3. Lingeman JE, Matlaga BR. Evan AP (2007).
Surgical management of uper urinary tract calculi Campbell Walsh Urology. Vol 2, 9"^ Edition, pp. 1431- 1957. Saunders Elsevier, Philadenphia.
4. Tran Van Hinh (2008). Dieu tri soi tiet nieubang tan sdi ngoai cd the. Dieu tri soi tiet nieu bAng phSu thuat it xam Ian. 106-119. NXB Y hoc, Tp Ho Chi Minh.
5 Tran Van Qudc, Tran Ngpc Sinh (2009). Cac yeu to anh hudng ket qua tan soi ngoai co the trong dieu trj soi cUc dudi than Yhpc Thanh pho Ho ChlMinh. 14(1): 16-20.
6 Nguyen'Viet Cudng (2009). Ket qua dieu trj sdi than b^ng phuong phap tan sdi ngoai cO the tren may HK-
ESWL-V tai Benh vien Binh Dan. Y DUOc hoc Quin sif.
34(4): 92-96.
7. Vu Le Chuyen, Nguyen Viet Cudng, Nguyin Tien De (2008). Tdng ket kinh nghiem tan sdi ngoai ca the sot nieu ta Benh vien Binh Dan. Y hoc thuc hinh. 631 + 632' 314-323.
8. Le Dinh Khanh (2005). Mot sd yeu to anh hu6ng den ket qua dieu tri sdi than c6 kich UiUdc 20-50mm b4ng may tan sdi ngoai cO the MZ-ESWL-VI. Y hoc thUC hinti 503(2): 20-23.
DAC DIEM KHQTP THAI DUUNG HAM BJNH T H I A N G TREN PHIM CAT LOP TIA CHUM NON
TOM TAT
Khdp thai dUdng ham (TMJ) la mot khdp dac biet nhit trong cd thi vdi nhCfng dac diem giai phau vi benh ly dac thu vung ham mil NhOng thay doi benh ly khdp thai dUdng ham anh hudng den ciu true xUdng va md mem khdp, cd thi dinh gii tren phim X quang vi cong hudng tU. Chup cit Idp dien toan tia chum ndn (CBCT) li mdt ky thuat mdi cho hinh inh tai tao chit luong chin doan cao, vdi uu diim liSu bOc xa thap hon ding ki va dd phan glii cao han so vdi chup cat Idp binh thudng. Di dinh gia nhOng thay doi benh ly tren phim CBCT, kien thOc ve die diim giai phau khdp thii duong ham binh thudng tren phim CBCT la rat quan trong ddi vdi bac sTrang ham mat trong vide chin doan bdnh /y khdp thii duang ham. Muc dich cOa nghien cOu nay nhim md ta die diim hinh thai khdp thai duang ham binh thudng tren phim CBCT d ngudi Viet Nam trudng thanh, lim cd sd cho viee danh gia nhitng thay doi benh ly khdp thai duang ham.
SUMMARY
Temporomandibular joint (TMJ) is one of the most sophisticated joints with specifications in anatomical and pathological characteristics of the craniofacial region. The pathological changes of the TMJ affect the hard and soft tissue of the joints that can be evaluated by X mys and MRI images. Cone beam computed tomograhphy (CBCT) is a newer technique producing reconstructed images of high diagnostic quality using lower radiation doses and higher resolution than normal CT. To evaluate the pathological changes of the TMJ on CBCT, the knowledge of normal anatomy of TMJ on CBCT is neccessary. The purpose of this study is to descnbe the anatomical characteristics of temporomandibular joint in adult Vietnamese with normal function of temporomandibular joint by cone beam computed tomography (CBCT).
