RU2610618C1 - Method for alveolar bone defects recovery by allogeneic bone blocks during direct dental implantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: incision is made in the jaw alveolar bone defect area. Mucoperiosteal flaps are exfoliated. Permanent collapsible implants are installed. During implant installation in the tooth area, the resulting dehiscence is covered by a particulated graft obtained by mixing autochips taken by means of a bone scraper and allochips taken from the cortical-fungoid alloblock. Cortical plate of the same block unit is used to cover dehiscence in the removed teeth area and to increse the upper jaw width. The blocks are fixed by mini-screws. The space between the blocks is filled particulated graft as a mixture of bone chips of autogenous and allogenous origin. Augmentation area is covered by a collagen membrane, mucoperiosteal flaps are laid in place. Suturing is performed using a monofilament.

EFFECT: decreased invasiveness of surgical implantation stages.

1 tbl, 10 dwg, 1 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to dentistry, and can be applied with direct implantation to restore defects in the alveolar crest of the jaw bones.

State of the art

Bone deficiency in the maxillofacial region is the situation that the dentist surgeon encounters on a daily basis. Such conditions as: bone atrophy in the region of the maxillary sinus, alveolar ridge, intraosseous defects of the jaw, defects of the cortical plate in the form of digestion and fenestration, furcation defects require one or another type of bone augmentation.

In accordance with the classification of Cawood J.I. & Howell R.A. 1998 4-6 class of atrophy of the alveolar ridge requires bone augmentation not only horizontally, but also vertically.

To date, a variety of forms and types of bone replacement materials have been proposed for the reconstruction of bone defects. To replace hard tissues, materials of a different origin are used in addition to autotissues. Allocation, xenograft (denatured bovine or pig bone), bioactive glass (coral structures), synthetic bone substitutes, such as hydroxyapatite, tricalcium phosphate, are possible alternative materials for use in augmentation of hard tissues.

There are various methods of dental implantation using autotissues (RF patents for inventions No. 2563367, publ. 09/20/2015, No. 2204355, publ. 05/20/2003, No. 2546104, publ. 04/10/2015, No. 2469675, publ. 20.12.2012, No. 2435547, publ. 12/10/2011, No. 2524780, publ. 08/10/2014, No. 2508070, publ. 02/27/2014, No. 2452429, publ. 10.06.2012). For autobone sampling, either extraoral or intraoral donor zones are used. Typical extraoral donor zones are: iliac crest, parietal bone, tibia, rib. On the one hand, extraoral donor zones allow large volumes of bone to be taken, but on the other hand, such operations require general anesthesia and a patient stay in the hospital, which makes it impossible to use such technologies in outpatient dental practice.

Bone sampling from intraoral donor zones, as a rule, does not require anesthesia and is performed on an outpatient basis. The most famous intraoral donor zones are: the chin symphysis, the zone of the external oblique line of the lower jaw, the zone of the cheek-alveolar buttress, the tubercles of the upper jaw. But the fence from these areas is fraught with a number of difficulties. A complication in the collection of bones from the area of the chin symphysis can be a violation of tactile sensitivity in the chin area and cosmetic defects. Fence of bone from the area of the external oblique line is associated with a risk of damage to the mandibular nerve, in addition, the block itself, as a rule, is homogeneous, containing only cortical bone, which significantly limits the use of such a block. When the bone is taken in the area of the cheek-alveolar buttress, the operational risk is minimal, but the volume is small for reconstruction of defects with a length of more than two teeth. The volume of bone taken in the area of the tubercle is very limited and can only be used for small bone defects. In addition, a bone fence in the area of the tubercle leads to deformation of the alveolar ridge in this area.

With any technique, the main drawback of autobone collection is the application of additional trauma to the patient. The reduction in the invasiveness of the surgical stages is especially important in elderly patients with concomitant pathology.

In addition, bone loss in the anterior alveolar wall after tooth extraction is a serious problem. This situation is a contraindication for direct implantation.

The closest technical solution to the proposed one is the method proposed by F. Curie (Khory F. Bone angmention in oral implantology, 2007. - P.115-124), which consists in taking a bone block from neighboring areas of the lower jaw (chin, jaw branch), including conducting a trapezoidal incision in the area of the defect of the alveolar ridge of the jaw, a linear incision in the area of the external oblique line or chin, sampling the autograft, cutting it longitudinally into two plates, fixing one plate with screws from the outer surface of the alveolar ridge. Obtaining bone chips from a part of the autoblock using a mill and placing it in the area of the defect. Further, with vertical and combined atrophy, the second plate is fixed with a screw on top and the wound is sutured. After 3-4 months, implants are installed, and subsequently, prosthetics are performed.

