RU2845608C1 - Method for elimination of soft and bone tissues deficiency in patients planning orthodontic treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to dentistry, and can be used in rehabilitation of patients with bone and soft tissue deficiency before planned orthodontic treatment. Method includes determining gingival phenotype and determining presence or absence of gingival recession. Full mucoperiosteal flap is incised, dissected and mobilised. Point perforations are formed within a receiving bone bed, and exposed roots are treated with ethylenediaminetetraacetic acid. Autogenous subepithelial connective-tissue graft is sampled from the palate, de-epithelialised and laid within a recession. Wound area is covered with collagen membrane, laid back and closed mucoperiosteal flap. At that, 8-12 months before the start of orthodontic treatment, after determining the gum phenotype, an impression is taken from the upper jaw dentition, a stone cast is cast and the frame of the resulting model is used to make a protective denture and hard palate tray modelled of vinyl plastic. After the autograft is sampled, a haemostatic sponge is placed on the wound donor surface, fixed with cross-shaped sutures and a pre-fabricated protective tray is put on. Then, intra-boron incisions and oblique paramarginal incisions are made in the region of teeth with recessions, a full-thickness mucoperiosteal flap is detached, autogenous bone chips are sampled from an external oblique line of a mandibular body. Resulting autogenous material is mixed with the xenogenic osteoplastic material in ratio of 1:1 and, after the point perforations are formed in the cortical bone tissue of the receiving bone bed, directed bone augmentation with the prepared mixture is performed in sequence starting from a vestibular surface of an alveolar process and finishing with an alveolar portion within the teeth. After that, the wound surface is covered with a collagen membrane, fixing to the periosteum surface with metal pins, connective tissue graft is laid and fixed, mucoperiosteal flap is mobilized and placed in place, successively fixing first with intra-papillary, then blanket sutures around each tooth. Sutures are removed from the donor hard palate on 7^th day, and from the gingival mucosa – on 21^st day.

EFFECT: method enables eliminating the bone and soft tissue atrophy accompanying the planned orthodontic treatment, as well as reducing postoperative complications represented by flap displacement into an initial position and cutting through the osteoplastic material.

1 cl, 17 dwg, 2 ex

Description

The invention relates to medicine, namely to dentistry, and can be used for the rehabilitation of patients with bone and soft tissue deficiency as a preventive surgical intervention before planned orthodontic treatment.

Gum recession is an apical displacement of the gingival margin with exposure of the root cementum, which is accompanied by the loss of attached gingiva and vestibular bone tissue. To diagnose true gum recession, it is necessary to visualize the boundary of the cementoenamel junction and exposure of the root cementum. There are etiologic factors and factors predisposing to the development of gum recession. The main etiologic factors in the development of gum recession include:

1. Thin phenotype of the mucous membrane. The characteristic features of a thin mucous membrane of the gum are: thickness from 0.5 to 1.5 mm, high and narrow papillae, as well as quite pronounced scalloping. In turn, a thin phenotype of the mucous membrane is not the cause of gingival recession, but in combination with predisposing factors, the likelihood of its development increases.

2. Cords of the mucous membrane, pathological attachment of the frenulum of the upper and lower lips. Due to the coronal attachment of the frenulum of the lips, ischemia of the marginal edge of the gum occurs. Also, the traumatic effect of the mucous cords leads to extensive (generalized) exposure of the necks of the teeth, which can also lead to the development of gum recession.

3. Deficiency of attached keratinized gingiva.

4. Anatomical structure of the tooth crown. Most often, in the absence of a physiological equator of the tooth, there is a violation of the distribution of chewing pressure, due to which the load on the ligamentous apparatus of the tooth and hard tissues increases significantly.

5. Occlusal trauma due to the lack of physiological tooth wear. Due to the lack of physiological tooth wear, occlusal overload occurs due to supracontact points, which in the case of malocclusion, occlusion disorders and tooth movement serves as a risk of gum recession.

6. Anatomical and morphological structure of the periodontium: fenestrations and dehiscences. This implies the difference between the morphology of the tooth and the alveolar bone. As a rule, in the area of large tooth roots, there is a deficiency of the cortical layer both on the vestibular side and the oral side. The deficiency of the cortical plate is insufficient attachment of the mucous membrane, which can also lead to the development of gum recession.

