rAPCHlYDlfOCLAMSANGTOS Tap 12-56 7/2017
Danh gia kit qua dilu tri phau thuat chinh hinh xuong ham tren benh nhan khe ho^ moi - vom mieng
Evaluation of orthognathic surgery in cleft lip and palate patients
Vu Tuin Hung Benh vien Rdng Hdm Mat Trung urmg
MtiC tiiu: Danh gia ket qua dieu tri p h l u thuat chinh hinh xUang ham tren benh n h i n khe hd mdi - vom mieng. Ddi tugng vd phuong phdp: Tai Benh vien Rang Ham Mat Trung uong Ha Noi tU nam 2011 den 2017 da tien h l n h p h l u thuat chinh hinh xUang cho 30 benh nhan bi di tat khe hd moi vom mieng;
phuong phIp: jVlo ta eat ngang, tien cdu. Kitqud. DQa vao cac tieu ehi ve tham my va chUe nang, ed 90%
benh nhan dat ket q u i tdt; 6,66% benh nhan dat ket qua kha va ty le benh nhan co k^t qua kem la 3,33%. Kit ludn: D l y chinh I I cO sd de chUng minh sU thanh cong cua phau t h u l t chinh hinh xUong mat tren benh nhan co khe hd moi - vom mieng.
Tdkhda: Khe hd moi vom mieng, p h l u t h u l t chinh hinh xuang ham.
Summary
Odjecf/Ve: Evaluation of orthognathic surgery in cleft lip and palate patients. Subject and method: At the National Hospital of Odonto-Stomatology in Hanoi from 2011 to 2017 have 30 patients with cleft lip and palate had orthognathic surgery; study method: Cross-sectional descriptive, prospective elinieal analysis. Result: Based on the criteria of aesthetics and function, 90% of patients achieved excellent results, 6.66% patients achieved good results and the rate of patients w/ith the poor performance 3.33%.
Conclusion: This is the basis to prove the success of orthognathic surgery combined with orthodontic treatment for facial reconstruction and dental rehabilitation.
Keywords: Cleft lip and palate, orthognathic surgery.
I . D a t v a n d e Q u i trinh phuc hdi ehUe nang v l tham my tren benh nhan khe hd mdi - vdm mieng p h l i qua nhidu quy trinh dieu trj;
Khe h d mdi - v d m mieng la mdt dj t i t bam sinh
thudng gap. Tren the gidi ty le khe h d mdi - vdm , , , , . , , , , •, ,. . , „ , , , „ „ ' , „ „ „ „ Af,,-. K, 6 thang phau thuat tao hinh moi.
mieng a tre mai sinh la 1/600-1/1000. O Viet Nam ^ ^
t^ le n l y 111 - 2/1000. Tai B^nh vien Rang Ham IVlat TU 12 den 18 t h i n g ddng khe h d v d m mieng.
rmng uong H I Ngi tQ 1985 -1995 d l md 1315 benh TU 7 den 12 tudi ghep xUang 6 rang neu ed gian nhan khe h d mdi - v d m mieng. Rieng nam 2011 md doan eung r i n g .
200 ea khe h d mdi - v d m mieng. TQ 12 tudi nan chinh rang lech lae.
. Benh nhan khe h d mdi - vdm mieng gay thieu
"Ngdynhdn hdi: 19/5/2017. ngdy chdp nhdn ddng: 29/5/2017 sin xuong ham tren do dd dan den bdnh nhan cd
"Ngimiphdn hdi. Vu TuanHiing bit ddi xUng mat, khdp can loai 111 chiem ty Id ldn.
Imail [email protected] - Binh vien Rdng Hdm Phlu thult ehinh hinh xUOng him II1 trong ele quy
\4^i Trunguang Xfinh cudl eung de phuc hdi chQe nang vl tham my 91
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
eho benh n h i n va dddc tien h l n h khi benh nhan tren 18 tudi.
TQ nam 2011 den nay tai Benh vien Rang Ham Mat Trung UOng Ha Ndi da tien h l n h p h l u t h u l t tren 100 benh n h i n bat ddi xQng mat, trong dd cd 30 benh n h i n cd khe hd mdi - vdm mieng dat ket qua tdt sau khi da dugc ehinh nha, lap ke hoach dieu tri ehi tiet dUa vao phim, I n h , p h l n mem chuyen dung, phau thuat tren mau va l l m mang phau thuat.
