RU2766977C1 - Method for stacking and stabilising granular osteoplastic materials in the recipient bed when eliminating complex defects of the jaw bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, in particular, to surgical dentistry. 3D computer modelling of the jaw bone defect reconstruction is executed. The defect is reformed in the 3D model of the jaw, the volume of bone reconstruction is modelled, the volume of reconstruction is calculated in a computer program, the template of the reinforced membrane is modelled, and surgical reconstruction is performed. An incision is made in the mucous membrane within the topography of the jaw bone defect: the mucous membrane and periosteum are incised along the greatest length of the defect, at a step of 4 to 5 mm to the oral side from the demarcation line of the multilayer flat keratinising and non-keratinising epithelium so that keratinising epithelium is present on both sides of the wound surface. The vestibular part of the muco-periosteal flap lining the bone defect is immobilised. A first lobe is formed, wherefor an incision is made along the periosteum from the inside of the flap at a step from the edge thereof of 10 to 12 mm. The flap is separated along the incision line of the periosteum into upper and lower segments. The upper segment of the flap with the periosteum remains on the tissues of the first lobe, and soft tissues are immobilised in the lower segment along the incision line of the periosteum, detaching the soft-tissue mass from the edge of the periosteum along the entire surface thereof to a depth of 10 to 15 mm, a second lobe is obtained. The lower segment of the periosteum is then completely released and a third lobe is obtained, wherefrom a consolidated muco-periosteal flap is modelled by including a membrane therein, made of a soft-tissue xenogenic collagen frame with integration of the cellular pool of a stromal vascular fraction, a platelet mass, and blood plasma fibrinogen. Implants with plugs are installed along the ridge of the defect. The vestibular muco-periosteal flap is divided into three lobes: muco-periosteal, soft-tissue, periosteal. The osteoplastic material is then laid in the bone defect, and the external relief of the reconstruction is modelled based on the calculated restoration boundaries. The layout of the osteoplastic material in the bone defect is therein executed above the upper border of the defect by one fourth of the vertical length thereof by a width exceeding the depth of the lower quarter of the defect by three times, with the osteoplastic material being supported in the upper part of the restoration on the native bone of the upper borders of the defect. The membrane is sutured to the oral segment of the muco-periosteal flap. The third lobe of the vestibular segment of the muco-periosteal flap is prepared for suturing the membrane covering the osteoplastic material thereto. The membrane is then laid to the third lobe in the vestibular direction from the oral to the vestibular part of the muco-periosteal flap and secured with a horizontal transmembrane external-internal suture, beginning from a puncture of the muco-periosteal mass in the distal direction outside the lower edge of the defect at a step from the medial border of 5 mm. Non-absorbable number 5.0 or 6.0 thread is used for suturing. A vertical suture is then applied, extending transmembranely, from the oral part of the muco-periosteal flap to the second lobe of the vestibular flap. A transmembrane return is performed through said lobe, exiting through the oral part, both ends of the ligature are tied, resulting in a consolidated muco-periosteal flap constituting a soft-tissue graft jacket. A continuous suture is then applied with a non-absorbable number 5 thread, and the wound is sutured tight. The stitches are removed after 10 to 14 days. A control examination and radiography are performed after four and twelve months.

EFFECT: method provides a possibility of creating a stable soft-tissue jacket for the external surface of the graft, preventing uncontrolled change in the shape and volume of the graft while eliminating external, internal, and combined bone defects of the bones of the facial skull of complex geometric shapes with restoration of the anatomical shape of the body part, ensuring predictable behaviour of the graft within the designed boundaries of the recipient bed, eliminating a second operation, and preventing impairment of vascularisation of the regenerating bone in the area of the eliminated defect, ensuring complete biotransformation of osteoplastic material and a predictable clinical outcome, reducing the material costs and the emotional discomfort of the patient.

1 cl, 12 dwg, 1 ex

Description

The invention relates to the field of dentistry and is aimed at preventing postoperative complications in the elimination of jaw bone defects by transplantation.

