RU2455953C1 - Method of vestibuloplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical dentistry and is intended for application in carrying out vestibuloplastry. Horizontal cut of mucousa is performed on the boundary of alveolar gum and movable mucous envelope of oral cavity vestibule. Dissection of flap is performed parallel to periosteum. Mucous flap and muscles are displaced in apecal direction to the depth of created vestibule. On periosteum rewsidual muscular fibres and connective tissue bands are excised. De-epithelialisation of submarginal keratinised gum is performed within 1-2 mm. Sampling of free gum transplant of required length is carried out on hard palate in area from canine to second molar of maxilla, indenting 3-4 mm from gum edge. After sampling, autotransplant is exposed in preparation "Perftoran" for one minute. In recipient zone preparation "Perftoran" is introduced into transitional fold in dose 0.01 ml/kg of body weight. Transplant is fixed on periosteum bed. First sutures are applied on transplant edges, after that, sutures, fixing and stabilising lower and upper edges of transplant are performed with placement of upper edge of transplant on de-epithelialised surface of keratinised gum. After that, transplant is fixed by blanket suture, which presses it to periosteum bed. In the last turn edge of mucous flap is fixed in the depth of newly created vestibule of cavity. In post-operative period applications with preparation "Perftoran" are performed 1 time per day for ten minutes during 3 days.

EFFECT: method makes it possible to improve functional result, reduce quantity of post-operative complications, creates conditions for accelerated regeneration of tissues due to increase of zone of keratinised gum and reduction of risk of free gum transplant necrosis.

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Description

The present invention relates to medicine, namely to surgery, and can be used when conducting vestibuloplasty of the oral cavity.

Currently, one of the urgent problems of periodontal surgery is the problem of the area of keratinized attached gums and related diseases of the dentition, such as a small vestibule of the oral cavity and recession of the gum. The small vestibule of the oral cavity is a fairly common pathology of the dentition, the prevalence of which is 8-62%. Studies have shown that a direct linear relationship is observed between the size of the attached gums and the frequency of occurrence of periodontal pathology, i.e. the wider the area of the attached gums, the lower the risk of developing periodontal diseases.

The need to develop new methods of vestibuloplasty, which would reduce the invasiveness of the operation, create conditions for improving microcirculation in the surgical wound and accelerate the regeneration of the mucous membrane, is beyond doubt.

A known method of vestibuloplasty described (Clark HB Deeping of labial sulcus by mucosal flap advancement: report of case // J. Oral surgery. - 1953. Vol. 11. - No. 2. - P.165-168), consisting in that after local anesthesia during the removal of soft tissues, a scalloped horizontal incision of the mucous membrane with a blade No. 15 is performed at the border of the alveolar gum and the movable mucous membrane of the vestibule of the oral cavity. Positioning the blade almost parallel to the bone, the flap is dissected parallel to the periosteum, without violating its integrity. The mucous flap is displaced in the apecal direction to the depth of the created vestibule. The finished periosteal bed is a periosteum, free of muscle fibers and connective tissue cords. After that, the edge of the mucous membrane is fixed with suture material to the periosteum.

However, the disadvantage of this method is that there remains an open wound surface that heals by secondary intention. Healing of open wounds by secondary intention involves scarring and a decrease in the depth of the vestibule of the mouth, as well as subsequent recurrence associated with the structural features of the newly formed tissue and postoperative reorganization of the scar.

A well-known method of vestibuloplasty was selected for the prototype of the invention, including scalloped horizontal incision of the mucous membrane along the transitional fold, dissection of the flap parallel to the periosteum, displacement of the mucous flap in the apecal direction to the depth of the vestibule, fixation with suture material to the periosteum (Bjorn H. Free transplantation of gingiva prop (Swed. Dent. J. 1963: 684-689). Further, in the known method, after infiltration nesthesia in the area of the hard palate, having previously determined the size of the graft by stencil or using a probe, a free gingival graft is taken from the hard palate. The first incision, which corresponds to the length of the graft, is indented 2-3 mm from the edge of the gums in the area of premolars, molars of the upper jaw. The scalpel is immersed to the bone. The second incision is carried out parallel to the first, stepping back to the width of the graft, while the scalpel is immersed to a depth of not more than 2 mm. Two subsequent sections connect the first, thereby limiting the size of the graft. After that, holding the flap with tweezers, detach it sharply, observing a uniform thickness. The optimal flap thickness is 0.75-1.25 mm, since such a flap gives the best aesthetic and functional result (Sullivan H., Atkins J. Free autogenous gingival grafts I. Principles of successful grafting. Periodontics 1968; 6: 121-129). An autograft is fixed with suture material on the periosteal bed.