DAT VAN DE
Khdp thai duong ham (TMJ) la mot khdp dac biet nhat trong cd the vdi nhifng dac diem giai phlu va benh ly dac thu vung ham maL Nhung thay doi benh ly khdp thai duong ham anh hudng den cau true xuong va md mem khdp, cd the danh gia tren phim X quang va cdng hudng tU. Trong cac ky thuat X quang khao sat hinh anh khdp thai dUOng ham, chup cat Idp dien
TRAN NGOC QUANG PHI, NGUYEN H Q U NHAN Dai hoc Y khoa Pham Nggc Thach toan tia chum ndn (CBCT) la mot ky thuat mdi cho hinh anh tai tao chat lUdng chan doan cao, cd do phan giai cao hdn so vdi chup eat Idp binh thudng va Uu iKem lieu bUc xa thap hdn dang ke [1,2]. Ky thuat nay cung ca'p eac hinh anh thu dUde theo mat phang song song hoac vudng gdc vdi tmc dai ciia lot cau thay vi mdt phang tran hay diing doc, giitp cung cap hinh anh chat lUdng cao cua cac thanh phan xudng ciia khdp thai dUdng ham tren tat ca cac mat phSng ba chieu khong gian. De danh gia nhung thay ddi benh ly tren phim CBCT, kien thut ve dac ^ e m giat phlu khdp thai duong ham binh thudng tren phim CBCT la ri\ quan trong ddi vdi bae sTrang ham mat trong viec chan doan benh ly khdp thai dUOng ham.
Hien nay tai Viet Nam chua cd nghien ciilj mo ta dac diem hinh thai giai phlu khdp thai dudng ham trSn phim CBCT, do do nghien cilU nay nham muc dich m6 ta dac diem hinh thai khdp thai duong ham binh thuflng tren phim CBCT, lam cd sd cho viec danh gia nhijng thay ddi benh ly khdp thai duong ham.
DOI TUpNG VA PHUONG PHAP NGHIEN CLfU Ddi tupng nghien ciru bao gom 40 benh nhan (18 nam, 22 riij', tuoi tU 15 den 58, dp tudi trung binh 38), cd khdp can hang I va tUOng quan xUOng hang I, khdng cd bat ky tien suf benh ly khdp thai dUdng ham.
tinh nguyen tham gia nghien ciifu. Cac dau hieu lam sang cho thay ehCfc nang khdp hoan toan binh thi/dng bao gom:
Khdng tieng keu khdp Khong dau khdp
Khdng rdi loan van dpng: Ha mieng binh thudng (tren 40mm). khong ha lech, khdng ha ziczac.
Benh nhan duoc chup phim cat Idp dien toan tia chum ndn vdi may Sirona XGplus d tU the can khit tmng tam va hinh anh thu dupc se phan tich tren 3 mffl cat khdng gian, bao gom mat eat difng dpc (vudng gdc tmc dai Idi cau) va mat cat difng ngang (song song taic dai Idi cau) va mat cat ngang dau Idi cau,
Cac dac d\em giai p h l u khdp thai dUOng ham difflc danh gia tren cac mat cat dUng dpc (sagittal view),
Y HOC THUC HANH (957) - S6 4/2015
dUng ngang (coronal view) va mat cat ngang (axial view), bao gom:
Kich thudc ngang dau loi cau (mat cat ngang) Ktch thudc trudc sau dau loi cau (mat cat ngang) Hinh thai loi cau tren mat cat dUhg dpc Hinh thai Idi cau tren mat cat dUhg ngang Gdc tmc ngang Idi cau (mat cat ngang) Gdc liSn Idi cau (mat cat ngang) Hinh thai hom khdp tren mat phang dUng dpc Tuong quan hdm khdp tren mat phing difng doc va khe khdp tren
Do ddc sudn sau Idi khdp (mat cat dUng dpc) Tren mat cat ngang, gdc tnjc ngang Idi cau va goc lien loi c^u duoctfnh nhu sau (hinh 1)-
Hinh 1: PhiAtng phap vi vd do dac goc tnjc ngang loi cau ((3) vd g6c lien loi c§u (a) tren mat cit ngang Ve dudng ndi cue ngoai (L) va cUc trong Idi cau (M).
Gdc tao bdi LM vdi dudng ngang Ly ((J) la gdc tnjc ngang Idi cau. Gdc true ngang Idi cau gom cd gdc tmc ngang Idi cau phai (pfj va gdc tmc ngang Idi cau trai (PR).
Gdc lidn Idi cau (y) = 180° - (PL +pf,)
Tren mat cat dung dpc, hinh thai hom khdp duoc danh gia tai vi tri lat cat tmng tam Dp sau hom khdp dudc do dac nhu sau (hinh 2)-
Hinh 2: PhiATng phap ve va do dac do sau hdm khi^, gdc si/dn sau loi fthdp (GLK) va goc loi cau (GLC) tren m|t cat diitig doc Tren mat cat dung dpc, ve mdt dudng ngang (Ex) tiep tuy^n dinh Idi khdp.
