RU2847235C1 - Method for managing postoperative wound using calcium alginate dressing in surgical treatment of patients with obstructed eruption of lower third molar - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to surgical dentistry, and is intended for use in dental surgical treatment of difficult teething of the third lower molar. After anaesthesia is carried out, L-shaped incision of the mucous membrane is performed along the alveolar crest from the retromolar region in the direction of the lower third molar, with subsequent extension vertically, at level of distal one-third of tooth crown, in direction of transitional fold. Method includes separation of mucoperiosteal flap, osteotomy in area of lower third molar, its segmentation using cutters under external cooling with normal saline. Method then includes fragmentary extraction of tooth by elevator, curettage of socket, application of approaching sutures and closure of mouth of socket with wound dressing based on calcium alginate fibres of size 5 × 1 cm for up to five days. During the scheduled inspections, antiseptic treatment is performed in the region of the extracted tooth with a solution of chlorhexidine bigluconate 0.05 %, and at the end of the inflammatory process, the sutures are removed and the patient is prescribed to independently wash the alveolar socket of the extracted tooth with chlorhexidine bigluconate 0.05 % 3 times a day until "clean water".

EFFECT: due to the use protocol of the calcium alginate fibre wound dressing in the postoperative period, the method enables reducing a degree of manifestation of postoperative inflammatory events in the patient and reducing a wound healing time.

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Description

The invention relates to medicine, namely to surgical dentistry, and can be used to optimize the course of the postoperative period in patients undergoing dental surgical treatment of difficult eruption of the third lower molar by managing the postoperative wound using a wound dressing based on calcium alginate (98-100 wt.% calcium alginate, 0-2 wt.% sodium alginate).

Complex removal of the third molar of the lower jaw is one of the main methods of dental surgical treatment of patients with difficult eruption.

The protocol for complex extraction of a lower third molar includes an incision and the development of a mucoperiosteal flap, an osteotomy in the area of the lower third molar, segmentation and fragmentary tooth extraction, socket curettage, revision of the resulting defect, and hermetic or non-hermetic closure of the surgical wound. The postoperative wound itself in complex extraction of a lower third molar includes a bony component—the socket walls and the bone defect formed as a result of the osteotomy—and a soft tissue component—the mucosa covering the crown of the erupting tooth (the hood) and the mucoperiosteal flap. According to the classification of wounds (Kuzin M.I., Kostyuchenok B.M. Wounds and wound infections. Moscow: Medicine, 1990, p. 592), such a wound can be classified as "surgical", "deep" and, taking into account the conditions, "contaminated" or "conditionally clean", and their management is assumed using a wound dressing (Kuzin M.I., Kostyuchenok B.M. Wounds and wound infections. Moscow: Medicine, 1990, p. 592). Taking into account the listed anatomical and physiological features of the area where the third lower molar is located, preference may be given to non-hermetic closure of the wound. In this case, postoperative wound management is carried out "under a tampon" using various wound dressings. Traditionally, an iodoform turunda is used as such a dressing, which consists of the main active ingredient - iodoform, and a gauze bandage. Iodoform has antimicrobial, anesthetic, and anti-inflammatory properties, which promotes prolonged necrectomy and wound granulation. A gauze dressing provides hemostasis and absorbs exudate during the first phase of wound healing. However, its absorption properties are limited because it is already impregnated with iodoform. Its drainage function is questionable, as the cotton swab is inserted into the socket opening, and drainage must proceed from the upper to the lower portions of the wound. An additional disadvantage of the gauze dressing is its adhesion to the blood clot and to the wound surface, which, when changing the dressing, causes pain in the patient and constant trauma to the blood clot and/or granulation tissue, the edges of the wound and thus leads to longer healing times (Vinnik Yu.S. et al., 2015; Filimonov Yu.V., 2018; Grigoryan A.Yu. et al., 2022; Sun YQ, Sun R al et. 2022; Wang XL, 2023).

Collagen-based dressings can be used as an alternative to gauze wound dressings. They have become widely used due to collagen's optimal handling properties, positive biointegration, and ability to form complexes with medications and stimulate regeneration, including with iodoform (Faizullin A.L., Shekhter A.B. et al., 2020).