Known "Method of directed bone regeneration of the jaw in case of atrophy of the alveolar process" (Dolgalev Alexander Alexandrovich, Zelensky Vladimir Alexandrovich, Mukhoramov Fakhriel Sadykovich, Boyko Evgeny Mikhailovich, Zelensky Ilya Vladimirovich, Mukhoramov Firyuz Fakhrielevich No. of security document 2648861, date of security document 28.03.2018), directed for augmentation of the alveolar process of the lower jaw in height and width. To do this, a longitudinal incision of the mucous membrane and periosteum is performed, the mucoperiosteal flap is detached from the lingual and buccal side, and the external cortical plate is decorated. After the formation of the receptive bed, filling it with a mixture of allogeneic graft with autogenous bone chips, covering the augmentate with a collagen membrane, its edges are filled under the periosteum. The periosteum is sutured with a resorbable suture material, and the mucous membrane above the periosteum is sutured with a non-resorbable suture material.

The disadvantages of the method are: 1. There is no 3D planning of defect reconstruction and 3D calculation of the volume of the osteoplastic material, taking into account changes in its physical and biological properties in the postoperative period; 2. 3D planning of membrane cutting is not carried out and a template of the membrane is not made; 3. The membrane freely fits under the periosteum and is not fixed to the tissues of the mucoperiosteal flap, which leads to its displacement and disclosure of the osteoplastic material; 4. The membrane is one-component, it is laid in a dry form, it is not prepared for laying and does not integrate with the patient's autologous cellular elements.

There is a known “Method for calculating the volume of osteoplastic material when planning an operation for guided bone tissue regeneration” (see RF patent No. scanned, their scans are obtained in the .STL format, then the data of the cone-beam computed tomography in the .DICOM format and the scans of the models in the .STL format are loaded into the Avantis 3D program and, according to the obtained data, a “grid” is built, and the reference points are compared data of cone beam tomography and scans with further installation of implants, then a surgical template is made and, based on the anatomical features of the alveolar ridge, the exact volume of bone-replacing material necessary for guided bone tissue regeneration is modeled and measured.

However, when used, this method has the following disadvantages:

> fabrication of a defect template by stereolithography, which is based on the subtraction of the model when designing an object, which reduces the accuracy of the replica and makes it impossible to model loose fractions;

> the method can only be used to restore open defects with a smaller inner perimeter and a larger outer perimeter of the outer borders of the defect of the alveolar process of the jaw;

> cannot be used for bone defects in the area of the body and jaw branch, for penetrating and through defects, because taking an impression of a defect for planning an operation can only be performed when it is surgically skeletonized, which is unacceptable and impossible to do for these purposes;

> when calculating the amount of osteoplastic material, only data on the volume of the bone defect and the volume of the material are taken into account, and changes in the indicators of the physical properties of the osteoplastic material in the postoperative period that change the initial volume of the implanted osteoplastic material are not taken into account;

> the collagen membrane is one-component, does not contain autologous structures of the mesenchymal-stromal fraction, blood elements and vascular growth factors, is laid in a dry form, it is not prepared for laying.

> 3D planning of membrane cutting is not carried out and a template of the membrane is not produced;

> the membrane freely fits under the periosteum and is not fixed to the tissues of the mucoperiosteal flap, which leads to its displacement and disclosure of the osteoplastic material.

Closest to the claimed invention (prototype) is the "Method of 3D computer modeling and reconstruction of the defect of the alveolar process of the jaw". The results of cone-beam computed tomography were converted into DICOM files and the defect was reformed in a 3D model of the jaw, then the volume of bone reconstruction was modeled using the ViSurgery program (Russia). Modeling of the upper border of the regenerate was carried out according to the level of bone tissue at the necks of the teeth limiting the defect. In the case of end defects of the dentition, the level of reconstruction was determined by the cervical level of the bone of the distally located tooth. The reconstruction volume was calculated in the program (in mm ³ ), and then this indicator was compared with the obtained bone volume. The template of the framework membrane was modeled in the same program. (A.A. Muraev. A new approach to volumetric reconstruction of complex alveolar bone defects. Modern technologies in medicine. 2017. 9(2): pp. 38-45).

