RU2332955C2 - Method of treatment of top microdistoclusion in children and device to this effect - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: cut of a mucosa in oral cavity is made. A junction of the top jaw and pterygoid processes of a sphenoidal bone is skeletanised. Pterygoid processes are separated from the top jaw. Skin is cut at the level of malar arches behind from bond of temporal and malar bones. Malar arches are skeletonised and sawn. The device for treatment of supramaxillary microdistoclusions is fixed by cementation of crowns on the top lateral teeth. The device contains a dilating screw connected, by means of beams for transferring pressure and moving, with metal orthodontic crowns cemented on lateral teeth, and a facial mask bridged by elastic draught with hooks located on the vestibular party on basic teeth. The device is equipped with the beams bridged to hooks, the said beams being located on the vestibular party. Two springs are rigidly fixed to a palatal surface of crowns to shift the forward teeth forward and aside.

EFFECT: group of inventions allows for reducing risk of traumatising and considering anatomic features of corrected area more precisely.

2 cl, 7 dwg, 1 ex

Description

The present invention relates to medicine, namely to dentistry, and can be used in maxillofacial surgery and orthodontics.

Congenital bilateral through fusion of the upper lip, alveolar ridge and palate (VDSNGN) is accompanied by deformation of the facial skeleton, characterized by upper microretrognathy and a complex combination of various dentofacial anomalies in the sagittal, transverse and vertical planes.

It is known that the most effective is the comprehensive rehabilitation of children with ADHD, including phased orthopedic, surgical, orthodontic and prosthetic care, physiotherapy and speech therapy (Blokhina S.I., Bobrovich T.N., Verbukh AM, etc. Specialized care for children with congenital pathology face and jaw in a rehabilitation center. Information letter. - Sverdlovsk, 1990. - P.21-23).

A significant variety of clinical manifestations of VDSNGN requires constant improvement of known and the creation of new methods and devices for therapeutic effects. A set of therapeutic measures for children with VDSNGN (Shulzhenko V.I., Zhivov V.N. A method of manufacturing a plate for the treatment of defects in non-union of the palate. Auth. St. No. 1519683. - B.I. No. 41, 1989; Shulzhenko V.I. ., Ayupova FS, Verapatvelyan AF The system of comprehensive rehabilitation of children and adolescents with congenital lip and palpebral fusion at the Department of Pediatric Dentistry, Orthodontics and Oral and Maxillofacial Surgery (DSO and ChLH) // New technologies in dentistry: (Sat scientific works). - Moscow-Krasnodar. - "Soviet Kuban", 2004. - P.173-179) includes the phased use of orthopedic and todonticheskih devices, and surgical procedures and other methods of influencing in the following sequence:

1. Preliminary correction of the size and position of the fragments of the upper jaw using a functional-forming plate V.I. Shulzhenko and the implementation of cheiloplasty.

2. Extension and lengthening of the upper dentoalveolar arch, protraction of the upper jaw using orthodontic removable and non-removable maxillary devices and face masks, as well as physiotherapy, massage, myogymnastics, speech therapy and uranoplasty.

3. Continuation of the complex orthodontic correction of the position of individual teeth, the shape and size of the dental arches, their ratio, the growth of the facial skeleton using removable and fixed intraoral orthodontic devices and facial masks, as well as myotherapy, speech therapy, and auto-osteoplasty of defects of the alveolar process of the upper jaw with the iliac scallop .

4. Expansion and lengthening of the upper dental alveolar arch, protraction of the upper jaw using fixed orthodontic appliances with a screw, bracket system and face mask, implementation of myogymnastics, speech therapy; completion of orthodontic treatment by replacing defects of the upper dental arch with a denture, the design of which serves as a retention apparatus.

Comprehensive rehabilitation is time-consuming, not effective enough in children with ADHD, complicated by upper microretrognathia, for the following reasons:

- maxillary orthodontic removable devices are not stable when used in combination with a face mask and elastic traction for traction of the upper jaw,

- unauthorized removal of a removable orthodontic device by an undisciplined patient significantly reduces the effectiveness of the treatment,

- thrust scar tissue of the palate prevents the expansion and lengthening of the upper dentoalveolar arch, especially when using removable orthodontic devices,

- the design of the screws for non-removable devices provides for the resizing of the upper alveolar arch in only one plane (expansion or elongation).

