ĐỊNH vị lồi cầu XƯƠNG hàm dưới TRONG PHẪU THUẬT CHẺ dọc CÀNH CAO để điều TRỊ SAI KHỚP cắn LOẠI III

B GIO DC V O TO B Y T TRNG I HC Y H NI NGUYN THU H ĐịNH Vị LồI CầU XƯƠNG HàM DƯớI TRONG PHẫU THUậT CHẻ DọC CàNH CAO Để ĐIềU TRị SAI KHớP CắN LOạI III TIU LUN TNG QUAN TIN S H NI - 2016 B GIO DC V O TO B Y T TRNG I HC Y H NI NGUYN THU H ĐịNH Vị LồI CầU XƯƠNG HàM DƯớI TRONG PHẫU THUậT CHẻ DọC CàNH CAO Để ĐIềU TRị SAI KHớP CắN LOạI III Ngi hng dn khoa hc: PGS TS Lấ VN SN Cho ti: ỏnh giỏ kt qu phu thut ch dc cnh cao xng hm di bnh nhõn sai khp cn loi III cú s dng khớ c nh v li cu Chuyờn ngnh : Rng Hm Mt Mó s : 62720601 TIU LUN TNG QUAN TIN S H NI - 2016 MC LC TRANG PH BèA MC LC DANH MC CC CH VT TT DANH MC HèNH DANH MC HèNH DANH MC CC CH VIT TT -TDH: XHD: XHT: Thỏi dng hm Xng hm di Xng hm trờn THUT NG ANH VIT - Bilateral Sagittal-Split Osteotomy (BSSO): Ch dc cnh cao hai bờn Sagittal-Split Ramus Osteotomy Ramus (SSRO): Ch dc cnh cao Intraoral (Transoral) Vertical Ramus Osteotomy (IVRO): Ct dc cnh cao ng ming T VN Sai khp cn loi III hay nhụ XHD l mt nhng than phin chớnh ca nhng bnh nhõn cú nhu cu phu thut [1] T l sai khp cn loi III qun th chõu u di 5% [2], nhng qun th chõu l 15 23% [3], ú 63 75% cú ngun gc xng [2],[3] K thut ch dc cnh cao (Sagittal Split Ramus Osteotomy SSRO), t c gii thiu bi Trauner v Obwegeser [4], ó hon thin dn v c s dng rng rói nht iu tr nhụ XHD [5],[6] Tuy nhiờn, phu thut lựi XHD vi SSRO c thc hin hai bờn cnh cao (Bilateral Sagittal-Split Osteotomy BSSO) l mt ba phu thut kộm n nh nht (di chuyn XHT xung di v lm rng XHT) [1] Ngoi ỏnh giỏ mụ mm nhỡn nghiờng hi hũa v khp cn thớch hp, mc tiờu chớnh ca phu thut l kt qu n nh lõu di v khp cn v xng Cỏc trng hp khụng n nh, cú th dn n tỏi phỏt sm hay mun, l ni lo cho c bnh nhõn v phu thut viờn Cỏc yu t nh hng n s n nh ca BSSO ó l ch ca nhiu nghiờn cu [5],[6],[7]; bao gm nh chnh nha trc phu thut [8], mc XHD lựi v hng di chuyn ca XHD [5],[9],[10], phng phỏp c nh xng gia mnh gn mnh xa, di lch li cu lỳc phu thut [1], [7],[11],[12],[13], sc cng mụ mm quanh XHD, thi gian c nh liờn hm [10],[14], Cỏc yu t ny nh hng mt cỏch c lp hay tỏc ng ln Trong ú v trớ li cu dng nh l yu t quan trng Thay i v trớ li cu khụng nhng nh hng n s n nh khp cn/xng, m cũn l yu t thun li phỏt trin du hiu v triu chng ri lon TDH [7],[15],[16] Nguyờn nhõn lm thay i v trớ li cu nhiu nht l c nh xng gia mnh gn v mnh xa khụng thớch hp Mc dự c nh cng chc c cho l tin b ln phu thut [17], vỡ loi b hay gim thi gian c nh 10 liờn hm nờn bnh nhõn thoi mỏi hn sau m [7],[18], nhng nu c nh xng khụng ỳng cú th lm cho li cu b xon, kộo dón hay t li cu quỏ cao khp, s dn n nhng bin chng nh sai khp cn, lon nng khp, tiờu li cu [19], Vỡ vy, gim t l tỏi phỏt sau BSSO khớ c