However, this method, when used, has the following disadvantages:

> in the absence of teeth, it is impossible to determine the outer boundaries of the 3D graft model in this way, which will lead to inaccuracies in determining the required amount of osteoplastic material;

> when calculating the amount of osteoplastic material, only data on the volume of the bone defect and the volume of material specified by the manufacturer are taken into account, without taking into account changes in the parameters of the physical properties of the osteoplastic material in the postoperative period, which change the initial volume of the implanted osteoplastic material;

> osteoplastic augmentation is a one-component, does not contain autologous structures of the mesenchymal-stromal fraction, blood elements and vascular growth factors, does not contain a dental implant.

> the collagen membrane is one-component, does not contain autologous structures of the mesenchymal-stromal fraction, blood elements and vascular growth factors, is laid in a dry form, it is not prepared for laying.

> 3D planning of membrane cutting is not carried out and a template of the membrane is not produced;

> the mucoperiosteal flap is not immobilized and is not cut into three petals;

> the periosteum on the mucoperiosteal flap is not separated into upper and lower fragments;

> the membrane freely fits under the periosteum and is not fixed to the tissues of the mucoperiosteal flap, which leads to its displacement and disclosure of the osteoplastic material.

The objective of the invention is to eliminate these shortcomings by developing a method for laying and stabilizing granular osteoplastic materials in the recipient bed when eliminating complex jaw bone defects by transplantation.

The implementation of the task is carried out by performing a sequence of actions aimed at laying out in a certain way the calculated volume of granular osteoplastic material in the bone defect and forming a stable soft tissue corset formed from soft tissue structures lining the bone defect and an aggregated membrane to cover and support the outer surface of the transplanted osteoplastic material.

The soft tissue corset is a consolidated mucoperiosteal flap formed from the immobilized vestibular part of the mucoperiosteal flap and an aggregated membrane. The aggregated membrane is made by the proposed method and includes a soft-tissue xenogenic collagen framework with autologous components of the patient integrated into it: a cell pool of the stromal-vascular fraction, platelet mass and blood plasma fibrinogen.

The sequence of actions of the method is implemented in three stages: 1. The stage of planning and coordinating the treatment plan with the patient: A. 3D calculation of the volume of the defect and drawing the design of the planned boundaries of the reconstruction and placement of granular osteoplastic material to eliminate the defect; B. predictive calculation of the required number of graft components and 3D planning of the aggregated membrane pattern; 2. The stage of preparation of the components of the aggregated membrane is carried out by the clinical and laboratory method for four weeks until the bone defect is eliminated by the surgical method; 3. The stage of clinical implementation of the method of laying and stabilizing granular osteoplastic materials in the recipient bed during the elimination of complex jaw bone defects by transplantation.

. вид Б - Разрез отступя на 4-5 мм

в оральную сторону от линии демаркации

неороговевающего и ороговевающего эпителия, на фиг.5 -. Стружка аутокости внесена в физиологический раствор при 37°С, на фиг.6 - По гребню дефекта установлены импланты с заглушками. Разделение вестибулярного слизисто-надкостничного лоскута на три лепестка: 1 - слизисто-надкостничный; 2 - мягкотканый; 3 - надкостничный, на фиг.7 - Раскладка костно-пластического материала и его фиксация. Агрегированная мембрана (1) фиксирована швами (2) к оральному сегменту слизисто-надкостничного лоскута. Третий лепесток вестибулярного сегмента слизисто-надкостничного лоскута (3) подготовлен к фиксации к нему агрегированной мембраны, накрывающей костнопластический материал (4), на фиг.8-. Агрегированная мембрана уложена в вестибулярном направлении на костнопластическом материале, фиксирована мембранной заглушкой к импланту (1), трансмембранным швом (2) от орального сегмента через агрегированную мембрану (3) к третьему лепестку (4) вестибулярного сегмента слизисто-надкостничного лоскута, на фиг.9 - Поэтапное закрытие трансплантата. А - вертикальные трансмембранные швы (1) фиксируют второй лепесток (2) и приближают третий лепесток (№); Б - оральный (4) и вестибулярный (5) лоскуты сближены и готовы к финальному наложению швов. После этого накладываем непрерывный шов не рассасывающейся нитью №5 и ушиваем рану наглухо. Пациент наблюдается, шва снимаются через 10-14 суток. Контрольный осмотр и рентгенография через четыре и двенадцать месяцев, на фиг.10 - Рана ушита наглухо непрерывным швом.The invention is illustrated by photographs, where figure 1 - Stage 3D planning of surgical removal of a bone defect: calculation of the volume of the defect and planning the cutting of the aggregated membrane, figure 2 - Pattern for cutting the aggregated membrane in a sterile package is ready for use, figure 3 - Marked the aggregated membrane is ready for use, packaged sterile for transportation to the operating room in a thermal container, figure 4 - view A - demarcation line of keratinized and non-keratinized stratified squamous epithelium of the oral mucosa

