RU2806519C1 - Method of increasing volume of jaw bone tissue - Google Patents

Abstract

FIELD: medicine; dentistry.

SUBSTANCE: invention is intended for use in the reconstruction of the atrophied alveolar part of the lower jaw or the alveolar process of the upper jaw with subsequent dental implantation. Under local infiltration anesthesia, an incision is made along the top of the alveolar ridge in the edentulous area. The mucoperiosteal flap is peeled off and in the edentulous area a triangular shaped bone block is taken with the apex facing the apex of the alveolar process, while the bone block is taken 5 mm below the alveolar process with the base of the bone block corresponding to the length of the defect located below the level of the root apexes by 5 mm. The sampling is performed using a surgical cutter and a bone chisel or a Piezosurgery piezoscalpel in the “bone special” mode. In the area of fixation of the bone block, on its base, two osteoperforations are first performed. Then the bone block is turned 180 degrees and placed on the receptive site with its base towards the apex of the alveolar process of the upper jaw or to the alveolar part of the lower jaw. Then the bone block is rigidly fixed using at least two microscrews with a diameter of at least 1.2 mm, and bone plastic material is placed in the reconstruction area and covered with a collagen membrane. Then the mucoperiosteal flap is additionally mobilized by dissecting the periosteum in the area of greatest thickness of the flap, the postoperative wound is closed without tension and sutured tightly with a combination of interrupted and mattress sutures.

EFFECT: due to the ideal fit and maximum area of contact of the bone block to the recipient area, the method ensures reliable fixation and stability of the volume of the bone block during the formation of the regenerate, allows to create favorable conditions for the migration of osteogenic cells and optimal conditions for subsequent implantation and orthopedic treatment without creating any additional extras or intraoral graft harvesting areas.

1 cl, 4 dwg, 3 ex

Description

The invention relates to medicine, namely dentistry, and can be used for reconstruction of the atrophied alveolar part of the lower jaw or alveolar process of the upper jaw, followed by dental implantation.

The concept of osseointegration and its clinical application in dentistry has radically changed the view on solving the problem of restoring the dentition and led to the creation of the most progressive prosthetic system. Currently, dental implantation is widely used as supports for orthopedic structures during treatment in both routine and complex clinical situations of partial and complete adentia. Modern implantation technologies ensure the effectiveness of this method by 95% and higher, opening up new opportunities for improving treatment measures aimed at the rehabilitation of dental patients (Kulakov A.A., Losev F.F., Gvetadze R.Sh., 2006; Olesova V. N. et al., 2008; Paraskevich V.L., 2009).

Despite this, according to scientific literature, in more than 30% of cases, standard implantation techniques cannot be used due to atrophy of the bone tissue of the alveolar processes in height and (or) thickness, low location of the bottom of the maxillary sinuses and pyriform opening, unsatisfactory bone quality and soft tissues in the area of proposed implantation (Drobyshev A.Yu., 2006, Ivanov S.Yu., 2008, Kulakov A.A. 2011).

At the same time, an active scientific search is being conducted in the direction of expanding the indications for dental implantation surgery. Various methods are being developed to correct severe alveolar bone atrophy, which limits the possibility of dental implantation.

There is a known method of plastic surgery of the alveolar process of the lower jaw No. RU 2417772 MPK A61B17/24. A semi-oval incision is made in the mucous membrane with the base facing the apex of the alveolar ridge. Vertical cuts are made, passing perpendicular to the alveolar process through the outer cortical layer. A horizontal cut is made along the alveolar ridge, connecting the vertical cuts. Level the bone bed with a milling cutter. An L-shaped bone fragment is taken from the patient's iliac crest, which is placed in the formed bone bed, fixed with microplates and microscrews and covered with a resorbable membrane. The mucoperiosteal flap is mobilized and placed on the wound without tension. The wound is sutured tightly with interrupted sutures.

The disadvantages of this method include the need for extaoral harvesting of a bone autograft, which creates additional trauma and labor-intensiveness of the method, and the impossibility of using it on an outpatient basis.

