RU2732313C1 - Method for one-stage elimination of class iii gingival recession and vestibuloplasty - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to surgical dentistry, periodontium plastic surgery. Elimination of III grade gingival recession involving the following stages: local anaesthesia is applied in the area of small vestibule and gingival recessions and in the area of transplant sampling on solid palate; bare dental roots are processed mechanically using a Gracie curette and chemically in the form of application of 17 % EDTA solution; using a microsurgical scalpel and tunnel spacing, tunnel access is formed in the area of recessions with one tooth gripping in each side from the operated defect; an incision is made below the mucous-gingival joint by 1.5–2 mm, a splitting of the flap in the coronary direction, a bed for the grafting; coronary reposition of the tunnel flap by means of a coupling and suture seams; free gum transplant intake from the appropriate size palate, de-epithelialization; transplant fixation on the prepared recipient bed by interrupted and matt sutures with non-resorbable suture material; sutures are removed on 14day.EFFECT: method enables closing the gum recession, deepening the oral vestibule by increasing the area of the attached keratinized gum.1 cl, 16 dwg, 2 ex

Description

The invention relates to medicine, in particular to dental surgery, plastic surgery of the periodontium.

In the literature, techniques for eliminating gingival recessions are widely described, such as coronal flap displacement, tunnel technique for eliminating recession, techniques with transplantation of various types of connective tissue transplants, double papillary flap technique, modifications of these techniques, the use of these techniques in eliminating single and multiple recessions. All these techniques work well in eliminating Miller class I and II gingival recessions, when the success of treatment is 100%, when even at the stage of diagnosis and treatment planning we can guarantee the patient that the overlap will work and there will be no relapse, since with these recessions changes in bone tissue are not expressed and there is no extensive loss of soft tissues. Due to its peculiarities, such as destructive changes in bone tissue, loss of soft tissues up to the exposure of the tooth root within or below the mucous-gingival junction and loss of the interdental papilla, elimination of class III gum recession cannot be so well predictable and the success of treatment cannot be achieved in less than 50% of cases (L. Chambrone. Evidence-BAsed periodontal and peri-implant plastic surgery. - Brazil, Springer. 2015. - p. 54).

Elimination of gum recession in conditions of a shallow vestibule of the oral cavity and other anatomical features is a more difficult task than treating these pathologies separately.

Methods for eliminating gum recession in the conditions of the shallow vestibule of the oral cavity using a two-stage technique (J. Zucchelli. Plastic surgery of soft tissues of the oral cavity. - M .: Azbuka dentist. 2014. - 403-414 p.) Have been described:

1) deepening of the vestibule of the oral cavity by increasing the area of the attached keratinized gums;

2) elimination of gingival recession due to coronary displacement of the split flap.

It is more convenient for the doctor and the patient to carry out a one-stage operation, since the number of surgical interventions is reduced; the risk of getting an additional volume of cicatricial changes is reduced; there is no need for additional collection and transplantation of a connective tissue graft taken from the sky, and, which is important for the patient, a reduction in the cost of manipulation.

It should be noted that in the literature there is no description of methods for eliminating class III gum recessions according to Miller (except for the consideration of individual clinical cases), and even more so there is no description of methods for eliminating such recessions in patients with a small vestibule of the oral cavity.

There is a known method of surgical treatment of gingival recession (Patent RU 2014118011 publ. 10.01.16), which includes taking a graft from the patient's palate at a distance of 2 mm ± 0.2 mm from the edge of the gums with its subsequent movement into the recession zone, characterized in that the fence the graft is carried out in the hard palate zone from the lateral incisor to the distal surface of the crown of the third molar, and it is modeled outside the oral cavity by de-epithelization. In this case, the graft is taken with a thickness of 2 mm ± 0.2 mm. This method is an example of a technique for eliminating gingival recession and transplanting a de-epithelized free gingival graft from the palate using a tunnel method without vertical incisions. The advantages of this method are a well-predictable result, as well as a highly aesthetic result without scarring. However, this method is suitable for eliminating miller grade I and II shallow recessions, but it is not indicated for eliminating Miller grade III gum recessions, and the method does not provide for deepening of the vestibule of the oral cavity.