D l y ehinh la co sd de chQng minh sU thanh cdng eua phau thuat ehinh hinh xUOng
2. Doi tugng va phuong phap 2.1.Dditdcng
Nghien cQu thUc hien tren 30 benh n h i n cd khdp c l n loai 111 xUOng do khe hd mdi - vdm mieng, duge phau t h u l t dieu trj tai Benh vien Rang Ham Mat Trung UOng Ha Ndi t d n l m 2011 - 2017.
Tiiu chudn chgn binh nhdn
Tat e l eac benh nhan bien dang mat, lech lac khdp c l n loai III xuang tren benh nhan ed khe h d mdi - vdm mieng duge chi djnh dieu tri bang phau t h u l t sau khi nan chinh rang.
Benh nhin > 18 tudi (qua tuoi tang trUdng xuang).
Cd dd didu kien phau t h u l t . Tieu chudn logi trd
Benh nhan cd benh ly ve xUang ham.
NhQng benh nhan ed benh ly toan t h i n cap tinh hole man tinh khdng ed du k h i nang t r l i qua cudc phau t h u l t .
2.2. Phucfngphap
Tien eUu, md t l e l t ngang. Tat c l eae benh nhan dugc dieu trj phau t h u l t , theo doi va danh g i l ket q u i theo cae mde thdi gian: Ngay sau md, 6 t u i n , 6 t h i n g sau phau t h u l t .
2.2.1. Khdm Idm sdng, chdn dodn
Tat e l eae benh nhan deu dugc k h I m v l d i n h gia ve lam sing.
Cdc chisd sg mat qua phim X-quang Tat c l eac benh nhan den duge chup phim sg tU xa (Cephalometric) va phim t o l n eInh (panoramic)
VO1.12-N7/2017 I trude va sau mo. T i t ca c l e phim dugc lam tai Khoa X-quang, Benh vien Rang H i m Mat Trung uong Ha Ndi theo tieu ehuan thdng nhat.
Lap kehogch trudc phdu thudt
Ke hoach dieu tri dugc vaeh chi tiet bao g6m phuong p h I p dieu trj, eac giai doan v l thdi gian dieu trj, sQ phdi hgp chinh nha trUde phau thuat thdi gian duy tri ket q u i , nhQng rui ro v l han die cua ket q u i dieu trj.
Phdi hop chinh nha trudc phau thudt , Muc dich cCia giai doan dieu trj ehlnh nha la di/a | c l e rang ve vj tri g i l l phau, s i p xep deu dan cac rang tren cung ham de c l l thien tdi da ve mat tham my v l chQc nang cho benh nhan eu the la:
Hudng dan rang v l sap xep eac rang va cau trOc | xUOng ham b i n g lUe cO hgc, thiet lap vj trf ly tifdng eua ele r i n g eUa theo ehieu trUdc sau va theo chi^u I dQng. Giai doan nay thQdng keo dai trong khoing 6
12 t h i n g tuy theo mQe do lech lae cua rang, va i duge tien hanh tai Khoa Chinh hinh Ring, Benh vl&n '
Rang Ham Mat Trung UOng H I Ndi. i Phdn tich phdu thudt trin mau hdm
Sau khi can sap d khdp c l n trung t i m , dat sap can vao m l u ham di t h l n h l i p mdi tuong quan khdp cSn thuc te cda benh n h i n vao cang nhai Quickmaster.
Cd dinh gia khdp vao vj t r i can khdp nay, vach mdt dudng thang di qua dinh mui ngoai cOa cac I r i n g d ham c l n phau thuat. Cat m l u ham theo dudng eat xUang dU kien. Sau dd ehgn lUa vj tri can khdp tdi Uu va dat lai cac mau ham vao vj triti/cfng quan ly tudng nay. Khoing elch xe djch gida cac dudng thang d mau h i m cho thay mQc dd can phai dich chuyen xuong.
Sau khi h o l n tat viee phau thuat trdn mau ham, dat lai eae mau n l y v I o vi trf tuang quan khdp c3nl#
tudng, chung tdi tien hanh l l m m l n g phau thuat bang nhUa d vj trf da dU djnh nly. ChUe nang cOa m l n g phau thuat la giQ eho sU tUong quan khdp can cua hai cung rang tren lam sang d tU the tdt nhat nhu da d u djnh ban dau, sau khi viec elt xU<Jng hoan tat.
Tien hdnh phdu thudt.
Diiu trj chinh nha sau phau thudt: Giai doan nay ' keo dai 6 t h i n g , de duy tri khdp can dn djnh. '
AP CHi Y Dl/CfC U M SANG 108 Tap 12-So 7/2017
2.2.2. Phuang phdp ddnh gid kit qud Thdi gian ddnh gid: D i n h g i l ngay sau phau thuat, iau p h l u t h u l t 3 t h i n g , sau 6 t h i n g v l sau 1 n l m .
