RU2610332C1 - Method for surgery of mandibular cysts of large size - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, in particular to dentistry, and can be used in carrying out operation of extended biopsy of cystotomy type, in the process of surgery of mandibular cysts of large size. Surgery of mandibular cysts of large size is performed by making cut of mucosa, separation of mucoperiosteal flap, excision of anterior wall of cyst. From 4 to 6 holes are drilled in cortical plate with 2-3 mm indent from its edge with bur. After that, mucoperiosteal flap is screwed into bone cavity and sewn through from vestibular side, realising puncture-in of suture needle at 6-8 mm distance from the edge of mucoperiosteal flap, with introduction of needle into a bone hole of cortical plate. Mucoperiosteal flap is bent over the edge of cortical plate and sewn through drilled holes with tying up interrupted sutures on the edge of cortical plate.

EFFECT: method ensures reduction of rehabilitation terms of patients, reduction of the number of visits to dentist and elimination of postoperative complications.

3 cl, 6 dwg, 2 ex

Description

The invention relates to medicine, in particular to dentistry, and can be used during an extended biopsy operation of the cystotomy type, in the process of surgical treatment of large sizes of the lower jaw cysts.

Among the operations performed by dental surgeons on an outpatient basis, operations for jaw cysts take the second place after tooth extraction (Soloviev M.M., Semenov G.M., Galetsky D.V. Surgical treatment of odontogenic cysts. Guide., M. , Publ.: SpetsLit, 2004, 127 pp.). Odontogenic tumors include ameloblastoma, and keratocyst and tooth-containing cysts (Karapetian I.S., Gubaidullina E.Ya., Tsegelnik L.N. Tumors and tumor-like lesions of the mouth cavity of the jaw, face and neck., M.). : Medical News Agency, 2004, 232 pp.). The clinical picture of these three cystic formations has a similar radiological picture, when ameloblastoma has not yet grown into the surrounding tissue, and a keratocystic tumor (previously a keratocyst) contains a retained tooth in the cavity.

To date, effective methods of surgical treatment of cystic formations have been developed. This applies mainly to small-sized cystic formations when cystectomy is indicated. With cystic formations of the lower jaw of large sizes, cystectomy is difficult, requires unreasonable preparation of a large number of teeth, and can lead to various kinds of complications, therefore cystotomy is indicated in these cases. In this case, the choice of surgical intervention depends on the exact determination of the extent of the formation, the position of the cyst cavity in relation to the maxillary sinus, the base of the nasal cavity, and in the lower jaw to the mandibular canal. Currently, the main method for studying bone tissue regeneration processes in surgical dentistry is an X-ray examination (S. A. Asnina, A. Yu. Drobyshev, and others. Modern technologies for radiation diagnosis of cystic jaw formations (clinical case). Radiology - Practice, 2012, no. 1, p. 70-73).

The operation “cystotomy” was developed by Partsch in 1892, which boils down to excision of the anterior wall of the cyst without completely removing the membrane. The basis for this method of surgical intervention was the anatomical affinity of the epithelium of the cyst wall with the epithelium of the mucous membrane of the oral cavity, which, upon contact, grow together and the cyst cavity, thus, turns into an additional bay of the oral cavity. Cystotomy is a method in which only the front wall of the cyst is removed, which is communicated with the vestibule or the oral cavity itself. The operation eliminates intracystic pressure and, as a consequence, leads to oppositional bone growth, resulting in a gradual flattening and reduction of the cystic cavity, until its complete disappearance. The operation is less complicated, non-traumatic, easier to tolerate by patients, however, a postoperative defect remains for a long time, which requires hygienic care.

There is a method of treating odontogenic cysts, which consists in making a pattern in the form of a mucoperiosteal flap from the vestibular side of the alveolar process, removing the bony part of the alveolar process, body and lower jaw branch over a long distance, removing part of the cyst membrane and laying it in place with the laying of catgut sutures . The cyst membrane is completely removed, followed by the combination of the cyst and oral cavities, after which the tamponade of the bone cavity is carried out by iodoform turunda with its constant replacement within 6-10 months (T. T. Robustova, Odontogenic inflammatory diseases. M .: Publishing House "Medicine", 2006, p. 664). However, this surgical intervention is accompanied by a large amount of damage, in particular, removal of the bone part from the vestibular side significantly reduces the strength of the lower jaw and can be complicated by a spontaneous fracture. In addition, the disadvantages are the long terms of wound healing, which are about 24 months.

There is also known a method of cystotomy of the jaw cyst, including anesthesia, an incision in the mucous membrane, cutting and screwing in the mucoperiosteal flap, treating the wound with antiseptic solutions, and 10-12 incisions are applied to the walls of the bone cavity with a surgical cutter within the compact substance with the formation of bone channels up to a depth of 2-3 mm and a length of 5-7 mm, the wound is treated with a laser from the Optodan apparatus for 10 minutes through a 0.05% miramistin solution, titanium granules “Natix” 0.7-1.0 mm in size are introduced into the bone channels since at 80%, the wound is isolated from the oral cavity with a Tachocomb plate treated with sterile saline for 2 minutes (RU 2442544, 02.20.2012). This technical solution was made by us as the closest analogue. The specified method is mainly aimed at providing stimulation of the process of osteogenesis, bone tissue regeneration, prevention of postoperative bleeding and hermetic isolation of the wound from the oral cavity without the use of mucoperiosteal flaps.

