Y Hpc TP. Ho Chi Minh * Tap 16 * Phu ban cua So 1 * 2012 Nghien cxhi Y hpc
KET QUA P H A U THUAT DAT LUI HAM VlJdl BANG KY THUAT CAT CHE DOC NGANH LEN XU'ONG HAM D U O I
Nguyen Van Hoa*
TOMTAT
Muc tieu: Ddnh gid kei qud dieu tri bieh dgng xuang hdm du&i (XHD) bdng ky thudt cat die doc ngdnh len trong phdu thudt (PT) dgt liii XHD.
Phuong phdp: Tren 28 benh nhan co bieh dgng nho xuang hdm duai g'om 22 nie, 6 nam tuoi tii 17-38, dugc plidu thugt tgi benh vien RHM tlidnh plio'Ho Chi Minh.
Kei qua: KH qua ve chuc ndng chung: 89,3%> dgt logi tdi vd 10,7% xq7 logi trung binh Ididng co logi kem, kei qua tie tham my: 100% dgt bgi toi.
Kei Xuan: Ky thugt cat che dgc ngdnh len XHD Id phuang phdp tiSu chuah cho dicu tri bieh dgng nho XHD. Kei qud aid nghien cuu dio thm/ ky thugt cat die dgc ngdnh len XHD vai cd'dinh cung to ra dgc biet hieu qud dw benh nhdn nlw hdm dieai.
Tii khoa: Cat die dgc ngdnh len XHD, cat XHD, diinh siea sai kh&p cdn do IB, chinh siea XHD, nho XHD, bien dgng xuang lidm.
ABSTRACT
RESULTS FOR TREATMENT SETBACK MANDIBULAR SURGERY BY BUATERAL SAGITTAL SPLTT OSTEOTOMY
Nguyen Van Hoa * Y Hoc TP. Ho Chi Minh * Vol. 16 - Supplement of No 1 - 2012:91 - 95 Objective: Comparison of results pr mandibular setback osteotomy by bilatei-a! sagittal split and intraoral vertical ramus osteotomy.
Method: The sample qf28 pateints (22 women vd 6 men) u?as treatmented in Odonto Maxillofadcd Hospitdl Ho Chi Minh City. They zoere surgical treatmented by bilateral sagittal split mandibular osteotomy.
Results: General functional results: 89,3% (25 pateints) were good, the remain weie medium. Aestlietic:
100% (28 patdnts) were good.
Conclutiotts: Bilateral sagittal split osteotomy were standard surgical regimen in the treatment of patients unth Class III dentofacial deformity. The results of this Study show that setback mandibular surgery Tvith rigid internal fixation zoas partiailm-ly good in nmndibukr protrusion patiens.
Keywords: Bilateral sagittal split mandibular osteotomy, intraoral vertical ramus mandibular osteotomy, correction of mandibular, correct class UI malocclusion, mandibular prognathism, dentofacial deprmity.
D A T VAN DE ^^ ^ ^ ^ thuat cat che doc nganh len XHD (BSSO). Theo thai gian ky tiiuat nay duoc eai Phlu thuat dau tien 6 Hoa ky do Hullihen ^^^ ^. ^^^ ^ . ^ ^.^ ^^ ^ ^ ^ . ^ giai phap thue hien vao nam 1849 de chinh sua tat nho ^^^ ^^ ^ ^ ^^^ pj^l^ ^^-^ ^ - ^ ^^. ^ ^^^^
ham duoi. Obwegeser (1957) dya tren co so cat y^.^g ^^ - ^^^ -^ g-^ ^^ ^i&i, it bien chung, xucmg theo cap va dien tich tiep xuc xuong, da
* Bo mon Phau thuat Tao hinh Tham my - Dai hgc Y khoa Pham Ngpc Thach
Tdc gid lien lgc: TS.BS. Nguyen Van Hoa DT: 0904397979 Email: [email protected]
Hoi nghi Khoa Hpc Ky Thuat Truang Dai Hpc Y Pham Ngpc Thach 2012
Nghien cuu Y hpc Y Hoc TP. Hb Chi M i n h * Tap 16 * P h u b a n ciia Sb 1 * 2012 thoi gian n3m vien ngan, ket qua co the fhay
ngay sau phlu thuat (FT).