Clinically, collagen-based preparations show a positive effect on local hemostasis, they are also able to partially absorb exudate, but do not affect the reduction of swelling and pain in the postoperative period in the patient (Ismail Şenera et al., 2015), in addition, collagen has low strength and stability, which, together with its protein nature, is one of the factors in the development of purulent-inflammatory complications after its introduction into a “deep” and “contaminated” or “conditionally clean” wound (C.J. Doillon, F.N. Silver, 1986, Weibrich G, Hansen T. et al. 2004).

Calcium alginate-based gel-forming dressings are among the most promising wound dressings available today. They are highly porous and highly hydrating. Their chemical composition and physical properties closely resemble those of the wound's internal environment, making them suitable for treating infected, purulent, purulent-necrotic, and other wounds, including deep wounds containing bone (Shandurenko I.N., 2006; Budko E.V., Chernikova D.A. et al., 2019; L. Chen, R. Shen, S. Komasa et al., 2014; Gustinelli Barbosa M.A. et al., 2020; de la Portilla F. et al., 2021).

A method of treating a wound after tooth extraction using an iodoform turunda is known. Iodoform has antimicrobial, anesthetic and anti-inflammatory properties, which promotes necrectomy and granulation of the wound. A gauze bandage allows for hemostasis and absorbs exudate (Zhitnitsky, GD Complications of difficult eruption of lower wisdom teeth [Text] / GD Zhitnitsky // Dentistry. - 1965. - No. 5. - P. 42-47). A method is known for stopping alveolar bleeding after tooth extraction by applying a gauze swab to the mouth of the socket of the extracted tooth [Grigoryan A. Yu., Bezhin A. I., Pankrusheva T. A., Sukovatykh B. S. Local therapy of purulent wounds with wound dressings. Surgery. Journal im. N. I. Pirogov. 2022; (11):42-48. https://doi.org/10.17116/hirurgia202211142]. A method for stopping bleeding after tooth extraction is known by tamponade of the socket with hemostatic collagen-based sponges and suturing the edges of the socket [Cho H, Jung HD, Kim B J, Kim CH, Jung YS. Complication rates in patients using absorbable collagen sponges in third molar extraction sockets: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2015; 41(1):26-29. doi:10.5125/jkaoms.2015.41.1.26]. A known method for closing a wound when removing a third lower molar is by screwing a pre-formed vestibular mucoperiosteal flap of an "L-shaped" shape into the socket of the extracted tooth relative to the fixed edge of the wound by "sliding", covering the area of the alveolar bone that is most susceptible to resection, and fixed in this position with guide sutures, an iodoform tampon treated with petroleum jelly is applied to the mouth of the socket, covering the upper third of the socket and providing mechanical protection with a permanent antiseptic effect, for retention of which an additional cruciform suture is used (Druzhinin A.E., Lomakin M.V., Soloshchansky I.I., Kitaev V.A. An improved approach to complex surgical treatment of retention and dystopia of the third lower molars. Practical guide. Moscow: Publishing House "Mercury", 2021, 60 c: ill.).

Although these methods are the most common, they are not always the direct management of a mandibular third molar wound. They are used to stop alveolar bleeding, and they do not always guarantee bleeding control after traumatic damage to the socket walls during complex extractions of the mandibular third molar. Furthermore, the absorption properties of gauze dressings are limited by the properties of the material itself. An additional drawback of gauze dressings is their adhesion to the blood clot and the wound surface. This causes pain for the patient when changing the dressing, as well as constant trauma to the blood clot and/or granulation tissue and the wound edges, leading to a longer healing period. Collagen-based hemostatic sponges may not absorb blood and may fall out of the extraction socket. Moreover, collagen-based wound dressings do not reduce swelling and pain in the patient during the postoperative period, and have low strength and stability, which, combined with its protein nature, is one of the factors in the development of purulent-inflammatory complications after its introduction into a “deep” and “contaminated” or “relatively clean” wound.

A known method of postoperative wound management involves closing the socket by mobilizing a flap to the lingual side and suturing the wound over the bone defect (Bychkov A.I. Prevention and treatment of inflammatory complications associated with the removal of the lower third molar with difficult eruption: Abstract of a Cand. Sci. (Medicine) dissertation. - Moscow, 1993). A known method of suturing the residual bone cavity after the removal of an impacted lower third molar includes an incision in the projection of the impacted tooth, forming a flap and closing the residual bone cavity with it after the removal of the impacted lower third molar using a surgical suture passing between the first and second molars of the mandible [Patent No. RU 2803137 C1 dated 09/07/2023].

