JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY Vol.12 - N''2/2017
Danh gia nhfrng thay ddi 6* mo mSm va mo ciing sau thu thuat c^t phan doan phia tru*6^c xuo'ng ham tren va ham du*6i
Evaluation of the changes of soft tissue and hard tissue after osteotomy procedure of anterior segment of maxilla, mandible
Nguyin Tai Son, Le Tan Hiing Benh vien Trung uong Qudn doi 108
Tomtit
Muc tiiu: Nham xac dmh tUong quan giUa nhUng thay doi mo mem va md cUng sau thO thuit c3t p h i n doan phia trUdc xUong ham tren, xuong h^m dudi va d i n h gia nhUng thay ddi khudn mat bang cleh dung cac phan tieh do so va do tren hinh chup. Boi tugng vd phuang phdp: Cae ddi tupng bao gdm 21 nCr va 9 nam (td 22 den 50 tudi) dupc chan doan la nhfi xUOng hai ham, dupe thUe hien thu thuat c3t phan doan phia trude xUOng ham tr^n va xuong ham dudi. Phim so nghieng va hinh chup mat thing trudc va sau md dUpc phan tich. Kit qud: Cd sU thay ddi dang ke trong tat c l ele thdng sd md cdng va md mem ngoai trU gdc mdi-clm. Ty 1^ sU ICii moi tren chia eho sU lui ring cUa ham t r i n la 0,67:1 va tJ le su lui mdi dudi chia cho sU lui rang eUa ham dudi la 0,89:1. Goe mui-moi v^ chieu dai nhan trung tang ign, chieu dai moi dd va chieu rpng mdi giam. Cd sU rpng ra nhe eda chieu rdng mui va sU xoay cCia dau mui khdng dupc ghi nhan. Kit ludn: Cat xUong phan doan phia trudc i^ mdt phuong thde dieu trj lUa chpn cho benh nhan nho xuong hai ham hoae nhd rang-xUPng d. Ky thuat nay khdng phUc tap, eac bien chUng sau md tdi thieu, sU tai phat cd gidi han, va nhUng thay ddi md mem d i p Ung vdi dieu trj thi cd th^ t i i n doan dupe.
Tifkhda: Cat xUOng, cat p h l n doan xuong h i m tren, dudi.
Summary
Objective: To determine the correlation between the changes of soft tissue and hard tissue after osteotomy procedure of anterior segment of maxilla, mandible and to evaluate the changes in the face by measurements on skull and on photographs. Subject and method: Subjects include 21 v^omen and 9 men (from 22 to 50 years old) with diagnosis of prognathism and were carried out osteotomy of anterior segment of maxilla and mandible. Lateral and anteroposterior radiographs pre-and post-procedure were analyzed. Result. There was a significant change in all parameters of hard and soft tissues except lip-chin angle. The ratio of stepping backwards between upper lip and upper incisors was 0.67:1 and the ratio of stepping backwards between lower lip and lower incisors was 0.89:1. Nasolabial angle and the length of philtrum increased, the length of red lip and the width of lip reduced. The width of nose basement
Ngdynhdnbdi. 21/12/2016. ngdy chdp nhdn ddng- 09/01/2017
Ngumphdn hoi. Nguyen Tdi Sam, Email: [email protected] - Benh vien Trung urmg Qudn dgi 108
TAP CHf Y DU'OC LAM SANG 108 Tap 12-Sd 2/2017 slightly increased and the rotation of tip were not acknowledged. Conclusion: Osteotomy of anterior segment could be recommended as a method of treatment in prognathism patients. Because this technique is not complicated, postoperative complication is minimal, recurrence is limited and the changes in soft tissues responding to the treatment could be prediaable.
Keywords: Osteotomy, segment maxilla, mandible.