The known method of bone grafting is No. RU 2698436 SPK A61C 7/006 (2019.05). Under local infiltration anesthesia, an incision is made along the top of the alveolar ridge. The mucoperiosteal flap is peeled off. The area of the recipient bed of atrophied alveolar bone tissue is determined. At least one bone block is taken in the area of the external oblique line of the lower jaw using a piezosurgery scalpel in the “bone special” mode and a bone chisel; zigzag notches are formed on at least one bone block on the surface that will be external after its installation into the wound, and on at least one bone block a groove is formed along its perimeter, along its entire lateral surface. Next, decortication of the vestibular surface of the jaw is performed using a cutter and osteoperforation is performed in the area of fixation of the bone block. Osteoplastic material is placed on the receiving area, at least one bone block is placed on top and it is rigidly fixed using at least 2 microscrews with a diameter of at least 1.2 mm, the reconstruction area is covered with a collagen membrane. Then the mucoperiosteal flap is additionally mobilized by dissecting the periosteum in the area of greatest thickness of the flap, then the postoperative wound is closed, matching its edges with an eversion using a combination of interrupted and mattress sutures.

The disadvantages of this method include the need for intraoral harvesting of a bone autograft, which creates additional trauma for the patient and the labor intensity of the method.

There is a known method for plastic surgery of the alveolar process of the mandible during its atrophy No. RU 2414181 IPC A61B17/24. The first horizontal cut is made along the entire length parallel to the top of the alveolar ridge, an indentation of 7-10 mm to the depth of the cortical layer to the spongy substance. A second horizontal cut is made along the top of the alveolar process from the lingual side to the depth of the cortical layer. Two vertical cuts are made, connecting the edges of the horizontal cuts and parallel to the outer surface of the alveolar process, to a depth of 3-5 mm. The formed bone fragment with the cutting plane running tangentially to the inferior alveolar canal is mobilized with a chisel and shifted upward to a height of up to 5 mm. A biomaterial that stimulates osteogenesis is introduced into the formed defect, which is covered with a resorbable membrane on top.

The disadvantages of this method include the fact that due to the mobility of the bone fragment, the result becomes unpredictable and there is no possibility of restoring the volume of bone tissue in case of atrophy along the width of the bone.

There is a known method of plastic surgery of the alveolar process of the lower jaw No. RU 2405474 IPC A61B17/24. A semi-oval incision is made from the vestibular side of the mucous membrane to the bone, with the base facing the apex of the alveolar process. Two vertical cuts are made, perpendicular to the alveolar process of the lower jaw and passing through the outer and inner cortical layers, after which a horizontal cut is made, connecting the vertical cuts and passing through the outer cortical layer and the cancellous part of the bone to the inner cortical layer. A rasp or osteotome is placed in the horizontal cutting area and a rotational movement is used to lift the bone fragment from the vestibular side with a fracture of the inner cortical plate. A biomaterial that stimulates osteogenesis is introduced into the formed defect. The bone fragment is fixed to the lower jaw using microplates and microscrews. The reconstruction zone is covered from above with a resorbable membrane. The mucoperiosteal flap is mobilized and placed on the wound without tension. The wound is sutured tightly with interrupted sutures.

The disadvantages of this method include the fact that there is no possibility of restoring the volume of bone tissue in case of atrophy along the width of the bone, the need to remove microplates and the associated traumatic and labor-intensive nature.

The closest technical solution to the problem is the method of plastic surgery of the alveolar part of the lower jaw during its atrophy No. RU 2558998 IPC A61B17/00 published on August 10, 2015, in which one incision is made in the mucous membrane to the bone on the lingual side of the alveolar ridge and two vertical incisions limiting the surgical field to transitional fold. The mucoperiosteal flap is peeled off vestibularly. Two longitudinal cuts of bone tissue connecting inside the bone at an angle of 90° are made along the top of the alveolar ridge and on the vestibular side, departing downwards from the top of the ridge 12 mm. Next, two vertical cuts are made, limiting the reconstruction zone and connecting the edges of the horizontal cuts, deviating 45° from the bone surface to the outside. The resulting bone fragment is separated and fixed with mini-screws to the same place in a new position, rotating the block along its longitudinal axis by 25-30°. The space formed between the bone block and the donor bone site is filled with a mixture of osteoplastic material and auto-shavings. The reconstruction zone is covered from above with a resorbable membrane. The mucoperiosteal flap is mobilized, placed on the wound without tension and sutured tightly.

The disadvantages of this known method include the fact that in the case of pronounced atrophy of the bone crest in width (less than 2 mm), there is no possibility of obtaining the optimal volume of bone in the reconstruction zone, since it is technologically impossible to make a vertical cut and ensure sufficient thickness of the fragment, which ultimately leads to to insufficient width of the alveolar bone.