The disadvantages of the method are: the invasiveness of the operation, due to the use of autoblocks, the inability to achieve the specified parameters of the graft and its rigid fixation, as well as the inability to use the method with significant defects of the jaws.

Disclosure of invention

The claimed method is based on the task of developing a method for the reconstruction of the jaw bones during rehabilitation of patients with partial and complete loss of teeth in conditions of bone deficiency.

The technical result achieved in the process of implementing this method is to reduce the invasiveness of the surgical stages of implantation, namely the reduction of soreness and duration of surgery.

The specified technical result is achieved by the fact that the method of repairing the defects of the alveolar bone using allogeneic bone blocks with direct dental implantation involves performing an incision in the area of the defect of the alveolar bone of the jaw, peeling the mucosal-periosteal flaps, installing a bone plate in the area of the defect and fixing, filling the formed space of the bone shavings followed by suturing the wound, and according to the invention, the digiscence is closed with a punctured graft, according to scientifically, by mixing autocrochs taken with a bone scraper and allocrosh taken from a cortical-spongy alloblock, a cortical plate of the same block closes the digiscences in the area of the extracted teeth and increases the volume of the upper jaw in width, the bone plates are fixed with mini-screws, and the space between them they fill with a punctured graft in the form of a mixture of bone chips of autogenous and allogeneic origin, the augmentation zone is closed with a collagen membrane, then I put mucoperiosteal flaps t in place, suturing is carried out using monofilament.

Brief Description of the Drawings

In FIG. 1 shows a photo of the condition of the prosthetic patient in the upper jaw before treatment.

In FIG. 2 shows the orthopantomogram of patient H. at the time of treatment.

In FIG. 3 shows a photo of the installation of a permanent implant in the area of the tooth 1.1, provisional implant in the area of the tooth 1.3.

In FIG. 4 presents a photo of an allogeneic bone block soaked in autoblood.

In FIG. Figure 5 shows a photo - digiscence in the area of the socket of tooth 2.1 is closed by an alloblock.

In FIG. 6 is a photo of the gum condition 10 days after surgery.

In FIG. 7 presents the orthopantomogram of patient X., x-ray control 3 months after surgery.

In FIG. Figure 8 shows a photo of the installation of an implant measuring 3.5 x 9 mm into the tooth area 1.4.

In FIG. Figure 9 shows a photo of the installation of an implant measuring 3.5 x 9 mm into the tooth area 2.4.

In FIG. 10 is a photo of the orthopantomogram of patient X., x-ray control 3 months after the second operation.

The implementation of the invention

The present invention is based on a clinical analysis of the results of the use of allogeneic bone blocks in 8 (4 men and 4 women) in the period 2010-2014.

The age of patients was from 52 to 68 years. Patients suffered from one or another somatic pathology. In all cases, alloblocks were used under conditions of atrophy of the alveolar ridge of the 4th degree (according to the classification of Cawood J.I. & Howell R.A.). At the same time, there were 4 patients with complete tooth loss, 2 patients with partial tooth loss, and 2 patients with one tooth loss.

In the preoperative period, clinical and laboratory examination of patients was performed. An X-ray examination of teeth and jaws was carried out (targeted intraoral images, orthopantomograms, computer tomograms with three-dimensional reconstruction of the image).

The question of the size of the used block was decided on the basis of modeling the situation dictated by the conditions in the oral cavity and the condition of the bone tissue of the receiving bed. For this, the size and topography of the defect of the alveolar ridge, the degree of atrophy of the alveolar ridge, the type of occlusion, the shape of the occlusal surface, etc. were determined on the models. And when examined using computed tomography, the following indicators were evaluated:

- the height and thickness of the alveolar processes of the jaws;

- the state of the alveolar process of the upper jaw with respect to the bottom of the alveolar bay of the maxillary sinus;

- the state of the alveolar process of the lower jaw with respect to the upper wall of the mandibular canal to the bottom;

- the condition of the marginal divisions of the alveolar bone around the remaining teeth;

- the form of the elements of the temporomandibular joint.

In the preoperative period, thorough rehabilitation of the oral cavity and the necessary orthopedic preparation were performed. In this case, the future localization of the implant and its superstructure was taken into account and it was carried out by the same team (orthopedist - dental technician), who performed prosthetics after the dental implantation operation.