Known recommendations for the rehabilitation of patients with microretrognatia. So, V.M. Bezrukov (V. Bezrukov, Methods of surgical treatment of upper micrognathia. - Dentistry, 1976. - No. 6. - p.29-32) to eliminate the upper jaw underdevelopment proposed the technique of cranio-maxillary separation according to Le For 3. The essence of the method is osteotomy according to type Le Fort 3, simultaneous movement to the structural position of the entire zygomatic-maxillary complex with subsequent fixation using bone sutures. The technical result of the method is the extension of the zygomatic bones and upper jaw and the normalization of occlusion. The method consists in the following: by the oral access through a horizontal incision of the mucous membrane along the transitional fold, the front surface of the upper jaws, zygomatic bones is exposed, the bottom of the nasal passages and the base of the nasal septum are separated from the mucous membrane, as well as the lateral walls of the nasal cavity at the level of the lower nasal passages. An osteotomy is performed on the front surface of the upper jaw bodies parallel to the lower edge of the orbit, departing from it by 5 mm and from the edge of the pear-shaped opening, through the cheekbones and tubercles to the pterygoid processes of the sphenoid bone. With the help of a curved bit, the pterygoid processes of the sphenoid bone are separated at the junction with the upper jaw. On the side wall of the nasal cavity, a vertical osteotomy is performed, departing from the edge of the pear-shaped opening by 5-10 mm, to the bottom of the nasal passage and then backward to the pterygoid processes. Cross the quadrangular cartilage. Auto-or allo-bone is placed in the resulting bone defects. The zygomatic-maxillary complex is fixed with bone sutures in the region of the zygomatic alveolar ridges and the anterior edge of the pear-shaped opening. Intermaxillary fixation lasts 6-8 weeks.

The disadvantages of the method:

- high injuries during surgery,

- the need for expensive tools

- the possibility of damage to the germ zones excludes the use of the method in children,

- the inability to perform the method without the use of auto- or allografts.

The evolution of methods of treatment of upper microgenia requires reducing the injuries of the operation and increasing the role of orthopedic effects. Known surgical and orthopedic method (Tairov U.T., Sukachev V.A., Gunko V.I. Surgical orthopedic method for the treatment of patients with deformations of the middle zone of the facial skeleton. // Dentistry. - 1980. - No. 1. - C. 35-38). The essence of the method adopted for the closest analogue, and the devices used for this, consists in intermittent osteotomy of the upper jaw along the vertical buttresses at the level of the infraorbital foramen, separation of the pterygoid processes of the sphenoid bone and further distraction of the upper jaw by an extraoral thrust to the thoracocervical corset. The technical result of the method is to extend only the upper jaw and normalize occlusion. Treatment is carried out in 2 stages. 1st — surgical: cut the mucous membrane along the transitional fold of the upper jaw from 14 (24) to 17 (27) teeth. Skeletonize the front surface of the upper jaw and its junction with the zygomatic bone. With a thin fissure boron, using a drill, they cut along the lines of the nasolabial and zygomatic buttresses. In the interval between the cut lines at the level of the infraorbital foramen in the horizontal direction, intermittent compactostotomy is performed. Using a curved osteotome, the pterygoid processes of the sphenoid bone are separated from the upper jaws. Cross the septum of the nose. 2nd stage - orthodontic: with the help of a tooth tray with hooks on the upper jaw and an extraoral traction with support on the thoracocervical corset, metered distraction is performed with a force of 2-5 kg for 28-70 days. At the end of distraction, the retention period lasts 2 weeks.

The disadvantages of the method:

- surgical intervention is traumatic,

- the need for continuous long-term wearing of the thoracocervical corset significantly limits the use of the method in children,

- the method is developed for the treatment of maxillary micrognathia as an isolated pathology, does not take into account the peculiarities of the anatomy of the upper jaw with VDSNG,

- gingival mouthguards constantly cover all surfaces of teeth and gums during the day, create a cariogenic situation and chronic trauma to the mucous membrane of the palate and gums during exposure to the device.

For the closest analogue, the device (Persin LS Orthodontics. Treatment of dentoalveolar anomalies. Edition 20, revised. - Moscow. Ortodent-Info LLC, 1999. - P.52-53), with an expansion screw, located in the region of the midline of the arch of the sky, with the help of which teeth are moved by means of dosed pressure of beams soldered from the palatine side to metal orthodontic crowns.

Disadvantages:

- unscrewing the screw of the device allows you to expand the dental arch only in the region of the abutment teeth,

- the use of the device eliminates the simultaneous extension of the dental arch,

- the device does not have elements that allow you to apply traction to protract the upper jaw.

