RU2840748C1 - Method for elimination of gingival recession - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical dentistry, periodontal surgery, and is applicable in class 1, 2, 3 recession of the upper and lower jaws, gum biotype variation within the teeth and implants, in small oral vestibule. Patient is locally anaesthetised within the recession and hard palate. Roots within the recession are mechanically and chemically treated with the use of curette-Gracey and EDTA. Graft is taken within a hard palate. Local anaesthesia is performed by a creeping infiltrate technique at a mental foramen on the lower jaw and within an outlet of the greater palatine foramen. Intra-furrow incisions are made in a recession area, and a tunnel flap is formed by means of a microsurgical blade and tunnel knives with interdental papillae left undissected. Graft is fixed under the tunnel flap with U-sutures from each end. Tunnel flap with the fixed graft is displaced coronally with overlapping the exposed root areas within the recession and fixed with blanket sutures. At 2-2.5 mm from a projection of an apical edge of the graft, an incision is made up to a periosteum in parallel with a keratinised gingiva. Flap is split in apical direction. Separated flap is fixed apically, deepening vestibule of oral cavity. Coronally displaced tunnel flap is pressed to a periosteum with mattress cross-shaped sutures; the sutures are removed on 10th day.

EFFECT: method enables reducing the number of doctor’s visits by the patient, eliminating a risk of graft rejection, as well as changing the gingival biotype and improving the aesthetic effect.

1 cl, 11 dwg, 2 ex

Description

The invention relates to medicine, namely to surgical dentistry, periodontal surgery, and can be used for recession of classes 1, 2, 3 of the upper and lower jaw, changes in the biotype of the gum in the area of teeth and implants, and a shallow vestibule of the oral cavity.

Gingival biotype is a term used to describe the thickness of the gingiva in the vestibular direction and includes a number of clinical parameters, the main ones being the height of the gingival papillae, thickness and zone of attached gingiva. A thin biotype is considered to be: a narrow zone of keratinized gingiva, gingival thickness <1.5 mm, width 3.5-5 mm. A thick biotype has a wide zone of keratinized gingiva, thickness> 1.5 mm, width 5-6 mm [Kostionova-Ovod I.A. Optimization of surgical treatment of a local form of gingival recession: diss... candidate of medical sciences, 14.01.14 - dentistry, Samara 2021; Farkhshatova R.P. Experimental and clinical rationale for the complex treatment of gingival recession: diss... candidate of medical sciences, 3.1.7 dentistry, Ufa 2022].

The depth of the vestibule of the oral cavity is usually defined as the length of the gap between the border of the transition of the mobile mucosa to the immobile one and the end of the gum. To determine the depth of the vestibule of the oral cavity, the distance from the edge of the gum to its bottom is measured with a graduated instrument. The vestibule is considered: shallow if its depth is no more than 5 mm; - medium - 5-10 mm; deep - more than 10 mm. [Propaedeutic dentistry: teaching method, manual: in 14 parts / T.V. Gerasimova, L.A. Zyulkina, E.E. Vorobyova [and others]. Penza: Publishing house of PSU, 2022. - Part 5. - 250 s].

A method for the simultaneous elimination of class III gingival recession and vestibuloplasty is known [Patent RU No. 2732313 date published. 09/15/2020], which includes the following stages: local anesthesia 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 treated mechanically and chemically; using a microsurgical scalpel and tunnel struts, tunnel access is formed in the area of recessions, capturing one tooth on each side of the operated defect; an incision is made below the mucogingival junction by 1.5-2 mm, splitting the flap in the coronal direction, forming a bed for placing the graft; coronal reposition of the tunnel flap using throw-over and sail sutures; collection of a free gingival graft from the palate of the appropriate size, de-epithelialization; fixation of the transplant to the prepared recipient bed with interrupted and mattress sutures using non-resorbable suture material.

The main disadvantage of this method is the method and location of fixation of the transplant, which increases the risk of its rejection and an aesthetic defect in the form of a pale pink patch at the base of the border of the transitional fold, and also with this technique the gum biotype changes only by increasing the zone of attached gum, while the thickness of the gum in this area remains the same, which is fraught with relapse of recession.

