MT S QUAN NIM V KHP CN

MC TIU 1. Nu c c im ca khp cn l tng. 2. Nu c tnh cht v ng dng thc hnh ca khi nim khp cn chc nng. 3. Tho lun c v khp cn sinh l v khi nim khp cn khng sinh l. 4. Nu c s pht trin dn ti quan nim khp cn thng bng v ng dng ca n. M U Trong lch s, c nhiu thi k v cho ti ngy nay, nhiu tc gi nhn mnh yu t hnh thi hc v c hc ca khp cn, tp trung ch vo rng v s n khp gia cc rng, a n vic to ra cc dng c c kh chnh xc, t m m phng hat ng ca khp thi dng hm v quan h gia hai hm. Theo , l s p dng mt kiu t duy c kh trong nhn thc v hnh thi-chc nng h thng nhai, xu hng n gin ha, ton hc ha cc qu trnh sinh hc vn uyn chuyn, thnh nhng qu trnh cng nhc, theo qui lut ca nhng cng thc ton hc, c hc. Hot ng ca h thng nhai con ngi khng ch tun theo nhng qui lut sinh hc-sinh l, hnh thi-chc nng m cn l s an xen phc tp v nhy cm vi trng thi tinh thn-tm l, cc yu t cm xc-tm linh ca mi ngi trong mi trng x hi. Ngy nay, quan nim cn khp khng ch gii hn vo vic nghin cu cc rng n khp vi nhau nh th no m phi bao gm ton b cc yu t thuc v cu trc v chc nng ca h thng nhai. V mc ch ny, khp cn (thc cht l cn khp) c chia thnh 3 nhm: khp cn l tng, khp cn sinh l, khp cn khng sinh l.
S phn bit v mt lm sng ca ba nhm ny cn c hiu r lm c s cho vic nhn xt, pht hin cc thay i, bt thng v bnh l.

1. KHP CN L TNG 1.1. nh ngha Khp cn l tng l khp cn c tng quan rng-rng ng theo m t l thuyt, b rng c quan h gii phu v chc nng hi ha vi cc cu trc khc ca h thng nhai, tt c trong tnh trng l tng.
Trc y, khp cn thng c gi l l l tng khi v mt gii phu, n c tng quan rng-rng, mi trng ng theo m t l tng (xem c im s n khp l tng ca b rng sa - trang 40 v b rng vnh vin - trang 48) (Hnh 3-17). Nhng nh vy, mi ch da trn nhng quan nim nh hng theo rng m khng quan tm n cc thnh phn khc ca h thng nhai. V mt thc hnh, khp cn l tng l mc tiu l thuyt mong mun t n, khng tnh n kh nng iu tr thc t.

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Hnh 3-17. Khp cn l tng.

1.2. c im ca khp cn l tng 1.2.1. Khp thi dng hm c chc nng ti u Mt khp cn l tng phi cho thy khp thi dng hm v tr chc nng ti u khi cc rng lng mi ti a: V tr li cu ti u (trng hoc gn trng vi v tr tng quan trung tm) vi cc li cu bnh thng v cu trc, ta vo a khp c cu trc v v tr bnh thng, a khp ta mt lm vo li khp theo hng trc trn v vi hot ng c ti u cng nh vi s n nh ti a v cn khp (Mc. Neil). 1.2.2. Khp cn trung tm trng vi lng mi ti a Khp cn trung tm (CO = Centric Occlusion) c nh ngha l S n khp ca cc rng khi hm di tng quan trung tm; trn i a s ngi bnh thng, khp cn trung tm thng khng trng vi v tr lng mi ti a. mt khp cn l tng, khp cn trung tm trng vi v tr lng mi ti a; ni cch khc, khp cn l tng, lng mi ti a din ra khi hm di tng quan trung tm.
y l nh ngha bnh thng theo trng phi hm hc, trong trng hp c tng quan ti u gia hai hm. Cn ch khp cn trung tm l v tr rng hng dn, li cu khng quyt nh v tr cc rng (xem chng 4 v chng 6). Khp cn l tng l mt khp cn n nh, khng c biu hin no v s thay i v tr ca rng hay m nha chu. Rng c sp xp trn cung hm sao cho lc nhai c hng theo trc ca rng cng nhiu cng tt, khng c chuyn ng sang bn do lc xon. S sp xp ca cung rng l kt qu ca cc lc t cc c quan xung quanh, c bit l h thng mi-m-li, tc ng ln b rng t mi hng.