Predisposing factors include:

1. Orthodontic treatment. In case of widening of the dental arch and excessive vestibular tooth movement, increased pressure is exerted on the cortical plate of the tooth, which leads to its lysis and loss of soft and hard tissues. The phenotype of soft tissues is also of great importance when planning orthodontic treatment, since under conditions of orthodontic tooth movement, slit-like defects of the outer cortical plate are formed.

2. Bacterial contamination. Gingival recession caused by a bacterial factor is not associated with a pronounced loss of attached mucosa in the papillae. In this case, gingival recession develops under the influence of microorganisms in soft plaque and dental deposits.

3. Traumatic factor. This includes: traumatic horizontal movements of a hard toothbrush, improper use of additional hygiene products - dental floss, which can lead to the development of Stillman's gaps, tongue/lip piercing, bad habits (biting hard objects). Also, this risk group can include iatrogenic factors: poor fit of the crown or composite restorations, formation of "overhanging edges", irrational treatment in the form of trauma to the gingival margin during tooth preparation, as well as non-compliance with the tactics of making marginal gum incisions if it is made in the center of the tooth crown, which will undoubtedly lead to the development of gum recession.

A method of surgical treatment of gum recession with simultaneous deepening of the vestibule of the oral cavity is known (patent No. 2301030). The method consists of making a crescentic incision to the bone in the area of gum recession, peeling off a crescentic flap with subsequent coronal displacement. Then, the vestibule of the oral cavity is deepened, the mucous membrane, submucous strands and muscle fibers are peeled off in the donor area to the bone tissue. Then, a fibrin membrane containing platelet growth factors is placed in the resulting space between the crescentic flap and the mobile mucous membrane. The disadvantages of the method are the high risk of flap displacement to its original position, as well as the impossibility of using this technique in conditions of generalized gum recession.

The prototype of the proposed invention is a method for one-stage restoration of the volume of lost bone tissue and attached gum (Vedyaeva A.P., Braylovskaya T.V., Potapova A.I., Kuzin A.V., Sogacheva V.V., 2024-04-25, Russian Federation patent for invention No. 28181780). After detachment of the mucoperiosteal split flap, perforation of the cortical bone plate is performed, osteoplastic xenogeneic material is placed, and covered with a collagen resorbable membrane. An autogenous connective tissue graft taken from the donor site of the hard palate is placed under the mucosal flap and fixed to it, partially covering the collagen membrane. The mobilized flap is placed in its original position and fixed with nodal and encircling U-shaped sutures.

The use of this treatment method has been studied exclusively in conditions of chronic periodontitis and periimplantitis. There is no data on its use in orthodontic treatment.

The technical task of the invention being manufactured is to develop a method for eliminating atrophy of bone and soft tissues during planned orthodontic treatment, as well as reducing postoperative complications in the form of displacement of the flap to its original position and cutting of the bone plastic material.

The main complaints of patients are most often aesthetic dissatisfaction and increased sensitivity in the area of exposed tooth roots. The problem of replenishing the lost volume of soft tissues is often associated with a deficiency of underlying bone tissue, which is an indication for surgical intervention, especially in patients planning or undergoing orthodontic treatment.

The technical result is achieved through the technique of fixing the bone plastic material, connective tissue graft and suturing the wound surface.

The claimed method is implemented as follows. Cone-beam computed tomography of the dentoalveolar system is performed with subsequent image processing in order to determine the initial level and thickness of the vestibular bone tissue. The size of the attached keratinized gum is assessed, the gum phenotype is determined, the presence or absence of gum recessions are determined using a periodontal probe, and their size is measured if any. A protective cap is manufactured in advance for the donor area of the hard palate in order to minimize pain by isolating the wound surface, as well as complications in the form of bleeding. The protective cap is a vinyl plastic frame of the dentition and hard palate, which ensures the isolation of the donor area from irritating factors, which in turn optimizes the healing process and makes it minimally uncomfortable for the patient.