The objective of the present invention is to create an effective method for plastic surgery of the alveolar part of the lower jaw when it is atrophied in width to create optimal conditions for subsequent implantation and orthopedic treatment without creating additional extra- or intraoral areas for graft collection.

The technical result to which the creation of this invention is aimed is to create an ideal fit of the bone block to the recipient area, ensuring reliable fixation of the bone block and stability of the volume of the bone block during the formation of the regenerate, creating a maximum area of contact of the bone block with the area of the recipient bed, creating favorable conditions for migration of osteogenic cells and no need to create additional extra- or intraoral areas for graft collection.

The specified technical result is achieved by the fact that in the area of edentia, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process, the bone block is rotated with a wide base towards the top of the atrophied width of the alveolar process of the upper jaw or the alveolar part of the lower jaw, thereby increasing the width of the bone the block is placed on osteoplastic material, which creates a congruent surface of the recipient zone, excluding the undercut zone, and the bone block is fixed with mini-screws. Filling the space between the bone block and the recipient zone with osteoplastic material creates favorable conditions for adaptation of the bone block and promotes osteoregeneration. At the end of the operation, a mucoperiosteal flap is placed, which is fixed with interrupted sutures.

The present invention is illustrated by the following figures:

Figure 1. Part of the lower jaw in the reconstruction zone with a cutting line (1) to isolate the bone block.

Figure 2. Scheme of rotation and fixation of the bone block with miniscrews (2).

Figure 3. Reconstruction zone with a fixed bone block and osteoplastic material around the perimeter of the block (3).

Figure 4. Scheme of reconstruction covered with a collagen membrane (4)

The method is carried out as follows.

Conduction and infiltration anesthesia is performed on the operated side, intramuscular or intravenous sedation. A linear incision is made along the top of the alveolar ridge. If there is an included defect in the dentition, two angular incisions are made on the proximal sides in the area of adjacent teeth, thereby forming a trapezoidal flap. If there is a terminal defect of the lower jaw, an angular incision is made at the medial edge, and an incision directed laterally and upward at the distal edge. Thus, in the case of an end defect, a trapezoidal flap is also formed, but with a significantly larger base compared to the apex. When performing an operation in the distal part of the upper jaw, it is optimal to create an L-shaped flap by making a linear incision in the center of the ridge, affecting the mucous membrane in the area of the tubercle of the upper jaw and adding a vertical incision along the medial edge of the intervention zone. The mucoperiosteal flap is folded back. Skeletonization of the surface of bone tissue by peeling off the mucoperiosteal flap is carried out with extreme caution and thoroughness, since even minimal ruptures of the mucous membrane in the incision area above the area of direct augmentation can lead to a more difficult period of postoperative rehabilitation or to exposure of the augmentation area, which will significantly reduce the effectiveness of the procedure. interventions. The width of the recipient bed, the edge of the bone of the atrophied alveolar part of the lower jaw or the alveolar process of the upper jaw are determined. In the edentulous area, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process (Fig. 1), but 5 mm below it and the base corresponding to the width of the defect, located 5 mm below the level of the apexes of the roots using a surgical cutter or Piezosurgery piezoscalpel » in the “bone special” mode and bone chisel. Two osteoperforations are performed in advance in the bone block at its base and in the area of fixation of the bone block. To activate the recipient bed, decortication of the vestibular surface of the jaw is performed using a cutter. For tight adaptation of the bone block to the prepared recipient bed, osteoplastic material is placed on the receiving site and the bone block is installed, turning it 180 degrees with a wide base to the top of the alveolar process of the upper jaw or the alveolar part of the lower jaw, atrophied in width. After which it is rigidly fixed using at least 2 microscrews (Fig. 2) with a diameter of at least 1.2 mm. Osteoplastic material is placed in the reconstruction zone along the perimeter of the block (Fig. 3) and covered with a collagen membrane (Fig. 4). Then the mucoperiosteal flap is additionally mobilized; for this purpose, careful dissection of the periosteum is performed in the area of greatest thickness of the flap and the postoperative wound is closed, carefully matching the edges of the wound, with a slight eversion using a combination of interrupted and mattress sutures.