khp cn trung tm, cc rng sau phi c s tip xc ng thi v cn bng hai bn, cc rng trc ch tip xc nh. Tng quan ny cho php s n nh ti a i vi khp thi dng hm v gim ti a lc nhai ln mi rng. Nh vy, khp cn trung tm, rng sau gi n nh cc tip xc rng v hm. 1.2.3. C s bo v ln nhau gia rng trc v rng sau Cc rng sau c sp xp sao cho n chu c lc nhai theo chiu dc. Ngc li, cc rng trc nghing v pha mi, khng thch ng chu lc theo chiu thng ng. Nh vy cc rng sau gip bo v cc rng trc trnh c cc lc chc nng qu mc theo chiu thng ng khi nhai, ngc li, cc rng trc duy tr s tip xc nh khp cn trung tm. Trong vn ng tip xc ra trc v trc bn, cc rng sau nh khp do hng dn ca cc rng trc. Cc rng trc hng dn hm di trong vn ng ra trc v trc bn: trong vn ng ra trc, cc rng ca tip xc v hng dn (hng dn rng ca), cc rng sau nh khp (Hnh 3-18). Trong chuyn ng trc bn, rng nanh gy nh khp tt c cc rng sau (hng dn rng nanh) (Hnh 3-19). Hng dn rng nanh v rng ca c hoangtuhung.com 2

gi chung l hng dn trc. Nh vy, khi thc hin vn ng ra trc v trc bn, cc rng trc hng dn hm di lm nh khp v bo v cc rng sau khi cc lc tc ng theo chiu ngang.

Hnh 3-18. Hng dn rng ca gy nh khp cc rng sau trong vn ng ra trc.

Hnh 3-19. Hng dn rng nanh gy nh khp cc rng sau trong vn ng sang bn.

Do cc rng trc xa cc c nng hm hn cc rng sau nn p lc t ln vng rng trc t hn. Nh vy cc rng trc th cm nhng lc ngang trong cc chuyn ng lch tm ca hm di tt hn, nhng lc ny tc ng c hi cho cc rng sau. c bit rng nanh c cu trc xng v t l thn/chn rng thch hp nht chu nhng lc ngang. Qua nghin cu Williamson, cc c nhai c gim hot ng khi cc rng sau nh khp trong chuyn ng ra trc v sang bn. Rugh v cng s cng ghi nhn iu ny cng din ra vi hng dn rng ci. Dng nh s tip xc trn mt rng l mt thun li, nh mt hng dn cho c ng sang bn (ngc vi s tip xc trn nhiu rng ).

Mt khp cn l tng l khp cn c c s bo v ln nhau ca cc rng trc v rng sau.

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1.2.4. Chc nng h thng nhai ti u Mt i hi i vi khp cn l tng l t c chc nng ti u. H thng nhai gn lin vi cc chc nng pht m, nhai, nut V tr cc rng phi m bo cho cc chc nng ny. Th d: cc rng ca trn phi cho php s tip xc b cn vi ng kh t ca mi di pht m r cc m /f/ hay /v/; cc rng ca trn v di phi c tng quan tip xc i u nhau ct thc n tt. Lc tc ng trn cc rng sau c hng theo trc rng vic nhai nghin thc n c hiu qu. Ngi c khp cn l tng phi cm thy mt s n nh, hon ton thoi mi, khng au, khng kh chu do tnh trng hot ng ca h thng nhai v trong giao tip (yu t thm m).
Trn c s cc nghin cu v lm sng v in c , c th kt lun rng nhng iu tin quyt cho mt khp cn l tng l: 1. Tng quan cn khp hi ha v n nh tng quan trung tm cng nh trong on gia tng quan trung tm v khp cn trung tm. 2. Thun li trong cc vn ng trt sang bn v ra trc. 3. Cc lc nhai thun li nht i vi s n nh rng. 4. Khng c nhng yu t c khuynh hng gy mt n nh. Mc d quan nim v khp cn nh trn lm cho nh lm sng c th gip nhng bnh nhn c mc chu ng thp i vi s khng hon ho ca khp cn hay nhng ngi b vim nha chu tin trin; nhng khng c ngha mt l tng nh th phi c p t ln bt k bnh nhn no c khp cn chc nng v m nha chu lnh mnh (Ash).