Tasks:

- when performing an osteotomy, reduce trauma, maintaining the integrity of the bone tissue at the base of the pear-shaped aperture, which positively affects the position of the base of the wing of the nose,

- to provide simultaneous dosed expansion, lengthening of the upper alveolar arch and protraction of the upper jaw,

- to exclude the deforming effect on the lower dentoalveolar arch during protraction of the upper jaw by providing support on the forehead and chin,

- to provide a stable, solid fixation of the device on the upper jaw when it is protraction to the face mask,

- improve the profile of the patient's face by extending the cheek-maxillary complex, normalize occlusion,

- to increase the effectiveness of complex treatment of upper microretrognathy by using the growth potential of the dentofacial area in children.

The essence of the invention by the method is as follows: osteotomy of the pterygoid processes of the sphenoid bone and zygomatic arch is performed with the condition that the vertical buttresses of the upper jaw are preserved, and then using the proposed device, the cheekbone-maxillary complex and incisors are protracted.

The essence of the proposed device for the treatment of upper micrognathia in children is the supply of the apparatus with hooks with beams located on the vestibular side, and two springs are rigidly fixed separately to the palatal surface of the crowns with the possibility of displacing the front teeth forward and to the side.

The technical result of the invention is the extension of the zygomatic-maxillary complex and the normalization of occlusion, which allows to increase the degree of medical rehabilitation, to ensure high-quality treatment until recovery, to provide a cosmetic effect, to shorten the treatment period and inconvenience of the patient during the treatment period.

The orthodontic device (Figs. 3, 4) consists of an expansion screw 5 with beams 6 soldered to metal orthodontic crowns 7 cemented on the lateral teeth, and crowns 7 from the vestibular side are connected to the beams soldered to them with hooks 8 connected by an elastic rod with face mask, to the palatal surface of the crowns 7 are soldered separately made two springs 9 with the possibility of displacement of the front teeth forward and to the side.

The method using the device is carried out in 2 stages.

Stage 1 - Surgical. An osteotomy is performed at the junction of the upper jaw with the pterygoid processes of the sphenoid bone and the zygomatic arch. By the intraoral method (Figs. 1 and 2), behind the tubercle of the upper jaw 1, an arcuate incision is made in the oral mucosa, the junction of the tubercle of the upper jaw 1 and pterygoid processes 2 of the sphenoid bone is skeletonized. Using a curved chisel, the pterygoid processes 2 are separated from the tubercle of the upper jaw 1 along line 3, after which the soft tissues are sutured tightly, or healing takes place by secondary intention. At the level of the zygomatic arches 4, posterior to the junction of the temporal and zygomatic bones, a horizontal skin incision is made 15-20 mm long, soft tissues are pushed apart, skeletonized and the zygomatic arches 4 are sawn with a drill, after which soft tissues are sutured tightly.

An orthodontic device (Figs. 3, 4) is fixed by cementing metal crowns 7 on the upper lateral teeth. By loosening a screw 5 with beams 6 soldered to the metal orthodontic crowns 7, the upper dental arch is dosed; move the front teeth in the vestibular direction, exerting pressure on their palatal surface by separately made springs 9. At the same time, applying elastic traction from the hooks 8 to the face mask, carry out the protraction of the upper jaw.

The benefits of surgery:

- significantly less traumatic;

- takes into account the peculiarities of the anatomy of the upper jaw of children with VDSNGN;

- maintaining the integrity of the bone tissue at the base of the pear-shaped aperture has a positive effect on the position of the base of the nose wing;

- the operation can be performed during planned corrective interventions and not constitute additional surgical intervention;

- the application of the method in children during the period of active growth allows you to use the growth potential of the dentofacial area (ALF).

Advantages of an orthodontic device:

- the device is non-removable, eliminates the possibility of unauthorized removal by the patient;

- fixing the device’s crowns on the teeth with cement reduces the risk of caries of the remaining teeth in comparison with removable mouth devices and does not interfere with oral hygiene;

- beams soldered to the metal crowns from the vestibular and oral sides touch all the posterior teeth and transmit to them the expanding effect of the screw;

- the traction springs are made separately and do not interfere with the expanding effect of the screw;

- traction springs provide uniform movement of the incisors in the vestibular direction;

- the force of the traction springs is regulated by a doctor;

- the design of the orthodontic device is strong, does not deform when using extraoral traction for traction of the upper jaw;

- the design of the orthodontic device allows you to simultaneously metered to expand and extend the upper dentoalveolar arch;

- metal crowns slightly dissociate the bite and provide unhindered sliding of the upper dentoalveolar arch relative to the lower;

- the design of the orthodontic device allows you to touch the cheekbone-maxillary complex with elastic traction to the face mask with support on the forehead and chin;

- the use of an orthodontic device eliminates the use of additional devices on the lower dentoalveolar arch.