nh v i v ỏp dng hn 30 nm qua Mt nhng phng phỏp s dng rng rói v ph bin nht c Luhr gii thiu nm 1985 Sau ú, nhiu tỏc gi [20],[21],[22] ng h quan im ny v a nhiu phng phỏp trỡ mnh gn phu thut, gim thiu thay i v trớ li cu phc hi s ng v chc nng bỡnh thng ca XHD Tuy nhiờn quan im ny cũn tranh cói vỡ cũn thiu d liu da trờn chng c [21] Xut phỏt t nhng lý trờn, tiu lun tng quan nhm cp n NH V LI CU XNG HM DI TRONG PHU THUT CH DC CNH CAO IU TR SAI KHP CN LOI III c tin hnh vi hai mc tiờu sau: 1/ Xỏc nh tm quan trng ca tỏi nh v li cu XHD phu thut ch dc cnh cao 2/ Trỡnh by c s lý thuyt ca tỏi nh v li cu XHD phu thut ch dc cnh cao 3/ Phõn tớch u, nhc im ca cỏc phng phỏp nh v li cu XHD phu thut ch dc cnh cao 37 v phu thut tht s Khớ c ch to t CT scan vi tỏi to 3D cú mt u c gn vo mỏng nhai v mt u gn vo mnh gn ca XHD, phn gn vo mỏng nhai cú th thỏo lp c Nhng tn kộm v cn cú phn mm h tr lp k hoch phu thut Hỡnh 3.14 Khớ c nh v ch to t CT scan vi tỏi to 3D [75] 3.2 K thut nh v li cu bng np thng v mỏng nhai v trớ tng quan trung tõm 3.2.1 C s lý lun nh v bng np thng v mỏng nhai v trớ tng quan trung tõm Tỏi phỏt sm mc nhiu hay ớt l iu khú trỏnh sau PTCH Trong phu thut XHD bng k thut BSSO, iu quan trng l trỡ v trớ li cu kt hp xng cng chc n nh kt qu xng/rng sau phu thut Cú khong 60% tỏi phỏt di mm c chiu ngang v chiu ng [34] Do ú, nhiu tỏc gi khuyờn nờn s dng cỏch riờng ca mỡnh nh v li cu lỳc phu thut, khụng nhng gim t l tỏi phỏt m cũn trỏnh nhng bin chng khp TDH thy thuc gõy hay suy gim chc nng nhai Phng phỏp nh v trớ li cu, l mng gn di ng, vo vựng c nh ca xng s mt nh xng gũ mỏ theo nguyờn lý ca Lurh, cú hiu qu trỡ v trớ li cu theo ba chiu khụng gian v ngy cũn c nhiu phu thut viờn s dng 38 Khớ c nh v li cu bng np thng v mỏng nhai v trớ tng quan trung tõm l phng phỏp tng i n gin, hu hiu v d thc hin iu kin Vit Nam Vỡ vy, chỳng tụi chn phng phỏp ny vi vi thay i nh c trỡnh by bờn di nhm phự hp iu kin nghiờn cu 3.2.2 Vt liu Hỡnh 3.15 H thng np vớt mini 1.0 ca hóng Jeil Korea Hỡnh 3.16 B np nh v bờn phi v bờn trỏi 3.2.3 Cỏc bc tin hnh 3.2.3.1 Trc phu thut - Ly du cn khớt ca bnh nhõn t th tng quan trung tõm: bnh nhõn ngi trờn gh nha t th lng thng ng Dựng hai lp sỏp hng ct theo hỡnh dng cung rng, h sỏp hi mm v t vo gia hai hm Bnh nhõn th gión v cn li cho n va chm sỏp, cú th hng dn nh 39 nhng hm di lui sau - Lờn giỏ khp bn l vi du cn tng quan trung tõm - Ch to mỏng nhai tng quan trung tõm bng nha t cng Hỡnh 3.17 Khp cn, mỏng nhai tng quan trung tõm 3.2.3.2 Trong lỳc phu thut A B C Hỡnh 3.18 Cỏc bc nh v li cu phu thut A Xỏc lp tng quan trung tõm bng mỏng nhai B B v t np nh v t cnh cao xng gũ mỏ C t li np nh v trc kt hp xng cng chc Gm giai on: A/ Ghi nhn v trớ li cu trc phu thut - C nh hai hm qua trung