2. KHP CN SINH L 2.1. Khng c mi lin h trc tip gia tnh trng khp cn v chc nng Trn thc t, ch mt s rt t ngi c khp cn l tng, hu ht u c mt khp cn xu (malocclusion) v mt phng din no , nhng c chc nng tt. Kh nng thch ng a s ngi nhng lch lc so vi l tng vn c th l bnh thng, n nh v hi ha.
Pullinger v cng s nghin cu trn 120 nam v 102 n khe mnh, tui trung bnh l 29. Lng mi ti a v tip xc lui sau trng nhau chim 29%. Trong s , 60% c tip xc rng ci mt bn v tr tip xc lui sau. Khng c s lin quan c ngha gia nhng ngi c s trt trung tm vi c ting ku khp thi dng hm. Tng t, khng c s lin quan gia ting ku khp thi dng hm v s tip xc rng ci 1 bn hm v tr tip xc lui sau.

Khp cn ca mt ngi c th lch lc so vi nhng tiu chun bnh thng nhng c chc nng tt, trong khi mt s ngi c khp cn vi nhng tng quan hnh thi hc ti u nhng li b nhng vn lon nng hm di. Khng c bng chng xc nh nh hng ca s n khp gia cc rng i vi hm di v lon nng khp thi dng hm l do kh nng thch ng nhng mc khc nhau ca h thng nhai ca mi ngi v c im bnh cn a yu t ca ri lon thi dng hm (Carlsson).
Nghin cu trn bnh nhn lon chc nng hm di khng th xc nh nhng ri lon tip xc mt nhai a n lon chc nng khp thi dng hm.

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2.2. Tiu chun ca khp cn sinh l chc nng Khp cn sinh l chc nng c cc c im sau: - Cc thnh phn ca h thng nhai hi ha v hnh thi v chc nng, gp phn n nh khp cn; hm di thc hin chc nng mt cch thoi mi, khng au, khng kh chu (au v/hoc kh chu l du hiu ca lon chc nng). - Khng c nhng du hiu thay i ca h thng nhai (do hot ng cn chc nng) mang tnh ang b ph hy: khng c s di lch hoc tri rng, khng c lung lay rng, khng c s dy khong dy chng nha chu, rng khng mn bt thng hay b nhy cm ng. - Hm di vn ng d dng, trn tru, ngha l khng c cn tr cn khp trong cc vn ng trt ca hm di. - trung tm, hm di c t do tm n hoc c hng dn n lng mi ti a. - Khng c than phin v thiu sc nhai (do mt rng); khng b mi c, khng au khp thi dng hm. - Khp cn sinh l cng tha ng v mt thm m i vi bnh nhn. Nh vy, ngi c khp cn sinh l chc nng khng c nhu cu iu tr. 2.3. S n nh khp cn Trn b rng t nhin, s n nh khp cn ph thuc vo tt c cc lc tc ng ln rng. C th nu tm tt cc lc, bao gm cc lc do thc hin chc nng, gm: - Lc ca h thng mi-m-li, - Cc thi quen chc nng v cn chc nng, - S ton vn ca rng v nha chu v mt hnh thi theo ngha rng ca t ny, - Tnh trng v s phi hp hot ng ca cc c hm, - Tnh trng khp thi dng hm. Khng th m t mt cch chnh xc cc lc gy mt n nh khp cn: cc rng thc hin vic iu chnh v tr trong sut i sng p ng vi nhng thay i t nhin ca lc nhai lin quan n mn rng; p ng vi nhng thay i bnh l nha chu hoc trng lc c, cng nh cc phc hi, phc hnh v cc th thut nha khoa khc. Hnh mu lc tc ng ln rng phc tp hn nhiu so vi cc cch phn tch lc thng c s dng trong vt l hc. Tuy nhin, trong kh nng thch ng ca h thng nhai, s cn bng lc vn c duy tr. (Cc lc va c nu trn hoc s c cp trong nhng bi chuyn bit) 3. KHP CN KHNG SINH L Hu ht mi ngi u c khp cn lch lc so vi khp cn l tng. Tuy vy, a s cng u c kh nng thch ng vi s lch lc v thc hin chc nng tt m khng b nhng du hiu hay triu chng no ca lon chc nng. Nhng du hiu v triu chng ca lan nng h thng nhai ch yu th hin trn ba thnh phn: h thng c-thn kinh, cc khp thi dng hm, rng v cu trc nng . Lon chc nng rng v nha chu th hin kh phong ph, ty thuc vo nguyn nhn gy ra, s c cp trong mt tp sch khc. Vn hat ng cn chc nng s c trnh by trong mt bi ring. V mt khp cn theo ngha i chiu vi b rng v hnh thi n khp l tng, biu hin ca tnh trng lon chc nng rng v nha chu nh rng lung lay, di

