 表十六 表十七 表十八
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系統識別號 U0007-1704200714494816
論文名稱(中文) 應用工具條件制約行幼童拉唇訓練之影響
論文名稱(英文) Effect of Lip Training of Preschool Children Using Operant Conditioning
校院名稱 臺北醫學大學
系所名稱(中) 牙醫學系碩博士班
系所名稱(英) Graduate School of Dentistry
學年度 90
學期 2
出版年 91
研究生(中文) 莊才逸
學號 M004089009
學位類別 碩士
語文別 中文
口試日期
論文頁數 68頁
口試委員 指導教授-吳英寬
關鍵字(中) 肌功能治療
拉唇訓練
工具條件制約
關鍵字(英) myofunction therapy
lip seal training
operant conditioning
學科別分類
中文摘要 於兒童生長發育時期,肌功能治療常藉由肌肉訓練來改善不協調的肌肉功能或矯治兒童齒列不整的問題,但學齡前兒童往往不了解訓練的重要而無法配合,使治療效果不佳。本研究結合工具條件制約與拉唇訓練,除調查學齡前兒童唇肌拉力的強度並比較拉唇訓練前後的差異,期能藉由獎勵模式增強學齡前兒童參與訓練的動機,測量拉唇訓練對強化唇肌拉力的影響程度。本研究共有277位學齡前幼童參與,其中實驗組147位,對照組130位。將所有幼童之初始唇肌拉力記錄後,實驗組幼童開始拉唇訓練,對照組則否。經三個月拉唇訓練後,實驗組及部份對照組幼童接受第二次唇肌拉力測量並加以記錄。實驗組幼童於第二次唇肌拉力測量後開始加入工具條件制約於拉唇訓練,再經三個月後所有幼童再做一次唇肌拉力測量並記錄。本研究發現所有參與研究之幼童第一次唇肌拉力測量值與幼童之身高、年齡有相關性,因此推測唇肌拉力強度可能與身體肌肉發育成熟度有關。實驗組與對照組第二次唇肌拉力測量值分為別448±222公克及358±172公克,兩者之間差異有統計上的意義(p<0.05);實驗組與對照組第三次唇肌拉力測量值分別為539±252公克及290±162公克,兩者之間差異有統計上的意義(p<0.01),由此可見拉唇訓練可增強唇肌拉力。在實驗組幼童無論以性別分別或年齡分別,三次唇肌拉力測量值兩兩相比皆有統計上的差異(p<0.01),由此可推論,唇肌拉力隨著訓練時間增長而增加,應用工具條件制約可加強幼童唇肌拉力測量值,尤其是女童,可能因本研究所用之增強物對女童較有增強效果。
英文摘要 During growth and development, myofunctional therapy via muscle training has been used to improve muscle dysfunction or to correct malalignment of dentition during early childhood. Preschool children usually do not understand the importance of training and result in uncooperativeness, which make treatment result unpredictable. The purpose of this study is to: (1) measuring the lip strength of preschool children;(2) evaluate the effect of lip training on changing of lip strength and (3) evaluate the effect of operant conditioning on lip training program. In addition to record the lip strength of preschool children, the differences of lip strength after lip training were also surveyed. Positive reinforcement was used to increase the motivation of preschool children to attend the training, therefore the increase of lip strength was expected. There were 277 preschool children attended this study, 147 of them were in the study group, 130 were in the control group. The lip training program started in the study group children after baseline lip strength was recorded. After 3 months, lip strength was recorded again from all of the children in the study group and part of the control group, meanwhile the operant condition was combined into the study group at this stage. Another 3 months later, lip strength recorded again on all the children. It has been found in this study that lip strength baseline data were correlated with the height and age; this could be related to the maturation of muscle. At the second stage, the mean of lip strength of the study and control group were 448±222g and 358±172g, the difference between them was statistically significant (p<0.05). At the third stage, the mean of lip strength of the study and control groups were 539±252g and 290±162g, the difference between them was statistically significant (p<0.01). Which demonstrated that lip training could increase lip strength. In the study group, there were significant differences of lip strength among three measuring stages respecting upon age and sex factor. It implied that lip strength increased with the training duration. The operant condition can improve the effect of the training on the lip strength, especially in the girls, probably due to the reinforcer used in this study were more effective for the girls than the boys.
論文目次 致謝………………………………………………….……….….I 中文摘要………………………………………………………...II 英文摘要………………………………………………………...V 目錄……………………………………………………………...VI 圖表目次………………………………………………………...VII 第一章 緒論 1 第二章 文獻回顧 3 第一節、口腔周圍軟組織與齒列的關係 3 第二節、工具條件制約理論 7 第三章 材料與方法 10 第四章 研究結果 15 第五章 討論 24 第六章 結論與臨床意義 32 參考資料 33 附錄 附錄一 唇肌拉力訓練家長同意書 57 附錄二 唇肌拉力獎勵記錄表 58 圖 表 目 次 表一、 工具條件制約基本類型…………………………….36 表二、 應用工具條件制約行幼童拉唇訓練之研究對象….37 表三、 應用工具條件制約行幼童拉唇訓練之研究對象咬合狀況………………………………………………… 38 表四、 全體幼童第一次唇肌拉力測量值與身高、體重、年齡、性別的相關性………………………………… 39 表五、 實驗組與對照組第一次唇肌拉力測量值(公克)及性別的比較………………………………………….…40 表六、 實驗組與對照組第二次唇肌拉力測量值(公克)及性別的比較…………………………………………… 41 表七、 實驗組與對照組第三次唇肌拉力測量值(公克)及性別的比較…………………………………………….42 表八、 實驗組與對照組第一次唇肌拉力測量值(公克)及年齡的比較…………………………………………….43 表九、 實驗組與對照組第二次唇肌拉力測量值(公克)及年齡的比較…………………………………………….44 表十、 實驗組與對照組第三次唇肌拉力測量值(公克)及年齡的比較…………………………………………….45 表十一、 實驗組與對照組三次唇肌拉力測量值之比較...46 表十二、 實驗組大班幼童三次唇肌拉力測量值之比較...47 表十三、 實驗組中班幼童三次唇肌拉力測量值之比較...48 表十四、 實驗組男童三次唇肌拉力測量值之比較……...49 表十五、 實驗組女童三次唇肌拉力測量值之比較……...50 表十六、 實驗組幼童三次唇肌拉力測量值之比較……...51 表十七、 對照組大班幼童三次唇肌拉力測量值之比較...52 表十八、 對照組中班幼童三次唇肌拉力測量值之比較...53 表十九、 對照組男童三次唇肌拉力測量值之比較……...54 表二十、 對照組女童三次唇肌拉力測量值之比較……...55 表二十一、對照組幼童三次唇肌拉力測量值之比較……...56
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