Example:

Patient D.A., turned to the department at the age of 9 years. From the anamnesis, it is known that earlier surgical interventions for VDSNGN were carried out. Orthodontic treatment with removable structures due to their irregular use was unsuccessful. Upon external examination, the profile is concave due to the retraction of the middle zone of the face and flattening of the upper lip. Cicatricial deformity led to a flattening of the palate, the laying of the tongue between the front teeth and lips, which is clearly demonstrated by the full face photographs and profile (Photo 1: a, b, c, d). Based on the results of the main and additional research methods, the diagnosis was formulated: “Bilateral congenital through fusion of the upper lip and palate after cheilo- and uranoplasty, mesial occlusion; bilateral palatine occlusion; open incisive disocclusion; upper microretrognathia; narrowing and shortening of the front of the upper dental arch; lengthening of the anterior lower arch; crowding, palatal inclination of the upper incisors ”and a treatment plan has been drawn up.

In accordance with the diagnosis, the patient began to receive comprehensive treatment at the clinical facilities of the Department of Pediatric Dentistry, Orthodontics and Maxillofacial Surgery of the Kuban State Medical University: in the dental clinic (medical history No. 11996) and maxillofacial department of the Children's Regional Clinical Hospital (medical history No. 19071).

In terms of preparation for the 1st surgical stage of treatment, an orthodontic device was manufactured.

An osteotomy was performed at the junction of the upper jaw with the pterygoid processes of the sphenoid bone and the zygomatic arch osteotomy. An intraoral access behind the tubercle of the upper jaw made an arcuate incision in the oral mucosa, the junction of the tubercle of the upper jaw and pterygoid processes of the sphenoid bone was skeletonized. With the help of a chisel, the pterygoid processes are separated from the tubercles of the upper jaw, after which the soft tissues are sutured. At the level of the zygomatic arches, posterior to the junction of the temporal and zygomatic bones, horizontal skin incisions were made 15-20 mm long, soft tissues were dissected in layers, skeletonized and the zygomatic arches were sawn with a drill, after which the soft tissues were sutured tightly.

10 days after surgery, an orthodontic device was fixed on the upper posterior teeth by cementing metal crowns, and a standard face mask with elastic traction was fitted in (Photo 2: a, b, c, d). Unscrewing the screw 1/4 turn 3-4 times a week, expanded the upper dental arch in the area of premolars and molars by 7.0 mm. The expansion of the lateral departments of the upper dental arch allowed us to achieve the correspondence of the width of the upper and lower dental arches. Once every 7-10 days, springs were activated to move the upper incisors in the vestibular direction. As a result, the anterior section of the superior dental arch was lengthened by 4.5 mm. The patient constantly used the elastic traction from the hooks of the device to the face mask and performed gymnastics for the muscles of the tongue and lips.

4 months after the start of treatment, as a result of expansion and lengthening of the upper dental arch, as well as protraction of the upper jaw, neutral occlusion was achieved, and the position and closing of the lips significantly improved. Scars in the area of the zygomatic arches are almost invisible. Upper jaw protraction using a standard mask, which transfers support to the forehead and chin, allowed the growth of the lower jaw to be delayed and the face profile of D.A. (Photo 3: a, b, c. D).

Claims (2)

1. A method of treating maxillary microrethrognathia in children, including an upper jaw ototomy and subsequent normalization of occlusion, characterized in that an incision is made in the oral mucosa, the junction of the upper jaw and pterygoid processes of the sphenoid bone are skeletonized, the pterygoid processes are separated from the upper jaw, and a skin incision is performed at the level of the zygomatic arches posterior to the junction of the temporal and zygomatic bones, the zygomatic arches are skeletonized and sawn, a device for treating the maxillary microretro is fixed gnathy by cementing crowns on the upper lateral teeth, the device has an expansion screw connected by means of beams with crowns, beams with hooks are fixed to the crowns from the vestibular side, connected by elastic traction with a face mask, two springs are rigidly fixed separately to the palatine surface of the crowns with the possibility of front displacement teeth forward and to the side, produce a metered extension of the upper dental arch by unscrewing the screw, move the front teeth in the vestibular direction, applying pressure ruzyne produce protragirovanie maxilla by applying elastic traction of the hooks to the face mask. 2. A device for the treatment of maxillary microretrognathia in children, containing an expansion screw connected by means of beams for transmitting pressure and movement with metal orthodontic crowns cemented on the lateral teeth, and a face mask connected by an elastic traction with hooks located on the vestibular side on the supporting teeth, characterized in that it is equipped with beams connected to the hooks located on the vestibular side, and to the palatal surface of the crowns are separately fixed two separate ruins with the ability to move the front teeth forward and to the side.

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