6 Viet Nam co mot sb benh vien chuyen nganh da tien hanh phau fhuat dieu tri cho cac bien dang nho XHD nhung van con rai rac va co cum, chua tap trung duoc trong khi thuc te nhu cau benh qua nhieu. De' cac ky thuat dieu hi dugc pho bien rpng rii, chung toi hen hanh nghien cuu de tai nay nhtoi muc tieu: trinh bay ky thuat mo va danh gja ket qua ve chuc nang an nhai, van dong ham va danh gia ket qua tham my sau dieu tri dat lui XHD bang ky thuat cat ehe dpe nganh len XHD.
DOITt/ONG-mL/ONGPHAPNGHIEN OJlJ
Dbi hrpng nghien curu
Nghien cuu thuc hien tren 28 benh nhan duoe xac dinh co biai dang nho xuong ham duod, dupe dieu tii phau thuat tir nam 2007- 2009.
Phmmg phap nghien cmi
Nghien euu tieh cuu, mo ta lam sang, theo doi dpc gom 28 benh nhan tieh cuu. Tat ca dugc dieu tri dat liii XHD boi ky thuat BSSO.
Ky thuat cat che dgc nganh len xucmg ham duoi.
Phau thuat eat XHD theo ky thuat BSSO dugc hen hanh trong dieu Iden gay me giam huyet ap co ho hap dieu khien voi bng ngi khi quan dat qua miii.
Rach mgt duong dgc theo bo buoc cua nganh len xuong ham duoi, keo dai ducmg rach xuong duoi va ra ngoai den rang coi lon thu- hai.
Boc taeh duoi mang xuong o mat trong va mat ngoai cua nganh len. Taeh ch6 bam cua co cin ra khoi mat ngoai nganh len XHD vira du de cit xuong.
Nang vat mem cot mac len khoi dpng mach va than kinh rang duoi, tiep tuc boc tach toi tan bo sau aia nganh len xucmg ham dm?i.
Duong cat dau ben o tren aia gai Spix khoang 0,5cni, duong cSt thii hai theo chieu diing thang qua lop ngoai ciia than xuong d
vimg cac rang ham ihii nhat hoac thii hai, va duong cat phai qua ba dum ciia than xuong ham duai. Duong cat dugc thuc hien voi mui khoan 702 hoae mpt cua dao chieu.
Sir dung nhieu luoi due sac, mong, ban rgng 5-7mm de che tach dgc nganh Ien, trong khi tien hanh che tach o nhanh nay xuong ham diHJi dugc chiu luc boi mot mpt dung cu nang xuong a ba sau nganh len de giiJ vimg nganh Ien.
Sau khi viee cat xuong hoan tat, dat lai XHD vao mbi tuang quan khop can da du dinh dat mang phau thuat va cb dinh lien ham. Co dinh xuong bang cac nep-mini, cat co dinh lien ham va khau dong vet thuong bang chi 3.0.
Phifong phap danh gja ket qua Bdnh gid k^ qud chiic ndng rieng
Ddnh gid chiec ndng dn nhaiTot: Chiic nang an nhai tot (lire nhai tro lai binh thuang).
TB: Chi nhai dupe thiic an mem (luc nhai yeu, con cam giae e ham).
Kem: Khong nhai nat thiic an (luc nhai yeu, dau khi nhai).
Ddnh gid chiec nang van dgng kliap Tot: Van dgng khop binh thuong.
TB: Van dgng khop kho khan, con dau.
Kem: Van dpng khop ham han che (ha mieng han che).
Ddnh gid daii hieu cdc benh ly a Idiop Tot Khong CO trieu ciiiing o khop thai duong ham.
TB: Co trieu chiing o khop thai duong ham.
Kem: Tang trieu chiing 6 khop thai duang ham.
