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8/7/2019 THM KHM KHP CN T TH A HM SANG BN

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B mn Khp Cn hc Vin o To Rng Hm Mt

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THM KHM KHP CN T TH A HM SANG BN

TS. V Trng Nh Ngc

MC TIU HC TP

1. M t c im gii phu khp cn a hm sang hai bn2. Trnh by mc tiu v phng php thm khm khp cn t th a

hm sang hai bn

i cng

Bc th 3 khi thm khm chc nng khp cn l a hm sang bn, c th

l bc quan trng nht. cc cn tr a hm sang bn thng xuyn l ngun gc

gy ri lon chc nng s-mt, thng lm trm trng cc tn thng nha chu.

Nh ng tc cn v a hm ra trc, chuyn ng a hm sang bn c dng

i (double aspect), c th thm khm chc nng (chuyn ng hng tm vi cc

im chm) hoc thm khm chuyn ng phn tch (chuyn ng ly tm vi cc

im chm rng)

Tht vy, cc chuyn ng hng tm v ly tm c hng dn bi cc c

khc nhau v t ghi trn giy cn sao cho khng chng nhau.

Cui cng, d chuyn ng chc nng hay phn tch, hnh trnh hng dn

cc chuyn ng tin-li (aller-retour) nghin rng v phi c tn trng cht ch

khi nghin cu.

Chuyn ng sang bn

Chuyn ng sang bn c thc hin khi hm di trt sang bn trn din

gn, sn trong ca nm tin nh ca rng hm trn v, c bit hn, trn mt

khu ci ca rng nanh. Ngoi l, din gn, sn ngoi ca nm khu ci hm trnc th to mt b mt hng dn (hnh 5-1)


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Hnh 5-1: B mt hng dn

Bn hm di di chuyn sang c gi tn l bn lm vic, bn i din gi

l bn khng lm vic.

Cn nh rng phn loi nh trn hon ton khng chnh xc. Chng hn nh

khi chng ta quan st, khi nghin cu chu k nhai, bn i din pha nhai cng can

thip tng t cui chu k nhai, trong giai on nghin thc n hng dn bt

u mt chu k mi (hnh 2-2). Tuy nhin theo quan im s phm, phn loi ny

vn c s dng.

c im chc nng sang bnC tn ti nhiu type chc nng sang bn khi thm khm.

Chc nng rng nanh

Cung rng PIM, bnh nhn trt rng hm di trn rng hm trn sang

bn, nhng gi cc im chm cho n t th u chm u. Rng nanh hm trn

ch hng dn hnh trnh ny trong sut hnh trnh. Ngay khi bt u v trong sut

hnh trnh, nh khp ca tt c cc rng l ton b.

Hnh trnh, c m t bi cc rng nanh hm di, c hai ng cong hi ha

trong mt phng trn (plan frontal) to ra hnh nh c in chapeau de gendarme

khi m t chu k nhai.


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Hnh 5-2a: chuyn ng

sang bn trn rng nanh

Hnh 5-2b: chu k nhai

ca chc nng rngnanh bn phi

Rng nanh hm trn c t chc nha chu khng tt nht v thch nghi nht

i vi chc nng sang bn. Chc nng rng nanh th thng xuyn v c coi

nh l chc nng sang bn l tng ngi ln tr.

Chc nng sang bn nhn chung i hi:

- Khp cn loi I rng nanh theo Angle- Chm khp PIM hon ho i vi rng nanh tham gia hnh trnh ngay t

u.

- St v Si thp hn cn cha ca rng ca bn v rng c nm- cn ph ca rng nanh quan trng hn cn ph ca rng tin ham,

hm, rng caTuy nhin, thm ch chng ch nh ti lp li mt cch h thng chc nng

ny, c bit khi mn rng tin trin a rng nanh vo chc nng nhm.

Chc nng trc- bn

cn ph v cn cha ca rng ca lin quan cht ch n cn ph

v cn cha ca rng nanh. Do vy, cc rng ca bn thng rt tham gia vo chc

nng bn: l chc nng trc-bn (hnh 5-3). Trong mt s trng hp, rng

ca bn, km theo hoc khng bi rng ca trung tm, c th ch hng dn chc

nng nu t chc nha chu lnh.


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Chc nng nhm

Bn lm vic, nhiu rng bao gm rng nanh, hng dn sang bn. Chc

nng nhm m bo bo v nha chu tt. Lc nhai phn b hi ha trn tt c cc

rng ca bn lm vic khng c cn tr i bn (hnh 5-4).