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lch, mn mt nhai, nt gy, nhy cm phn nh tnh trng ri lon chc nng do vt qu kh nng thch ng ca rng v m nha chu. Nhng du hiu v triu chng nh vy khng bt ngun t c im cu trc ca b rng m l do vic s dng khp cn nh th no mi ngi, thng l do cc thi quen cn chc nng: nghin, sit cht rng vn kh ph bin trong cng ng (Mohl). Do , thut ng khp cn khng sinh l khng ng ch nguyn nhn v kt qu, cng khng phi l mt bnh. Khp cn khng sinh l l tnh trng c vn v quan h gia hai hm hoc c chc nng khng c m bo v cn c iu tr. 4. KHP CN THNG BNG
Khp cn thng bng, c v s pht trin quan nim ln ng dng thc hnh c l l mt trang bi trng nht trong lch s cn khp hc ni ring v nha khoa phc hi ni chung. Quan nim v khp cn thng bng, v vy, s c trnh by theo lch s pht trin ca vn .

4.1. nh ngha Khp cn thng bng l khp cn c s tip xc u v ng thi tt c mt chc nng ca hai hm v trong mi vn ng trt ca hm di. Trong khp cn thng bng, c s tip xc ng thi bn lm vic v bn khng lm vic trong cc vn ng sang bn v ra trc.
Nhng hnh thc thng thng, t nhin ca khp cn l khp cn bo v ln nhau, c nh ngha l c s nh khp ca cc rng bn khng lm vic trong cc chuyn ng lch tm ca hm di. S nh khp ca cc rng bn khng lm vic trong chuyn ng sang bn v ca cc rng sau trong chuyn ng tip xc ra trc gip bo v cc rng bn khng lm vic.

4.2. Lch s
Nm 1855 Bonwill, nh ton hc v nha s, trnh by nhng quy lun hnh hc v c hc ca s n khp cc rng. L thuyt ca Bonwill to ra mt khung nhn thc v tnh cht thng bng ca khp cn.
Bonwill phn tch v m t hm di nh mt tam gic u 10cm vi 3 nh l 2 li cu v gc cn gn ca rng ca gia di (Hnh 3-20). Quan nim hnh hc l tng ny nhm mc ch t c s tip xc nhiu nht trn cc rng ci nh v rng ci ln v cng lc c s tham gia ca cc rng ca trong chuyn ng sang bn. Kt qu ca khp cn thng bng l s cn bng hot ng ca cc c hai bn mt cch ng thi v t c s tip xc nhai ln nht mi chuyn ng, hn na, c s cn bng v p lc v lc trn ton b cung rng. Vic p dng nhng quan nim ny c l gip gim bt s nghing v lt ca hm gi ton b khi thc hin chc nng trong ming. Theo sau l thuyt ny, gi khp Bonwill ra i l dng c u tin ng dng nhng nguyn tc ton hc vo gi khp (Hnh 3-21 A ,B).

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Bn knh 4 inches

Tam gic Bonwill

Tam gic Balkwill

Hnh 3-20.

A. William G. A. Bonwill (1838-1899); B. Tam gic Bonwill (tam gic ABC).

Hnh 3-21. Ga khp Bonwill (1858). Theo mt bn v ca Bonwill c copy li.

Nm 1883, Walker ghi nhn ng i ca li cu l nghing v pha di do dc ca li khp. ng thit k mt kiu gi khp c ng i ca li cu iu chnh c v mt dng c ghi ngoi mt phc tp ghi nghing ca ng chuyn ng ca li cu mi ngi (1896) (Hnh 3-22, 3-23).

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Hnh 3-22. Ga khp sinh l ca Walker, b phn iu chnh li cu c th iu chnh c theo tng ngi.

Hnh 3-23. Dng c o gc ca ng i li cu ca Walker.

Nm 1890, quan nim khp cn thng bng c F. G. Spee cng b. Spee trnh by nhn xt v chc nng ca b rng t nhin ngi, trong , theo Spee, (1) mt nhai ca cc rng hm di trt trn mt nhai cc rng trn; (2) cc vng tip xc ny nm trn cng mt mt cong v (3), trc ngang ca mt cong ny i xuyn qua mt im pha sau ng l. T nhn xt ny, dn n khi nim m sau ny c gi l ng cong Spee (Hnh 3-24).

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Cng thi gian ny, E. H. Angle cng xy dng bng phn loi v khp cn (h thng phn loi Angle, 1887).

Hnh 3-24.