There is also a known method for eliminating deep gingival recessions with a shallow vestibule of the oral cavity [Patent No. 2760836 date published. 11/30/2021] consisting in the fact that, under local anesthesia, a trapezoidal incision of the mucous membrane is made in the area of teeth that have recessions, retreating 10 mm from the edge of the attached gum, the incision starts from the tooth located next to the recession; then the mucous membrane is peeled off from the underlying tissues along the vault of the vestibule, dissecting the muscle fibers and cords at an angle to the periosteum; then the flap is fixed along the bottom of the vestibule to the periosteum using a flat continuous suture by inserting a needle with a thread into the mucous flap on one side, passing the needle through the periosteum and then pulling the needle out of the periosteum, without fixing with knots; After 3 months, the recessions are closed using the coronally displaced flap technique with a subepithelial graft, for which a modified intrasulcular incision is made using the envelope technique under infiltration anesthesia, a split flap is formed without tension, the subepithelial graft is collected, and the collection site is sutured with Prolene 6.0; the resulting graft is fixed with sutures in each interdental space in the direction from the lingual surface to the vestibular and back to the lingual, fixing the knot on the inner surface; then the flap is mobilized and fixed with vertical mattress sutures in each interdental space, a wrapping suture is added around each tooth, then the flap is pulled up and a knot is tied, and anchor sutures are applied along the bottom of the vestibule with Prolene 6.0 suture material.

The disadvantages of the method are: an aesthetic defect, namely a large number of scars that will be after the first and second operations, since the technique involves a large degree of trauma; the number of operations; the time frame for obtaining the desired result, namely the closure of the recession

The technical result of the claimed invention is a reduction in the number of operations required to achieve a full clinical effect, elimination of transplant rejection during transplantation, a change in the gum biotype, complete closure of recession and an increase in the depth of the vestibule of the oral cavity.

The technical result is achieved by fixing the gingival graft under the tunnel flap and plastic surgery of the vestibule of the oral cavity.

For the treatment of a patient with class 1, 2, 3 gingival recession, thin gingival biotype and shallow vestibule of the oral cavity, a technique is presented with a detailed analysis and description of its implementation.

The procedure is illustrated by figures 1-5. The oral cavity is treated with an antiseptic solution and a dental retractor is installed. Infiltration anesthesia, using the creeping infiltrate method, is administered in the area of the vestibule of the oral cavity, on the upper and lower jaws, at the mental opening on the lower jaw, and in the area of the outlet of the large palatine foramen. A free gingival graft is collected from the area of the hard palate [O. Tsur, M. Hürzeller. Plastic and aesthetic surgery in periodontology and implantology. Ch. 7, p. 194].

Next, we propose to treat the exposed root surfaces (2) with gingival recessions (1) using a Gracey curette and application of 17% EDTA solution, rinsing with a physiological sodium chloride solution. Intrasulcular incisions (3) are made in the recession area using microsurgical blades, a mobilized tunnel flap (4) is formed with periodontal knives, without dissecting the interdental papillae. The graft is fixed under the tunnel flap with U-shaped sutures (5) at each end. The mobilized flap (4) is fixed coronally with wrapping sutures (6) with overlapping of the exposed root areas (2) in the recession zone (1) with a 6-0 monofilament thread. A linear incision (7) is made 2-2.5 mm below the projection of the apical edge of the transplant by 2-2.5 mm, parallel to the zone of keratinized gum. The mucous flap is peeled off apically and fixed to the periosteum with 5-0 monofilament sutures (8); mattress cross-shaped sutures (9) are applied to the coronal tunnel flap, for pressing it to the periosteum with 5-0 monofilament threads; the sutures are removed after 10 days.

The inventive level of the proposed method consists in reducing the frequency of patient visits to the doctor - one operation is sufficient, performing the necessary manipulations within one visit; eliminating the risk of transplant rejection, changing the gum biotype and improving the aesthetic qualities of the result.

