RU2476163C1 - Method of upper jaw reconstruction in case of alveolar process defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely, to plastic restorative surgery and is intended for application in restorative microsurgery, maxillofacial surgery. Dissection of hard palate is performed. Two mucous-periosteal flaps are cut out in the area of upper third of palate, wound is sutured with wound surface outside with formation of nasal lining. Radial bone of skin-and-bone flap on vascular pedicle is modelled in form of trapezium, for which purpose microplate is fixed to it by means of screws and two saw cuts are made from the side of spongy layer perpendicular to bone length. Plasty is performed with skin-and-bone and free mandibular bone autotransplants with blocking bone cracks with bone chips from transplants. Transplants are covered with skin part of flap with application of sutures from alveolar process mucosa, hard palate and sutures through skin flap. Vascular pedicle of transplant is passed into submandibular area through submucosal layer of buccal area and anastomosis between donor and recipient vessels is formed.

EFFECT: method makes it possible to eliminate through defect of hard palate and alveolar process of maxilla, improve act of chewing and swallowing, reduce inflammation of ENT organs due to plasty with free revascularised skin-and-bone radial and on radial and free bone mandibular autotransplants, modelled congruent to defect.

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Description

The present invention relates to medicine, namely to plastic reconstructive surgery, and can be used in the practice of reconstructive microsurgery, maxillofacial surgery, dentistry in the treatment of patients with a defect in the alveolar process, causing complications of the digestive tract.

A known method of forming the frontal part of the upper jaw, upper lip, vestibule of the oral cavity and hard palate [RF Patent No. 2303413, 2007], which consists in the fact that they produce horizontal cuts of the radius in depth of about 1.0 cm after identification of the vascular bundle, dissection of the periosteum , then carry out vertical cuts on both sides, respectively. Further, with the help of a raspator, the osteotomized fragment of the radial bone is separated and raised in combination with the skin-fascial site on the radial vessels. The bony part of the flap is fixed to the distal fragments of the upper jaw with mini-screws.

The disadvantages of this method are: the lack of the possibility of forming a natural anatomical bone bend of the frontal maxilla.

The objective of the invention is a method for the reconstruction of the jaw with a defect in the alveolar bone, which allows the formation of a natural anatomical bone bend, the ability to prepare the alveolar bone for further prosthetics and, as a result, improve speech, chewing and swallowing, reduce the occurrence of inflammatory phenomena from the ENT organs, reduce number of congestion in the nasopharynx.

The problem is solved by the method of reconstruction of the upper jaw with defects in the alveolar process, including dissection of the mucosal-periosteal membranes of the alveolar process and the hard palate, and plastic surgery with free revascularized cutaneous-bone radiation and free bone-lower mandibular autografts, which differ in the degree of and screws, perform two cuts on the side of the spongy layer perpendicular to the length of the bone, so that the bone is curved beats in the form of a trapezoid, then the skin part of the flap is sutured to the wound surface area, thus closing the bone autografts with the skin surface outward and moving the vascular pedicle to the side of the facial artery that was previously selected, with single interrupted sutures to the mucous membrane of the upper lip and hard palate, then suture through the skin a flap to the mucosa of the alveolar process and the hard palate, according to the orthopedic plaster model, control the graft fitting in the recipient area, the vascular pedicle is carried out in the left under the jaw region through the submucosal layer of the left buccal region and form anastomoses between the donor and recipient vessels.

In practice, a split free bone autograft is taken by dissecting the oral mucosa closer to the lower lip, departing from the transition fold 2 cm above the frenulum using an electrocoagulation knife, at an angle of 45 ° relative to the plane of the vestibular part of the lower lip in the projection of 33-43 teeth to a depth of 1 mm , then, taking the subcutaneous layer of the transitional fold of the lower lip at the frenum level using Adson forceps and pulling the resulting flap 1 mm to the alveolar process of the lower jaw, perform an incision w of the fiber of the lower lip parallel to the muscle lowering the lower lip and chin muscle with an electrocoagulation knife from the chin in the projection of 33-43 teeth, reaching the transitional fold, cut the chin muscle in the area of attachment to the chin symphysis of the lower jaw depth to the periosteum of the chin symphysis, then the nasal with a Molt racer bluntly cut the periosteum of the chin symphysis parallel to the mucous incision in the projection of 33-43 teeth, then the soft tissues of the mucosa are removed from the periosteum of the lower lip and alveolar process of the lower jaw, thus freeing the bone of the chin symphysis, the periosteum is diverted to the chin holes in the lateral sides. Oscillating saws carry out bone cuts at an angle of 90 °, retreating 5 mm apically from the tops of the roots of the teeth, medially from the chin holes and upward from the lower border of the lower jaw, getting a rectangular shape in the region of the chin symphysis, then at a angle of 70 ° with a round mill, conducting around rectangular cut, form bone chips, while forming a place for the introduction of the bit. A curved bone chisel is inserted into the subcortical layer of the obtained bone rectangle, and a cortical-spongy rectangular bone autograft having a natural curvature in the center of the rectangle is separated by gentle swaying.