The disadvantages of these techniques include a relative contraindication to suturing and hermetic closure of the wound in case of an infected wound, which requires open management (not hermetic closure), which otherwise can lead to further infection of the wound, the consequence of which will be alveolitis, limited osteomyelitis of the socket, abscesses and phlegmons of the soft tissues of the maxillofacial region.

A method for preserving the socket of an extracted tooth using a four-layer, step-by-step filling with bone grafting material is known. The socket of the extracted tooth is preserved using a four-layer, step-by-step filling with bone grafting material. Local anesthesia is administered, followed by atraumatically separating the orbicularis ligament from the tooth, and then atraumatically removing the tooth roots. The socket of the extracted tooth is then filled with bone grafting material, over which a collagen-containing material is placed. Finally, the wound is hermetically sutured (Patent No. 2756873, October 6, 2021). A method for treating a wound after tooth extraction is known, which includes filling the socket with a bone modulator and closing the wound, characterized in that the soft tissues around the socket are exfoliated from the bone and the wound is closed with a wound covering in the form of a collagen plate covered with a layer of fibrin glue components, which is placed under the exfoliated soft tissues (Patent No. RU 2238047 C1 dated 04/22/2003).

The disadvantage of these methods is the use of bone grafting material or a bone modulator in the conditions of a "deep" and "contaminated" or "relatively clean" wound, which can independently lead to purulent-inflammatory complications, the risks of which increase in combination with hermetic suturing of the wound.

The technical result of the invention is the implementation of a protocol for the use of a wound dressing based on calcium alginate fibers in the postoperative period in patients undergoing dental surgical treatment of difficult eruption of the third lower molar, which leads to a lesser degree of severity of postoperative inflammatory phenomena in the patient and a reduction in wound healing time.

A method is proposed for managing a postoperative wound using a calcium alginate-based dressing in dental surgical treatment of patients with difficult eruption of the third lower molar, which consists of administering anesthesia, making an incision in the oral mucosa in the area of the third lower molar, detaching the mucoperiosteal flap, osteotomy in the area of the third lower molar and its segmentation using cutters under external cooling with a saline solution, fragmentary removal of the tooth with an elevator, curettage of the socket, application of approximation sutures and closing the mouth of the socket with a wound dressing based on calcium alginate fibers measuring 5x1 cm.

List of figures

Fig. 1. View of the surgical area in the oral cavity before surgery.

Fig. 2. Radiograph of tooth 48.

Fig. 3. Incision of the mucous membrane in the surgical area with subsequent detachment of the mucoperiosteal flap.

Fig. 4. Fragmentation of tooth 48.

Fig. 5. The socket of the extracted tooth 48, filled with a blood clot.

Fig. 6. The opening of the socket of the extracted tooth 48 is covered with a wound dressing made of calcium alginate.

Fig. 7. View of the postoperative area in the oral cavity on the 1st day after surgery.

Fig. 8. View of the postoperative area in the oral cavity on the 3rd day after surgery.

Fig. 9. View of the postoperative area in the oral cavity on the 7th day after surgery.

Fig. 10. View of the postoperative area in the oral cavity on the 10th day after surgery.

Fig. 11. View of the surgical area in the oral cavity before surgery.

Fig. 12. Radiograph of tooth 38.

Fig. 13. Incision of the mucous membrane in the surgical area with subsequent detachment of the mucoperiosteal flap.

Fig. 14. Osteotomy in the area of tooth 38.

Fig. 15. The socket of the extracted tooth 48.

Fig. 16. The opening of the socket of the extracted tooth 48 is closed with an iodoform turunda.