I . D a t v a n d e
NgUdi Ddng A ndi ehung ed khuynh hudng nhd xUOng hai ham h o l e nhd xuong d hai ham nhieu hPn so vdi ngUdi da trang [1], [2]. Viec nhd bdn rang cdi nhd de keo lui c l e rang phia trUde la mdt trong nhufng lUa chpn dieu trj eCia ehinh nha dien hlnh [3].
Tuy nhien, dieu tri n l y t r d nen phdc tap hon nhidu d ngUdi Idn bdi vi nhOfng khd khan trong viee dat dUpc sUdi chuyen r i n g sinh ly, thdi gian dieu trj d l i hon.
Xet nhifng gidl ban ndi tai nay, viee nhd bdn rang cdi nhd v l keo lui bang phau thuat eac phan doan phfa trudc dung ky thuat cat xuong dudi chdp rang dang 6ugc chap nhan nhU la mdt phupng thde dieu trj tdt hpn so vdi chinh nha don thuan [4].
Cat XUPng phan doan phia trUdc xuong ham tren dUpc Cohn-Stock m d t l dau tien vao nam 1921.
TU dd, nhdng bien t h e ve thiet ke dudng rach md mem va dUdng c i t xUOng d l dugc nhidu phau thuat vien thuc hien, tuy nhien, nhieu van de van edn tdn tai chang ban nhU hoai tU p h l n doan xuong phia trudc d l dupe tai djnh vj, ehet tuy ele r i n g (die bidt la rang nanh), sU rdng ra eua nen c I n h miji, va sU xoay ve phia tren eua dau mui. De t r i n h nhdng bien chUng nhU v l y , e l t xUOng p h l n doan phfa trudc cd cai tien d xuong ham tren da dupe phat trien va dupe bao d o tai Dai hdi P h l u t h u l t Sp-ham-mat chau Au tai Zurich vao nam 1996 [4]. Ky t h u l t mdi nay chi c l n mdt dudng rach n g l e h hanh lang tU ring nanh nay qua r i n g nanh kia. Mdt dUdng c i t XUPng theo chieu ddng dupe thuc hien d khoang d l nhd rang. Sau do, cat xUOng theo chieu ngang qua hai phien xuong vd gida chdp chan rang nanh va hd le de ndi c l e dudng cat xUOng d phia ben p h l i va ben t r l i vdi nhau (Hinh 1). NhUng thay ddi d the nhin t h i n g thi rd rang ed tam quan trpng Idn va thudng la mdt trong nhOng tieu chuan ehinh de theo dd benh n h i n cdng nhan thanh edng cCia dieu
tri. Vi the, chung tdi danh g i l nhufng thay doi d ca the nhin thang v l nghieng cua khudn mat trUdc va sau dieu tri. Muc dich cua b i o cao nay I I : Xdc dinh tuang quan giCfa nhd^ng thay doi mo mem, mo cdng sau thu thudt cdt xuang phdn dogn phia trUdc dxuang hdm tren va xuang hdm dUdi COng nhu ddnh gia nhiing thay doi khuon mat bang cdc phdn tfch do sg vd do trin hlnh chup.
Hinh 1. Cat xUOng phan doan trude d xuong ham tren.
A, Thiet ke dudng cat xuong phan doan trudc. B, Bde tieh mang xUOng v l cat xUOng theo chieu ngang tU ben
dudi cua gai mui trUdc, hd le. C, Cd dinh d vj tri mdi.
2. Ddi tuong va phuong phap
Gdm 21 nOf va 9 nam (tudi tU 22 den 50} dUgc chan doan I I nhd xuong hai h i m v l t r l i qua e l t xuong phan doan phfa trUde d xUOng h i m tren, xuong ham dUdi tai Benh vien Ring H i m Mat thanh pho Hd Chi Minh v l Benh vien Trung Uong Quan dpi 108 ti^ thang 5/2012-5/2015.
Nghien cdu hoi cUu ve nhdng thay ddi m d mem va md cUng sau thd t h u l t eat xuong phan doan phfa trUde d xUOng ham tren va xuong ham dudi. T u lieu trude va sau md bao gdm phim sp nghieng, hinh ehup mat nghieng va mat thang. Cle sd do sau md duoc thuc hien it nhat la 6 t h i n g sau md.
