• TAP CHI NGHIEN CUU Y HOC
P H A U T H U A T G H E P M O LIEN K^T LAP DAY S 6 N G HAM VUNG MAT RANG HAM TREN PHiATRlfaC
Trdn Ngoc Phu'cng T h a o \ Nguydn Thj Mai Phu'0'ng\ Hoang Dao Bao Tram^
'Bgnh vien Rdng Hdm Mdt Thdnh phd Hd Chi Mmh, ^Dgi hgc Y Duvc Thanh phd Hd Chl Mmh Nghien CLW danh gid kk qua lam sdng dp dgng ky thuat ghep mo lien kel cd ket hop vat di chuyen v4 phia thdn rang de lap ddy song ham vung mat rdng ham tren phia tru&c. tren 10 benh nhdn (25 - 45 tudi) Danh gid cdc chi s6 Gl. be day sdng hdm (ngodi trong). vd sw hdi Idng cua benh nhdn sau phdu thual ba thdng vd iinh trang viem nhidm cai thien cd y nghia (Gl 0,66 ± 0,48 Iruoc phau thugt 0,41 ± 0,49 sau phdu thuat. p < 0,001), b§ day s6ng ham tang cd y nghia (2,15 ± 0,86 mm truoc phdu tliu$l, 3,29 ± 0,99 mm sau phdu thudt, p < 0,001). 90%, b$nh nhdn hdi long. Kit qua cho thay ghep mo lien kdt kdt hgp vai di chuyen ve phia thdn rang dd ldp ddy bd day song ham vimg mat rang tru&c khi lam phue hmh c6 dinh la ky Ihugl cd nhieu wu diem ty le the tich lap ddy vung thieu hdng cao, co the tien luong kdl qua. nang cao tham my, hd tra phue hinh cd dmh dat kel qud tdt wu, ky thugt luong doi de thgc hign. it bien chung
Tir khoa: ghep mo lien k4t, p h l u thuat vat di chuyen ve phia than rang
I. OAT
V A NOE
Kmh Id xa hdi ngay cang phat tnen, yeu
•cdu phue hdi chirc nang va thdm my cua benh nhan ngdy mdt eao, ddi hdi nhO'ng cai lidn vd ky Ihuat Phdu thudt ldp ddy sdng ham d vung mat rang Id mdt trong ede phdu thudt tao hinh nha chu nhdm gidi quydt linh trang Ihidu hdng sdng hdm, ddc bidt d viing mdt rang ham tren phia trudc, Id viing ed ydu edu tham my cao Trudc khi tien hdnh phau thudt, can xdc dmh kich thuoe, thd tieh cua vimg mdt md tren sdng ham mdt rang de chon vung cho ghep thich hap,
Mdt s6 nghien eiru cua edc tac gia tren thd gidi eho thdy viing eho manh ghep thich hap nhdt Id mem mac khau cdi cirng [1] Hai ydu td quan trong eho phep tidn hdnh phau thuat cd su- dung mdm mac khau cai lam manh ghep la kich thude viing nhan ghep, bd day va dien tich vLjng cho ghep [2]
Dia chi hen he Tran Ngoc Phuong Thao 263 - 265 Tran Hung Dao. Qu$n 1. thanh pho Ho Chi Minh Email [email protected] NgSynhan 27/03/2013 Ngay duvc chap thuan 20/6/2013
Khdng chi neng trong phdu thudt tao hinh nha ehu, manh ghep tu' mem mac khau cai cung cdn d u a c sw dung trong ede phau thudt tai tao mdi bi thidu hong do cdt bd khdi u hay phdu thudt mi mdt [3] Mdt sd nghien ciru xac dmh bd day mdm mac khau cdi vung cho ghep cung da duoe thue hidn tai Viet Nam Irong nhung nam gdn day [4, 5]
Nghien ciru nay duo'c lien hdnh nham danh gid kdt qua Idm sang sau 3 thang cua phdu thudt ldp ddy md thidu hdng tren sdng ham, ap dung ky thudt ghep md hen kdt, kdt hap vat di chuyen vd phia than rang d vung mat rang phia trudc
II. 0 6 l TU'O'NG VA PHU'aNG PHAP
1. Ddi tu'O'ng