Trong thc hnh lm sng, y l chc nng kh thng bng: trn mi

rng tham gia chc nng, cc im chm ng thi v lc u nhau t PIM n t

th u chm u. Mt khc, nu t chc nha chu yu, hnh trnh cn trn cc rng

hm c nguy c tr nn sang chn

Chc nng nhm sau

Hnh 5-3: Chcnng trc bnca rng 12 v13

Hnh 5-4a:Chc nng

nhm t rng21 n 26


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Thng gp trong trng hp h khp pha trc. Ch c cc rng c nm

pha sau hng dn chc nng (hnh 5-5a)

Khp cn thng bng

Rng hm bn khng lm vic tham gia chc nng sang bn vi cng cng nh bn lm vic (hnh 5-5b)

Type khp cn ny c nghin cu lm thng bng hm gi lp. Trn

nha chu lnh, im chm khng lm vic c th c duy tr.

Hnh 5-5a: chc nng nhm sau phi Hnh 5-5b: Khp cn thng bng

v tr nha chu yu tng ng vi rng hm, hnh trnh tr nn sang chn v cth khng phi c bo tn.

Chc nng tip sc (trung gian, relais)


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Chc nng bn, trong trng hp h khp rng

nanh, c th c hng dn bt u hnh trnh bi

mt hoc hai rng c nm (14 v 15) c Si thp

nht. Kt thc hnh trnh, rng nanh (13) c trchnhim hng dn St v ra cn.

Chc nng tip sc hon ton c th c chp

nhn trn t chc nha chu lnh.

Chuyn ng li cu

Trong cc chu k nhai, chuyn ng a hm sang hai bn cng c hng

dn bi li cu di s hng dn ca cc c. Hng dn rng nanh, l hng

dn pha trc m bo s nh khp pha sau. Ngc li, chc nng nhm hoc c

khp cn h hoc nghin rng, nh khp pha sau khng lm vic c to iu

kin bi chuyn ng ca li cu.

Chuyn ng sang bn phn tch c th c nghin cu trn phim CT

Scanner.


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Hnh 5-7a: Chuyn ng sang bn phn tch

Trong sut giai on u c tip xc cc, li

cu thc hin chuyn ng ng ngang. Li

cu lm vic thc hin chuyn ng khi uBennet (MIB) m bin trung bnh c tnh

l 1mm. Trong phn ln cc trng hp,

chuyn ng c nh hng ra sau, ln trn

v ra ngoi. Chuyn ng ln trn lm tng

lc rng hm v lm trm trng tc dng

cn tr ca bn lm vic.

Li cu bn khng lm vic thc hin chuyn ng sang bn tc thi (MLI) vo trong,

xung di nh v ra trc to tc dng nh khp nh cc rng cng bn. Ngc

li, trong chuyn ng ny c hng nm ngang chim u th, n cng tng lc truyn

n cc rng hm.

Khi bnh nhn c chc nng nhm, c bit cng cc rng hm, cn nh

gi chuyn ng sang bn ca li cu trc khi iu chnh cn v thc hin hm

gi.

Cn ch b mt hng dn lan rng n nh xa ca nm khu ci (hnh 5-7b).

Hnh 5-7b: Chuyn ng li cu v dichuyn ca mt rng tin hm hm ditrn b mt hng dn hm trnDi chuyn ra pha sau ca rng hmdi t l vi s li ca li cu (MIB),MIB ph thuc vo bin MLI

1: MLI v MIB = 0, khng li 34 trn bmt hng dn 242: MLI v MIB = 1,5, li nhiu 34 trn

b mt hng dn 24


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Mc tiu ca khm a hm sang bn

- Nghin cu cc cn tr cn- Ghi nhn v tr v hng ca cc mt mn- Xc nh cc rng hoc rng hng dn chuyn ng

Cn tr lm vic sang bn (IT lat)

IT lat l mt cn tr lc trt trong sut hoc mt phn chuyn ng sang

bn lm vic. C th do rng chi, trm rng hoc chp rng iu khc km (hnh

5-9a).

Trn mt rng c t chc nha chu yu, lc bn qu mnh to mt cn tr

lm trm trng t thng nha chu (hnh 5-8)

Ngc li, trn t chc nha chu lnh, cng mt rng c th ch hng dn

sang bn, n khng to ra cn tr nu hnh trnh cn hi ha.

Hnh 5-8 a v b: Nghin rng trn22, khng chm 23 lm trm trnghn tn thng nha chu.Hnh 5-8c: Tn thng trong

xng nm thnh xa ca 22, racn c mt mn


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Cn tr khng lm vic sang bn (INT lat)

INT lat nm bn khng lm vic, l mt cn tr gy tr ngi chc nng

ca bn lm vic (hnh 5-9b). Trn t chc nha chu yu, mt hnh trnh khng lm

vic cng to ra mt cn tr.

Bn lm vic Bn khng lm vic

Hnh 5-9a: IT lat thng nm trn din

gn trong ca nm ngoi hm trn hoc

trn mt khu ci ca rng ca v rng

nanh trn.