There is also known a method for eliminating gingival recession (Patent RU No. 2421166 publ. 20.06.2011.), Which consists in the fact that an incision of the oral mucosa is made from the molars of the left side to the molars of the right side, retreating from the mucogingival junction by 8-12 mm, in intrasulcular incisions are made in areas of teeth with recessions. Separate the oral mucosa from the circular muscle, submucosa. The periosteum is displaced in the apical direction. The area of alveolar bone digiscence is skeletonized. Next, a bone graft is taken from the intraoral localization area of 15-25 mm × 8-15 mm. Plates are formed from the cortical layer of the graft with a thickness of 1-1.5 mm in width by 2-4 mm larger than the size of the digiscence, with which it is closed, fixing the plates with the help of mini-screws. A bone crumb is prepared from the spongy layer of the graft, which is distributed between the plates. The method allows to reduce the risk of recurrence of gum recession, to ensure a long-term treatment result. The disadvantages of this method are the invasiveness of the operation, a significant amount of surgery, the presence of a focus of healing by secondary intention; and also the fact that the technique is also not designed to eliminate Miller class III gingival recessions.

The known method of vestibuloplasty (Patent RU No. 2455953 publ. 20.07.2012.) Consists in the fact that a horizontal incision of the mucous membrane is carried out at the border of the alveolar gum and the movable mucous membrane of the vestibule of the oral cavity, followed by dissection of the flap parallel to the periosteum, the flap and muscles are displaced in the apical direction to the depth of the created vestibule, muscle fibers and cords on the periosteum are excised, de-epithelialization of the submarginal keratinized, free gingival graft is taken and exposed in the Perftoran preparation for one minute, followed by the graft fixation and injection of the preparation.

The advantages of the method are the improvement of the functional result and the decrease in the number of postoperative complications. The method is aimed at eliminating the conditions of the shallow vestibule of the oral cavity, an increase in the zone of keratinized attached gums is provided, while the drug "Perftoran" helps to improve blood supply in the postoperative area. This method also does not provide for the elimination of gum recession, in particular, Miller class III recession.

At the stage of diagnosis and planning of surgical intervention, it is necessary to measure the depth of recession (s), width of recession (s), loss of periodontal attachment; measure the depth of the vestibule of the oral cavity (less than 5 mm is considered shallow), note the presence of additional strands and bridles; assess the level at which the apex of the interdental papilla is located; it is necessary to direct the patient to a cone-beam computed tomogram in order to obtain reliable information about the state of the bone tissue of the interdental septa.

Thus, at the diagnostic stage, the maximum data should be obtained on the level of soft tissues in the area of gingival recession, on the presence of complicating anatomical features; about the state of hard tissues: about the level of the vestibular cortical plate, and about the state of interdental bone septa in the area of gum recession.

Based on the data obtained, it is possible to diagnose gum recession (with specification of the class according to Miller's classification) and the shallow vestibule of the oral cavity.

In the presence of the symptoms described above (gingival recession, loss of periodontal attachment, and bone loss, cortical resorption, insufficient gingival attachment zone), the main diagnosis in a patient is usually chronic periodontitis (localized or generalized). Therefore, before surgery, it is necessary to treat the inflammatory manifestations of periodontitis: to carry out scaling and rootplening, to prescribe local anti-inflammatory drug therapy, to teach the patient the correct oral hygiene. After 21-30 days, an operation can be scheduled. Additional preliminary drug therapy is not required.

The objective of this invention is to perform an operation to eliminate the recession of the III class gums in the conditions of the shallow vestibule of the oral cavity with simultaneous vestibuloplasty with the transplantation of a free gingival graft from the palate.

For the treatment of patients with Miller class III gum recession and with a small vestibule of the oral cavity, a single-stage operation technique is provided.