A. Ferdinand Graf von Spee (1855-1937). B. Hnh chp s (t pha bn) ca von Spee.

u th k XX, A. Gysi (1910) ph phn vic s dng cc gi khp bn l ng m n gin kh ph bin hi , nhng cng nhn thy s phc tp ca vic p dng cc k thut Walker ghi cc nghing ca ng i li cu v xy dng cc phng php n gin hn ghi nhn chnh xc hn cc ng i ca li cu. Gysi a ra nhiu loi gi khp mi trong giai on ny (Hnh 3-25).

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Hnh 3-25. A. Ga khp thch ng ca Gysi (1912), B. Ga khp iu chnh c cong ca hng dn li cu, C. Ga khp Wippunktarticulator (1908) (mt trong nhng ga khp iu chnh c u tin ca Gysi), D. Afred Gysi (1865-1958)

Phng php n gin nht c lng dc li cu ca bnh nhn l ghi du bng sp trong ming, k thut ny (Christensen, 1902) vn c p dng rng ri n ngy nay trong nha khoa phc hi. Pht trin cc quan nim ca Bonwill v Spee, G. S. Monson (1920, 1922, 1932) trnh by quy lut hnh cu gii quyt cc vn khp cn (Hnh 3-26).

Hnh 3-26. A. Ga khp ca Monson ng dng l thuyt chm cu, B. George S. Monson (1869-1933)

Nm 1955, Mc Collum ci tin cung mt ca Snow (G. B. Snow pht minh ra cung mt 1907), gn cung mt vi hm di v nh , to ra cung mt xc nh c trc bn l. Mt cp cung mt trn v di c dng hnh thnh mt my v truyn

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(pantograph), c th ghi chuyn ng ca li cu trong khng gian ba chiu trong cc vn ng ra trc v sang bn. McCollum v cc cng s (1962) s dng thut ng Hm Hc (Gnathology) ch mn hc nghin cu v chuyn ng ca khp thi dng hm, o c cc yu t c bn ti lp v s dng trong chn on v iu tr khp cn.
Ngi ta tin rng nu 1 gi khp c th bt chc ng tng quan ca hm v chuyn ng ca li cu th c th to c cc rng n khp nhau mt cch l tng.

Cc loi gi khp iu chnh c cng pht trin mnh trong thi k ny, cho php vic ghi li v ti lp ng i ca li cu. Ngy nay, ngi ta nhn thc r rng rng i vi b rng t nhin, cc tip xc bn khng lm vic th khng c gi tr tht s, v n khng gip lm gim bt lc stress ln cc rng bn lm vic, m (ngc li), chng c th l nhng yu t gp phn gy tn thng do chn thng (khp cn) Schuyler (1953) Khp cn thng bng l mt bin php c gi tr trong phc hnh, ch yu gip hm gi ton b c n nh. Trong thc hnh phc hnh, t c khp cn thng bng, cn xem xt mi quan h gia nm yu t (b nm Hanau hay cng thc Thielemann), th hin nh sau: dc li cu x dc rng ca Khp cn thng bng = nghing Mt phng cn x di tn trng cung x cao ca mi ng cong Spee

Th d: Nu dc li cu tng th phi gim dc rng ca; Nu dc mt phng cn tng th cn gim ng cong Spee hoc tng cao ca mi. Cn ch y khng phi l mt cng thc ton hc, m vn l ch yu t ang c xem xt nm tng trn hay tng di ch khng phi l t s hay mu s. Tm tt Khp cn l mt phn ca h thng nhai. Ton b h thng thc hin chc nng nh mt th thng nht v b nh hng khng ch bi rng m bi s tc ng qua li ca tt c cc thnh phn ca h thng nhai. Mi tng quan khng r rng gia nhng ri lon khp cn v tnh trng lon nng hm di c trnh by trong cc nghin cu gn y ch ra tm quan trng v tnh cht bnh cn a yu t ca ri lon thi dng hm. Vai tr ca khp cn trong vic gy ra ri lon chc nng ca h thng nhai vn cn ang bn ci, nhng nhng nh hng v mt sinh c hc ca phc hp s mt a n lon nng hm di c khng nh. Ch duy nht mt yu t khp cn th khng th a n lon nng hm di. Tuy nhin bnh l v khp cn kt hp vi cc yu t khc nh thi , thi quen, tm l, sinh l s tr thnh c ngha. Tnh cht a yu t ca lon nng thi dng hm kt hp vi kh nng thch ng a dng phong ph ca tng c th lm cho vic nh gi vai tr c th ca khp cn trong vic gy ra lon nng hm di tr nn phc tp.

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