RU2790523C1 - Method of gentle uranostaphyloplasty that prevents shortening of the soft palate - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular, to maxillofacial surgery and dentistry. The cleft margins are freshened. Mucosal and periosteal flaps are cut out on the fracture fragments. The sphenoid bone winglets hooks are broken and displaced to the midline. Vascular and nerve bundles are mobilized. The soft palate muscles are dissected. A unilateral fragment with vascular pedicle is cut out of the larger mucosal-periosteal flap of the anterior hard palate. Then a transverse transverse nasal mucosa incision is made along the border of the soft and hard palate to create an artificial defect. After that, a unilateral fragment of the mucosal-periosteal flap of the hard palate anterior part on the feeding vascular pedicle is turned and inserted into the artificial tissue defect between the soft and hard palate with the mucosal surface towards the nasal cavity. The fragment is sutured to the nasal mucosa on all sides of the artificial defect. The wound is sutured in layers.

EFFECT: method makes it possible to lengthen the superficial tissues of the nasal mucosa of the soft palate in one step, prevent shortening of the soft palate and formation of rough through scarring, improve functional results of treatment by restoring feeding and speech function, and fully rehabilitate the sick child.

2 cl, 6 dwg, 2 ex

Description

The present invention relates to medicine, namely to maxillofacial surgery and dentistry.

A known method of plasty to eliminate palatopharyngeal insufficiency after plasty of an isolated cleft palate G.I. Semenchenko et al., 1979. In the presence of shortening of the soft palate, and palatopharyngeal insufficiency after primary uranoplasty, a muco-periosteal flap of the anterior hard palate was used on two feeding legs (vascular-nerve bundles) on both sides. A high positive assessment of this method of surgical elimination of palatopharyngeal insufficiency was confirmed by the stability of the oral pressure coefficient, high positive dynamics of the bioelectrical activity of the muscles of the pharyngeal ring, contrast radiography, computed tomography [Semenchenko G.I., Vakulenko V.I., Lukyanenko V.A. , Kryklyas G.G. Surgical methods for restoring palatopharyngeal closure after unsuccessful outcomes of uranoplasty // Stomatology, 1986; 3: - p. 51-52].

However, this method, taken as a prototype, has a significant drawback: the patient is forced to endure a rather severe surgical intervention twice, since the author proposed this method as a secondary operation to correct palatopharyngeal insufficiency after a primary unsuccessful operation.

EFFECT: prevention of shortening of the soft palate during the primary operation in the postoperative period, the formation of rough penetrating scars in the area of the soft palate, improvement of the functional results of treatment due to the restoration of the function of nutrition and speech, which makes it possible to completely rehabilitate the sick child, and protects him from repeated surgical interventions.

The invention is illustrated by the following figures. In FIG. 1 shows a diagram of the stage of preparation of fragments of the cleft of the hard and soft palate; in fig. 2 - diagram of the stage of cutting out a fragment of a unilateral mucoperiosteal flap on a supplying vascular pedicle from the anterior hard palate; in fig. 3 - diagram of the stage of suturing a fragment of a unilateral mucoperiosteal flap on a feeding pedicle from the anterior hard palate into an artificial defect between the nasal mucosa of the hard palate and soft palate; in fig. 4 - scheme of the final stage of the operation with a completely sutured wound; in fig. 5 - photograph of the bones of the hard palate in the norm with the level of the posterior nasal spine in the norm (at the level of the hooks of the pterygoid processes); in fig. 6 - diagram of bone fragments of the hard palate with a congenital cleft (the middle part of the hard palate (spina nasalis posterior) is absent).