Ddnh gid kit qud gidi phdu D i n h gia khdp can:
Tdt: Khdp can binh t h u d n g h o l e loai I, long mui tdi da d khdp can trung tam.
Trung binh: Sai khdp can loai I h o l e loai 11, ed diem cham sdm d khdp can trung tam.
Kem: Sai khdp can loai II h o l e loai III, can ddi dau hoac can ngugc vung rang cdi, hoac c l n h d vung rang cUa.
Danh g i l sd do n h i n trac sau phau t h u l t : Dua tren sd do trung binh ket qua phuc hdi tren phim X-quang.
Ddnh gid kit qud chdc ndng rieng Banh gia ehUe nang an nhai:
Tdt: ChQe nang an nhai t d t (luc nhai t r d lai binh thudng).
Trung binh: Chi nhai dugc thQe an mem (iQc nhai yeu, cdn e l m giac e ham).
Kem: Khdng nhai nat thQc an (lUc nhai yeu, dau khi nhai).
D i n h g i l chQc n l n g van ddng khdp;
Tdt: Van dgng khdp binh thQdng.
Trung binh: Van ddng khdp khd khan, cdn dau.
Kem; Van ddng khdp ham han che ( h i mieng han ehe).
Danh g i l dau hieu cac benh ly d khdp:
Tdt Khdng cd trieu chQng d khdp thai dUong h i m . Trung binh: Cd tridu chQng d khc^ t h l i duang h i m . Kem: Tang trieu chUng d khdp t h l i duang ham.
Ddnh gid kit qud chdc ndng chung
Dda v I o hieu q u i an nhai va lue can, van ddng khdp t h l i duong ham, dau hidu benh ly d khdp t h l i duang h i m .
Ket q u i t d t khi e l 3 tidu chf dat loai tdt.
Ket q u i trung blnh khi it nhat c l 3 tieu chf xdp loai trung binh.
Ket qua kem khi cd it nhat 1 tieu chi xep loai kem.
Ddnh gid kit qud thdm my
Dua vao sd do ele gde tren phim sg sau phau t h u l t , dua vao su hai hda cua khudn mat, dUa vao b i n g eau hdi danh gia danh eho benh nhan.
Tdt; Sd do eac gdc tren phim sg thay ddi ve g i l trj chuan, khudn mat hai hda. Benh nhan hai Idng.
Trung binh: Sd do ele gde tren phim sg thay ddi ve g i n gia trj chuan, khudn mat tUong ddi hai hda.
Benh nhan hai Idng nhung ehua thda man.
Kem: Sd do cac gdc tren phim sg ed thay ddi, khudn mat tuang doi hai hda. Benh n h i n khdng hai Idng.
Bdnh gid kit qud chung
Chung tdi d i n h gia ket q u i chung theo 3 tieu chi g i l i phau, chQe n l n g va tham my:
Ket qua tot khi ea 3 tieu chi dat loai tdt.
Ket qua trung binh khi it nhat ca 3 tieu ehi xep loai trung binh.
Ket q u i kem khi cd ft nhat 1 trong 3 tieu chf xep loai kem.
3. Ket qua
B i n g 1 . Dac d i e m ve g i d i
So lUtfng T y l e %
Nam 12 40
ua
18 60 Ty le nQ chiem 60% phan I n h nhu cau tham my cua nQgidi cao hon.
Bdng 2. Dac d i e m vi Iche h d m o i - v o m m i e n g Oac diem
Khe hd moi ddn thuan Khe hd vom mi&ng ddn thuan
Khe hd mdi va khe hd vdm mieng
T^ng
So lUtfng 6 3
16 SO
TJIc%
20 26,66
43,34 too Trong 30 bdnh n h i n nghidn cQu cd 6 benh nhan (20%) ehi bj khe h d mdi don thuan va 16 benh n h i n bj khe hd mdi v l khe hd vdm chidm 43,34%.
93
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N°7/20I7
BIng 3. T^ le cac loai phau thuat Bang 7. Ket qua dieu tri
PhUtfng phap phau thuat
Phau thuat mot ham Phau thuat hai ham
T6ng
S6IUdng 6 24 30
T J l e %
20 80 100 Phau thuat 2 ham chiem da so 24/30 trddng hdp (80%).