gian mỏng nhai t th tng quan trung tõm - Rch niờm mc bc l XHD theo k thut BSSO Rch niờm mc ngỏch li hm trờn khong 1,5 cm vựng tr gũ mỏ (trng hp m hm di) hoc theo ng rch LeFort I (trng hp m hai hm) - Bt mt np i t mt ngoi cnh cao n xng gũ mỏ trờn ng 40 ct LeFort I Np c b sỏt th ng C nh np, bo m mi bờn hai vớt iu ny s giỳp xỏc nh tng quan gia XHD vi s mt Hỡnh dng np v l nh s giỳp t li ỳng v trớ ca li cu - Thỏo np nh v v mỏng nhai tng quan trung tõm B/ Ct xng: tin hnh phu thut nh thng qui mt hay hai hm nh k hoch C/ nh v li v trớ li cu XHD - Kim tra v mi b cn tr xng gia mnh gn v mnh xa - C nh hai hm qua trung gian mỏng nhai sau cựng - Trc bt np vớt kt hp xng vựng cnh ngang XHD, t li np nh v phc hi li v trớ trc m ca li cu - Tip tc tin hnh kt hp xng vựng cnh ngang XHD Chỳ ý b np chớnh xỏc trỏnh xon li cu sit cht vớt - Thỏo np vớt nh v - Khõu úng cỏc vt m - Bnh nhõn c c nh hm khong tun Sau thỏo c nh liờn hm, hng dn bnh nhõn mc thun ng hm 41 KẫT LUN Tm quan trng ca tỏi nh v li cu XHD phu thut ch dc cnh cao Vai trũ ca phu thut chnh hm chnh sa d dng rng mt c chp nhn rng rói Tuy nhiờn, thay i v trớ li cu phu thut nh hng trc tip n s n nh xng/khp cn sau m; cng nh phỏt trin du hiu v triu chng khp TDH õy l ch ca nhiu nghiờn cu Vỡ vy trỡ v trớ li cu l mt nhng yu t quan trng nht ngn nga tỏi phỏt sau BSSO Li ớch ca tỏi nh v li cu XHD phu thut ch dc cnh cao Mc ớch ca tỏi nh v li cu bo m kt qu phu thut n nh, gim nh hng cú hi cho khp TDH vỡ vy ci thin chc nng nhai ca bnh nhõn Kinh nghim ca tụi v y hin cú, khuyờn rng nờn s dng khớ c nh v li cu phu thut, nht l nhng trng hp bnh nhõn cú tin s lon nng khp hay nhng trng hp d dng mt cõn xng i vi bnh nhõn sai khp cn loi III cú chc nng khp bỡnh thng, cú th khụng cn dng khớ c nh v li cu, nhng phu thut viờn phi kinh nghim trỡ v trớ li cu cng ging nh trc phu thut u, nhc im ca cỏc phng phỏp nh v li cu xng hm di phu thut ch dc cnh cao Cú nhiu phng phỏp nh v li cu t n gin n phc tp, mi phng phỏp u cú mt thun li v hn ch La chn phng phỏp no l tựy theo kinh nghim ca phu thut viờn v iu kin c s vt cht sn cú K thut nh v li cu bng np thng v mỏnh nhai tng quan tõm ca chỳng tụi, v lý thuyt tha cỏc mc tiờu ca nh vi li cu theo ba chiu khụng gian Phng phỏp n gin, d s dng v cú hiu qu S dng phng phỏp ny cựng vi khỏm k bnh nhõn trc m, lp k hoch iu tr phự hp, cú th t c kt qu phu thut nh mong mun, thm vi nhng bnh nhõn cú kh nng kộm n nh xng/khp cn hay cú nguy c ri lon TDH sau phu thut TI LIU THAM KHO Yang H.J., Hwang S.J (2014) Contributing factors to intraoperative clockwise rotation of the proximal segment as a relapse factor after mandibular setback with sagittal split ramus osteotomy Journal of Cranio-Maxillofacial 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