After the studies and the diagnosis were made, a treatment plan was drawn up, including bone augmentation surgery, implantation followed by orthopedic treatment.

Complete and subtotal tooth loss is often accompanied by severe atrophy of the alveolar ridge. Bone loss during periodontitis or when the supporting teeth are overloaded with prostheses is especially intense.

The following clinical case is an example.

Patient H., aged 63 years old, came to us with complaints of loss of chewing teeth in the lateral parts of both the upper and lower jaw, the mobility of the remaining teeth in the frontal parts of both jaws, and the failure of removable and non-removable prostheses. Loss of teeth occurred during the 30-35 years of the patient's life due to complicated forms of caries and periodontitis. From the anamnesis of life - the patient suffers from hypertension II-III art.

On examination: on the upper jaw there is a bridge-like structure from tooth 1.3 to tooth 2.2 with supports on teeth 1.2 and 2.1. Partial removable laminar denture. Tooth mobility 1.2 and 2.1 III degree.

On the lower jaw a bridge structure from tooth 3.3 to tooth 4.4 with support on all teeth from 3.3 to 4.4. Partial removable laminar denture. The mobility of teeth II-III degree, the destruction of the crown part of the teeth 3.3, 3.2 under the crowns (Fig. 1).

In the study of alveolar ridges, a complete absence of an alveolar ridge in the region of molars of the upper and lower jaw was revealed, which corresponds to grade 5 atrophy, a crest 2-3 mm wide in the area of premolar molars of the upper jaw - grade 4 atrophy, bone deficiency in the area of the walls of the holes in the area of remaining teeth.

Diagnosis: Partial tooth loss, terminal unlimited defects of all dentitions, periodontitis of the II-III degree, chronic periodontitis of teeth 3.3, 3.2. Atrophy of the alveolar ridge of the upper and lower jaw 4-5 degrees (Fig. 2). Hypertension II-III Art.

The overall risk level for the SAC system (ITI recommendations, 2009) was rated by us as high (Table 1).

Table 1. Assessment of the overall level of risk in patient X.

In connection with the presence of concomitant somatic pathology, the treatment plan was developed according to the principles of reducing the invasiveness of surgical stages.

The following treatment plan was formulated:

Stage 1

In the area of the upper jaw:

Extraction of teeth 1.2, 2.1.

Installation of permanent implants in tooth zones 1.1 and 2.1.

Installation of provisional implants in the tooth zones 1.3 and 2.3.

Bone grafting of the alveolar ridge from the tooth zone 1.4 to the tooth zone 2.4.

In the lower jaw area:

Removal of all teeth.

Installation of permanent implants in the area of the teeth 3.1, 3.4, 4.1 and 4.4.

Installation of provisional implants in the area of the teeth 3.3 and 4.3.

2 stage

Prosthetics by provisional constructions.

3 stage

In the area of the upper jaw:

Installation of permanent implants in the area of teeth 1.4 and 2.4.

4th stage

Opening implants, prosthetics with permanent structures.

All operations were performed under local anesthesia. At the first stage, an incision was made in the upper jaw from tooth zone 1.5 to tooth zone 2.5. Mucoperiosteal flaps are exfoliated. Permanent collapsible implants of size 3.5 x 11 mm were installed in the tooth zones 1.1, 2.1 according to the protocol with immediate loading and provisional collapsible implants of size 3.0 x 13 mm in the tooth zones 1.3, 2.3. When installing the implant in the area of the tooth 1.1, digiscence formed (Fig. 3). Digiscence was closed by a punctured graft obtained by mixing autocroch taken with a bone scraper and allocroc taken from a cortical-spongy alloblock (Fig. 4).

A cortical plate of the same block was used to close the digiscences in the area of the extracted teeth 1.2, 2.1, increase the volume of the upper jaw in width in the area of the teeth 1.3, 1.4, 2.3, 2.4. Blocks are fixed with mini-screws. The space between the blocks is filled with a punctured graft in the form of a mixture of bone chips of autogenous and allogeneic origin (Fig. 5). The augmentation zone was closed with a collagen membrane, the mucoperiosteal flaps were put in place, the sutures were monofilament.

The following were prescribed: antibiotics, non-steroidal anti-inflammatory drugs, oral baths with antiseptic solutions. In the postoperative period, moderate swelling of soft tissues, pain of moderate intensity for 3 days was noted. The patient felt satisfactory. In FIG. 6 is a photo of the gum condition 10 days after surgery. 3 days after the operation, impressions were taken and provisional metal-acrylic prostheses were made.