Under local infiltration and conduction anesthesia Sol. Ultracaini 1:200000 1.7 ml. intrasulcular incisions are made, as well as oblique paramarginal incisions in the area of teeth with recessions of up to 3 mm using a 15 C scalpel blade, a full-layer mucoperiosteal flap is exfoliated. The surface of the roots is treated with an ultrasonic scaler, the exposed surfaces of the roots of the teeth are smoothed and polished with curettes, and treated with EDTA (ethylenediaminetetraacetic acid). In the area of the donor site on the palate, infiltration anesthesia Sol. Ultracaini DS 1:200000 1.7 ml is administered. Using a 15 scalpel blade, a subepithelial connective tissue graft of the required size is collected, the graft is de-epithelialized on the surface of the slide, prepared according to size and thickness. A hemostatic sponge is placed on the wound donor surface, cross-shaped fixing sutures are applied with Vicryl 4.0 material, and a pre-fabricated protective mouth guard is put on. To make a protective mouth guard, the patient is referred to a dentist - orthodontist in advance of the operation, impressions are taken from the upper jaw dentition and a plaster model is cast, according to the frame of which a protective mouth guard is subsequently made of vinyl plastic. Using a Micross scraper, autogenous bone chips are collected from the area of the external oblique line of the body of the lower jaw. The resulting autogenous material is mixed with xenogeneic bone plastic material in a 1:1 ratio. In the area of the receiving bone bed, an osteotomy of the cortical bone tissue is performed using a drill and a spherical bur for the purpose of subsequent formation of a blood clot to ensure blood supply to the bone material. Guided bone regeneration is performed sequentially: the vestibular surface of the alveolar process / alveolar part in the area of the teeth is augmented with autogenous bone chips and xenogeneic osteoplastic material in a 1:1 ratio, covered from above with a collagen membrane of the required size, which is fixed to the surface of the periosteum with metal pins using an oscillating tip. A subepithelial connective tissue graft is placed and fixed under the mucous flap. The mucoperiosteal flap is mobilized, placed in place, sequentially fixed first with intrapapillary, then with wrapping sutures around each tooth. The sutures are removed from the donor area of the hard palate on the 7th day, in the area of the mucous membrane of the gingival margin after 21 days.

Example 1

Patient A., 21 years old, after unsuccessful first orthodontic treatment with bone tissue deficiency (Fig. 1-3), generalized gingival recession of class I according to Miller in the area of teeth 1.3, 2.3, 3.2-4.2 CBCT (Fig. 4-5): apical resorption of the cortical vestibular plate on the lower jaw more than 1/3 of the length of the roots of the teeth, protrusion of 1.3-2.3. Repeat orthodontic treatment is planned after bone and soft tissue grafting.

Protocol of the operation: 8 months before the start of orthodontic treatment, the patient underwent infiltration and conduction anesthesia with Sol. Ultracaini DS 1:200000 1.7 ml in the area of teeth 1.4-2.4 and 3.4-4.4, intrasulcular incisions were made using a 15C scalpel blade, a full-layer mucoperiosteal flap was exfoliated with a microraspatory and mobilized. Next, the tooth roots were treated using an ultrasonic scaler, smoothed and polished with burs, curettes, and EDTA was applied. Infiltration anesthesia with Sol. UltracainiDS 1:200000 1.7 ml was administered in the area of the donor site on the palate. Using a 15 scalpel blade, a connective tissue graft of the required size was collected, de-epithelialization of the graft was performed on the glass surface, preparation according to size and thickness. A hemostatic sponge is placed on the wound donor surface, fixed with cross-shaped sutures using Vicryl 4.0 material, and a prefabricated protective mouth guard is put on. Point perforations are made in the area of the receiving bone bed in the region of teeth 1.3-2.3 (Fig. 6) and 3.3-4.3 using a bur. The subepithelial connective tissue graft is fixed under the mucous flap in the area of teeth with thin mucous membrane. Using a Micross scraper, autogenous bone chips are collected from the area of the external oblique line of the body of the lower jaw on the left. The resulting autogenous material is mixed with xenogeneic bone plastic material in a 1:1 ratio. Guided bone regeneration was performed sequentially: the vestibular surface of the alveolar process in the area of the teeth was augmented with autogenous bone chips and xenogeneic osteoplastic material in a 1:1 ratio, collagen membranes were placed on top, fixed to the surface of the periosteum with metal "nails" (pins) (Fig. 7-8). A connective tissue graft was placed in this area on top. The mucoperiosteal flaps were mobilized, placed in place, sequentially fixed with intrapapillary and wrapping sutures with suturing of the connective tissue graft vestibularly and lingually around each tooth. The sutures were removed from the donor area of the hard palate after 7 days, in the area of the mucous membrane after 21 days (Fig. 9).

