RU2586456C1 - Method for perforation of maxillary sinus in patients with hemophilia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to surgical dentistry, and is applicable in maxillary sinus perforation in patients with hemophilia. Palate mucosa are incised. Triangular full palate flap is peeled, after which formed full palate flap is split with a scalpel on subepithelial vascularised graft and epithelial flap. Cicatrical-modified tissue of buccal region is dissected without preparation and mucosa strip is de-epithelialised from vestibular side. Subepithelial vascularised palate flap is moved to close them perforation in area of extracted tooth, inserted into incised tissues buccal region and fixed all tissue in set of U-sutures as a mattress sutures. Epithelial flap of second layer is closed with a defect on sky, a side surface on a projection of perforation de-epithelialised strip of mucosa from vestibular side and fixed on periphery of wound with interrupted sutures.

EFFECT: method, due to creation of load-resistant plastic combination of tissues, reduces probability of postoperative haemorrhage.

1 cl, 1 tbl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to surgical dentistry.

Surgical treatment of patients with hemophilia should be carried out in a hematological hospital on the background of hemostatic replacement therapy. In patients with an uncomplicated history, this complication is most often eliminated by means of plastic surgery with a displaced buccal flap [Gubaidulina E.Ya. About the technique of operative closure of maxillary fistula // Dentistry. - 1959. - No. 1. S. 49-55]. Under normal conditions and following the methodology, the method is quite effective, however, in the case of an unfavorable postoperative period due to the inflammatory process or the formation of a hematoma, a flap tension may occur with loss of fixation and relapse of the oroantral communication. In such cases, a fold and a complex of scarred soft tissues are formed on the site of the previously used buccal flap, which is difficult to use repeatedly for plastic surgery of relapse of the oroantral. In addition, with the preparation of these tissues, the likelihood of developing a hematoma is high. Limited microcirculation of scarred tissues and pressure on the flap of the formed hematoma can lead to divergence of sutures and the occurrence of repeated relapse of the oroantral message. In patients with hemophilia, the likelihood of such an outcome is particularly high due to impaired hemostatic function. If in patients with an uncomplicated history it is possible to allow the possibility of multi-stage surgical treatment, in patients with hemophilia due to bleeding, the high cost of hemostatic replacement therapy and the high probability of another relapse, reuse of the buccal flap is irrational.

A known method of plastics perforation of the maxillary sinus (Fig. 1, a and b) [Shchipsky A.V., Mukhin P.N., Filatkina I.V. The method of plastic perforation of the maxillary sinus // Patent for the invention No. 2370220. Publ. 10/20/2009. Bull. No. 29]. Under local anesthesia (infiltration and conduction anesthesia), an incision of the mucous membrane of the palate is made along the gingival margin in the presence of teeth or along the edge of the alveolar ridge from the palatine side of the toothless jaw. The incision is extended distally perforation, an additional incision is made to the palatine suture in the area of the canine or the first premolar. A triangular full-layer palatal flap is peeled off, after which the formed full-layer palatal flap is cleaved with a scalpel into a subepithelial vascularized flap 1 (Fig. 1, a and b) and an epithelial flap 2 (Fig. 1, a and b). With a mild submucosal basis, such manipulation should be especially careful in order to avoid perforation of the mucous flap. The subepithelial vascular palatal flap 1 is moved, covering them with perforation 3 (Fig. 1, b) in the area of the extracted tooth, and sutured under the vestibular edge of the gum from the buccal side with a U-shaped suture 4 (Fig. 1, a and b), as a mattress. The epithelial flap 2 is laid in its original place, covering it with a defect in the sky, and fixed at the periphery with interrupted sutures 5 (Fig. 1, a). This method is selected for the prototype. The disadvantages of the prototype are: the need for dissection of scarred tissues of the buccal region, the likelihood of a hematoma, less resistant to stress plastic tissue combination.

The objective of the invention is to increase the efficiency of plastic perforation of the maxillary sinus in patients with hemophilia.