Then, a mucosal incision is made from the second premolar to the retromolar region with similar tools used to access the chin symphysis, the periosteum is detached, trying not to damage the neurovascular bundle in the area of its exit from the chin, then with the same tools used to collect the chin bone graft, they carry out bone cuts in the region of the branch of the lower jaw, retreating 5 mm distally from the chin holes and the base of the lower jaw, thus carried fence monokortikalnogo bone autograft with mandible. Similarly, a bone autograft is taken from another branch of the lower jaw.

The resulting bone-spongy grafts are crushed in a bone mill and the resulting bone chips, mixed with venous blood, are used with a bone spoon to block bone gaps.

Then, the radius of the skin-bone flap is modeled by fixing a long microplate from using micro screws, two cuts are made from the spongy layer, perpendicular to the length of the bone, so that the bone bends in the form of a trapezoid, then the skin part of the flap is sutured to the area of the wound surface, so closing the bone autografts with the skin surface outward and moving the vascular pedicle to the side of the facial artery that was previously isolated, with single nodal sutures to the mucosa of the upper lip and hard palate, Sutures are inserted through the skin of the flap to the mucosa of the alveolar bone and hard palate. According to the orthopedic plaster model, graft fitting in the recipient zone is monitored, the vascular pedicle is carried out in the left submandibular region through the submucosal layer of the left buccal region, anastomoses are formed between the donor and recipient vessels.

Example:

Patient V.I., 35 years old, was admitted to the microsurgery department of the Russian Scientific Center for Surgery. Acad. B.V. Petrovsky RAMS with complaints of speech impairment, an act of chewing and swallowing, constant stagnation in the nasopharynx of the mucous discharge from the nasopharynx, caused by a through defect in the alveolar process, causing complications from the ENT organs.

The data of clinical, speech therapy, endoscopic and other objective research methods showed a defect in the alveolar process of the upper jaw, and was diagnosed with a post-traumatic defect in the alveolar process of the upper jaw.

A patient under endotracheal anesthesia, with his head raised about 30 ° above the body level, is dissected in the hard palate, two mucoperiosteal flaps are cut out in the upper third of the palate and the wound surface is sutured outward, forming the nasal lining. Next, recipient vessels are isolated. A flap is taken from the forearm with the release of the radial artery and vein, the radius of the skin-bone flap is modeled by fixing the microplate with microscrews, two cuts are made from the spongy layer perpendicular to the length of the bone, so that the bone bends in the form of a trapezoid, then the skin part the flap is sutured to the area of the wound surface, thus closing the bone autotransplants with the skin surface outward and drawing the vascular pedicle to the side of the facial artery that was previously isolated, in single nodes sutured seams to the mucosa of the upper lip and the hard palate, then stitches are inserted through the skin of the flap to the mucosa of the alveolar process and the hard palate. According to the orthopedic plaster model, graft fitting in the recipient zone is monitored, the vascular pedicle is carried out in the left submandibular region through the submucosal layer of the left buccal region, anastomoses are formed between the donor and recipient vessels.

The postoperative course is smooth, without complications. Sutures were removed on the 14th day. Primary healing. On the 7th day the patient was transferred to the rehabilitation rehabilitation treatment department, where he underwent a course of physiotherapeutic treatment, including magnetotherapy, an initial course of therapeutic physical culture.

Speech therapy was aimed at setting the right breath, making sounds during spontaneous speech. After a two-week course of treatment, he was discharged home in satisfactory condition at the rehabilitation treatment department. To continue the course of speech therapy, the patient was given homework assignments for breathing and speech. At the control examination after 3 months, an improvement in speech, an act of chewing and swallowing, and the absence of congestion from the ENT organs were noted.

The proposed method allows to eliminate the defect in the alveolar ridge, improve speech, the act of chewing and swallowing, reduce the number of occurrences of inflammatory phenomena from the ENT organs, and reduce the number of congestive events in the nasopharynx.

Claims (1)

A method for reconstructing the upper jaw with defects in the alveolar ridge, including plastic surgery with a revascularized skin-bone radiation autograft, characterized in that a hard palate is dissected, two mucosal-periosteal flaps are cut out in the upper third of the palate and sutured by the wound surface to the outside, forming a nasal lining; the radius of the skin-bone flap on the vascular pedicle is modeled in the form of a trapezoid, for which a microplate is fixed to it with screws and two cuts are made from the cancellous layer perpendicular to the length of the bone; perform plastic surgery with skin-bone and free mandibular bone autografts with blocking of the bone gaps with bone chips from the grafts; grafts are closed with the skin part of the flap, stitching with the mucosa of the alveolar process, the hard palate and sutures through the skin flap; Further, the vascular leg of the graft is carried out to the submandibular region through the submucosal layer of the buccal region and an anastomosis is formed between the donor and recipient vessels.