Khoang each tU diem cao nhat hdm khdp (S) den Ex (SE) la dp sau hdm khdp.
Gdc tao bdi sudn sau Idi khdp vdi Ex (y) la do ddc sudn sau Idi khdp.
Ve tuong quan hinh thai hom khdp va khe khdp tren, chung tdi danh gia ti sd giijfa khe khdp tren va do sau hdm khdp.
Hinh thai Idi cau tren mat cat difng doc dUdc danh gia tai mSt c i t tmng tam, gdm 3 loai:
Nghieng trudc Thing Nghieng sau
Tat ca cac sd do deu dUOc thut hien 2 Ian bdi cung mot ngudi, hai Ian do each nhau 1 tuan va sau dd lay ket qua tmng binh hai Ian do. MUc do chinh xac doi hoi giij'a 2 Ian do la khong qua 0.1mm. Ket qua do dac dupc so sanh giua hai ben. danh gia bang kiem djnh "t- test" bat cap. Sau do, lay sd lieu trung binh kich thudc Idi cau hai ben de danh gia sU khac biet giiJa nam va nu, sCr dung kiem dinh "t-test" dpc lap. ? nghla thdng ke dupc xac djnh vdi P<0,05.
KET QUA
Bang 1 So sanh kich thudc Idi cau 2 ben Kich thuflc lot cau
Kich thudc ngang Kich thifdc tnjdc sau
LOI cau (P) 17,57 + 2,75
L6icau(Tl 17,64 ±2,24 7,32 ±1.10
0,4137 0,2280 B a n g 2 : S o s a n h k i c h t h u d c Idi c a u giUa n a m v a nij"
Kich thuoc ngang Kich ttiudclrudc sau
19.04 ±2,03 7.33 ± 1,06
16,24 ±1,83 7.19 ±1.03
0,0001 0.3492 B a n q 3; H i n h t h a i loi c a u
IHinli thai loi cau Nghiei^ truft:
Thanq Nam SL 25 15
31,25
%
18,75
t r e n m a t c a t d i m q d o c Nil SL 28 12
35,00
%
15.00 Tonq sfi SL 63 17
66,25
%
33,75 B a n q 4" H i n h t h a i loi c a u t r e n m a t c a t d i m q n q a n q Hinh thai
loi cau Dang tf6n
Dang I6i Dang goc Danq phing
Nam SL
9 13 10 8
11,25
%
16,75 12,50 10,00
NO SL 14 6 12 8
17,50
%
7,50 15,00 10,00
Tdnq scl SL 23 19 22 16
28,25
%
23,75 27.50 20,00 B a n g 5: G o c ioi c a u t r e n m a t c a t n q a n q Gcc ngang la cau (P)
Goc ngang loi cau (T) Goc lien I6i cau
21,10±6,46 20,29 ±6.41 142,26 ±13,11
22.44 ±5,94 22.41 ± 5.22 135,16 ±6,64
0,1140 0,0246 0,0322 B a n g 6: H i n h t h a i h o m I<h6p t r e n m a t c a t d i l h q d o c Do sau hom khdp (P)
Dp sau hom khop (T) Dp doc loi khcp (P) DP doc Idi kh6p (T) Ti le khe khdp/hom khdp (P) T7 le khe khopyhdm khdp (T)
Nam 7,60 ±1,29 7,12 ±1,28 55,18±10,2e 53,46±11,32 0,53 ±0,16 0,59 ±0,12
Nil 6,67±1,12 6,50 ±1,52 50,99 ±8,57 52,92 ±9,14 0,59±0,19 0,59 ±0,20
0,0169 0,0290 0,1058 0,1332 0,2083 0,4975
BAN LUAN
Khdp thai di/ong ham ia mot l<hdp mang tinh chat doc dao nhat trong co the, hdn nua cac phim qui u'dc khong the danh gia chinh xac vi tri cija idi cau trong hom l<hdp. Vi vay, cac l<y thuat tien tien hdn ia can thiet de danh gia dac diem giai phlu chinh xac [2]. Su phat tnen cija ky thuat chup cat idp tia chum non (CBCT) ra ddi da giup tao ra hinh anh tai tao ba chieu vdi chat
Y HOC THirC HANH (957) - SO 4/2MS
lupng chan doan cao [3,4], Trong nghien ciai nay, chiing toi sCf dung phuong phap CBCT cho viec danh gia cac dac diem giai phau khdp thai dUdng ham binh thudng tren ngUdi Viet.