. view B - Incision indented by 4-5 mm

on the oral side of the demarcation line

non-keratinized and keratinized epithelium, figure 5 -. Autobone shavings are introduced into saline at 37°C, in Fig.6 - Implants with plugs are installed along the crest of the defect. Separation of the vestibular mucoperiosteal flap into three petals: 1 - mucoperiosteal; 2 - soft tissue; 3 - periosteal, figure 7 - Layout of the osteoplastic material and its fixation. The aggregated membrane (1) is fixed with sutures (2) to the oral segment of the mucoperiosteal flap. The third lobe of the vestibular segment of the mucoperiosteal flap (3) is prepared for fixing to it an aggregated membrane covering the osteoplastic material (4), Fig.8-. The aggregated membrane is laid in the vestibular direction on the osteoplastic material, fixed with a membrane plug to the implant (1), transmembrane suture (2) from the oral segment through the aggregated membrane (3) to the third lobe (4) of the vestibular segment of the mucoperiosteal flap, in Fig.9 - Gradual graft closure. A - vertical transmembrane sutures (1) fix the second petal (2) and bring the third petal closer (No.); B - oral (4) and vestibular (5) flaps are brought together and ready for final suturing. After that, we apply a continuous suture with a non-absorbable thread No. 5 and sutured the wound tightly. The patient is observed, the suture is removed after 10-14 days. Control examination and radiography after four and twelve months, figure 10 - The wound is sutured tightly with a continuous suture.

The technical result of the method is achieved by the following conditions of action.

STAGE 1 PLANNING AND AGREEING THE TREATMENT PLAN WITH THE PATIENT

Based on the 3D X-ray image of the skull bones, the computer program determines the topography, design, and volume of a complex bone defect in the axial, frontal, and sagittal planes, analyzes the results of the patient's laboratory tests, establishes and voices the clinical diagnosis, discusses treatment options, agrees on the treatment plan chosen by the patient, and documents accompanying the treatment are signed.

Based on the signed treatment plan, the boundaries of the restoration of the external contours of the relief of the surface of the bone defect are designed, and a blank profile template of the external relief of the restoration and the template of the membrane is drawn (Fig. 1). After determining the volume of restoration and manufacturing the membrane pattern, the pattern is packed in a kraft bag and sterilized in a known way (Fig. 2).