Comparative studies of the method developed by us were carried out with those proposed in patent RU No. 2732313 (control group - 4 patients) and in patent No. 2760836 (control group - 4 patients)

Thus, we have proposed new steps in comparison with analogues: intrasulcular incisions in the recession zone, formation of a tunnel flap, fixation of the graft under the flap, coronal displacement of the tunnel flap, an incision retreating from the projection of the lower edge of the graft by 2-2.5 mm, which is made to the periosteum, splitting the flap in the apical direction and fixing it with interrupted sutures apically, applying mattress cross-shaped sutures to the tunnel flap.

Thus, the use of the tunnel technique for closing the recession and deepening the vestibule of the oral cavity allowed us to achieve a successful result and advantages in closing the recessions.

Clinical example 1 (Fig. 6-11)

Patient M., 35 years old, came to the dental clinic complaining of an aesthetic defect (root exposure) in the area of the lower jaw anterior teeth and sensitivity to temperature stimuli. Examination revealed: the vestibule of the oral cavity is reduced, recessions in the area of 3.2, 3.1, 4.1, 4.2. CBCT images revealed vestibular and approximal bone resorption by 1/3 of the root length in the lower jaw anterior teeth.

Diagnosis: Gum recession 3.2, 3.1, 4.1, 4.2 teeth (K06.0) Miller class 3.

The following treatment was performed: professional oral hygiene 4 days before the operation, correction and training in individual hygiene, treatment of the oral cavity with an antiseptic solution; installation of a dental retractor, infiltration anesthesia (using the creeping infiltrate method) in the area of the vestibule of the oral cavity (on the upper and lower jaws), at the mental opening on the lower jaw, in the area of the exit of the large palatine opening, a free gingival graft is taken from the area of the hard palate. Treatment of exposed root surfaces (2) of teeth 3.2, 3.1, 4.1, 4.2 with gingival recessions using Gracey curette and application of 17% EDTA solution, intrasulcular incisions (3) are made in the area of teeth 3.3, 3.2, 3.1, 4.1, 4.2, 4.3 using microsurgical blades, a tunnel flap (4) is formed with periodontal knives, the interdental papillae are not dissected; fixation of the graft under the tunnel (4) flap with U-shaped sutures (5) at each end. Fix the mobilized tissues coronally with wrapping sutures (6), overlapping the exposed root areas (2) in the recession zone (1) with monofilament suture material size 6-0. A linear incision (7) is made 2 mm below the projection of the apical edge of the transplant, parallel to the zone of keratinized gum; the mucous flap is separated apically, with fixation of the apical flap to the periosteum with interrupted sutures (8). Mattress cross-shaped sutures are applied (9); on the coronal tunnel flap (4), for pressing against the periosteum with monofilament suture material size 5-0, application of adhesive balm to the wound surface, local cold.

It is recommended to avoid heating the surgical field, physical activity, and coarse food. Painkillers and local treatment of the wound with an antiseptic solution are prescribed.

Removal of sutures after 10 days. Control visit after 3 weeks (Fig. 11), result: closure of recession, increase in gum thickness, increase in the area of keratinized gum.

Clinical example 2.

Patient M., 29 years old, came to the dental clinic complaining of an aesthetic defect (root exposure) in the area of the front teeth of the lower jaw and sensitivity to temperature stimuli. Examination revealed: the vestibule of the oral cavity is reduced, recessions in the area of 33.5, 3.4, 33. CBCT images revealed vestibular resorption of bone tissue by 1/4 of the root length