The technical result of the claimed method is to reduce the rehabilitation of patients, reduce the number of visits to the dentist and eliminate postoperative complications.

The technical result is achieved by the fact that surgical treatment of cystic formations of the lower jaw of large sizes is carried out by excision of the anterior wall of the cystic formation and peeling of the mucoperiosteal flap, while in the cortical plate, departing from its edge 2-3 mm, drill from 4 to 6 holes , then the mucosal-periosteal flap is screwed into the bone cavity and stitched through from the vestibular side, making a suture needle at a distance of 6-8 mm from the edge of the mucoperiosteal flap, and introducing a needle into the bone hole of the cortical plate, while the mucoperiosteal flap is bent over the edge of the cortical plate and stitched through the drilled holes, tying the nodal sutures along the edge of the cortical plate.

In addition, the method consists in the fact that after flashing, the cortical plate is located in the center, and the mucoperiosteal flap covers it from the vestibular and lingual sides.

The method also consists in the fact that after tying the nodal sutures along the edge of the cortical plate, casts are taken to make the obturator.

The method is as follows.

Surgical treatment of odontogenic large jaw cysts using the claimed technique is performed when the vestibular cortical plate is of sufficient height. After anesthesia, a trapezoidal incision is made, the base to the transitional fold, the mucoperiosteal flap is peeled off. A cortical plate is perforated with a trepan, the holes are connected in a circle. Then, with a mill, the bone hole is expanded to the size of a cyst. The upper and front part of the cyst membrane is excised with a scalpel and sent for histological examination. In the cortical plate, departing from the edge of 2-3 mm, 4-6 holes are made with a boron, the mucoperiosteal flap is screwed into the bone cavity and stitched through, making an injection from the vestibular side at a distance of 6-8 mm from the edge of the flap. Then the needle is inserted into the bone hole, the mucoperiosteal flap is bent over the edge of the cortical plate and stitched with a suture needle through the drilled holes. Nodal sutures are tied around the edge of the cortical plate. Thus, a sandwich is obtained, in the center of which cortical plastic is located, and on its vestibular and lingual sides, a mucoperiosteal flap. In this regard, we get the edge of the cortical plate, covered with epithelialized mucous membrane. This allows you to take casts for the manufacture of the obturator, immediately after tying the nodal sutures along the edge of the cortical plate, that is, on the day of surgery. You can also take casts a week later, after the intervention, when the swelling of the soft tissues completely disappears.

After 10 days, after removing the seams, the obturator is adjusted and installed in the area of the defect. Regardless of the diagnosis received, all patients undergo X-ray examination (orthopatomogram and MSCT) 3, 6 and 12 months after the operation, which allows us to decide on the need for subsequent surgical intervention.

Using the indicated patient management technique (suturing the epithelized flap to the vestibular cortical plate of the jaw during cystotomy) can reduce the number of visits and reduce the rehabilitation time for patients with tooth-containing cysts and keratocystic tumors by eliminating long-term management of patients (frequent change of iodoform swab).

Using this method, 12 out of 44 patients were operated on, this is due to the fact that this method was used in operations with a sufficiently preserved cortical plate height. Of these, 6 patients with keratocystic tumor and 6 with tooth-containing cyst. In all cases, patients did not have postoperative complications. Patients went to the dentist only for x-ray control after 3, 6 and 12 months, and the rehabilitation period was reduced to 10-14 days.

Examples of the method.

Example 1

Patient S., born in 1959. Received with complaints of periodic pain, discomfort in the lower jaw on the right. The configuration of the face is not changed, the opening of the mouth is in full. The patient was taken x-ray. An orthopantomogram determines the rarefaction of the bone tissue of the lower jaw on the right in the body region and branches of the lower jaw with clear contours, 6.0 × 4.0 cm in size (see Fig. 1) and multispiral computed tomography (see Fig. 2). Diagnosis: keratocystic tumor of the body and branches of the lower jaw on the right.