The disadvantage of this method is that it does not allow to increase the thickness of the gums of the submarginal zone, which is the key to a stable long-term result and the absence of relapse. The lower edge of the autograft is fixed after the mucous flap is fixed in the depth of the newly created vestibule, which worsens the control of suturing the lower edge of the free gingival graft. In addition, in the postoperative period, necrotic changes in the graft occur, and therefore measures are needed to reduce the risk of necrosis of the free gingival graft and accelerate its regeneration.

The objective of the invention is to increase the area of keratinized gums, change the biotype of the gums, reduce the morbidity of the operation, early relief of inflammation and restore the microvasculature of the free gingival transplant in the postoperative period.

The problem is solved in that in the known method of vestibuloplasty, including performing scalloped horizontal incision of the mucous membrane along the transitional fold, dissection of the flap parallel to the periosteum, displacement of the mucous flap in the apecal direction to the depth of the vestibule, fixation with suture material to the periosteum, after the displacement of the flap in the apical direction of the flap to the depth of the created vestibule, de-epithelization of submarginal keratinized gums with ceramic boron is performed using of my tip (1: 1) within 1-2 mm depending on the size of available keratinized tissues, after performing anesthesia in the area from the canine to the second molar of the upper jaw, departing from the gingival margin of 3-4 mm, a free gingival graft is taken using mucotome tip, expose a free gingival transplant in the Perftoran preparation for 1 minute, fix the graft on the periosteal bed, placing its upper edge on the de-epithelial surface of the gum, then fix the mucous flap deep In addition to the newly created vestibule, Perftoran is introduced into the transitional fold in the amount of 0.01 ml / kg per 1 kg of body weight, in the postoperative period, applications with Perftoran are administered for three days once a day for 10 minutes.

The present invention meets the criterion of "novelty", because in the process of conducting patent information research of materials discrediting the novelty of the invention, not identified.

The present invention meets the criterion of "inventive step", since no technical solutions with essential features of the proposed method have been identified.

The drug "Perftoran" was originally intended as a blood substitute with gas transport function.

Lipophilic fluorocarbons dissolve in the lipids of cell membranes and thereby modify them, affecting their channels and receptors. Dissolving in erythrocyte membranes, fluorocarbons liberate them from oligopeptides, make them easily deformable (Kuznetsova I.N., Rybakova L.P. Surface properties and interaction of perfluorocarbon particles with blood proteins // Organofluorine compounds in biology and medicine. - Pushchino, 1999. - P.277-278; Radaev S.M. Ostapchenko D.A., Rosenberg Yu.M., Lisovskaya I.L., Moroz V.V., Ataullakhanov F.I. Influence of perftoran on the structural and functional changes of red blood cells in patients with trauma and blood loss. // Organofluorine compounds in medicine and Biology, Pushchino, 2002. - Collection of materials of the XII International Conference (June 25-26, 2002) - P.85-91), which reduces blood viscosity, improves their passage through capillaries, and, consequently, oxygen delivery to tissues, especially in zone of ischemia and hypoxia, where blood circulation is impaired. By modifying the membranes of red blood cells, proxanol emulsions of fluorocarbons prolong their life in the bloodstream, preventing hemolysis and have a membrane-stabilizing effect, thereby improving the conditions for the delivery of gases by red blood cells.

Indications for the use of the drug "Perftoran" in the clinic of emergency cases are the presence of shock of any origin, coma, blood loss, both acute and chronic, purulent-septic conditions, embolism, burn disease, combined and multiple injuries, open heart surgery, transplantology .

As a rule, the drug “Perftoran” in maxillofacial surgery is used to locally improve oxygenation and microcirculation of the affected area (Petrova I.N. Evaluation of the effect of perftoran on homeostasis in patients with defects and deformations of the maxillofacial area // Abstract ... k.m Science., M. - 2005. - 25 pp.), (RU patent No. 2226658, published in BI from 06.20.2008).

For the same purpose, it is known to process a skin flap and a donor site (patent application 2007120787/14, RU patent No. 2350322, published on 03/27/2009) or transplant exposure in the Perftoran preparation (RU patent No. 2283095 from 09/10/2006).

The following methods are known for administering a dose of Perftoran:

- in the form of interstitial injections according to the type of infiltration of the operated tissues or into the blood supplying vessels of the operated tissues (preparation volume 0.1 ml per kg body weight; 0.1 ml per 1 cm.sq. for skin flap); RU patent No. 2326665, publ. from 06/20/2008;

- in the form of irrigation and applications in the postoperative period (0.3 ml per 1 cm.sq. of skin flap); RU patent No. 2350322, publ. from 03/27/2009;

- in the form of an autograft exposure in the Perftoran preparation (from 10 to 20 minutes); RU patent No. 2283095 from 09/10/2006.