STAGE 2 OF PREPARATION OF THE COMPONENTS OF THE AGGREGATED MEMBRANE BY THE CLINICAL-LABORATORY METHOD

The aggregated membrane includes a soft-tissue xenogenic collagen scaffold (Component No. 1) with autologous components of the patient integrated into it: a cell pool of the stromal-vascular fraction (Component No. 2), platelet mass (Component No. 3) and blood plasma fibrinogen (Component No. 4). The preparation of the aggregated membrane is carried out as follows: for the preparation of Component No. 2, 200 ml of adipose tissue is taken from the anterior abdominal wall by tumescent lipoaspiration three to four weeks before surgery, the adipose tissue is repeatedly washed with phosphate-saline solution, and subjected to enzymatic treatment with type 1 collagenase solution after which the cells of the stromal-vascular fraction are isolated, which are placed in sterile culture Petri dishes with a growth medium, and then placed in a gas CO ₂ incubator for cultivation at a temperature of +37 ° C and a CO ₂ content of - 5% for 7-14 days until a monolayer is reached , after which the cells are planted 2-3 times on another dish (passaging) until 50 million cells are reached; on the day of readiness for transplantation, the patient undergoes a puncture of the cubital vein, sampling of peripheral blood in a volume of 40 ml into 4 tubes with K2 EDTA for the preparation of Components No. 3 and No. 4, the tubes are centrifuged in two modes: 1 soft mode for the purpose of settling erythrocytes and leukocytes, then blood plasma is taken from 4 tubes into a separate one to obtain Component No. 4, then in the second centrifugation mode we get 6 ml of Component No. 3, on the day of the operation, Component No. 1 is added to 2 ml of Component No. 3. Before making Component No. 1, it is degassed by placing it in a saline solution at a temperature of 37°C for 20 minutes in two changes of the solution in a thermostat. Before aggregation, to increase the free area of the internal surfaces of the membrane filled with air, component No. 1 goes through a degassing stage by immersing in saline at +37°C in two waters for 20 minutes each in a thermostat (Fig. 1). It has been experimentally established that when component No. 1 is immersed for 20 minutes in saline at 37 degrees, air is forced out of all membrane cavities. The temperature of 37 degrees is taken as it coincides with the temperature of the cell incubator for the preparation of components 2, 3, 4 and to avoid stress testing by cells during their aggregation. Physiological saline was used for degassing because its partial pressure (0.9) corresponds to the partial pressure of blood serum. Degassing in two waters is carried out because air and small particles of material are removed in the first water, and gas residues are removed in the second waters, as a result of which the pores become available for the cellular elements of components 2, 3, 4 and the germination of vessels from the recipient bed. This allows you to increase the area of contact with the inner surfaces of the membrane. The internal volume of the membrane increased in this way, due to the displacement of air bubbles, becomes available for greater diffusion by components No. 2, 3. membranes into the soft tissue covering of the bone and maintaining the estimated volume of the restored bone, which improves the nutrition of the underlying bone, avoids postoperative complications and repeated surgical interventions, and optimizes the treatment time.

Component No. 1 prepared in this way, after aggregating it with Component No. 3, is integrated with Component No. 2 in a volume of 15 million cells, then another Component No. 3 is added until all components are completely immersed, then 200 μl of a sterile solution of calcium gluconate with a temperature of 37 ° C is added , after which the resulting mixture is incubated at a temperature of 37°C for 5-15 minutes, until a fibrin clot is formed. The aggregated membrane is ready for use. The aggregated membrane is packed under sterile conditions in a bottle with Component No. 4, labeled and transported to the operating room in a thermal container (Fig. 3).

STAGE 3. CLINICAL IMPLEMENTATION OF THE METHOD

The implementation of the clinical stage of the proposed method is as follows. We carry out preparatory measures for the surgical removal of a bone defect by transplantation according to a well-known protocol. We make an incision of the mucous membrane within the topography of the jaw bone defect using our method, namely: to increase the strength of the wound edges and optimize the fusion of the wound edges, we dissect the mucous membrane and periosteum along the largest length of the defect, retreating 4-5 mm to the oral side from the line of demarcation of the multilayer flat keratinizing and non-keratinizing epithelium so that keratinizing epithelium is present on both sides of the wound surface (Fig. 4). Next, in the topographic boundaries of the bone defect along the incision line, we separate the edges of the wound into the oral and vestibular parts up to the bone, then disconnect the vestibular part of the mucoperiosteal flap from the bone surface of the defect by immobilizing the soft tissue array outside the defect. We carry out a visual assessment of the defect and prepare the bone surface of the defect for the introduction of granular osteoplastic material. We collect bone chips from the bone surface with a bone scraper and place the auto-bone chips in saline at 37°C in a metal cup maintaining a temperature of 37°C (Fig. 5).

In order to eliminate the bone defect and subsequent fixation of the reconstruction within the design boundaries, they begin to form a stable soft tissue corset to cover and support the outer surface of the transplanted osteoplastic material. The vestibular part of the mucoperiosteal flap is split into three lobes: mucoperiosteal, soft tissue and periosteal, and the entire array is shifted to the vestibular side. For this purpose, the first lobe is formed from the previously immobilized vestibular part of the mucoperiosteal flap lining the bone defect. lower segments. The upper segment of the flap with the periosteum remains on the tissues of the first lobe. In the lower segment, soft tissues are immobilized along the cut line of the periosteum, detaching the soft tissue array from the edge of the periosteum along its entire surface 10-15 mm deep - a second petal is obtained. The lower segment of the periosteum is released completely and the third lobe is obtained, from which a consolidated mucoperiosteal flap is modeled by including the previously made aggregated membrane in it. (Fig. 6).