Example 2

Patient V., 34 years old, with generalized gingival recession of class I according to Miller in the area of teeth 3.1, 3.3, 3.4, 3.5 and bone tissue deficiency in the area of teeth 3.3-4.3 (Fig. 10-12), on CBCT: apical resorption of the cortical vestibular plate by 1/3 of the length of the roots of teeth 3.3-4.3 (Fig. 13).

Surgical protocol: 12 months before the start of orthodontic treatment, the patient underwent infiltration anesthesia with Sol. Ultracaini DS1:200000 1.7 ml in the area of teeth 4.4-3.5, using a 15C scalpel blade, intrasulcular incisions and oblique paramarginal incisions were made in the area of teeth with recessions, a full-layer mucoperiosteal flap was exfoliated with a microraspatory and mobilized. Next, the tooth roots were treated with an ultrasonic scaler, smoothed and polished with burs, curette application of EDTA. In the area of the donor site on the palate, infiltration anesthesia with Sol. UltracainiDS 1:200000 1.7 ml was performed. Using a 15C scalpel blade, a subepithelial connective tissue graft of the required size was collected, then de-epithelialized on the surface of a glass slide, prepared according to size and thickness. A hemostatic sponge was placed on the wound donor surface, fixed with cross-shaped sutures using Vicryl 4.0 material, a pre-fabricated protective mouth guard was put on. The connective tissue graft was placed and fixed with simple interrupted sutures under the mucous flap in the area of the teeth with recessions. Using a Micross scraper, autogenous bone chips were collected from the area of the external oblique line of the body of the lower jaw on the right. The obtained autogenous material was mixed with xenogeneic bone-plastic material in a 1:1 ratio. Point perforations were made in the area of the receiving bone bed using a bur. Guided bone regeneration was performed sequentially: the vestibular surface of the alveolar process in the area of the teeth was augmented with autogenous bone chips and xenogeneic osteoplastic material in a 1:1 ratio, a collagen membrane was placed on top, fixed to the surface of the periosteum with metal pins. The mucoperiosteal flaps were mobilized, placed in place, sequentially fixed with intrapapillary and wrapping sutures with suturing of the connective tissue graft vestibularly and lingually around each tooth. The sutures were removed from the donor area of the hard palate after 7 days, in the area of the mucous membrane after 21 days (Fig. 14-17).

Claims (1)

A method for the one-stage elimination of bone and soft tissue deficiency in patients planning orthodontic treatment, including determining the gingival phenotype and the presence or absence of gingival recessions, making an incision, delaminating and mobilizing a full-layer mucoperiosteal flap, forming point perforations in the area of the host bone bed, treating the exposed roots of the teeth with ethylenediaminetetraacetic acid, collecting an autogenous subepithelial connective tissue graft from the palate, deepithelializing it and placing it in the recession area, covering the wound area with a collagen membrane, placing the mucoperiosteal flap in place and suturing it, characterized in that 8-12 months before the start of orthodontic treatment, after determining the gingival phenotype, an impression is taken from the dental arch of the upper jaw, a plaster model is cast and, according to the framework of the resulting model, a protective mouthguard of the dentition and hard palate, modeled from vinyl plastic, is made, after collecting the autograft, a hemostatic sponge is placed on the wound donor surface, fixed with cross-shaped sutures and a pre-fabricated protective mouthguard is put on, then intrasulcular incisions and oblique paramarginal incisions are made in the area of the teeth with recessions, a full-layer mucoperiosteal flap is peeled off, autogenous bone chips are collected from the area of the external oblique line of the body of the lower jaw, the resulting autogenous material is mixed with xenogenic bone-plastic material in a 1:1 ratio and, after forming point perforations in the cortical bone tissue of the receiving bone bed, targeted bone augmentation with the resulting mixture is sequentially carried out, starting from the vestibular surface of the alveolar process and ending with the alveolar part in the area of the teeth, after which the wound surface is covered with collagen membrane, fixing it to the surface of the periosteum with metal pins, place and fix the connective tissue graft, the mucoperiosteal flap is mobilized and placed in place, sequentially fixing it first with intrapapillary, then with wrapping sutures around each tooth, the sutures are removed from the donor area of the hard palate on the 7th day, in the area of the mucous membrane of the gingival margin after 21 days.