Ddnh gid kei qud chiic nang chung Dua vao hieu qua an nhai va luc can, van dgng khop thai duong ham (KIDH), dau hieu benh ly a khop thai duong ham.
Ket qua tot khi ca 3 tieu chi dat loai tot.
Ket qua trung binh khi it nhat ca 3 tieu chi xep Ioai trung binh.
Hpi nghi Khoa Hpc Ky Thuat Tnrong Dai Hpc Y Pham Ngpc Th^ch 2012
Y Hpc TP. Hb Chi Minh * Tap 16 * Phu ban cua Sb 1 * 2012 Nghien cihi Y hpc
Ket qua kem khi co it nhat 1 tieu chi xep loai kem.
Bdnh gid ket qud tham my
Dua vao sb do cac gbe tren phim sp sau PT, dua vao su hai hoa oia khuon mat, dua vao bang eau hoi danh gia danh cho benh nhan.
Tot So do cac goc tren phim sg thay doi ve gia tri ehuan, khuon mat hai hoa. Benh nhan hai long.
TB: So do cac goe tren phim so thay dbi ve gan gia tri chuah, khuon mat tuong dbi hai hoa.
Benh nhan hai long nhung chua thoa man.
Kem: So do cac goc tren phim sg co thay doi, khuon mat tuong doi hai hoa. Benh nhan khong hai long.
KET QUA VA BAN LUAN Hieu qua nhai va lire can
Bdng 1. Tieh trim CTE diiec ndng dn nhai (n=28).
Thai dilm danh gia Ngay sau PT 3thSngsauPT 6 tiling sau FT 9 thang sau PT
Tit 0 9 13 23
TB 0 18 11 0
Kem 28
0 0 0
S6 BN den llilm tia 28 27 24 23 Tat ea cac BN sau PT, xuong ham da dugc dua ve vi tri giai phau moi, nen cai thien ro ret ve mat tham my, tuy nhien chiic nang an nhai trong thoi gian dau co bi anh huong, 6 bang 1 thbng ke 28 BN cat che dgc nganh len XHD eo hoae khong ket hpp phau ttiuat XHT eho thay:
Ngay sau mb, tat ca BN deu ha mieng han che, van dpng ham duoi kho khan nen phai dimg fhiic an long va ubng nuac trai cay trong nhirng ngay dau. Sau 3 thang BN chi moi ah dupe thiic an mem, va thuong co nhirng cam giae nhu: e ham khi an nhai hay dau khi van dgng manh xuong ham nen khong dam nhai nghien thiic an. Dieu nay cung dehieu vi hp chua thich nghi vai tu the can khap mod, hon nira day la giai doan xuong ham dang trong thoi ky sua chiia va tai tao ciia qua trinh lien xuong. O giai doan tir 6-9 fhang qua trinh lien xuong hau nhu da hoan tat, su lien xuang scmi hay mupn tiiy thupc vao miic do mat xuong, tuoi tac ciia benh
nhan hay su nhiem khuan vet thucmg. O nhom nghien aiu hieu qua nhai va luc can ciia benh nhan dugc binh phuc sau 6 thang phau thuat va bn dinh chiie nang nay sau 9 thang. Phau thuat ehinh sira xuong ham gop phan thiet lap lai tinh trang cac phan loai sai khap can tro ve cin khap binh thuong, la yeu tb cai thien siic nhai ciing nhu Ihay doi ve mat tiiam my. Ket qua tren ding phii hgp voi mgt sb tac gia:
Harada K.'^' do luc can va di$n tich tiep xiic aia khop can 6 nhiing benh nhan co tat nho ham duoi, tnroc va sau phau thuat cat che dgc nganh len xuang ham duoi. Khao sat benh nhan vao nhimg thoi diein: trubc phau thuat 2, 4, va 8 tuan, 3 va 6 thang sau phau thuat va do luc can va di?n tieh tiep xiic eiia doi tupng khoe manh binh thubng de lam doi chiing. Ket qua:
luc can va dien tieh tiep xiic cua khop can tiiap nhat vao thoi diem 2 tuan sau phau tiiuat va hoi phuc lai dugc bang miic dp truoc phau thuat vao thoi diem 6 tiiang sau phau thuat Tuy nhien, ngay tiioi diem nay thi luc can va dien tich tiep xiic aia khop ein van kem htm so vcii luc can va ciien tich tiep xiic ciia khop cin 6 nguai binh thuong. Phau thuat chinh siia xirong ham theo ky thuat BSSO lam cai ttiien luc can so voi truoc khi dugc dieu tn tren nhiing benh nhan nho ham duoi.