The osteoplastic material is placed into the bone defect and the external relief of the reconstruction is modeled along the calculated boundaries of the restoration (Fig. 7). The introduction of the calculated volume of granular graft fractions is carried out taking into account the coefficient of compaction and saturation of the osteoplastic material with liquid according to the developed rule for laying out granular osteoplastic materials to eliminate jaw bone defects, the essence of which is as follows: 1. - in the upper jaw, the placement of the osteoplastic material into a bone defect is carried out beyond the upper border of the defect along the native bone by one fourth of the vertical length of the defect with the thickness of the material on top, exceeding the depth of the lower quarter of the defect twice; 2. - in the lower jaw, the placement of the osteoplastic material into a bone defect is carried out above the upper border of the defect by one fourth of its vertical length by a width three times greater than the depth of the lower quarter of the defect, with the support of the osteoplastic material in the upper part of the restoration on the native bone of the upper borders of the defect.

Next, the aggregated membrane is cut according to the pattern of the profile template, fitted at the defect site over the osteoplastic material laid in the described manner, and fixed to the medial and distal edge of the oral part of the mucoperiosteal flap with transmembrane interrupted sutures (Fig. 7). Then the membrane is laid to the third lobe in the vestibular direction from the oral to the vestibular part of the mucoperiosteal flap and fixed with a horizontal transmembrane external-internal suture, which begins with a puncture of the mucoperiosteal array in the distal direction outside the lower edge of the defect, departing from its medial border by 5 mm (Fig. 8). Upon exiting from under the periosteum, the ligature penetrates transmembrane in the distal direction through the membrane, fixing it and penetrating under the periosteum of the distal edge, exits outwards 5 mm away from the distal edge of the defect. Then the needle is injected 5 mm above the distal puncture and moves transmembrane in the opposite direction to the medial edge, penetrates through it and exits 5 mm away from the medial edge. Both ends of the ligature are tied together. For suturing use non-absorbable thread number 5.0 or 6.0. Then a vertical suture is applied, going transmembrane, from the oral part of the mucoperiosteal flap to the second lobe of the vestibular flap, returning through it transmembrane back, exiting through the oral part, both ends of the ligature are tied (Fig. 9). Thus, a consolidated mucoperiosteal flap is obtained, which is a soft tissue corset of the graft. After that, a continuous suture is applied with a non-absorbable thread No. 5 and the wound is sutured tightly. The patient is observed in the clinic, the stitches are removed after 10-14 days. Follow-up examination and radiography after four and twelve months.

Thus, the calculated volume of the osteoplastic material, taking into account changes in its physical and biological properties in the postoperative period, and the formed soft tissue covering of the graft in the form of a consolidated mucoperiosteal corset, made by the proposed method, create conditions for rapid vascularization and biotransformation of the graft, and contribute to activation of the participation of autologous cell-tissue components of the patient, integrated into the soft tissue framework of the xenogenic collagen membrane, in the processes of reparative regeneration in the area of the bone defect. This makes it possible to create a stable soft tissue corset for the outer surface of the graft, formed from soft tissue structures lining the defect and an aggregated membrane.

CLINICAL EXAMPLE

Patient C, 32 years old.

Using a 3D X-ray image of the skull bones, the computer program determines the topography, design, and volume of a complex bone defect in the axial, frontal, and sagittal planes; the boundaries of the restoration of the external contours of the relief of the surface of the bone defect are designed; 1) - stage of 3D planning of surgical removal of a bone defect: calculation of the volume of the defect and planning of cutting the aggregated membrane. Membrane pattern is made.

After determining the volume of restoration and manufacturing the membrane pattern, the pattern is packed in a kraft bag and sterilized in a known way (Fig. 2). The template for cutting the aggregated membrane in a sterile package is ready for use.

Spend the preparation of the components of the aggregated membrane clinical and laboratory method (Fig. 3). The labeled aggregated membrane is ready for use, packaged sterile for transportation to the operating room in a thermal container.