Bing 4. Ty If thay do! phan xUtfng
Trddc phlu thuat Sau phau thuat
SNA
73,8
73,5 SNB
78,5
75,5 ANB
-4,7
+3 Gdc ANB dat g i l trj +3 sau phau thuat giup e l i thien nhidu ve t h i m my eho benh nhan.
Bang 5. Ty le thay doi phan mem
Trudc phau thuat Sau phau thuat
Goe mui moi (dd)
54,87
77,5
T^ le: Tang tren/tang dUdi
mat
1,04/1
1,03/1
T^le SnIi/SnMe
1/3,305
1/2,85
TJ le phan mem thay ddi ro ret sau phau t h u l t d gdc mui mdi tQ 54,87° len den 77,5°.
Bing 6. T$ le tai bien trong qua trinh phau thuat
c h l y m l u Gay xddng Tdn thudng dly than kinh
Tong
So lUtfng 1/30
0 2/30 3/30
T ^ l c % 3,3
0 6,7
10 Sau 3 t h i n g Sau 6 t h i n g Sau 1 n l m
Tot
27
in 27
Trung binh
3 2 2
Kem
° 1
'1
1 %Ty le tai bien ton thdong than kinh chiem 2/3 benh nhan.
T)- le dat ket qua t d t duy tri t d sau 3 thing den 1 j nam la khong thay doi 27/30 benh nhan.
4. Ban luan
Trong so 30 benh nhan bj khe hd mdi - vom mieng dUdc tien hanh phau t h u l t chinh xddng thi ty le n d chiem 60% cho thay nhu cau tham my ciia nil gidi thddng cao hdn. B&nh nhan bj khe hd moi vJ vdm mieng ludn kem theo bl^n dang xddng ham tren kem phat trien dan den lech lac khdp cln loai lil dac biet la benh n h i n bj khe hd mdi va vdm mieng hai ben. Ty le khe hd moi vom mieng 2 ben trong nhdm nghien cdu cOa chung toi chiem ty \% khi cao 16/30 benh nhan (43,34%). Bieu nay cho thay su bat can xdng gida xddng ham tren va h i m dddi tren benh nhSn khe hd moi 2 bSn Idn nen nhu cau diSu tr! cao. Theo cac t i c gia tren the gidi nhu cau dieu tli p h l u thuat chinh hinh xddng ham tren benh nhan khe hd moi vom mieng khoang 25% - 76,5%. Tuy nhien, is Viet Nam do dieu kien kinh \.i cila ngi/Si dan con han che nen t^ le benh nhan khe hd moi- vom mieng dddc ti^n hanh phau t h u l t chinh hinh xddng cdn thap. TJ le phau thuat 1 ham cCia chiing toi chiem ty 16 6/30 bSnh n h i n , phau t h u l t 1 hSm ', thddng dddc tien hanh doi vdi xddng ham tren Xddng ham tren dddc cat rdi theo ky t h u l t Lefort I de day ra trddc hoac/va xudng dddi tCiy vao finh trang thieu s i n cOa xdong ham tren. Tuy nhiSn 44 vdi cac trddng hdp c6 sir bat can xdng cila mat phang khdp theo mat phang thang ddng hoac Sj bat can xdng q u i Idn glOa xddng ham tren va d * thl chung toi deu quyet djnh p h l u t h u l t haj ham Theo Georglade nen phJu thuat hai ham &i " 9 * trang cho sd thieu san q u i mdc cua xddng him treh.
tranh p h l i dda ra trddc xddng ham tren qua n h i W su co ked'cua seo sau phau t h u l t tao hlnh moiw
TAP CHl Y DUOC LAM SANG 108 Tap 12-56 7/2017
vdm mieng. Bay cung I I yeu to g l y ra su t l i p h l t sau dieu trj.
Quyet djnh p h l u t h u l t hai ham eho benh nhan duoc danh gia dua vao k h I m tren l l m s i n g va phau thuat g i l dinh tren m l u . TQ dd, ehung tdi lap ke hoach chi tiet de xae djnh vj tri xQOng h i m tren va xUOng ham dudi de dat duae ea chQc n l n g khdp can va tham my khudn mat. Vdi phau t h u l t nay, ehung tdi da cli thidn duac gde ANB dat gia trj +3 sau phau t h u l t giup cll thien nhieu ve tham my cho benh n h i n . Ty le p h l n mem thay doi rd r e t gdc mui mdi tQ 54,87 do tang len 77,5 dp sau phau thuat dieu nay khIng dinh k h i n l n g cli thien tham my cua phau t h u l t .