Clinical example 1

Patient Yu., 22 years old, complained of intermittent pain and discomfort in the lower jaw on the right when eating. Examination revealed that the mucous membrane in the area of tooth 4.8 was pale pink, moderately moist, and painless upon palpation. Tooth 4.8 is located under the oral mucosa, semi-impacted, and cut through by the medial-vestibular tubercle (Fig. 1). A radiograph revealed a crescent-shaped area of bone rarefaction with clear contours in the area of the distal surface of tooth 4.8 (Fig. 2). The patient was referred to the surgical dentistry department for further examination by a dental surgeon. After examination and consultation, the doctor made a diagnosis according to ICD-10 KO 1.0 (Impacted teeth), a clinical diagnosis of semi-impacted tooth, and a decision was made to extract tooth 4.8. Sol. was administered under conduction and infiltration anesthesia. Articaini 4% 1:100000 3.4 ml, an L-shaped incision was made from the retromolar area along the alveolar ridge in the direction of tooth 4.7, at the level of the distal third of the crown of tooth 4.7, it was extended vertically, in the direction of the transitional fold. The mucoperiosteal flap was separated (Fig. 3). Osteotomy and segmentation of tooth 4.8 were performed with burs under cooling with saline solution (Fig. 4), tooth 4.8 was fragmentarily removed with an elevator (Fig. 5). Curettage was performed. Hemostasis. Approximating sutures were applied. The orifice of the socket was closed with a wound dressing based on calcium alginate fibers measuring 5 × 1 cm (Fig. 6).

On the first day, the patient complained of minor pain in the postoperative area (3 points on the visual analogue scale). Edema of the soft tissues of the buccal area was noted (2 points). On examination, the mucous membrane in the postoperative area was slightly hyperemic and edematous, and the sutures were intact. The area of the extracted tooth #4.8 was treated with an antiseptic solution of 0.05% chlorhexidine bigluconate. The calcium alginate dressing was intact and visualized in the socket of the extracted tooth #4.8 (Fig. 7).

On the third day, the patient complained of minor pain in the postoperative area (3 points on the visual analogue scale). Soft tissue swelling in the buccal area was noted (2 points). Upon examination, the mucous membrane in the postoperative area was slightly hyperemic and edematous, and the sutures were intact. The area of the extracted tooth, size 4.8, was treated with an antiseptic solution of 0.05% chlorhexidine bigluconate. This resulted in the natural leaching of the calcium alginate-based wound dressing. A new calcium alginate dressing was applied (Fig. 8).

On the 7th day, the patient noted an improvement in his condition. Upon examination, the mucous membrane in the area of the missing tooth 4.8 was pale pink and moderately moist. There was no pain (0 points on the visual analogue scale). There was no swelling of the soft tissues of the buccal area. The mucous membrane in the area of the extracted tooth was pale pink and moderately moist. The sutures were removed. Antiseptic treatment of the area of the extracted tooth 4.8 was performed with a 0.05% chlorhexidine bigluconate solution, which resulted in the natural washing out of the calcium alginate-based wound dressing (Fig. 9). Epithelialization of the socket was noted. The patient was prescribed independent rinsing of the socket of the extracted tooth with a 0.05% chlorhexidine bigluconate solution 3 times a day until the water was clear. A follow-up examination is scheduled for the 10th day.

Ten days later, the patient's general condition was satisfactory, with no complaints. The mucous membrane in the surgical area was pale pink, moderately moist, and the socket was healing. The area of the extracted tooth, No. 4.8, was treated with 0.05% chlorhexidine bigluconate; the wound was clean, with signs of significant epithelialization (Fig. 10).

Clinical example 2

Patient A., 34 years old, complained of intermittent pain and discomfort in the left lower jaw when eating. Examination revealed that the mucous membrane around tooth 3.8 was pale pink, moderately moist, and painless to palpation. Tooth 3.8 was located under the oral mucosa and was impacted (Fig. 11). A radiograph revealed a crescent-shaped area of bone rarefaction with clear contours in the area of the medial surface of tooth 3.8; the crown of tooth 3.8 rested against the distal root of tooth 3.7 (Fig. 12). The patient was referred to the surgical dentistry department for further examination by a dental surgeon. After examination and consultation, the doctor made a diagnosis according to ICD-10 KO 1.0 (Impacted teeth), the clinical diagnosis was impacted tooth, and a decision was made to extract tooth 3.8. Under conduction and infiltration anesthesia with Sol. Articaini 4% 1:100000 3.4 ml, an L-shaped incision was made from the retromolar area along the alveolar ridge in the direction of tooth 3.7, at the level of the distal third of the crown of tooth 3.7 it was extended vertically, in the direction of the transitional fold. The mucoperiosteal flap was separated (Fig. 13). Osteotomy was performed from the vestibular side in the area of the neck of tooth 3.8 with burs under cooling with physiological solution (Fig. 14), tooth 3.8 was segmented and fragmentarily removed with an elevator (Fig. 15). Curettage was performed. Hemostasis. Approximating sutures were applied. The orifice of the socket was closed with an iodoform turunda (Fig. 16).