10 benh nhdn tuoi tii' 25 - 45 ddn kham tai Benh vien Rang Hdm Mdt thdnh phd Hd Chi Mmh tir thang 3 - 10/2009. ly do ddn khdm Id mdi tham my viing rang ham tren phia trudc, mudn d u a c can,thiep dd cd kdt qua tdt vd Ihdm my sau khi lam phue hmh Benh nhan duac cung edp Ban thdng tin ve nghien ciru, Ban md la quydn loi va nghTa vu ciia nguoi
TCNCYH 83 (3)-2013
95
T A P CHl NGHIEN CLTU Y HQC
tham gia nghidn eifu, vd ky xdc nhdn Phi6u linh nguydn tham gia nghidn ciru
Phdn bo cdc vijng thieu hong md trdn mau nghidn cuu 90% d viing R13 - R23. 10% d vimg R 2 2 - R 2 4
Cdc bdnh nhdn dug'C ehulin bi cdc b u d c eo ban' hudng d i n vd sinh rdng midng, ego vdl, chup anh ngodi mdt vd trong mi$ng, chyp phim quanh chdp viing ghdp, xdt nghidm mdu
Tieu chu^n c h o n m l u
Khuyet h6ng md mdm viing mat rdng ham trdn phia trude (£ 3 dan vi) gdy m^t tham mJ cho phyc hinh rdng eo dinh, tinh trang vd smh rang mieng tot hodc duo'c eai thidn sau giai doan hudng ddn vd smh rdng mieng va dieu In nha ehu so khdi, ed chi dmh phdu thudt ghdp md hen ket
Tieu chudn loai tru'
Bdnh nhan dang cd benh viem nha chu; cd thdi quen hiit thude Id, ed chan thuang khdp cdn d viing nhan ghep ma chua duae loai trir, ehdng chi dmh phdu Ihual nha chu do ede bdnh loan than tim maeh. lieu dudng, huydt dp
Quy trinh phau thuat
1 Sira soan viing nhdn ghep theo ky thudt vat tam giac hodc vat hinh thang cd be ddy vat ban phdn vd todn phdn (lidn tiep nhau lai dudng noi mem mac nudu rdi va n u d u dinh),
^ Lay manh ghdp md lien kel d khau edi, dp dung ky thuat Bruno
3 Co dmh manh ghep vdo viing nhan manh ghdp bdng chi tieu 4 O, 5 O
4 • Chdm sdc sau phdu thudt vdi thudc todn thdn va tai chd
5 est ehl sau 10 ngdy, ldi kham hang tuan trong thang dau tien, sau dd mdi thang 1 ldn trong 3 thang
Tieu chuan danh gia Cac ehl so danh gia'
- Chi s6 n u d u Gl (Loe vd Silness, 1967) [6]
- B^ ddy s6ng ham theo chidu ngodi trong:
c = a - b (Hinh 1) (Lang NP, 1997) [7], (NovaesABJr, 2001) [8]
k
?/
Hinh 1 . Xac djnh chieu cao niFau su-ng hoa
- S u hdi Idng cua bdnh nhdn sau 3 th^ng phdu thuat, Penh nhan tra ldi vd kel qua dieu tn theo 3 mirc (1) hai Idng, (2) tam duoc, (3) khdng hdi long
Cdc dj> lieu lam sang d u a c ghi nhan ngay trudc khi didu In phdu thudt vd 3 th^ng sau phdu thudt
Kidm scat sai lech thong tin: Bac sT danh gid dgc lap vdi bdc sT phdu thudt, dd kien dmh k > 0 , 7 .
XiJ ly s 6 lieu
S u dung k i l m dmh t-student de so sanh chl sd n u d u Gl, be day sdng ham theo chi^u ngoai trong d viing mat rdng d cac thdi diem trudc p h i u thudt vd 3 thdng sau phdu thuSt
£>^o dii'C nghien ciPu
De c u a n g nghien c u u d u o c thdng qua Hoi ddng Y dire trong nghidn ciru Y smh hoc cua Benh vien Rang Ham Mat Thanh pho HdChi Mmh Cac bdnh nhdn d u a c ehan doSn, chi dinh phdu thudt vd hdi c h i n de thdng qua ho sa duyet mo theo dung quy chd hdi chan Irudc phdu thudt eua bdnh vidn, duoc cung cap day du ede thdng tin ve tinh trang laf
• " TAP CHI NGHIEN CUU Y HOC sdng vd kd hoach phdu thudt, ky tdn xac nhan ddng y l u nguydn tham gia nghien ciru.