Cac tai bien trong phau thuat cd the x l y ra do day la phau thuat phUe tap lien quan nhieu tdi than kinh, maeh mau, ddi hdi p h l u t h u l t vien p h l i cd kinh nghiem v l can trong
Tai p h l t sau phau thuat chinh hinh xuong cda benh n h i n khe h d mdt, vdm mieng ludn dUOc ghi nhan theo Hochban ty le tai phat cao gap 4 lan so vdi benh nhan khdng bj khe hd mdi vdm mieng.
Trong 30 benh nhan phau thuat sau mot nam chung tdi da p h l i phau t h u l t lan 2 cho 1 benh n h i n . Ca 3 benh n h i n ket q u i ban che khi ehi p h l u thuat day ham tren ra trUdc. Cd rat nhieu nguyen nhan dan den t l i phat nhusQthieu s i n cua xuang ham tren va phln mem qua Idn kem theo sueo keo eua seo vdm mieng, thdi gian duy tri cda m l n g phau t h u l t it, djch chuyen xUOng qua nhieu... de han che t l i phat vdi tat c l bdnh nhan dich chuyen xudng dUdI hdn 2mm chung tdi deu tien h l n h ghep xUang t u t h l n . 5. Ket ludn
TQ n l m 2011 den nay tai Benh vien Rang Ham Mat Trung UOng Ha Ndi da tien h l n h p h l u thuat chinh hinh xuang cho 30 benh nhan cd khe h d mdi - vdm mieng cd tf- le nQ/nam la 2/3. Trong cac benh nhan n l y t;? le phau thuat hai ham la 80%, dieu nay cho thay vdi bdnh nhan khe hd mdi - v o m mieng phau t h u l t hai ham la phuong I n 6dac lUa ehpn chu yeu. Vdi ele benh nhan ed khe h d mdi h o l e khe hd vdm mieng 1 ben gay bidn dang xUOng ham tren it han so vdi 2 ben nen ed t h e phau thuat 1 h i m . Vdi 90% benh nhan dat ket q u i tdt, d l y ehinh la eO sd
de ehUng minh sU thanh cdng eua phau t h u l t chinh hinh xuang mat trong dieu trj b i t ddi xQng xUong h i m mat d benh nhan ed khe h d mdi - vdm midng.
Tai lieu t h a m k h I o
1. Nguyen Thj Kim Huang, Tran Ngoc Quang Phi, Llm Ngoc An (1993) Tmh hinh df tat khe hd mdi, hdm ich tgi thdnh phd Ho Chi Minh (1976 -1986). K^
yiu edng trinh nghien cUu khoa hoc 1975 - 1993.
Vien Rang Ham Mat thanh phd Ho Chi Minh xuat b i n , tr. 189-193.
2 Phan Thj XuIn Lan (2004) Khdi niem viphau thuat chinh hinh. Chinh hinh rang mat - Kien thQc co b i n va dieu tri d u phdng. Nha Xuat b i n Y hpc chi nhlnh TP. Hd Chi Minh, tr. 232-252.
3. Le Thj Nhan (1977) Mot so cdch phdn logi lech Igc rdng hdm. Rang Ham Mat tap 1. Nha Xuat b i n Y hpe, tr. 445-449.
4. Mai Thj Thu ThIo, Doan Qudc Huy, Phan Thj Xuan Lan (2004) Phdn log! khdp cdn theo ANGLE. Chinh Hinh Rang Mat, Nha Xuat ban Y hpc, tr. 67-76.
5 Johan P, Reyneke (2004) Surg/co/ technique.
Essentials of Orthognathic Surgery. Chapter 5:
247-282.
6. John Daskalogiannakis DDS, M Se FRCD (C), Menisha M, DDS (2009) The need for orthognathic surgery in patients with repaired complete unilateral and complete bilateral cleft lip and palate. Cleft Palate-Craniofacial Journal 46(5).
7. Proffit, WR (2000) Comb/ned surgical and orthodontic treatment. Contemporary Orthrodontic.
Chapter 22:315-358.
8 . Posnlck JC (1996) Orthognathic surgery for the cleft lip and palate patient. Semin orthod 2(3): 205-214.
9. Thongdee P, Samman N (2005) Stability of maxillary surgical movement in unilateral cleft lip and palate with preceding alveolar bone grafting.
Cleft Palate Craniofac J 42:664.
10. Scolozzi P (2008) Distraction osteogenesis in the management of severe maxillary hypoplasia in cleft lip and palate patients.-} Craniofac Surg 19:1199.
95