The technical result consists in eliminating the need for the preparation of scarred tissues of the buccal region, reducing the likelihood of postoperative bleeding, creating a load-resistant plastic tissue combination.

This is achieved due to the fact that after cleavage of the palatal flap, the subepithelial vascularized flap is fixed inside the dissected scarred tissues of the buccal region from the vestibular side without their preparation and, additionally, in the projection of perforation, the subepithelial vascularized flap is closed with an epithelial flap superimposed on the deepithelial side of the vestibular tissue.

The elimination of the need for the preparation of scarred tissues of the buccal region is ensured by the fact that the complex of soft tissues from the vestibular side is dissected without exfoliation. A decrease in the likelihood of postoperative bleeding is ensured by the fact that the vessels of the dissected wound of the buccal tissues, after the subepithelial flap is inserted into it, are pressed with fixing U-shaped sutures according to the type of mattress sutures. In the event of a hematoma, it is eliminated by the fact that the excess blood between the subepithelial and epithelial flap is removed using rubber drainage installed in the space between them. The creation of a stress-resistant plastic tissue combination is achieved by the fact that the subepithelial flap is fixed after dissection inside the soft tissue complex from the vestibular side and is completely blocked from the outside by an epithelial flap laid and fixed on a de-epithelial strip of the mucous membrane from the vestibular side.

The proposed method was tested in clinical conditions to eliminate the recurrence of oroantral communication in conditions of scarred soft tissues and postoperative bleeding in patients with hemophilia, which showed the reliability of the method, its compliance with all the stated requirements (table. 1).

The method is illustrated by drawings illustrating the invention:

FIG. 1, a is a diagram of the location of subepithelial and epithelial flaps after plastic surgery of the oroantral communication using the prototype method (bottom view);

FIG. 1, b is a diagram of the location of subepithelial and epithelial flaps after plastic surgery of the oroantral communication using the prototype method (sectional view);

FIG. 2, a - arrangement of subepithelial and epithelial flaps after plastic surgery of the oroantral communication using the proposed method (bottom view);

FIG. 2, b is a diagram of the location of subepithelial and epithelial flaps after plastic surgery of the oroantral communication using the proposed method (sectional view).

The method is as follows.

Under local anesthesia (infiltration and conduction anesthesia), an incision of the mucous membrane of the palate is made along the gingival margin in the presence of teeth or along the edge of the alveolar ridge from the palatine side of the toothless jaw. The incision is extended distally perforation, an additional incision is made to the palatine suture in the area of the canine or the first premolar. A triangular full-layer palatal flap is peeled off, after which the formed full-layer palatal flap is cleaved with a scalpel into a subepithelial vascularized flap 1 (Fig. 2, a and b) and an epithelial flap 2 (Fig. 2, a and b). Cicatricial tissues of the buccal region are dissected without their preparation and de-epithelialized a strip of the mucous membrane from the vestibular side. The subepithelial vascular palatal flap 1 is moved, the perforation 3 is closed with it (Fig. 2, b) in the area of the extracted tooth, inserted into the dissected tissues of the buccal region and all tissues are fixed together with U-shaped sutures 4 (Fig. 2, a and b) type of mattress seams. An epithelial flap 2 covers the defect in the palate with a second layer, imposes a lateral surface on the projection of perforation 3 (Fig. 2, b), a de-epithelized strip of the mucous membrane from the vestibular side and is fixed around the wound periphery with interrupted sutures 5 (Fig. 2, a and b).

Drainage between the flaps is done with a narrow strip of rubber directly or in the postoperative period according to indications in the event of a hematoma.