Theo Kobayashi T.P' gii tri trung bmh hieu cjua nhai 6 eac benh nhan truoc khi dieu tri chi bing 46% gia tri trung binh oia nhom doi chiing CO khop cin binh thuang. Sau PT hieu qua nhai da dupe cai thien nliieu hon nhung van chi 6 miic 60% so vai nhom dbi chiing.
Tmh trang KTDH sau PT
Bdng 2. Tinh trgng KTDH sau PT.Trifu Chiang a Khop Co t n ^ chi>ng a Khop Kh6ng tri§u chung d Khop
Tong
JnriKFT 6 22 28
SauPT 8 20 28 Trong sb 22 benh nhan dupe c^t BSSO truoc phau tiiuat khong co roi loan khap tiiai duong ham, nhung kiem tra sau 6 thang phau thuat thi CO hai benh nhan chiem ti le 9,5%, phat hien co
Hpi nghi Khoa Hpc Ky Thuat Tnrdng Dai Hoc Y Pham Ngpc Thach 2012
Nghien curu Y hpc Y Hpc TP. Hb Chi M i n h * Tap 16 * P h u ban cua Sb 1 * 2012 tieng keu lup cup Odiiic khop) o khop tiiai
duong ham khi ha mieng. So di co tinh trang nay la do thoai hoa KTDH tu su van ep ciia luc dinh vit tai cac mat oia hai manh xucmg dat chong len nhau khi ket hop xucmg, tao ap lue cho loi cau trong 6 chao, hien tugng nay chi xay ra khi giiia hai doan xuong da cat hinh thanh mgt khoang h^ng 6 vi tri moi, viec eb dinh cae mat cit cua hai manh xuong se tao ra mgt luc xoin lam xoay loi cau trong o chao. Delammat luc xo5n nay, 6 co so ehiing toi xir dung nep titan uon cong theo hinh dang tu nhien aia 2 manh xirong sau khi dit lai o \i tri moi, de co dinh xucmg. Vi neu nep khong uon theo hinh dang oia xuung thi xuong se di chuyeh ve phia nep, va khap can se bi anh huong true tiep. Con Luhr (trich din theo'^') tiii de xuat sir dimg mgt dung cu dinh vi de giii mbi lien quan thich hop giiia loi cau va o chao. Trong khi Hu J.<^' bao cao sau phau thuat thi co 60% cae benh nhan eo trieu ehiing 6 khdp tiiai dircmg ham truoc phau tiiuat eho biet chiic nang eiia khop nay khong dugc cai thien sau phau thuat, va 8% nhiing b?nh nhan khong trieu chiing truoc phau thuat cho biet eo trieu chiing phat sinh sau phau thuat tae gia ket luan. Pahkala R.HI'* cho biet trieu ehiing 6 KTDH giam sau phau thuat cu the: cai thi?n ve kha nang an nhai dugc thong bao 61%, 40% het dau 6 khop, tuy nhien co 12% benh nhan cho biet tinh trang 6 KTDH tra nen te han sau phau thuat. Hau het benh nhan (73%) hai long voi ket qua, khong eo benh nhan nao bao cao la khong hai long.
Tinh trang roi loan cam gjac sau PT Bdng 3. Tmh trgng roi bgn cdm gidc sau PT.