Diagnosis: Gum recession 3.5, 3.4, 33 teeth (K06.0) Miller class 2

The following treatment was performed: professional oral hygiene 4 days before the operation, correction and training in individual hygiene, one-stage closure of the recession and vestibuloplasty; treatment of the oral cavity with an antiseptic solution; installation of a dental retractor, infiltration anesthesia (using the creeping infiltrate method) in the area of the vestibule of the oral cavity (on the upper and lower jaws), at the mental opening on the lower jaw, in the area of the exit of the large palatine opening, a free gingival graft is taken from the area of the hard palate. Treatment of exposed root surfaces of teeth 3.5, 3.4, 33 with gingival recessions using Gracey curette and application of 17% EDTA solution, intrasulcular incisions are made in the area of teeth 3.5, 3.4, 33 using microsurgical blades, a tunnel flap is formed with periodontal knives, the interdental papillae are not dissected; fixation of the graft under the tunnel flap with U-shaped sutures at each end. Fix the mobilized tissues coronally with locking sutures, covering the exposed root areas in the recession zone with monofilament suture material size 6-0. An incision is made 2.5 mm below the projection of the apical edge of the graft, parallel to the zone of keratinized gum; detachment of the mucous flap apically, with fixation of the apical flap to the periosteum with interrupted sutures. Mattress cross-shaped sutures are applied; on the coronal tunnel flap, for pressing against the periosteum, with monofilament suture material of size 5-0, application of adhesive balm to the wound surface, local cold. It is recommended to avoid heating the surgical field, physical activity, and coarse food. Painkillers are prescribed, local treatment of the wound with an antiseptic solution, removal of sutures after 10 days; a follow-up visit is in 3 weeks.

Description of the figures

Fig. 1. The surface of the tooth roots is treated and a tunnel flap is prepared.

1 - recession zone;

2 - root surface;

3 - intrasulcular incisions;

4 - tunnel flap.

Fig. 2. Fixed graft under the tunnel flap

4 - tunnel flap;

5 - U-shaped seam;

6 - wrap stitches.

Fig. 3. Preparation of the plastic surgery of the vestibule of the oral cavity

5 - U-shaped seam;

6 - wrap stitches;

7 - linear section.

Fig. 4. Plastic surgery of the vestibule of the oral cavity in the area of recession

5 - U-shaped seams;

6 - wrap stitches;

7 - linear section;

8 - nodal sutures.

Fig. 5. Fixed covering tunnel flap to the periosteum

5 - U-shaped seams;

6 - wrap stitches;

7 - linear section;

8 - nodal sutures;

9 - mattress cross stitches.

Fig. 6. Patient M. The surfaces of the tooth roots in the recession zone have been treated.

1 - recession zone;

2 - root surface;

Fig. 7. Patient M. Tunnel flap performed

3 - intrasulcular incisions;

4 - tunnel flap.

Fig. 8. Patient M. Fixed graft under the tunnel flap

4 - tunnel flap;

5 - U-shaped seams;

6 - wrap stitches.

Fig. 9. Patient M. Plastic surgery of the vestibule of the oral cavity in the area of recession

5 - U-shaped seams;

6 - wrap stitches;

7 - linear section;

8 - nodal sutures.

Fig. 10. Patient M. Fixed covering tunnel flap to the periosteum

5 - U-shaped seams;

6 - wrap stitches;

7 - linear section

8 - nodal sutures;

9 - mattress cross stitches

Fig. 11. Patient M. Result after 3 weeks - closure of recessions.

Claims (1)

A method for eliminating gingival recession that includes local anesthesia in the area of the recession and hard palate, mechanical and chemical treatment of the roots of the teeth in the recession zone using a Gracey curette and EDTA solution, collection of a graft in the area of the hard palate, characterized in that local anesthesia is performed using the creeping infiltrate method at the mental opening on the lower jaw and in the area of the exit of the large palatine opening, intrasulcular incisions are made in the recession zone and a tunnel flap is formed using a microsurgical blade and tunnel knives, the interdental papillae are not dissected, and the graft is fixed under the tunnel flap with U-shaped sutures at each end; the tunnel flap with a fixed graft is shifted coronally, overlapping the exposed areas of the roots in the recession zone and fixed with twisted sutures, retreating from the projection of the apical edge of the graft by 2-2.5 mm, an incision is made to the periosteum, parallel to the zone of keratinized gum, the flap is split in the apical direction, the separated flap is fixed apically, deepening the vestibule of the oral cavity; the coronally shifted tunnel flap is pressed to the periosteum with mattress cross-shaped sutures, the sutures are removed on the 10th day.