In the proposed method, the autograft is exposed in the Perftoran preparation to maintain its viability and better survival, while taking into account the small thickness of the autograft, as a result, the absorption of active substances is faster, the mucosal flap is exposed in the drug for 1 minute. The introduction of the drug "Perftoran" in the transitional fold in an amount of 0.01 ml / kg body weight (0.7-1 ml) allows you to create a depot of the drug in the operated area. In the postoperative period, it is advisable to carry out applications with the oxygen-transporting drug “Perftoran” for 3 days, since starting from the 4th – 5th days oxygen suppresses collagen formation, osteogenesis and collagen breakdown prevails over its synthesis.

The invention when used gives the following positive effect:

- the essential features given in the formula allow you to create a fully functional zone of keratinized gums;

- reduction in the number of postoperative complications, in particular cases of necrosis of the autograft, in connection with a more rapid restoration of their own free flap blood flow;

- reduction of postoperative soft tissue edema, the likelihood of bleeding in the area of the postoperative wound, a decrease in pain;

- reduction of operation time and the number of manipulations;

- reduction of postoperative rehabilitation of patients, restoration of quality of life in a shorter time;

- creating conditions for accelerated regeneration of soft tissues in the area of postoperative wounds;

- in the bottom of the newly created vestibule of the oral cavity, a non-coarse retaining scar is formed;

- reducing the likelihood of a relapse of the disease due to the formation of a zone of full keratinized epithelium.

The method was tested on 30 patients of the dental clinic GOU VPO Nizhny State Medical Academy of the Ministry of Health and Social Development of Russia.

The proposed method is as follows.

After performing local anesthesia in a zone with a deficiency of keratinized gums, along its entire length with simultaneous abduction of soft tissues, a horizontal incision of the mucous membrane is performed with a blade No. 15 at the border of the alveolar gum and the movable mucous membrane of the vestibule of the oral cavity, repeating the contour of the mucogingival line. Positioning the blade almost parallel to the bone, the flap is dissected parallel to the periosteum, without violating its integrity. The mucous flap and muscles are displaced in the apecal direction to the depth of the created vestibule, residual muscle fibers and connective tissue cords on the periosteum are excised using gingival scissors. The finished periosteal bed is a periosteum, free of muscle fibers and connective tissue cords. De-epithelialization of the submarginal keratinized gum with ceramic boron is carried out using a direct tip (1: 1) within 1-2 mm, depending on the size of the keratinized tissues. At the next stage of the operation, infiltration anesthesia is performed in hard palate. Using a graduated periodontal probe determine the required length of the graft. A free gingival graft is sampled using a mucotome tip (F. Aesculap, Germany) on a hard palate in the area from the canine to the second molar of the upper jaw, departing from the gingival margin of 3-4 mm. The length of the free gingival graft is determined by needs. The width of the autograft is fixed with a blade width of 6.5 mm, the thickness is 0.75 mm and is uniform throughout. After collection, the autograft is exposed in the Perftoran preparation for one minute. In the recipient zone, Perftoran is introduced into the transitional fold in the amount of 0.01 ml / kg body weight (0.7-1 ml). A free gingival graft is fixed with suture material on the periosteal bed with suture material "Prolen" 6-0 on an atraumatic needle. The first sutures are applied along the edges of the graft, fixing it in length. Then, sutures are made that fix and stabilize the lower and upper edges of the graft, while the upper edge of the graft should be located on the de-epithelized surface of the keratinized gum. After this, the graft is fixed with a twisting suture, pressing it to the periosteal bed. Lastly, the edge of the mucous flap is fixed in the depths of the newly created vestibule of the oral cavity with suture material “Prolen” with a diameter of not more than 5-0, 6-0 on an atraumatic needle. In the postoperative period, for 3 days perform applications with the drug "Perftoran" once a day for 10 minutes. In the postoperative period, the patient is prescribed an external pressure dressing during the first days after the operation, it is recommended to apply ice locally from the skin in the area of the operation, observe oral hygiene and make oral baths with saline after each meal, and starting from 5 days after surgery, use “Solcoseryl Dental Adhesive Paste” in the form of applications in the operated area 2 times a day until the sutures are removed. A sparing diet is recommended during the first week after surgery. The stitches fixing the autograft are removed on the 5th day, the stitches fixing the mucous flap on the 7-8th day.

The application of the proposed method can be demonstrated by the following clinical example.

Patient S., 35 years old, turned to a dental clinic with complaints of exposure of the neck of the teeth in the lower jaw, as well as their increased sensitivity. The examination revealed gingival recessions in the area of teeth 45, 44, 42, 41, 31, 34, 35 of the I class according to Miller, from the level of enamel-cement compound not more than 1 mm; in the area of teeth 43, 32, 33 - II class according to Miller, from 1.5 to 2 mm from the enamel-cement border. The depth of the vestibule on the lower jaw does not exceed 2.5 mm. GI (Sillness-Loe) = 0.25, Rassel index = 0. Teeth 33, 34, 35 have wedge-shaped defects.