111. KiT QUA
. Chisd nu'du Gl
Bang 1. Chi sd nu-du Gl (mm)
n = 10 Gl
TruCTC p h l u thuat (mm) J , SD 0,66 0,48
Sau phau thuat (mm) Z, SD 0,41 0,49
P
< 0,001
Chl sd nudu GI trudc phdu thudt Id 0,66 ± 0,48, d thai diem 3 thdng sau phdu thuat da giam, chl cdn 0,41 ± 0,49, khac bidted y nghTa thdng ke (p < 0,001) Nhu vdy, ed su cai thien tinh trang vidm nhidm trdn lam sang mdt each ed y nghia sau phdu thuat
2. Bd day sdng ham theo chidu ngoai trong
Bang 2. Be day sdng ham viing mat rang (mm)
n = 10 Bdddy sdng ham
Trude phdu thuat (mm) 7/ SD A l
2,15 0,86
Sau phdu Ihuat (mm)
Z2
3,29 0,99 P
< 0,001
Be day sdng ham theo chieu ngoai trong trude phdu thual Id 2,15 + 0,86, dd duac nang len sau phdu thudt, va d thai diem 3 thang sau phdu thudt dat 3,29 ± 0,99 mm Nhu vdy sau 3 thang ph§u thuat, bd ddy sdng ham theo chidu ngodi trong tdng mdt cdch cd y nghia thdng ke (p< 0,001)
3. Thdm my va sif hai Idng cua benh nhan O' thai diem 3 thang sau p h i u thudt, d l i t ca edc trudng hap didu tri ddu dat duoe su lanh thuong lien tidp vdi md nudu xung quanh, khdng thay gidi han giOa manh ghep vdl mo nudu Idn cdn, phue hinh dat yeu cdu thim my 9/10 bdnh nhdn hdi Idng, 1/10 benh nhdn tam hai Idng vi viing ghep chua hoan loan ldp ddy khoang mdt rang khd ddi tCr rang 22 ddn rang 24 (3 don vi)
Hinh anh mdt sd tru'dng hop lam sang Trw&ng hap 1: Nguydn Thi Ngoc Ph , nu', 45 tuoi Nghd nghiep Ca sT
Chan doan: Thieu hong md mem viing R11,12 ( 2,15mm ) tir 5 ndm qua
Ngdy dieu tn 26/03/2009
Phau thudt ghep md lien kdt vimg Khau cdi kdl hap vat di chuyen ve phia than rang.
TCNCYH 83 (3) - 2013
TAP CHi NGHIEN CU'U Y HQC •
t
T h i e i i m 6 2 , 1 5 i i i [ n V I I I K I 1 1 \-A
Trudc phdu thudt
ep mo hen kcl 5x6x2mm
Sau phdu thudt
L a p d a y 3 , 4 0 m m v u n g 11,12
Sau 3 thdng Tru'dng h a p 2: Benh nhdn Ld Thi T , nir, 47 tudi Nghd nghidp Doanh nhan Chdn doan: Thieu hong md mem vung R I I , 2 1 , 22 (2mm ) t u 8 ndm qua Ngdy dieu In 15/04/2009
Phdu thudt ghep md md hen ket viing khau cdi kdt hop vat di chuyen vd phia than rdng ThieLi i n o 2,0 m m v u n g 11 2 1 , 2 2 Manhgiiep mo lien kel 6 x 8 x 2 m m L a p (Jay 3 3 0 m m v u n g 11.21,22
J
Trude phdu Ihual Sau phdu thuat Sau 3 thang Tru-ang hp-p 3 Nguyin Thi My D , nu', 35 tuoi Nghd nghiep Ky s u .
Chan doan: Thidu hdng md mdm viing R I I , 12, 2 1 , 22 (1 40 mm) 15 nam qua Ngay didu In. 30/07/2009
Phdu thudt ghep 2 manh md lien kdt vung khau cdi kdt hap vat di ehuydn ve phia than rang
^0**'*''^*^' ^ - . > .