Clinical examples

Example 1. Patient D., 38 years old, complained about an aesthetic defect in the absence of teeth 3.4, 3.5, 3.6. An examination of the oral cavity revealed: a defect in the dentition is caused by the absence of 3.4, 3.5, 3.6. teeth. According to the patient, tooth loss occurred 3 years ago as a result of chronic periodontitis. In the area of missing teeth 3.4, 3.5, 3.6. a bone tissue defect on the vestibular surface is determined. The width of the alveolar part of the lower jaw in the area of the defect is 1.5 mm. The mucous membrane is pale pink in color, moderately moisturized.

Diagnosis – K 08.1 Loss of teeth due to accident, extraction or local periodontal disease. K 08.2 Atrophy of the edentulous alveolar margin.

A diagnostic x-ray examination was performed. According to CBCT data, the initial width of the alveolar part of the upper jaw was 1.3 mm, height - 15 mm.

The patient was offered restoration of the dentition in the upper jaw using dental implants after preliminary reconstruction to increase the volume of alveolar bone tissue in the area of missing teeth 3.4, 3.5, 3.6 using an autologous bone block and osteoplastic material. After a clinical and laboratory examination, agreement on a treatment plan and sanitation of the oral cavity, surgical treatment was carried out, including the following stages:

Under infiltration anesthesia, a trapezoidal incision was made in the mucous membrane in the area of teeth 3.4, 3.5, 3.6. The mucoperiosteal flap was detached. An assessment of the reconstruction area has been completed. Using a “Piezosurgery” piezoscalpel in the “bone special” mode and a bone chisel in the edentulous area, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process, but 5 mm below it and the base corresponding to the width of the defect, located below the level of the apexes of the roots on 5 mm. To activate the recipient bed, decortication of the vestibular surface of the jaw was performed using a milling cutter, and osteoperforations were performed in the area of fixation of the bone block. For tight adaptation of the bone block to the prepared recipient bed, the space between the bone block and the recipient site is filled with bone chips and a bone block is installed on top of the reconstruction zone, which is rigidly fixed with at least 2 microscrews with a diameter of 1.2 mm. The reconstruction area is covered with a collagen membrane. The mucoperiosteal flap was mobilized by carefully dissecting the periosteum in the area of greatest thickness of the flap and the postoperative wound was sutured, carefully matching the edges of the wound with a combination of interrupted and mattress sutures.

Example 2. Patient F., 58 years old, complained about an aesthetic defect in the absence of teeth 1.1, 1.2, 1.3. An examination of the oral cavity revealed: a defect in the dentition is due to the lack of

1.1, 1.2, 1.3 teeth. According to the patient, tooth loss occurred more than 2 years ago as a result of chronic periodontitis. In the area of missing 1.1, 1.2, 1.3, a bone tissue defect on the vestibular surface is determined. The mucous membrane is pale pink in color, moderately moisturized. In the area of missing 1.1, 1.2, 1.3 teeth, cicatricial changes in the mucosa are observed.

Diagnosis – K 08.1 Loss of teeth due to accident, extraction or local periodontal disease. K 08.2 Atrophy of the edentulous alveolar margin.

A diagnostic x-ray examination was performed. According to CBCT data, the initial width of the alveolar part of the upper jaw was 2.0 mm, height – 18 mm.

The patient was offered restoration of the dentition in the upper jaw using dental implants after preliminary reconstruction to increase the volume of alveolar bone tissue in the area of missing teeth 1.1, 1.2, 1.3 using autologous bone blocks from the edentulous area and osteoplastic material. After a clinical and laboratory examination, agreement on a treatment plan and sanitation of the oral cavity, surgical treatment was carried out, including the following stages:

Under infiltration anesthesia, a trapezoidal incision was made in the mucous membrane in the area of teeth 1.1, 1.2, 1.3. The mucoperiosteal flap is detached. An assessment of the reconstruction area has been completed. Using a “Piezosurgery” piezoscalpel in the “bone special” mode and a bone chisel in the edentulous area, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process, but 5 mm below it and the base corresponding to the width of the defect, located below the level of the apexes of the roots on 5 mm. To activate the recipient bed, decortication of the vestibular surface of the jaw was performed using a milling cutter, and osteoperforations were performed in the area of fixation of the bone block. For tight adaptation of the bone block to the prepared recipient bed, the space between the bone block and the recipient site is filled with bone chips mixed with blood plasma, which is obtained in a medical centrifuge, and a bone block is installed on top of the reconstruction zone, which is rigidly fixed with at least 2 microscrews with a diameter of 1.3 mm . The reconstruction area is covered with a collagen membrane. The mucoperiosteal flap was mobilized by carefully dissecting the periosteum in the area of greatest thickness of the flap and the postoperative wound was sutured, carefully matching the edges of the wound with a combination of interrupted and mattress sutures.