IVlat phang tham chieu dUpc ve de thUc hien c l e sd do la mat phang ngang Frankfort (dUdng H) va mat phang thang dUng qua nasion, vudng gdc vdi mat phang FN (dUdng V) (Hlnh 2).
71
JOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY Vol.12-N'2/2017
Hinh 2. Cac diem mdc do so Tren the nhin nghieng, 4 sd do tuyen tfnh va 3 sd do gdc duoc danh gia:
1. Dp nhd mdi tren: Ls den dUdng V.
2. Dp nhd rang cCfa tren; IA den dUdng V.
3. Dp nhd mdi dUdl: Li den dUdng V.
4. Dp nhd rang cda dUdi: IB den dUdng V.
3. K^t qua
5. Gdc mui-mdi: Cm-Sn-Ls.
6. Gdc dp nghieng eda dinh mui: N'-Pm va dudng H.
7. Gdc m d i - c l m : Li-B'-Pg'.
6 t h e nhin t h i n g , bdn so do theo tuyen tinh dupe danh gia: Be rdng mui, bd rdng mdi, chi^u dai n h i n t r u n g va chieu day mdi dd. Ty le gi&a nhOfng sd do nay v l chieu rdng khde m i t trong cung dupc t i n h .
1. Be rpng mui: Canh mui den canh mui.
2. Be rdng mdi: Khde mep ddn khde mep.
3. Chieu dai nhan trung: Subnasale den dinh cQa eung Cuspid.
4. Chieu day mdi do: Dinh eua cung Cuspid den Stomion.
NhUng thay ddi trudc md v l sau md dupc tinli toan bang each l l m tinh trU cac g i l tri tUOng ung eho mdi benh n h i n , trung binh va dp lech chu^n dugc tinh toan cho tCrng sd do. DU lieu dUpc phan tieh vdi vdi phan mem SPSS 2012.
Bang 1 . Thay doi mo m4m trong the nhin ben So do
Do nho moi tren (mm) D6 nho rang ciia tren (mm) Do nho moi dudi (mm) Do nho rang cCfa dacfi (mm) Goe mui-moi (°) Dp nghieng dinh mui (°) G6c moi-cam (°)
Diem do so Ls den dudng V IA den dudng V Li den dudng V iB den dudng V Cm-Sn-Ls N'-Prn va dudng H Li-B'-Pg
Trudc mo 21,13±3,16 11,15±3,29 19,48 ±3,76 7,57 ±3,52 94,96 ± 9,67 59,90 ± 3,45 139,68 ±18,61
Sau mo 17,28 ±3,31 5,21 ± 3,26 13,94 ±3,59 1,14 ±3,73 109,03 ±9,08
59,18 ±3,34 130,86 ±13,68
Thay doi 3,86 ±0,92 5,93 ±1,15 5,55 ±1,19 6,43 ±1,25
•14,07 ±5,22 0,72 ±0,70 8,81 ± 16,60
Gia trip
<0,01
<0,01
<0,01
<0,01
<0,01
<0,01
<0,01 Nhgn xet: Cac phan tich dieu trj cho thay co su l<hac biet co y nghTa d tat c i cac thong sd mo m^m v& m6 cutng duoc do, ngoai trU gdc moi-cam. Trung blnh nhOng thay doi ve xuong la lui xuong ham tren 5,93 ± 1,15mm, va lui ham dudi 6,42 ± 1,25mm. Ty le cCia su lui moi tren so vdi I iii rang cda tren la 0,67:1, vS tJ IS IM
TAP CHl Y Dl/aC L A M S A N G 108 Tap 12-56 2/2017
Bibng 2. Thay doi d the nhin mat thang So do
Be rpng mut (%) Be rong moi (%) Chieu dai nhan trung (%) Be day mdi (%)
Tnldc mo
103,24 ±7,54 135,28 ±12,04
67,41 ± 7,37 24,33 ± 4,20
Sau mo 106,14±7,17 129,74 ±10,78
69,93 ±6,79 21,36 ±3,60
Thay doi -2,91 ± 3,57
5,54 ±5,46 -2,51 ± 1,67 2,96 ± 2,44
Gia tri p
<,01*
<,01«
<,01«
<,01*
* Bleu thj thay ddi chung cd y nghia (p<0,01).