Trudc p h l u thual Sau phdu thudt Sau 3 thdng
IV. BAN LUAN
Ddi vdl phue hinh co dmh tren vimg ed be day song ham bi mdt sau nho rang, phdn nhip eua phue hinh thudng duae thidt ke day han va nhd nhieu han vdo viing md nha chu bi
Ihieu hong, ben canh nhuac diem vd tham my, thidt ke phue hinh kidu nay lam ve sinh rdng mieng trd nen khdng thuan ldi, din tdi linh Irang viem n u d u n h i l u d phan hdp noi giCr tru vd nhip Trong khi dd, k i l m soaly&uto
" TAP CHI NGHIEN CU'U Y HOC viem nhilm Id rat quan trong khdng chi doi vdi
phue hinh co dmh md cdn dam bao cho k i t qua d i l u In, ghep md hen k i t on dmh lau ddi theo Martins G vd cdng s u [9]
Trong nghien eiru nay, edc bdnh nhdn d l u cd su cai Ihien v l tinh trang viem n h i l m sau phdu thuat, vdi ehi sd n u d u trung binh ban dau la 0,66 ± 0,48 vd giam xuong cdn 0,41 ± 0,49 d thdi diem 3 thdng sau phdu thudt K i t qua cd duac nay cd I h l la do, Phue hinh e6 dmh mdi duac Idm trdn viing mdt rang cd b l day sdng hdm d u a c nang len ngang bdng vd hen tuc vdi b l day n u d u eiia 2 rang tru hai ben, do vdy md vide ve smh rang mieng, kha nang chai rCra cua bdnh nhdn cung nhu kha nang l u chai rira ngay lai phue hinh da hieu qua hon nhilu Ngodi ra, benh nhan cung duac hudng ddn vd y thirc han v l linh trang rang mieng cua minh
B l day vung mdt rang tang theo chilu ngoai trong sau phdu thudt ghep md hen kdt duac xem la mol Irong nhung lieu chudn quan Irong danh gia thanh cdng eiia phuong phap phdu thudt Idm tang b l ddy sdng ham viing mat rang eiia phue hinh ed dmh Trong nghien ciru nay bd ddy trung binh sdng hdm vung mdt rang trudc phdu thuat cd Ihieu hong la 2,15 + 0,86 mm da duac tang len 3,29 ± 0,99 mm sau 3 thang Muc tang 1,14 mm thdp hon so vdi mirc 2,1 mm trong nghidn CLTU cua Hams RJ [10], nhung cao hon so vdi mirc 0,7 mm trong nghien ciru ciia Borghetti A, GliseJ[11]
Trong nghien c u u ndy, trung binh b l day sdng ham. vung mdt rang bi thidu hong trudc phau thudt la 2,15 ± 0,86 mm, eao han nghien ciru cua Harris [3] la 1,19 ± 0,99 mm Theo Reiser GM, su co rut v i t thuang, s u lieu bdt cac md md trong thanh phdn Idp md hen k i t duoc ghep trong qua trinh Idnh thuang dd gay anh hudng ddn k i t qua phdu thuat [1]
Ky thudt ghep md hen ket ket hap vat di chuyen vd phia than rdng chua d u o c dp dung rdng rdi lai Vidt Nam trong d i l u In ldp ddy b l ddy sdng ham mdt rdng trudc khi phue hinh ed dmh Nghien eiru da cho thdy kha ndng dp dung ky thudt nay, vdi chl dmh phu hop vd ky thudt dimg quy each, cd the cho ty le thdnh cdng cao tren Idm sdng Tuy nhien, cdn cd nhung nghidn cii'u vdi c d mdu Idn han, thue hidn tren nhCimg vung thilu hong kich thude Idn han, va theo ddi Irong thdi gian dai han
V. K^T LUAN
Nghien eiru theo ddi 10 trudng hop d i l u tn phdu thuat ghep md lien ket Idp ddy sdng ham mdt rang k i t hap vat di chuyen v l phia thdn rang K i t qua sau 3 thang cho thdy ddy Id mdt ky thudt cd n h i l u uu didm dai ty Id thd tich lap ddy viing thidu hdng cao, cd thd tidn luang duac k i t qua, dap ifng duac yeu cdu v l thdm my, hd tra cho phue hinh cd dmh dat k i t qua ldi uu, ky thudt tuong ddi dd thue hien, It gdy bidn ehii'ng sau phdu thudt
Lai cam en
Chdn thdnh cam an Ban giam ddc Benh vien Rdng Ham Mat Thanh phd Hd Chi Mmh va Khoa D i l u In long hop ky Ihual cao da img hd va tao d i l u kien tdt nhdt cho nghidn eiru nay, cam an s u hap tac quy bau tii' phia ede benh nhdn tham gia nghien cu'u
TAI LIEU THAM KHAO
1. Reiser G.M., Bruno J.F., Mahan P.E. et al (1996) The subepithelial connective tissue graft palatal donor site Anatomic considera- tions for surgeons Int J Periodontics Restora- tive Dent ^6. 131 - 1 3 7