Ve dac diem kich thudc Idi cau, kich thudc lo! cau d nam trung binh la 19,04 ± 2,03 (mm), Idn hon so vdi d nu la 16,24 ± 1,83 (mm) (bang 2). Tuy nhien kich thUdc trudc sau Idi cau khong cd sU khac biet giCfa nam va nu, vdi kich thUdc trung binh la 7,19 - 7,33 (mm) Su khac biet kich thudc loi cau giCfa hai ben la khdng c6 y nghTa thdng ke (bang 1). Kich thUdc Idi cau d ngUdi Viet ca nam va nUtheo chieu ngang va chieu trudc sau deu nhd hon dang ke so vdi ngUdi da trang. Ket qua nghien ciflj cua d ngUdi da tr§ng ciia Solberg va cong su (1985) [5] cho thay kich thudc ngang Idi cau trung binh d nam la 21,8 (mm) va d nu" la 18,7 (mm), con kich thudc trudc sau trung binh d nam la 10,1 (mm) va nU la 9,8 (mm) So sanh vdi nghien ciru cua May Al- koshab va cong su [6], thi kich thudc Idi cau trong nghien cifu cua chiing tdi lai ket qua lai tUOng ddng.
Ve hinh thai loi cau, trong mat cat dimg doc, da so cd hudng nghieng trudc, chiem tl le 66.25%. Thuc te lam sang ghi nhan nhieu trudng hop Idi cau cd hudng nghieng sau, tuy nhien, nhung trudng hop nay thudng c6 tUdng quan xuong md, NhUng trUdng hdp khao sat trong nghien cUu nay deu c6 tUOng quan xUong trung binh. Do CO le la ly do chiing tdi khdng ghi nhan nhung trudng hpp hudng Idi cau nghieng sau trong nghien cifu nay. Trong mat cat difng ngang, Idi cau c6 4 hinh dang khac nhau, trong dd dang trdn va dang gdc chiem tl le cao hon {bang 4) Ve hinh dang Idi cau, hieu nghien cifu cho tha'y tl le cac dang l<hac nhau, nhung sU khac biet khong dang ke. trong do dang loi chiem ti le cao nhat trong cac nghien cuU, chiem tU43% [7] den 50% [5], Trong nghien ciru ciia chiing toi, dang Idi chiem tl le 23%, thap han dang tron va dang goc. Dang trdn theo cac nghien ciai co ti le thap nhat, lU 0% [5) den 12% [7], nhUng trong nghien cUu cua chung toi, lai chiem tl le cao nhat: 28%, Dang phSng trong nghien cifu cua chiing loi tUdng dong vdi nghien cUu cua Solberg [5] va Chnstensen [7],
Khao sat tren mat cat ngang, gdc ngang Idi cau giua hai ben khong cd su khac biet co y nghTa thong ks. tuy nhien goc ngang Idi cau (T) d nam thap hdn d nU (p = 0,0246) Goc lien Idi cau d nam trung binh la 142.26° ± 13.11^ cao hon so vdi d n{/: 135,16° ± 6,64", Trong cac nghien cifu ve goc loi cau tren binh dien ngang, cac lac gia chu yeu danh gia goc lien idi cau noi chung, khong so sanh giiia nam va nU. Goc lien Idi cau theo cac nghien cUu trung binh tC/ 145° - 160° [9j va tU 150° - 170° [8] NhU vay, goc lien Idi cau tren ngUdi Viet nhd hdn so v6i goc lien loi cau ngUdi da trang. Gdc ngang loi cau co lien he v6i tuong quan xuong theo chieu diing Khi tUong quan xUdng ddng, gdc ngang loi cau se cang thap va khi tUdng quan XUdng md, gdc ngang !di cau se cang cao [1], Nhdm benh nhan nghien ciru nay c6 tuong quan xuong tmng binh theo chieu difng Cac nghien cifu ve dac diem goc lien Idi cau cOng khdng danh gia tUdng quan vdi tuong quan xUOng.