Clinical example

Patient Z., 41 years old, was hospitalized in the hospital of the hematological scientific center of the Ministry of Health of Russia with complaints of liquid food getting into the nose while eating, periodic purulent discharge from the hole of the removed 26 tooth. Complaints appeared six months ago after the removal of 26 teeth and plasty of the resulting perforation with a buccal flap. On admission, they found obstructed nasal breathing on the left, while trying to inflate the cheeks, the patient noted the passage of air from the mouth to the nose. 24, 25, 26 teeth were missing. When probing the hole 26 of the tooth, the probe penetrated into the maxillary sinus, a drop of purulent contents was obtained from the hole. In the area of the upper arch, in place of the buccal flap used for plastic perforation, a sedentally scarred gum fold was found. On CT scans in the maxillary sinus, a decrease in airiness was observed due to inflammatory mucosal hyperplasia. According to the coaugogram, the level of factor VIII was 0.5% of the required norm.

Diagnosis: Chronic perforated maxillary sinusitis on the left; oroantral communication in the area of the 26 tooth; hemophilia A, severe form; deforming osteoarthrosis of the knee joints.

Hemostatic therapy: a saturating dose of factor VIII 50-70 U / kg was administered 30 minutes before the operation, a repeated dose of ½ of the saturating dose immediately after the operation, bringing the level of factor VIII to 80-150%. Further, the drug was administered every 8 hours, from 4 days - every 12 hours, from 8 days -1 times a day. After reducing the level of factor VIII to 30-50% of the drug, starting from day 15, the drug was administered every 48 hours at a dosage of 30-35 U / kg.

Operation: plasty of relapse of the oroantral communication in the region of the 26 tooth with vascularized subepithelial and epithelial palatal flaps; radical sinusotomy. Under endotracheal anesthesia (conduction and infiltration anesthesia were undesirable due to additional trauma), plastic oroantral communication in the tooth region 26 was performed using the proposed method. For this, an incision was made along the alveolar ridge and perpendicular to the palatine suture in the region of the 24 tooth, a triangular palatal flap was exfoliated, which was then split into the external epithelial part and the internal subepithelial part. Scarified soft tissues were longitudinally dissected and the mucous membrane was de-epithelized in the form of a narrow strip along the previously used buccal flap. After rotation, the internal subepithelial part was inserted into dissected soft tissues from the vestibular side and the formed tissue complex was fixed with U-shaped mattress sutures. The outer epithelial part of the palatal flap was laid outside on the subepithelial flap and on the de-epithelialized edge of the soft tissues from the vestibular side, fixing it along the perimeter of the wound with interrupted sutures. After plastic surgery, through the standard incision along the transitional fold, the maxillary sinus was sanitized, an anastomosis was formed in the region of the lower nasal passage, the sinus cavity was plugged with iodoform turunda with levomikol. After applying a pressure dressing for 2 hours after the operation, an ice bubble was externally applied. In the postoperative period, analgesic, antibacterial and desensitizing therapy was performed. Iodoform turunda was removed gradually: partially on the 5th day, completely on the 7th day. After removing turunda from the suture line, minor bleeding occurred, which stopped after draining the epithelial flap with a strip of rubber without the formation of a hematoma of tissues. The intensity of repeated bleeding on day 17 was lower than the previous one, which did not require repeated drainage. In contrast to the case with plastic surgery of perforation with a buccal flap, after which the hematoma caused a relapse of the oroantral message, in this case the bleeding was less intense due to the features of the proposed method of plastic surgery and did not disrupt the healing process after drainage. Relapse of the oroantral communication in conditions of scar tissue was eliminated, which was confirmed by remote observations.

Claims (2)

1. The method of plastic surgery of the perforation of the maxillary sinus, which consists in closing it with a displaced palatal flap, split into subepithelial vascularized and epithelial flaps, while the subepithelial vascularized flap is applied to the perforation, and the epithelial flap closes the wound in the sky, fixing it with a distinct U-shape the fact that after cleavage of the palatal flap, the subepithelial vascularized flap is fixed inside the dissected scarred tissues of the buccal region with on the vestibular side, without their preparation, and additionally in the projection of perforation, close the subepithelial vascularized flap with an epithelial flap superimposed on a de-epithelial strip of tissue from the vestibular side. 2. The method according to p. 1, characterized in that in the event of a hematoma, excess blood between the subepithelial and epithelial flap is removed using rubber drainage installed in the space between them.

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