2. Rose L.F., Mealey B.L., et al (2004) Periodontics Chapter 21 Periodontol Plastic and Reconstructive surgery 405 - 77.
TCNCYH 83 (3)-2013
TAP CHi NGHIEN CU'U Y HQC
3. Bouchard P., Malet J., et al (2000) Decision - making in aesthetics Root cover- age revisited Periodontol 27, 97 - 1 2 0 .
4 Nguydn Meo (2007) Kich thude cua don VI rdng-nudu do trdn rdng eii'a giu'a hdm tren (theo ky thudt chup ben song song). LuSn vdn Thac sy Y hpc.
5. Trdn Thj Ydn Nga (2007) Kich Ihudc ghep md lien k i t lap day song hdm Lu$n vdn Thac sy Y hoc
6. Loe H. (1967) The gingival index, plaque index and retention index systems J Penodonto/38, 6 1 0 - 6 1 6
7. Borghetti A., Glise J., Monnet-Corti V.
et al (1999) Comparative clinical study of a bioabsorbable membrane and subepithelial connective tissue graft in the treatment of human gingival recession J Periodontol 70, 1 2 3 - 1 3 0
8. Harris R.J. (1997) A comparision of two techniques for obtaining a connective tissue graft from the palate, Int J Periodontics Re- storative Dent 17, 26^ - 2 7 1
9. Lang N.P., Loe H. (1972) The relation- ship between the width of keratinized gingiva and gingival health J Periodontal 43, 623
10. Novaes A.B.Jr., Grisi D.C, Molina G.O. et al (2001) Comparative 6-month clini- eaf study of a subepithelial connective tissue graft and aceellular dermal matrix graft for the treatment of gingival recession J Periodontal 72, 1 4 7 7 - 1 4 8 4
11. Martins G., Andia D . C , SaMum A.W.
et al (2004) Smoking may affect root cover- age outcome. A prospective clinical study in humans J Periodontol 7 5 , 5 8 6 - 5 9 1
Summary
SUB - EPITHELIAL CONNECTIVE TISSUE GRAFT IN SOFT TISSUE AUGMENTATION OF ANTERIOR MAXILLARY EDENTULOUS AREA
This study Vi'as to evaluate the eiinical efficacy of sub - epithelial eonneehve tissue graft sur- gery with coronal flap in soft tissue augmentation of anterior maxillary antenor edentulous area Sub-epilhehal eonneehve tissue graft surgery with coronal flap was performed on 10 patients (25 to 45 years old) with a chief complain of the unaneslhelie maxillary antenor prosthe- sis Gl, the thickness of soft tissue, and the patient satisfaction were compared before and 3 months after the surgery Three months after sub - epithelial surgery, an adequate anesthetic outcome was achieved with a decrease of Gl from 0 66 ± 0 48 to 0 41 ± 0 49 (p < 0 001) and an increase of soft tissue thickness from 2 15 ± 0 86 mm to 3 29 + 0 99 mm (p < 0 001), 90%
patients were salished with the surgery Sub-epithehal connective tissue graft surgfery with coronal flap can be considered as an effective method in soft tissue augmentation of antenor maxillary edentulous area The prognosis of anesthetm outcome could also be dehned
Key words: sub-epithelial connective tissue graft (SCT); surgery with coronal flap