3 months after the first operation (see Fig. 7 - the orthopantomogram of patient X., X-ray control), permanent implants were inserted into the tooth area 1.4 of size 3.5 x 9 mm and into the tooth area 2.4 of size 3.5 x 9 mm, mini -screws removed. During implant placement, good engraftment of bone blocks and good stability of implants installed in the wells of the extracted teeth were noted. (Fig. 9, 10).

After another 3 months, during the follow-up examination of the resorption, there were no signs of peri-implantitis (Fig. 10 — OPT of patient X, X-ray control), which made it possible to establish shapers and proceed with permanent prosthetics.

Findings:

The use of allogeneic bone blocks is indicated for severe atrophy of both the upper and lower jaw.

The use of alloblocks allows you to install implants directly into the wells of the extracted teeth even in the presence of extended digiscences and, in fact, in the absence of the anterior wall of the hole.

The use of allogeneic bone blocks significantly reduces soreness and the duration of surgical intervention due to the lack of the need for the collection of donor bone.

The use of allogeneic bone provides the ability to form bone blocks of any shape for any part of the jaw.

The use of allogeneic bone material and a collagen membrane prevents early resorption of alloblocks.

Recommendations:

The use of allogeneic bone blocks requires the surgeon to appropriate manual skills and a deep understanding of the principles of bone tissue regeneration.

The use of allogeneic bone blocks requires careful preoperative planning.

Fixation of allogeneic bone blocks should ensure their highest stability and immobility in the augmentation zone.

In connection with the probable resorption of the augmentate, it is necessary to introduce an excess volume of the punctured graft in the form of a mixture of allo (xeno) and auto shavings.

Mucoperiosteal flaps should cover the augmentation area without tension.

It is strongly not recommended to expose the augmentation zone to any loads in the postoperative period.

The installation of implants during augmentation of the alveolar bone with alloblocks is preferably carried out according to a delayed protocol.

Conclusion:

The use of alloblocks is the method of choice for the rehabilitation of elderly patients and having somatic diseases during augmentation of the alveolar crest of the jaw in conditions of bone deficiency.

A comparative analysis of the claimed invention showed that the set of essential features of the claimed method for repairing defects of the alveolar process using allogeneic bone blocks with direct dental implantation is not known from the prior art and, therefore, meets the patentability condition of "Novelty".

In the prior art there were no signs that coincided with the distinguishing features of the claimed invention and affecting the achievement of the claimed technical result, therefore, the claimed invention meets the patentability condition "Inventive step".

The above information confirms the possibility of using the claimed method in medicine, namely in dentistry, which can be used with direct implantation to repair defects of the alveolar crest of the jaw bones, and therefore meets the patentability condition "Industrial Applicability".

Literature:

Dolgalev A.A. Possibilities of 3D-technologies in planning implantological treatment / et al. A.Yu. Remov, E.M. Boyko // Russian Bulletin of Dental Implantology, - 2013, No. 1, P. 23-27.

Dolgalev A.A. Recovery of complex in shape defects of the alveolar ridge of the jaw or, et al. Boyko E.M.// Russian Journal of Dental Implantology, - 2014, No. 2, P. 52-56.

Buser D. 20 years of guided bone regenerationin implant dentistry. Hannover, Quintessence 2009.

Cordaro L., Terheyden H. Ridge augmentation procedures in implant patients. A staged approach. Berlin, Quintessence, 2014.

Esposito M., Grusovin M.G., Felice P., Karatzopoulos G., Worthington H.V., Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants - a Cochrane systematic review. Eur J Oral Implantol. 2009; 2: 167–184. [PubMed].

Claims (1)

A method for repairing defects of the alveolar ridge using allogeneic bone blocks with direct dental implantation, including making an incision in the area of the defect of the alveolar ridge of the jaw, flaking off the mucosal-periosteal flaps, installing a bone plate in the area of the defect and fixing, filling the created space with bone shavings, followed by suturing of the wound characterized in that the digiscence is covered with a punctured graft obtained by mixing autocritic, taken with the help of braids of a scraper, and allochros taken from a cortical-spongy alloblock, a cortical plate of the same block closes the digiscences in the area of the extracted teeth and increases the volume of the upper jaw in width, the bone plates are fixed with mini-screws, and the space between them is filled with a divided graft in the form of a mixture bone chips of autogenous and allogeneic origin, the augmentation zone is closed with a collagen membrane, then the mucoperiosteal flaps are placed in place, suturing is carried out using monofilament.

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