Operation protocol:

1) oral bath with 0.05% chlorhexidine solution;

2) carrying out infiltration anesthesia in the area of gingival recession and in the area of collection of a connective tissue graft from the palate;

3) treatment with Gracey curettes of tooth root surfaces with gingival recessions, application of 17% EDTA solution for 2 minutes; irrigation of 0.9% sodium chloride solution (Fig. 1);

4) a tunnel approach is performed with an eye scalpel (thawing of the gingival flap) in the area of gingival recession and in two adjacent teeth from the medial and distal sides (Fig. 2);

5) with a 15-C scalpel, an incision is made 1.5-2 mm below the mucous-gingival junction for the entire length of the insufficient zone of the keratinized gum;

6) the mucous flap is exfoliated in the coronary direction as in vestibuloplasty with the transplantation of a free gingival transplant taken from the palate;

7) to the previously prepared composite "bridges", or Polypropylene 6-0 twisted sutures, the gingival flap is fixed in the coronal direction so as to cover the gum recession (Fig. 3);

8) a free gingival graft of the appropriate size is taken from the sky to the receiving bed in the area of the planned vestibuloplasty;

9) the graft is de-epithelized;

10) the graft is fixed to the periosteum in the area of the prepared receiving bed in the area of the planned vestibuloplasty with interrupted, cross mattress sutures Polypropylene 6-0 or 7-0 (Fig. 4);

11) local cold, pain reliever.

Recommendations for the patient in the postoperative period:

• pain reliever if necessary;

• on the first day: local cold for 1 minute every hour;

• limitation of physical activity;

• limitation of temperature conditions;

• the food is not rough, not hot, not irritating;

• limitation of speech activity;

• it is prohibited to "show seams";

• on the day of the operation, the couple should not be cleaned in the area of the operation, from the second day - irrigation from a syringe with a broken needle with an antiseptic solution.

The stitches are removed on the 14th day after the operation.

The technical result of this invention is to obtain an overlap of gingival recession, deepening the vestibule of the oral cavity by increasing the zone of attached keratinized gums.

Clinical example 1

Patient S., 35 years old, applied to the periodontal department of the Center for Maxillofacial Surgery and Dentistry of the Moscow State Medical University. A.I. Evdokimova with complaints of exposure of the roots of the teeth, increased sensitivity of the teeth, bleeding gums and bad breath. Orthodontic treatment was carried out over 10 years ago. Based on the clinical examination (the gum is hyperemic, edematous, bleeds during probing, periodontal pockets 3.5-5 mm, the presence of supra- and subgingival dental deposits; the number of gingival recessions in the region of the lower anterior teeth - 4, the depth of recessions 4.2-5 mm. 4.1-6 mm, 3.1-3 mm, 3.2-2 mm; vestibule depth - 2 mm) (Fig. 5) and data from additional X-ray research methods (Fig. 6) (the level of inflammatory bone resorption of interdental septa up to 1/3 of the length of the tooth roots) the diagnosis was made: K05.31 (chronic generalized periodontitis) and K06.0 (gum recession) of the III class according to Miller.

Treatment performed:

1) complex treatment of inflammatory periodontal diseases according to the scheme: local drug anti-inflammatory therapy, training in individual oral hygiene, scaling and rootplening in the area of all teeth;

2) the observation period is about 3 months;

3) the operation of simultaneous elimination of gingival recessions by vestibuloplasty (Fig. 7), removal of sutures after 14 days (Fig. 8);

4) dynamic observation after 1 and 3 months (Fig. 9).

Clinical example 2

Patient K., 20 years old, applied to the periodontal department of the Center for Maxillofacial Surgery and Dentistry of the Moscow State Medical University. A.I. Evdokimov with complaints of exposure of the roots of the teeth, increased sensitivity of the teeth, bleeding gums and bad breath in the area of the lower front teeth (Fig. 10). Based on the clinical examination (the gum is hyperemic, edematous, bleeds during probing, periodontal pockets 3.5-5 mm, the presence of supra- and subgingival dental deposits; the number of gingival recessions in the region of the lower anterior teeth - 2, the depth of recessions 4.1 - 3.5 mm, 3.1 - 1.5 mm; the depth of the vestibule is 1 mm, measurements were carried out after the course of anti-inflammatory therapy) (Fig. 11) and data from additional X-ray research methods (Fig. 12) (the level of inflammatory resorption of bone tissue of interdental septa up to 1/3 of the length of the tooth roots) diagnosed : K05.31 (chronic generalized periodontitis) and K06.0 (gum recession) III class according to Miller. Treatment performed:

1) complex treatment of inflammatory periodontal diseases according to the scheme: local drug anti-inflammatory therapy, training in individual oral hygiene, scaling and rootplening in the area of all teeth) (Fig. 11);

2) the observation period is about 1.5 months (Fig. 13);

3) the operation of simultaneous elimination of gingival recessions with vestibuloplasty (Fig. 14), removal of sutures after 14 days (Fig. 15);

4) dynamic observation after 1 and 3 months (Fig. 16).

Brief description of the figures.

FIG. 1. shows the mechanical treatment of the bare surfaces of the teeth with Gracie carriages and the chemical treatment in the form of an application for 2 minutes of 17% EDTA solution.

FIG. 2. shows the creation of a split gingival flap by tunnel approach using an ophthalmic scalpel.

FIG. 3. shows the incision below the mucous-gingival junction by 1.5-2 mm and the formation of a bed for graft transplantation as in vestibuloplasty; fixation of the split flap with cap and sail sutures to composite bridges.

FIG. 4. shows the fixation of a de-epithelialized free gingival graft of the appropriate size on the prepared recipient bed with interrupted and mattress sutures.

Figure 5. presents a clinical example 1: a similar situation; the number of gingival recessions in the area of the lower anterior teeth is 4, the depth of recessions is 4.2 - 5 mm. 4.1-6 mm, 3.1-3 mm, 3.2 - 2 mm; vestibule depth - 2 mm

FIG. 6.Clinical example 1 is presented: data from intrarotum contact radiography: bone resorption of interdental bone septa up to 1/3 of the length of the tooth roots.

FIG. 7. clinical example 1 is presented: the view of the patient immediately after the operation of the simultaneous elimination of gingival recessions with vestibuloplasty.

FIG. 8. clinical example 1 is presented: view after 14 days at the time of suture removal.

FIG. 9.Clinical example 1 is presented: 30 days after surgery.

FIG. 10. presents a clinical example 2: the initial clinical situation - signs of gingival inflammation, such as bleeding on probing, edema, hyperemia, profuse subgingival dental deposits; pathological high attachment of the frenum of the lower lip.

FIG. 11. shows a clinical example 2: the patient's view 30 days after the course of anti-inflammatory therapy: the number of gingival recessions in the lower frontal teeth - 2, the depth of recessions 4.1 - 3.5 mm, 3.1 - 1.5 mm; the depth of the vestibule is 1 mm.

FIG. 12. presents a clinical example 2: on cone-beam computed tomography - the level of inflammatory resorption of bone tissue of interdental septa up to 1/3 of the length of the roots of the teeth.

FIG. 13 shows a clinical example 2: the view of patients immediately before operations - the gums are pale and dense, without signs of inflammation.

FIG. 14. shows a clinical example 2: a view of a patient immediately after the operation of one-stage elimination of gingival recessions with vestibuloplasty.

FIG. 15 shows a clinical example 2: a view of a patient after 14 days at the time of suture removal.

FIG. 16. shows a clinical example 2: a view of a patient 30 days after surgery.

Claims (1)

A method for eliminating class III gum recession, including the following stages: local anesthesia is performed in the area of the shallow vestibule and gingival recessions and in the area of graft collection on the hard palate; exposed tooth roots are processed mechanically using Gracie curettes and chemically in the form of application of a 17% EDTA solution; with the help of a microsurgical scalpel and tunnel spacers, a tunnel access is formed in the area of recessions with the capture of one tooth in each side of the operated defect; an incision is made below the mucous-gingival junction by 1.5-2 mm, the flap is split in the coronary direction, a bed is formed for placing the graft; Coronary reduction of the tunnel flap using cap and sail sutures; collection of free gingival graft from the palate of the appropriate size, deepithelization; fixation of the graft to the prepared recipient bed with interrupted and mattress sutures with non-resorbable suture material; removal of stitches is carried out on the 14th day.

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