Nhdn xet: Phan tieh tUong quan Spearman, hd sd tuong quan (r) la 0,646 ddi vdi su di chuyen mdi trdn so vdi sU di chuyen cCia rang cCra tren, va la 0,756 ddi vdi sU dl chuyen mdi dUdi so vdi sU di chuyen cua r i n g cCra dUdi.
Su tang gdc mui - mdi tU 94,96 ± 9,67° len 109,03 ± 9,08° tao cho mdi tren bdt nhd va dinh mui nhd nhieu hPn. Be rdng mui cd the t i n g 2,92%
(p<0,01), dp nghleng dinh mui g i l m 0,73% (p<0,01), sU rdng ra nhe cua nen canh mui va sU xoay cua dinh mui dupc quan sat. Be rdng mdi va be day mdi dugc g i l m lan lUOt l l 5,54% (p<0,01) va 2,96%
(p<0,01), va chieu dai n h i n trung t i n g 2,50%
(p<0,01). Dieu nay eho thay mdi t r d nen nhd hon.
Khdng cd thay doi cd y nghTa thong ke x l y ra d gdc m d i - c l m .
4. Ban luan
Cat xuong phan doan phia trude dUpc chi djnh trong trudng hop yeu c l u di chuyen nhieu cac r i n g trude nhung tai djnh vj rang chi b i n g dieu t n ehinh nha khdng the dupc vi ele yeu t d khieh quan n h u mUc dp di chuyen rang, tinh trang nha ehu, va ele yeu t d ehu quan e h i n g ban nhu tudi benh n h i n , thdi gian dieu t n , tinh trang kinh te, cdng viec va x l hdi [3], [4].
C i t xUOng p h l n doan phia trUde, dac biet d xuong ham tren khdng don g i l n . Nhieu c l i tien d l dupe thuc hien bdi nhieu phau thuat vien. Cohn-
Stock la ngudi dau tien gidi thieu dUdng cat xUPng hanh lang - khau cai de ehinh chdng nhd ham.
Wassmund da gidi thidu dUdng ham khau c l i de e l t xUPng k h I u cai nham di chuyen tjnh tien phan doan nay, ma khdng gay ra can sau. Schuehardt d l thUc hien thu t h u l t theo 2 giai doan cleh nhau 4 tuan de n g I n ngUa hoai t d cae p h l n doan da dUpc di ddng.
Wunderer da c l i tien ky t h u l t nham tao ra mdt phau trudng rdng hPn de cat xuong khau c l i , tang cung cap mau eho doan xUflng duoc eat thdng qua ddng maeh vIeh ngan mui sau va ddng maeh mui - khau cai bang each thuc hien dUdng rach phia khdp can.
Tuy nhien, nhieu van de da n l y sinh ra. Khdp can bi s l u hpn bdi vl xUong la mia va v I e h ngan mui khdng bj tach ra va phan doan xUPng dupe dupe e l t ehl nghieng ra sau. Phau thuat giai doan 2 thi vat v l hpn cho e l benh nhan lan p h l u thuat vien. Ludn cd mdt kha nang hoai t d khdng ehi d xuong ma con d rang bat ky lue nao.