Example 3. Patient K., 45 years old, complained about an aesthetic defect in the absence of teeth 4.5, 4.6. An examination of the oral cavity revealed: a defect in the dentition is caused by the absence of 4.5, 4.6 teeth. According to the patient, tooth loss occurred 3 years ago as a result of chronic periodontitis. In the area of missing teeth 4.5, 4.6. a bone tissue defect on the vestibular surface is determined. The width of the alveolar part of the lower jaw in the area of the defect is 1.5 mm. The mucous membrane is pale pink in color, moderately moisturized.

Diagnosis – K 08.1 Loss of teeth due to accident, extraction or local periodontal disease. K 08.2 Atrophy of the edentulous alveolar margin.

A diagnostic x-ray examination was performed. According to CBCT data, the initial width of the alveolar part of the upper jaw was 1.3 mm, height - 15 mm.

The patient was offered restoration of the dentition in the upper jaw using dental implants after preliminary reconstruction to increase the volume of alveolar bone tissue in the area of missing teeth 4.5, 4.6 using an autologous bone block and osteoplastic material. After a clinical and laboratory examination, agreement on a treatment plan and sanitation of the oral cavity, surgical treatment was carried out, including the following stages:

Under infiltration anesthesia, a trapezoidal incision was made in the mucous membrane in the area of teeth 4.5, 4.6. The mucoperiosteal flap was detached. An assessment of the reconstruction area has been completed. Using a “Piezosurgery” piezoscalpel in the “bone special” mode and a bone chisel in the edentulous area, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process, but 5 mm below it and the base corresponding to the width of the defect, located below the level of the apexes of the roots on 5 mm. To activate the recipient bed, decortication of the vestibular surface of the jaw was performed using a milling cutter, and osteoperforations were performed in the area of fixation of the bone block. For tight adaptation of the bone block to the prepared recipient bed, the space between the bone block and the recipient site is filled with bone chips and a bone block is installed on top of the reconstruction zone, which is rigidly fixed with at least 2 microscrews with a diameter of 1.2 mm. The reconstruction area is covered with a collagen membrane. The mucoperiosteal flap was mobilized by carefully dissecting the periosteum in the area of greatest thickness of the flap and the postoperative wound was sutured, carefully matching the edges of the wound with a combination of interrupted and mattress sutures.

Reconstruction of the atrophied alveolar part of the lower jaw and the alveolar process of the upper jaw using the proposed method was performed in 35 patients. The formation of regenerate for the installation of dental implants occurred 4-6 months after reconstruction.

Thus , the known methods of increasing the volume of jaw bone tissue are either unnecessarily traumatic for the patient, or labor-intensive and expensive, or do not provide a tight fit of the graft and, accordingly, a predictable result, which is a significant drawback.

Claims (1)

A method for increasing the volume of jaw bone tissue, characterized by the fact that, under local infiltration anesthesia, an incision is made along the top of the alveolar ridge in the edentulous area, the mucoperiosteal flap is peeled off, and in the edentulous area, a triangular-shaped bone block is taken with the apex facing the apex of the alveolar process, with In this case, the bone block is collected 5 mm below the alveolar process with the base of the bone block, corresponding to the length of the defect, located 5 mm below the level of the apexes of the roots. Moreover, in the area of fixation of the bone block, on its base, two osteoperforations are first performed, then the bone block is turned 180 degrees and placed on the receiving area with the base to the apex of the alveolar process of the upper jaw or to the alveolar part of the lower jaw, then the bone block is rigidly fixed using at least two microscrews with a diameter of at least 1.2 mm, and osteoplastic material is placed in the reconstruction area and covered with a collagen membrane, then the mucoperiosteal flap is additionally mobilized by dissecting the periosteum in the area of greatest thickness of the flap, the postoperative wound is closed without tension and sutured tightly with a combination of nodal and mattress seams.