An incision is made in the mucous membrane within the topography of the jaw bone defect by the proposed method, namely: to increase the strength of the wound edges and optimize the fusion of the wound edges, the mucous membrane and periosteum are cut along the largest length of the defect, retreating 4-5 mm to the oral side from the line of demarcation of the multilayer flat keratinizing and non-keratinizing epithelium so that keratinizing epithelium is present on both sides of the wound surface (Fig. 4).

, виб Б - разрез отступя на 4-5 мм

в оральную сторону от линии демаркации

неороговевающего и ороговевающего эпителия.Figure 4 view A - line of demarcation of keratinized and non-keratinized stratified squamous epithelium of the oral mucosa

, vib B - incision retreated by 4-5 mm

on the oral side of the demarcation line

non-keratinizing and keratinizing epithelium.

The bone chips are collected from the bone surface with a bone scraper and the auto-bone chips are placed in saline at 37°C in a metal cup maintaining a temperature of 37°C (figure 5).

The vestibular part of the mucoperiosteal flap lining the bone defect is immobilized, the first lobe is formed, for which purpose an incision is made along the periosteum from the inside of the flap at a distance of 10-12 mm from its edge and it is separated along the line of the periosteum incision into the upper and lower segments. The upper segment of the flap with the periosteum remains on the tissues of the first lobe. In the lower segment, soft tissues are immobilized along the cut line of the periosteum by detaching the soft tissue array from the edge of the periosteum over its entire surface to a depth of 10-15 mm - a second petal is obtained. The lower segment of the periosteum is released completely and the third lobe is obtained, from which a consolidated mucoperiosteal flap is modeled by including the previously made aggregated membrane in it. (Fig. 6). Implants with plugs were placed along the ridge of the defect. Separation of the vestibular mucoperiosteal flap into three petals: 1 - mucoperiosteal; 2 - soft tissue; 3 - periosteal.

The osteoplastic material is placed into the bone defect and the external relief of the reconstruction is modeled along the calculated boundaries of the restoration (Fig. 7). The layout of the osteoplastic material in the bone defect is carried out by the proposed method above the upper border of the defect by one fourth of its vertical length to a width exceeding the depth of the lower quarter of the defect by three times, with the support of the osteoplastic material in the upper part of the restoration on the native bone of the upper borders of the defect. In Fig.7. The layout of the osteoplastic material and its fixation are shown. The aggregated membrane 1 is fixed with sutures 2 to the oral segment of the mucoperiosteal flap. The third lobe of the vestibular segment of the mucoperiosteal flap 3 is prepared for fixing to it the aggregated membrane covering the osteoplastic material 4.

Then the membrane is laid to the third lobe in the vestibular direction from the oral to the vestibular part of the mucoperiosteal flap and fixed with a horizontal transmembrane external-internal suture, which begins with a puncture of the mucoperiosteal array in the distal direction outside the lower edge of the defect, departing from its medial border by 5 mm (Fig. 8). For suturing use non-absorbable thread number 5.0 or 6.0. Figure 8 shows how the aggregated membrane is laid in the vestibular direction on the osteoplastic material, fixed with a membrane plug to the implant 1, transmembrane suture 2 from the oral segment through the aggregated membrane 3 to the third lobe 4 of the vestibular segment of the mucoperiosteal flap.

Then a vertical suture is applied, running transmembrane, from the oral part of the mucoperiosteal flap to the second lobe of the vestibular flap, returning through it transmembrane back, exiting through the oral part, both ends of the ligature are tied (Fig. 9). Thus, a consolidated mucoperiosteal flap is obtained, which is a soft tissue corset of the graft.

Figure 9 shows the gradual closure of the graft. A - vertical transmembrane sutures 1 fix the second petal 2 and bring the third petal 3 closer; B - oral 4 and vestibular 5 flaps are brought together and ready for final suturing.

After that, a continuous suture is applied with a non-absorbable thread No. 5 and the wound is sutured tightly (Fig. 10). The patient is observed, the suture is removed after 10-14 days. Follow-up examination and radiography after four and twelve months.