ThoH gian sau PT Ngay sau PT
3Th4ng 6 thing 9 thang 12 thing
S6BN Tile%
28 20 11 3 0
100%
71.4%
39.3%
10.7%
0 l ^ u het BN deu co roi loan cam giac 6 ca 2 ben ngay sau FT, tinh trang roi loan giam dan tiieo ttiai gian, den 9 thang sau PT chi con 3 BN CO rbi loan nhung 6 miic do nhe hoae co mgt sb
benh nhan tra lai con rbi loan nhung hinh nhu ding thich nghi cfan, neu khbng de y thi cam giac nhu binh tiiuong. Than kinh cam giac hoi phuc hoan toan 6 tiioi diem 12 tiiang sau PT.
Hien Urgng nay theo chiing tbi trong qua trinh boc taeh bpe lb be mat trong nganh Ien XHD, CO the gay ra nguy co ton ttiuong hoac keo cang day tiian kinh rang dudi, hoae hinh ttianh khoi mau tu 6 vimg phau tich. Mpt nguyen nhan khac quan trgng hon la than kinh rang duoi true tiep bi chen ep giiia hai manh xucmg sau khi nep vit De han che tinh trang nay oia Dautrey cai tiai duong cat xuong nim ngoai bng rang duoi nen than kinh rang duoi khong bi chen ep giiia hai manh xucmg, Cai ti&
nay lam giam dang ke bien chiing roi loan cam giac a moi duoi. Theo kinh nghiem cua tac gia, su rbi loan than kinh cam giae ho^c di cam tam thai 6 moi duoi 2 den 3 thang sau PT va chi xuat hien 6 10% sb BN, nhung khong BN nao bi mat earn giae vinh vien 6 moi duoi.
Sau PT BSSO, Karas N.D."i nhan tiiay rang ngay sau phau thuat ti le roi loan cam giac la 70%. Sau 6 thang cam giac nay co binh phye nhung binh phuc mot each ch^m rai.
Ket qua chiic nang chung
Bdng 4. Kei qud phiu thugt (n'=28).T6t TB Kim Tong
Chi>c ning chung 25 (89,3%)
3 (10,7%) 0 28
Dua vao hieu qua an nhai va luc cin, van dong khop thai duong ham, dau hieu benh ly 6 khop thai duong ham, danh gia 6 moc 9 tiiang sauPT.
Ve tham my sau PT Ddnh gid kei qud tham my
Bdng S.Gid tri cdc so do TB ciia bien dgng qud sdn XHDsaiiPT(n=28).
Cac s6 do nhan ti^c GicSNB Goc i6i mat Goc GoGn-SN
GiatiTB 84,9°
-7,2"
33,6"
Gii tij ET 80,8"
-9,28"
30,07"
Hpi nghi Khoa Hpc Ky Thuat Truang Dai Hpc Y Pham Ngpc Thach 2012
Y Hpc TP. Hb Chi Minh * Tap 16 * Phu ban cua Sb 1 * 2012 Nghien cuu Y hpc
Cac sd do nhan trie Chieu d^i ting giOa mgt / chieu dai XHD Chieu cao t^ng gi&a / tang diroi h . mat
Gia tri TB 1/1,34 1/1,03
Gia tri BT 1/1,3 1/0.98
^ ^ Dua vao sb do eac goc tren phim sg sau PT, dua vao su hai hoa aia khuon mat, dira vao bang cau hoi danh gia danh eho benh nhan ve tieu chuah thain my ket qua ti Ie nay dat 100%.
KET LUAN
U"u diem dian aia ky thuat BSSO la: tranh dupe seo 6 da, ttioi gian co dinh lien ham ngin.