The proposed method of sparing uranostaphyloplasty, which prevents shortening of the soft palate, is performed as follows. With a scalpel, the edges of the cleft are refreshed by making a linear incision along the edge of the cleft. At the same time, the tissues of the soft palate are pulled with tweezers by the tongue so that the incision is even and straight. On a small and large fragment, the edges are refreshed from the tongue to the incisors. In the region of the hard palate, an incision is made up to the bone, 3-4 mm away from the edge. Then cut out the mucoperiosteal flaps 1, making incisions to the bone along the mucous membrane of the inner surface of the alveolar process of the small and large fragment, to the level of 5.4 and 6.4 teeth (Fig. 1). Then an incision is made from the last upper molar along the pterygomandibular fold, not reaching the neck of the last lower tooth 0.5-0.7 mm. In the depth of the incision with a wide raspator, the tissue is bluntly pushed apart to the internal pterygoid muscle, the hook 2 of the pterygoid process (hamulus pterygoideus) is broken at the base with a finger and shifted to the midline along with the muscles attached to it (Fig. 1). Then, with a wide raspator, from the side of the alveolar process, the mucoperiosteal flaps 1 are peeled off to the large palatine opening (Fig. 1). Then neurovascular bundles (vascular pedicles) 3 are mobilized by pulling from the palatine openings (Fig. 1). Then, the mucous membrane 4 of the nasal cavity is detached from the posterior edge of the hard palate and the nasal surface of the palatine processes of the upper jaw (Fig. 1). After that, the palatine mucoperiosteal flaps 1 on the vascular pedicles 3 are freely displaced posteriorly and towards the midline (Fig. 1). The muscles of the 5 soft palate are prepared: the palatal part of the palatopharyngeal (m. palatopharyngeus), palatoglossal muscles (m. Palatoglossus) and the anterior bundles of the muscle that lifts the palatine curtain (m. levator veli palatini) are separated from the posterior edge of the plane of the sky, from the bone nasal septum and from the edge of the cleft palate (Fig. 1). Muscles 5 exfoliate from the adjacent nasal 4 and oral 6 mucous membranes along the edge of the wound from the hook 2 of the pterygoid process of the sphenoid bone to the uvula of the soft palate (Fig. 1). As a result of this, the released anterior ends of the muscles easily turn towards the midline, which creates more favorable conditions for sewing them together in an end-to-end fashion. From a larger mucoperiosteal flap of the anterior hard palate, a one-sided fragment 7 is cut off on the feeding vascular pedicle 3 (Fig. 2) of the mucoperiosteal flap of the anterior hard palate. The size of a unilateral fragment of the mucoperiosteal flap of the anterior hard palate on the supplying vascular pedicle is 3-3.5 cm by 1.5-2 cm, which corresponds to the size of the congenital defect of the missing bone tissue of the hard palate. Hemostasis is performed during the operation.

The next stage begins with a through transverse incision of the nasal mucosa along the border of the soft and hard palate in order to create an artificial defect 8 (Fig. 2). Then the nasal mucosa 4 in the area of the hard palate is sutured with vicryl. Throughout the hard palate, starting from the anterior section, the nasal mucosa 4 is sutured to the opposite nasal mucosa 4. Next, the nasal mucosa of the soft palate is sutured with vicryl. Then one-sided fragment 7 of the muco-periosteal flap of the anterior hard palate is rotated and inserted on the supplying vascular pedicle into an artificial tissue defect between the soft and hard palate, the mucous surface towards the nasal cavity, and it is sutured to the nasal mucosa from all sides of the defect with vicryl thread (Fig. .3). Then, the ends of the muscles 5 turned in the transverse direction are sutured in layers with vicryl according to the “end to end” type (Fig. 3). Then the oral mucosa of the soft palate 6 and the mucoperiosteal flaps 1 are sutured with vicryl (Fig. 4). The mucoperiosteal flaps 1 are maximally shifted down and back, placed on the bare parts of the fragments of the hard palate and fixed with vicryl in the anterior section to the sutured nasal mucosa 4 (Fig. 4). The peripharyngeal niches and open wounds in the area of the hard palate are packed with hemostatic material fibrillar.

In the proposed method of sparing uranostaphyloplasty, which prevents shortening of the soft palate, the structures of the soft palate together with the muscle block are fixed at a level corresponding to the normal muscle attachment, due to the filling of the congenital defect of the missing bone tissue with a unilateral fragment of the mucoperiosteal flap on the feeding vascular pedicle. Thus, shortening of the soft palate is prevented in the long-term period, and unlike the prototype, the operation is performed in one stage and does not require additional surgical interventions.

Normally, the posterior nasal spine (spina nasalis posterior) - the place of attachment of the palatine aponeurosis and the tongue muscle (m. uvulae), is located at the level of the hooks of the pterygoid process of the sphenoid bone (Fig. 5). With a congenital cleft, the bone fragments of the hard palate are significantly shortened, while the middle part (spina nasalis posterior) is absent (Fig. 6). Fixation of the soft palate with a unilateral fragment of the mucoperiosteal flap on the supplying vascular pedicle in this case performs the function of the missing bone skeleton.

The use of the proposed method allows in one step to lengthen the surface tissues of the nasal mucosa of the soft palate by the size of a unilateral fragment of the mucoperiosteal flap on the feeding vascular pedicle, which prevents shortening of the soft palate and the occurrence of palatopharyngeal insufficiency. The stages of cutting out, rearranging and suturing a unilateral fragment of the mucoperiosteal flap on the supplying vascular pedicle from the anterior hard palate are not technically difficult and increase the duration of the operation by no more than 10 minutes.

The essence of the invention is illustrated by the following clinical examples.