The diagnosis was made: periodontal disease of mild severity, small vestibule of the oral cavity in the lower jaw, gingival recession.

The treatment plan has been drawn up: 1. Vestibuloplasty of the lower jaw using a free gingival graft from the hard palate in the area of the teeth 43, 32, 33.

2. General treatment.

3. Treatment of wedge-shaped defects.

4. After 6 months, the plastic closure of the recession.

At the first stage, after receiving an infiltration anesthesia on the lower jaw, the recipient bed was prepared: in the area of teeth 46, 45, 44, 43, 42, 41, 31, 32, 33, 34, 35, 36, a horizontal incision of the mucous membrane was performed with blade No. 15 on the border of the alveolar gum and the movable mucous membrane of the vestibule of the oral cavity, repeating the contour of the mucogingival line. The flap was dissected parallel to the periosteum. The mucous flap and muscles are displaced in the apecal direction, the residual muscle fibers and connective tissue cords on the periosteum are excised using gingival scissors. De-epithelization of submarginal keratinized gums with ceramic boron (f. Kometdental, Germany) using a straight tip (1: 1) within 2 mm in the area of teeth 46, 45, 44, 43, 42, 41, 31, 32, 33, 34, 35, 36. The edge of the mucous flap at this stage is not fixed. An infiltration anesthesia was performed on a hard palate on the left, with the help of a graduated periodontal probe, the autograft length was determined. The free gingival graft was taken using the tip-mucotome in the region of 14, 15, 16, 17 teeth, departing from the gingival margin of 3-4 mm. After collection, the autograft was exposed in the Perftoran preparation for one minute. In the recipient zone, perftoran was introduced into the transitional fold in the amount of 0.01 ml per 1 kg of body weight (0.7-1 ml). The free gingival graft is divided by a scalpel into 2 fragments, which are fixed respectively in the region of 43, 32, 33 teeth with suture material “Prolen” 6-0 on the periosteal bed. Lastly, the edge of the mucous flap was fixed in the depths of the newly created vestibule of the oral cavity with suture material “Prolen” 6-0. In the postoperative period, during the first 3 days, applications with Perftoran were used once a day for 10 minutes. Postoperative care included the above activities. The stitches fixing the autograft were removed on the 5th day, the stitches fixing the mucous flap on the 8th day. On the next day after the operation, moderate swelling of the soft tissues of the chin region was observed, in the oral cavity - moderate swelling of the transitional fold. The pain in the postoperative region is insignificant, in the area of the hard palate - moderate.

When applying this set of measures on the 2nd day after the operation, swelling of the soft tissues of the face, pain in the postoperative area are absent, the wound of the hard palate granulates. The mucous membrane of the transitional fold in the postoperative region is pink, the wound heals by first intention, there are phenomena of desquamation of the epithelium of the autograft, necrotic changes are absent.

On the 5th day, the sutures that fixed the autograft were removed. Free gingival graft of pink physiological color, consistent, no necrotic changes. The surrounding mucosa without visible inflammatory changes. Hard palate wound in the epithelialization stage. Pain is absent.

On the 7th day, the remaining seams were removed. A soft, delicate scar is formed at the bottom of the vestibule. The hard sky wound healed.

Formed a wide area of the attached gums on the lower jaw. During the control examination after 1 month, the area of the attached gums on the lower jaw is at least 4 mm, in the area of the teeth 33, 32, 43, 44 - up to 5 mm. In the area of teeth 44, 43, 42, 41, 31, 32, 33, the phenomenon of “creeping attachment” is observed.

The use of traditional methods in other patients led to a longer healing period of the postoperative wound, as well as a less favorable result of surgical intervention, including in the long term.

Claims (1)

The method of vestibuloplasty, including performing a scalloped horizontal incision of the mucous membrane along the transitional fold, dissection of the flap parallel to the periosteum, displacement of the mucosa of the flap in the apical direction to the depth of the vestibule, fixation with suture material to the periosteum, characterized in that after the flap is displaced in the apical direction to the depth of the created de-epithelialization of submarginal keratinized gums depending on the size of existing keratinized tissue ceramic boron using a straight tip (1: 1) within 1-2 mm, after performing infiltration anesthesia in a hard palate in the area from the canine to the second molar of the upper jaw, departing from the gingival margin of 3-4 mm, a free gingival transplant is taken with using the tip-mucotome, a free gingival graft is exposed in the Perftoran preparation for 1 min, the graft is fixed on the periosteal bed, placing its upper edge on the de-epithelized surface of the gum, then the mucous flap is fixed deep In addition to the newly created vestibule, Perftoran is introduced into the transitional fold in the amount of 0.01 ml per 1 kg of body weight, in the postoperative period, during the first 3 days, applications with Perftoran are administered once a day for 10 minutes.