Ve hinh thai hdm khdp tren mat eat difng doc, iS sau hdm khdp ghi nhan d nam cao hdn d nU ed y nghia thdng ke ca hai ben, tuy nhien dp ddc sudn sau I6i khdp d hai gidi khdng cd sU khac biet cd y nghla thong ke {bang 6). Ti le khe khdp tren va dd sau hom kh^
cho thay khdng c6 sU khac biet va y nghTa cua tf l§
nay cho thay khi hom khdp cang sau. khe khdp tren sg cang rdng.
KET LUAN
Qua khao sat giai phlu khdp thai duong binh thudng tren phim cat Idp tia chiim ndn, chiing toi ghi nhan mdt so dac diem sau' (1) kich thUdc Idi cau theo chieu ngoai trong d nam trung binh: 19,04 ± 2,03 (mm), Idn hon so vdi d nu la 16,24 ± 1,83 (mm); (2) kich thudc gan xa khong cd sU khac biet giu^ nam vi r\U. trung binh: 7,2 - 7,3 (mm) va kich thudc ngoai trong va gan xa deu nhd hOn rd ret so vdi ngudi da trang; (3) gdc lien loi cau d nam cao hdn d nU, nhung deu thap hon so vdi ngUdi da trang (4) hinh thai Idi cau tren binh dien ngang c6 4 dang nhung tl le phan bL deu khac biet vdi nhung nghien cifu cCia cac tac glai khac. Du lieu thu thap duoc trong nghien cifu nay tiy vpng se la mot tai lieu tham khao hu\i ich cho viec danh gia iam sang dac diem giai phlu khdp thai diitJng ham trong cac mdn hpc vdi chUe nang khdp binh thudng ciing nhu tren thuc hanh lam sang trong chan doan hinh anh benh ly khdp thai dUdng ham qua phim cat Idp dien toan tia chum,
TAI LIEU THAM KHAO
1. Tsiklakis K, Syriopoulos K, Stamatakis HC,, Radiographic examination of the temporomandibular joint using cone beam computed tomography. Dentomaxillofac Radiol, 2004:33,196-201.
2. Kobayashi K, Shimoda S. Nakagawa Y, YamamolcS A Accuracy in measurement of distance using limH«P cone beam computerized tomography. Int J Oral rulaxillofac Implants. 2004,19-228-31. Kikuchi K, Takeudu S, Tanaka E, Shibaguchi T, Tanne K. Assodalion., between condylar position, joint morphology and?
craniofacial morphology in orthodontic patients without^
TMJ disorders. J Oral Reliabil. 2003,30:1070-5 3 Kinniburgh RD, fvlajor PW, Nebbe B, West K, Glover KE. Osseous morphology and spatial relationships.!
of the temporomandibular joint: Comparisons of normal and anterior disc positions. Angle Orthod. 2000;70.70^0,
4, Blaschke D, Chase DC. Differences in TMJ condylar temporal relationships in normal men and women J Dent Res. 1984,63:266-72.
5 Solberg, W K , Hansson, T, L.. Nordstrom. B.: Thi temporomandibular joint in young adults at autopsyU' morphologic classification and evaluation. J Oral Rehr' 12:303-321,1985.
6. May Al-koshab, Phrabhakaran Nambiar, Jacob John Assessment of Condyle and Glenoid Fossa I\(1orphQlogy Using CBCT in South-East Asians, PLOS ONE journal pone 0121682 Inarch 24, 2015
7 Christiansen, E. L., Chan, T. T, Thompson, J. R-, Hasso, A. N., Hinshaw, D. B. Jr, Kopp, S : Computed tomography of the norma! temporomandibularjoint. Scand J Dent Res 95: 499-509, 1987
8, Yale, S. H., Ceballos, M.. Kresnoff, C. S, Haupffuehrer, J, D.: Some observations on the classification of mandibular condyle types. Oral Surg Oral Med Oral Pathol 16: 572-577, 1963.
9. Norman D. Mohl et al. A Textbook of occlusion
Quintessence Publishing 1988, p. 83. ]
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