A decision was made to conduct surgery. The patient was operated on 02.20.2013. The operation is a cystotomy using the method of a sandwich technique for the formation of an epithelized flap. To do this, we performed an excision of the anterior wall of the cystic formation and exfoliation of the mucoperiosteal flap. Then, in the cortical plate, departing from its edge 3 mm, 6 holes were drilled with a boron. Then the mucoperiosteal flap was screwed into the bone cavity and stitched through from the vestibular side. The suture needle was inserted at a distance of 6 mm from the edge of the mucoperiosteal flap. In this case, the needle was inserted into the bone hole of the cortical plate, and the mucoperiosteal flap was bent over the edge of the cortical plate and stitched through six drilled holes, tying the nodal sutures along the edge of the cortical plate. After flashing, the cortical plate was located in the center, and the mucoperiosteal flap covered it from the vestibular and lingual sides. After tying the nodal sutures along the edge of the cortical plate, casts were taken to make the obturator. After 10 days, after removal of the sutures, the obturator was fitted and installed in the area of the defect. In a patient after surgery, the period of incapacity for work was reduced by 14 days. There was also no need for dressings and visits to the dentist once a week. No inflammatory complications were observed. The period of complete regeneration of the bone wound was reduced to 10 months.

Orthopantomogram one year after surgery.

The orthopantomogram determines the complete restoration of bone tissue in the body region and branches of the lower jaw and the contours of the mandibular canal (see Fig. 3).

Example 2

Patient P., born in 1997. Received with complaints of aching pain, a feeling of fullness and awkwardness in the area of the tooth 4.6., Round swelling in the area of the tooth 4.6. lower jaw on the right. The patient was taken x-ray. An orthopantomogram determines the rarefaction of the bone tissue of the lower jaw on the right in the area of the tooth 4.6 with a size of 6.0 × 4.0 cm (see Fig. 4) and multispiral computed tomography (see Fig. 5). Diagnosis: Tooth cyst of the lower jaw on the right.

A decision was made to conduct surgery. The patient was operated on 03/15/2013. The operation is a cystotomy using the method of a sandwich technique for the formation of an epithelized flap. To do this, we performed an excision of the anterior wall of the cystic formation and exfoliation of the mucoperiosteal flap. Then, in the cortical plate, departing from its edge 2 mm, 4 holes were drilled with a boron. The mucoperiosteal flap was screwed into the bone cavity and stitched through from the vestibular side. The suture needle was inserted at a distance of 8 mm from the edge of the mucoperiosteal flap. In this case, the needle was inserted into the bone hole of the cortical plate, and the mucoperiosteal flap was bent over the edge of the cortical plate and stitched through six drilled holes, tying the nodal sutures along the edge of the cortical plate. After flashing, the cortical plate was located in the center, and the mucoperiosteal flap covered it from the vestibular and lingual sides. After tying the nodal sutures along the edge of the cortical plate, casts were taken to make the obturator. After 10 days, after removal of the sutures, the obturator was fitted and installed in the area of the defect. In a patient after surgery, the period of incapacity for work was reduced by 18 days. No dressings and visits to the dentist once a week were required. No inflammatory complications were observed.

Orthopantomogram one year after surgery.

заполнил костный дефект. Имеется разрежение костной ткани в области зуба 4.6, заполненное костными баночками. Наблюдается перестройка кости.On the roentgenogram (see Fig. 6), the clear contours of the mandibular canal are determined. Bone regenerate on

filled a bone defect. There is a rarefaction of bone tissue in the area of the tooth 4.6, filled with bone jars. There is a restructuring of the bone.

With classical cystotomy, 4 weeks pass before the manufacture of the obturator. Moreover, the entire period until the epithelization of the edges of the wound is complete, the patient needs to change the iodoform swab 1 time per week, and therefore, the patient is on average on the sick leave for 24 to 28 days.

The proposed method reduces the period of disability and the rehabilitation of patients, reduces the number of visits to the dentist and eliminates postoperative complications. An extended biopsy of the type of cystotomy, consisting in a sandwich technique for the formation of an epithelized flap, is both a medical and a diagnostic measure. The application of this technique provided high therapeutic efficacy, since none of the 12 patients had to be hospitalized for jaw resection. Observation of patients for 1-5 years made it possible to recommend this type of surgical intervention as the first stage of surgical treatment of patients with large sizes of cystic formations of the lower jaw.

Thus, the claimed method provides the effectiveness of surgical treatment of cystic formations of the lower jaw of large sizes and can be used in practical dentistry.

Claims (3)

1. A method of surgical treatment of cystic formations of the lower jaw of large sizes, including an incision in the mucous membrane, exfoliation of the mucoperiosteal flap, bone formation, excision of the anterior wall of the cystic formation, characterized in that in the cortical plate, departing from the edge of the bone cavity 2-3 mm , from 4 to 6 holes are drilled with boron, then the mucoperiosteal flap is screwed into the bone cavity and stitched through from the vestibular side, making a suture needle at a distance of 6-8 mm about t of the edge of the mucosal-periosteal flap, and introducing the needle into the bone hole of the cortical plate, while the mucosal-periosteal flap is bent over the edge of the cortical plate and stitched through the drilled holes, tying the nodal sutures along the edge of the cortical plate. 2. The method according to p. 1, characterized in that after flashing the cortical plate is located in the center, and the mucoperiosteal flap covers it from the vestibular and lingual sides. 3. The method according to PP. 1, 2, characterized in that after tying the nodal sutures along the edge of the cortical plate, casts are taken to make the obturator.

Images