NhUng van de n h u vay nen dUpe t r i n h , vi the y tUdng cua ky thuat eat xuong phan doan phia trUdc cd cai tien da dUpc n l y sinh ra. Ky thuat mdi nay ehi can raeh phia hanh lang t d rang nanh sang rang nanh. Mdt dudng eat xUong thang dUng dupc thUe hien d k h o i n g nhd rang cdi nhd thU nhat. Sau dd, e l t xuong theo chieu ngang qua hai vd xuong gida dinh cOa r i n g nanh va hd le dupe tien hanh de ndi ele dudng e l t xUPng theo chieu dUng d phia ben p h l i v l ben t r l i (Hinh 3). Hai phien xUang vd ehl thi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N''2/2017
rang mdt dUdng c i t xUOng phia khau c l l dupe thuc hien trong cung mdt phau t h u l t cd dUdng e l t xUong theo chieu ngang d mat ngoai. Tuy nhien, nd doi hdi su kheo leo va day du dung eu.
di/omg c i t xuvng
Hinh 3. Minh hoa dudng cat xUOng theo chi^u ngang va theo chieu dUng trong thu thuat e l t xUOng p h l n
doan phia trudc cd cai tien d xUPng ham tren dupc quan sattuthe nhin ben
Cd nhieu Uu diem vdi ky t h u l t mdi nay so vdi ele ky t h u l t truyen thdng. Lay bdt xuong, bao gom xUong I I mia v l vIeh n g I n mui, I I thu thuat can thiet eho bat ky sU di chuyen dinh hUdng n l o eua p h l n doan xuong duoc cat, cd the dupe thUe hien khi nhin thay toan bd phau trudng. K h i nang hoai tU dugc g i l m bdi vi tuan hoan m l u dupe d i m bao vdi nidm mae khau cai nguydn ven, bao gdm eae mach mau khl'u c l i . Su thay ddi d mui ed the' dupc tdi thieu vdi sU keo lui tdi thieu cda cac md mem can mui. Ky thuat nay eung tiet kiem thdi gian p h l u thuat, dUa den it stress sau md han.
Da cd nhieu bao d o trong y van ve nhdng sU thay ddi md cdng va md mem sau phau thuat chinh ham, nhUng it cd y van ve phau thuat p h l n doan phia trudc cOa xUOng ham tren va xUOng ham dUdi.
Nguyen nhan do nhUng tien bd trong c l e ky thuat ehinh nha ndn eat xUong phan doan phfa trUde hiem khi dupe thuc hien d nhUng benh n h i n bi nhd rang - xUPng 6, v l ngudl chau A thudng cd khuynh hUdng nhd hai ham nhieu hon ngudi da t r l n g , ma d hp dp nhd eua tang mat giUa hau nhu dugc xem la binh
thudng [5], Tuy nhien, dieu nay gicf d l y dang doi thay; nhieu ngudi c h l u A xem khudn mat liji (giong n h u ngUdi da trang) thi dep hon va tham chf la loai tham my ly tUdng eho hp. Hidn nay, yeu eau chinh dp nhd XUPng hai ham va nhd rang - xuong d hai ham thi t i n g Idn nhanh ehdng [6], [8].
Lew [9], va NadkarnI [10] da b i o d o nhiing thay ddi net nhin nghieng sau khi cat xuong phan doan phia trude d xuong ham trdn vdi xuang ham dudi. TJ le keo lui m d i tren so vdi keo lui rang c^a ham tren la 0,5:1,10; 0,43:1,9 va 1:3,11 trong khi ty le keo lui cua mdi dUdi so vdi rang cUa dUdi la 0,75:1,10; 0,71:1,9 va 2:3,11; nhUng tf' le nay cho thay r i n g cd nhdng thay ddi nhd hon nhieu cua m d mem so vdi so vdi sU thay ddi cda nghien cu'u nay. Dieu n l y ed t h e la do sU khIe biet ve mdc do di chuyen ra sau eOa cac rang trUde ham tren, ky t h u l t phau t h u l t , be day mdi va sdc manh cOa mdi, mUc do md m d , eo va ehung tdc. NhCfng yeu t d nay p h l i dUpc xem xet de nghien cdu trong tUPng lai. Ngoai thay ddi theo chieu trUdc - sau cua mdi tren v l dUdi, be day mdi ro rang bj gi^m va chieu dai nhan t r u n g dUpc tang [4]. Tuy nhien, nen can than t r o n g viec chpn lUa loai phau thuat nay eho nhufng benh n h i n cd b d mdi do tdi thieu h o l e ehieu d l i nhan t r u n g dai.