The patient is monitored dynamically, the sutures are removed after 10-14 days. Follow-up examination and radiography after four and twelve months. The patient is healthy.

Technological and clinical results of using the proposed method are:

- the determination of the required amount of graft is made not only by geometric data, but by the totality of changes in the postoperative period of physical and biological indicators of the used osteoplastic material, which take into account the nature of the change in the physical and biological properties of the graft fractions in the postoperative period;

- prevention of uncontrolled changes in the shape and volume of the graft when removing external (not penetrating into the cancellous bone), internal (penetrating and penetrating) and combined bone defects of the bones of the facial skull of a complex geometric shape with the restoration of the anatomical shape of the organ;

- ensuring the predictable behavior of the graft within the design boundaries of the recipient bed, both in the elimination of internal and in the augmentation of external bone defects;

- exclusion of the second operation and prevention of violation of the vascularization of the regenerating bone in the area of the defect to be repaired, which ensures a complete biotransformation of the osteoplastic material and a predictable clinical result, reducing material costs and psycho-emotional discomfort of the patient.

Claims (1)

A method for laying and stabilizing granular osteoplastic materials in the recipient bed during the elimination of complex defects of the jaw bones, containing 3D computer modeling of the reconstruction of the jaw bone defect based on the results of cone-beam computed tomography, reformation of the defect in the 3D model of the jaw, modeling the volume of bone reconstruction, calculation of the volume of reconstruction in computer program, modeling of the frame membrane template, surgical reconstruction, characterized in that the mucous membrane is cut within the topography of the jaw bone defect, namely: the mucous membrane and periosteum are cut along the largest length of the defect, retreating 4-5 mm in the oral side from the line demarcation of the stratified squamous keratinizing and non-keratinizing epithelium so that keratinizing epithelium is present on both sides of the wound surface, the vestibular part of the mucoperiosteal flap lining the bone defect is immobilized, the first th petal, for which an incision is made along the periosteum from the inside of the flap, departing from its edge by 10-12 mm, and it is separated along the line of the periosteum incision into the upper and lower segments, the upper segment of the flap with the periosteum remains on the tissues of the first lobe, and in soft tissues are immobilized in the lower segment along the periosteal incision line, detaching the soft tissue array from the edge of the periosteum along its entire surface 10-15 mm deep, the second lobe is obtained, then the lower segment of the periosteum is completely released and the third lobe is obtained, from which a consolidated mucoperiosteal flap is modeled , by including a membrane made of a soft tissue xenogenic collagen skeleton with integration of the cell pool of the stromal-vascular fraction, platelet mass and blood plasma fibrinogen, implants with plugs are installed along the crest of the defect, the vestibular muco-periosteal flap is divided into three lobes: muco-periosteal , soft tissue, periosteal after which the osteoplastic material is placed into the bone defect and the external relief of the reconstruction is modeled along the calculated boundaries of the restoration, and the osteoplastic material is laid out into the bone defect above the upper border of the defect by one fourth of its vertical length by a width exceeding the depth of the lower quarter of the defect by three times , with the support of the osteoplastic material in the upper part of the restoration on the native bone of the upper borders of the defect, the membrane is fixed with sutures to the oral segment of the mucoperiosteal flap, the third lobe of the vestibular segment of the mucoperiosteal flap is prepared for fixing the membrane covering the osteoplastic material to it, then the membrane is laid to the third lobe in the vestibular direction from the oral to the vestibular part of the mucoperiosteal flap and fix it with a horizontal transmembrane external-internal suture, which begins with a puncture of the mucoperiosteal array in in the distal direction outside the lower edge of the defect, 5 mm away from its medial border, a non-absorbable thread number 5.0 or 6.0 is used for suturing, then a vertical suture running transmembrane is applied from the oral part of the mucoperiosteal flap to the second lobe of the vestibular flap, they return through it transmembrane back, exit through the oral part, both ends of the ligature are tied and a consolidated mucoperiosteal flap is obtained, which is a soft tissue corset of the graft, after which a continuous suture is applied with a non-absorbable thread number 5 and the wound is sutured tightly, the patient is observed, the sutures are removed after 10 -14 days, then conduct a control examination and x-ray after four and twelve months.

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