Do (iien tieh mat tiep xiic rpng ciia hai manh xuong xe-tach nen dam bao dupe viec lien xucmg nhanh chong va cho phep thay dbi vi tri giua hai doan xuong voi bien dp rpng va manh xucmg cb the di chuyeh ra sau (trong truang hpp ham bi nho ra trubc), hoac ra truoc (trong tnrong hgp ham bi thut ra sau), va xoay de chinh sua lai khi bi l&ch sang ben. Chinh tinh linh hoat nay da lam eho ky thuat BSSO tro nen phb biai. Mot uu diem niia cua ky thuat nay la khong CO bieh dbi dang ke giiia loi cau xuong ham duoi trong o chao. Cae co nhai nhanh chong thich iing voi lien quan giai phlu va chuc nang moi hinh tiianh sau phau thuat
Nhugc diem chinh ciia ky thuat BSSO la ty le cao cac truang hgp bi mat cam gjac a moi duoi. Sau PT BSSO tanh trang rbi loan cam giac xuat hien a tat ca cae benh nhan. Than kinh binh phuc dan theo thai gian 71,4% sau 3 thang, 39,3% sau 6 ttiang, 10,7% sau 9 thang va sau 12 thang thi xem nhu binh phue hoan toan.
Nhom 28 BN duge eit va dat liii XHD ttieo ky tiiuat BSSO ket qua 6 thoi diem sau 9 thang PT: 89,3% BN xep Ioai tot, 10,7% BN xep loai trung binh, khong eo loai kem. Lam phat sinh ttiem trieu chiing KTDH 6 2 BN chiem ti le 9,5%.
Doan xuong 6 phia ben ngoai duong cat co
the bi gay vun, neu nganh len xutmg ham diroi mong, do db phai cue ky than trpng khi tieh hanh cat xuong de tranh biSi chiing nay.
Nhiing bien chiing khae ciia phau thuat BSSO gom co: chay mau, tac duong ho hap, hoai hi xirong hoac nhiem khuSi, va thuong tbn day than kinh mat Ngoai ra, giam cam giae 6 luai Cling CO the xay ra neii day than kinh luoi bi clwi ttiuong trong khi phau tich mat trong nganh len XHD.
Phlu fhuat chinh siia xuong ham Iam thay dbi vi tri giai phau cua xirong harn, tao tuong quan moi giiia 2 cung ham va tucmg quan giira xucmg ham va khbi sp mat, ty le cac ^ g mat tro ve gia tri ehuah.Khung xucmg can doi la nen tang quan trpng cho tinh thaim my aia he ttiong mb irtem ben tren. Ve than my eo the thay tiiay doi ngay sau phau ttiuat, hau het benh nhan va gia dinh deu hai long ve ket qua dieu tri. Ve ttiam my 100% BN xep Ioai tot.
TAI LIEU THAM KHAO
1 Harada K, Kikudii T., Mianduma S., Sato M, Chkuca K, Omura K. (2003), "Oianges in tele force and dentoskeletal morpiiology in prognathK patioils after orthognathic surgery". Oral Surg.
OralMed OmlPatM OralRadiot Endod,%(6),pp Si9-65i 2 H u J, Wang D., Zou S, pOOO), "EHeds of mandibular se*ad; on
the temporomandibular Join^ a corr^arison of djlique and sagjttal ^ l i t ramus osteotomy", / Oral MaxSk^ Surg, 58 (4), pp^
375-38a
3 JossCU.,ThyerU.W.{2008),-Stabilih'oftfiehardandsofttissue profile after mandibular advancement in sa^tfal ^ E t osteotomies: a kaigitudmal and long-term follow-up study", Eur
;Orttod,30(I).pp.l&-23
4 Karas ND., Boyd S-B., S n n D P . (1990). "RecDvery of neuroseisory functiwi folbwing orthognatfiic surgerv", / Oral Max-aii^. Surg,4S (2), pp, 124-134.
5 Kobayashi T , Hcaima K, Siii^aki S, Nak^ima T (2001), Xhanges in masticatory fuiv±on after orthognaflnc treatmait m patients with mandibular prognathisn", Br j . Oral MaxHlt^
Swr^, 39 (4), pp. 260-265.
6 Pahkala ItH„ Kellokoski J.K. (20O7), 'Surgcak>rthodontic treatmod arid pabents' functional and psydiosodal weD-bemg", Am I Ortitod-Denlofadal O T % J , 132 (2), pp 158-164.