Trong nghien cUu nay ve d t xuong phan doan phfa trudc ed d i tien, su bdc tach md v l cat xUong theo ehieu ngang dupe thue hien Xii phia ben diffii cua hd le de tdi thieu hda nhUng thay ddi mui khong mong mudn. Be rdng nen canh miJi tang 2,92%, di/a tren be rdng giOa hai khde m i t trong, cho thay si/
tang that sU la 1mm. Dp nghieng cua mui ting 1°, dua tren dudng FH, eho thay khdng ed sugia tang cd y nghTa lam sang. Nhdng thay ddi ve hinh thai mui sau khi d t xuong p h l n doan phia trudc cd th^
khdng so s i n h dupc vdi nhUng thay ddi do nhiing phuong p h I p khac bdi vi sU it di ve nghien ciJu doi vdi chCi de nay.
5. Ket l u a n
Ky thuat cat xUOng p h l n doan phia trUde, moi
TAP CHl Y DL/OC LAM SANG 108 Tap 12-56 2/2017
ddi cCia rang cUa tren v6i sU di chuyen ra sau cda xUong ham tren. Mdi dUdi dupe di chuyen vdi ty Id b i n g 89% rang eUa dudi. Gdc mui - mdi tang trung b i n h l 4 , r .
Cit xUOng p h l n doan phia trude la phUPng phap dieu t n dUpc lUa chpn d nhOfng benh n h i n bj nhd xUPng hai ham va/hoac nhd rang - xUOng d hai ham. Ky thuat thi khdng qua phdc tap, c l e bien chUng sau md thl tdi thieu, t l i p h l t thi han che v l nhCfng thay ddi md mem d i p Ung vdi phau thuat thi cd tinh tien d o l n nhieu hon.
Hinh 4. Benh nhan trude va sau phau thuat cat xUong phan doan phia trUdc
Tai lieu t h a m khSo
1 Miyajima K, Menamara JA, Kimura T et al (1996) Craniofacial structure of Japanese and European-
American adults with normal occlusions and well- balanced faces. Am J Orthod Dentofacial 110:431.
Chung CS, Kau MC, Walker GF (1982) Racial variation of cephalometric measurements in Hawaii. J Craniofac Genet Dev Biol 2:99.
.. Ddng KhIc Tham (2004) Chinh hlnh Rdng Mat. Nh^
Xuat ban Y hpe.
•. Yong-Ming Chu, Leonard Bergeron, Yu-Ray Chen (2009) Bimaxiilary Protrusion: An Overview of the Surgical-Orthodontic Treatment. Semin Plast Surg 23: 32-39.
i. Bell WH, Condit CL (1970) Surgical-orthodontic correction of adult bimaxiilary protrusion. J Oral Surg 28:578.
>. Radney Ll, Jacobs JD (1981) Soft tissue changes associated with surgical total maxillary intrusion.
Am J Orthod 80:191.
'. Cupar i (1954) Surgical treatment of alterations in form and position of the maxilla. Osterr Z Stomatol 51:565.
I. Morris DE, Moaveni Z, Lo U (2007) Aesthetic facial skeletalcontouring in the Asian patient. Clin Plast Surg 34:547-5569.
1. Lew/ KK, Loh FC, Yeo JF et ai (1989) Profile changes following anterior subapical osteotomy in Chinese adults with bimaxiilary protrusion. Int J Adult Orthodontic and Orthognathic Surg 4:189.
0. NadkarnI PG (1986) Soft tissue profile changes associated with orthognathic surgery for bimaxiilary protrusion. J Oral Maxillofac Surg 44:851.