On the first day, the patient complained of pain in the postoperative area (4 points on the visual analogue scale). Swelling of the soft tissues of the buccal area was noted (2 points). On examination, the mucous membrane in the postoperative area was hyperemic, edematous, and tender to palpation; the sutures were intact. The area of the extracted tooth #3.8 was treated with an antiseptic solution of 0.05% chlorhexidine bigluconate. The iodoform turunda was intact and visualized intact in the socket of the extracted tooth #3.8.

On the third day, the patient complained of significant pain in the postoperative area (6 points on the visual analogue scale). Soft tissue swelling in the buccal area was noted (4 points). Upon examination, the mucous membrane in the postoperative area was hyperemic, edematous, and tender to palpation; the sutures were intact. The area of the extracted tooth (3.8 mm) was treated with antiseptic solution of 0.05% chlorhexidine bigluconate, and the iodoform turunda was replaced. Hemorrhagic discharge was noted during the replacement of the iodoform turunda and antiseptic treatment of the socket of the extracted tooth with 0.05% chlorhexidine bigluconate solution.

On the 7th day, the patient noted a slight improvement in his condition and complained of pain (5 points on the visual analogue scale). On examination, soft tissue swelling in the buccal region was noted (1 point), and the mucous membrane in the area of the missing tooth 3.8 was slightly hyperemic, slightly edematous, and tender to palpation. The area of the extracted tooth 3.8 was treated with an antiseptic solution of 0.05% chlorhexidine bigluconate, and the iodoform turunda was replaced. There were no signs of epithelialization.

On the 10th day, the patient's general condition is satisfactory. He complains of mild pain in the postoperative area (2 points on the visual analogue scale), and the mucous membrane in the postoperative area is slightly hyperemic and slightly edematous. The area of the extracted tooth, size 3.8, was treated with 0.05% chlorhexidine bigluconate solution, and the iodoform turunda was replaced. Slight signs of epithelialization are noted.

On the 14th day, the patient noted an improvement in her condition and complained of slight pain in the surgical area. Upon examination, the mucous membrane around the missing tooth, No. 3.8, was pale pink and moderately moist. The area around the extracted tooth, No. 3.8, was treated with 0.05% chlorhexidine bigluconate, and the iodoform turunda was replaced. Slight signs of epithelialization were noted.

On the 17th day, the patient's general condition was satisfactory, with no complaints. The mucous membrane in the surgical area was pale pink and moderately moist. The iodoform turunda was removed. The area of the extracted tooth, size 3.8, was treated with antiseptic solution of 0.05% chlorhexidine bigluconate, and the socket was closed. Signs of epithelialization were noted (Fig. 10). The patient was instructed to independently rinse the socket of the extracted tooth with 0.05% chlorhexidine bigluconate solution three times a day until the water was clear. A follow-up examination was scheduled for the 21st day.

On the 21st day, the patient's general condition is satisfactory, with no complaints. The mucous membrane in the surgical area is pale pink and moderately moist. The area of the extracted tooth, 3.8, was treated with 0.05% chlorhexidine bigluconate solution; the wound is clean, with signs of significant epithelialization.

Claims (1)

A method for managing a postoperative wound using a calcium alginate-based wound dressing in surgical treatment of patients with difficult eruption of the third lower molar, including anesthesia, making an L-shaped incision in the mucous membrane along the alveolar ridge from the retromolar region in the direction of the lower third molar, followed by vertical extension at the level of the distal third of the crown of the tooth in the direction of the transitional fold, detachment of the mucoperiosteal flap, osteotomy in the area of the lower third molar, its segmentation using cutters under external cooling with a saline solution, fragmentary tooth extraction with an elevator, curettage of the socket, application of approximation sutures and closure of the socket opening with a 5x1 cm calcium alginate fiber-based wound dressing for up to five days, while during routine examinations, antiseptic treatment is performed in the area of the extracted tooth with a solution of chlorhexidine bigluconate 0.05%, and after the inflammatory process is completed, the sutures are removed and the patient is prescribed to independently rinse the socket of the extracted tooth with a 0.05% chlorhexidine bigluconate solution 3 times a day until the water is “clear”.