Hnh 5-9b: Hnh trnh INT lat thng

nm trn din xa, sn trong v nh

nm khu ci trn; n c th bao gm

cc im ta khp cn.Mt INT ph hy s hi ha ca chuyn ng sang bn v c th c nhng

hu qu trm trng cho b my nhai, n l cc im chu cc lc bn ln c th

gy sang chn cho rng v m nng

Loi cn tr ny, kt hp vi cc sang chn tm l cng c th l im khi

u cho thi quen nghin rng.

Cui cng, INT lat c th gy ra phn x trnh v gy di chuyn hm di

lm tng hot ng c, i khi l nguyn nhn gy ri lon c hoc khp.

V tr v hng ca cc mt mn

Mt mn thng gp nht nm trn hnh trnh INT lat.


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V phn cc mt mn tng phn, nm trn hnh trnh lm vic, n thng c

do cc ming trm v nht l cc chp m dc chc nng gia tng, mun hay

khng lm gim bin chu k nhai (hnh 5-10)

Hnh 5-10: Nghin rng do tng dc chc nng

Hnh 5-10a: Mu thc hin nm 1972,

trn bnh nhn 40 tui, mn 43 v 33

khng c ngha v ging nhau

Hnh 5-10b: Vo nm 2002, mn 33tng ng vi rng t nhin mn sinh lbnh thng. Ngc li, mn rt r trn43 l hu qu ca nghin rng trcbn phi do rng s ta trn 13, dcchc nng tng.

Ngoi ra, khng c chuyn chc nng nhm c thit lp t t do mn

sinh l cc rng thnh chc nng rng nanh bng cch mi Si v St (hnh 5-11).

Nghin cu rng hoc cc rng c th hng dn chc nng

Nh trc y, khm gii phu c b sung bi khm chc nng nh

du cc rng hng dn chuyn ng sang bn; kh nng chc nng phi c

nh gi. Cht lng m nng ca rng c nh gi: la chn cch iu

chnh cn bng cch mi bt hoc p thm.

Phng php thm khm: thm khm cn thn ng cong b tr, su ca

nm, chuyn ng sang bn nh hng nghin cu cc cn tr c th nhn thybng cc giy cn.


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Thm khm ng cong b tr

ng cong Spee: tt c ng cong Spee c th gy ra ri lon cc chuyn

ng chc nng trong khi a hm ra trc cng nh a hm sang bn v gy ri

lon c hoc khpng cong Wilson: khi hng dn trc bn thp (rng b mn hoc chc

nng nhm), phi thm khm ch ng cong Wilson: nm li hm di rt

cao gy IT lat, s nghing tin nh ca rng hm trn to thun li to INT lat

(hnh 1-35b)

su ca nm: su ca nm ln cng gy ra cc cn tr bn khi mn

rng lm gim vai tr hng dn chc nng ca rng trc (hnh 5-13)

Quan st cc chuyn ng a hm sang bn

Khi chuyn ng sang bn vi im chm rng d dng, khng b ngt

qung, phn tch cn pht hin t cn tr.

Bnh nhn thng kh thc hin theo yu cu chuyn ng sang bn. ch

ra hng di chuyn, yu cu bnh nhn t ngn tay trn rng nanh hm hm trn.

Chuyn ng vi im chm rng c lp li nhiu ln sang phi v sang tri.

Quan st rng lung lay bng cch nhn v s pht hin cc cc tr sang bn. Nu

nghi ng yu cu bnh nhn lm ng tc nghin mnh cc rng theo cch tng

dn tng bin lung lay rng.

nh du cn tr lm vic (IT lat)

Cc im ta nm trn b mt hng dn c quan st khi thm khm

PIM. Yu cu bnh nhn nhai trn giy cn t mi bn cung rng. Thc hin

cc chuyn ng lch tm v hng tm trn cc cung rng c lm kh. chnh trnh cn cho php ghi li v tr v hng ca cc IT lat trn s cn. Cui

cng, phi ch trong qu trnh nhai giy cn, cc rng hm di thc hin

chuyn ng trc-bn. Nhiu hnh trnh trc bn c th gy ra sang chn.

nh du cn tr khng lm vic (INT lat)


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Hnh 5-15: Mt mn cn chc nng sang bn

Mt mn rng ca v rng nanh hm trn v hm di bn tri th rt r. L hu

qu ca nghin rng cn chc nng sang bn tri.

Kt lun

im khi u chuyn ng chc nng c th b ri lon bi cc im chmqu mc, cc cn tr li hm, a hm ra trc hoc sang bn. Cc mt mn rt r

ch ra tnh trng nghin rng c th lm trm trng cc tn thng nha chu c

sn hoc gp phn lm co tht c.

Ch : m bo kt qu iu tr, cn lm qun t th PIM c (c th bng

nt chn rng ca, p thm, chnh nha) nh gi t th mi so vi t th c.

Kt thc thm khm khp cn bng cch khm ng tc ngm ming sinh l.

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