Example 1. Patient Kh.Sh., 2 years 6 months old, diagnosis: Congenital complete cleft of the alveolar process, soft and hard palate on the left. Secondary deformity of the upper lip and wing of the nose on the left.

The cheilorhinoplasty operation was performed at the age of 3 months. Complaints about the violation of the function of nutrition and speech.

Objectively: At this time the child is somatically healthy. Local status: on examination, the mucous membrane of the soft and hard palate is pale pink. The width of the defect in the region of the alveolar process is 3 mm, in the middle of the hard palate - 12 mm, at the level of the boundaries of the hard and soft palate - 13 mm, at the level of the uvula - 14 mm. The vomer is deviated to the healthy side, is located obliquely, connects to the palatine process of the upper jaw with the palatal edge.

After a clinical examination under endotracheal anesthesia, the patient was operated on. Made sparing uranostaphyloplasty, preventing shortening of the soft palate, according to the claimed method. A unilateral fragment of a mucoperiosteal flap of the anterior hard palate on a supplying vascular pedicle, 3 cm by 1.5 cm in size, was used. In the postoperative period, wound healing by primary intention. Soft palate of sufficient length, mobile. The postoperative scar is hardly noticeable. Full mouth opening.

After 3 months, a follow-up examination of the patient was carried out. The child's condition is satisfactory. Somatically healthy. Local status: on examination, the mucous membrane of the soft and hard palate is pale pink. Soft palate of sufficient length, mobile. The postoperative scar in the area of the hard palate is in the form of a groove, in the area of the soft palate - gentle, inconspicuous. The uvula of the soft palate is pronounced.

A nasopharyngoendoscopic examination was performed. When pronouncing the sounds "a", "and" and swallowing, the palatopharyngeal shutter closes completely. Closing occurs according to the valve type - mainly due to the rise of the soft palate.

Example 2. Patient MS, 2 years 1 month, diagnosis: Congenital cleft of the soft and hard palate. Complaints about the violation of the function of nutrition and speech.

Objectively: At this time the child is somatically healthy. Local status: on examination, the mucous membrane of the soft and hard palate is pale pink. The width of the defect in the area of the middle of the hard palate is 12 mm, at the level of the boundaries of the hard and soft palate - 15 mm, at the level of the uvula - 16 mm.

After a clinical examination under endotracheal anesthesia, the patient was operated on. Made sparing uranostaphyloplasty, preventing shortening of the soft palate, according to the claimed method. A one-sided fragment of a mucoperiosteal flap of the anterior hard palate on a supplying vascular pedicle, 3.5 cm by 2 cm in size, was used. In the postoperative period, wound healing by primary intention. Soft palate of sufficient length, mobile. The postoperative scar is hardly noticeable. Full mouth opening.

After 3 months, a follow-up examination of the patient was carried out. The child's condition is satisfactory. Somatically healthy. Local status: on examination, the mucous membrane of the soft and hard palate is pale pink. Soft palate of sufficient length, mobile. The postoperative scar in the area of the hard palate and soft palate is gentle and inconspicuous. The uvula of the soft palate is pronounced.

A nasopharyngoendoscopic examination was performed. When pronouncing the sounds "a", "and" and swallowing, the palatopharyngeal shutter closes completely. Closing occurs according to the sphincter type - due to the rise of the soft palate and the side walls of the pharynx.

We used this method of uranostaphyloplasty in 17 patients aged 2 to 3.5 years with congenital cleft palate.

Claims (2)

1. The method of sparing uranostaphyloplasty, including refreshing the edges of the cleft, cutting out the muco-periosteal flaps on the fragments of the cleft, mobilizing the neurovascular bundles, breaking and shifting the hooks of the pterygoid processes of the sphenoid bone to the midline, layer-by-layer suturing of the wound, characterized in that additionally from a larger according to the size of the mucoperiosteal flap of the anterior hard palate, a one-sided fragment is cut off together with the vascular pedicle, then a through transverse incision of the nasal mucosa is performed along the border of the soft and hard palate in order to create an artificial defect, after which a one-sided fragment of the mucoperiosteal flap of the anterior hard palate is cut off on the supply the vascular pedicle is turned and inserted into the artificial tissue defect between the soft and hard palate by the mucous surface towards the nasal cavity, and it is sutured to the nasal mucosa from all sides of the artificial defect. 2. The method according to claim 1, characterized in that the size of a unilateral fragment of the mucoperiosteal flap of the anterior hard palate on the supplying vascular pedicle is 3-3.5 cm by 1.5-2 cm, which corresponds to the size of the congenital defect of the missing bone tissue hard sky.

Images