RU2827004C1 - Method for stopping haemorrhage in donor area of hard palate - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgical dentistry. A free gingival graft is sampled within a hard palate under application and infiltration anesthesia. Wound surface is exposed to laser examination at wave length 445 nm and power 1 W in a continuous mode using a non-initiated fiber with a distance from the tip of the light guide to the wound surface of 4.5–5 mm using a dynamic technique for 3 minutes. Thereafter, a protective anti-inflammatory periodontal dressing of “СОЕ РАК” is fixed on the wound.

EFFECT: method enables providing hemostasis in the surgical field when collecting a full-thickness free gingival graft from the palate, a de-epithelized free gingival graft from the palate and a connective tissue graft from the palate, reducing blood loss in the patient, reducing the length of the operation and preventing the risk of haemorrhage in the early postoperative period.

1 cl, 2 ex

Description

Field of technology to which the invention relates

The invention relates to medicine, to surgical dentistry, namely to methods for stopping bleeding in the donor zone of the palatal surface of the upper jaw when taking a free gingival transplant from the palate. The method can be used to stop bleeding when taking a full-layer free gingival transplant from the palate, a de-epithelialized free gingival transplant from the palate, and a connective tissue transplant from the palate.

State of the art

One of the complications of the free gingival flap transplantation operation from the palate is bleeding from the donor site (Rossmann J.A., Rees T.D. A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding // Journal of Periodontology. - 1999. - Nov. - №70(11). - P. 1369-1375).

Currently, various surgical techniques, medical devices and hemostatic materials are used for hemostasis in the donor area.

Surgical techniques include pressing a gauze swab soaked in a 3% solution of hydrogen peroxide to the bleeding wound surface, which allows the bleeding to be stopped within 5-10 minutes. However, there is a risk of bleeding in the near future and in the long term.

Surgical techniques also include pressing a sterile gauze pad moistened with saline solution to the bleeding wound surface, which allows the bleeding to be stopped within 5-10 minutes. And with this method there is a risk of bleeding in the near future and in the long term (Rossmann J.A., Rees T.D. A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding // Journal of Periodontology. - 1999. - Nov. - №70(11). - P. 1369-1375).

A similar surgical technique is pressing a gauze swab soaked in herbal extract to the bleeding wound surface, which allows stopping the bleeding within 5-10 minutes. However, there is also a risk of bleeding in the near future and in the long term (Keceli H.G., Aylikci B.U., Koseoglu S., Dolgun A. Evaluation of palatal donor site haemostasis and wound healing after free gingival graft surgery // Journal of Clinical Periodontology. - 2015. - Jun. - №42(6). - P. 582-589).

To stop bleeding from the donor area in the hard palate area, hemostatic sponges, fixed with various types of sutures, and biofilms are used.

Thus, a method for stopping bleeding by fixing a hemostatic sponge to the wound with continuous mattress sutures or cross mattress sutures has been proposed (Luchsheva L.F., Kravchenko V.A., Shulzhenko V.G., Yakimov N.N. Operation of transplantation of a full-layer mucous graft in the area of the hard palate // Healthcare of the Far East. - 2013. - No. 2 (56). - P. 107-111).

The disadvantages of this method are the duration of surgical intervention associated with the need to fix the hemostatic material with surgical sutures, the need to purchase consumables, the sufficient complexity of fixing surgical sutures in the area of the hard palate and the risk of bleeding in the long term.

To stop bleeding from the donor zone in the hard palate area, the use of oxidized regenerated cellulose has been proposed (Rossmann J.A., Rees T.D. A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding // Journal of Periodontology. - 1999. - Nov. - No. 70 (11). - P. 1369-1375).

The disadvantages of this method also include the duration of the surgical intervention associated with the need to fix the hemostatic material with surgical sutures, the need to purchase consumables, the sufficient complexity of fixing surgical sutures in the area of the hard palate and the known risk of bleeding in the first 7 days of the postoperative period.

A method for stopping bleeding by fixing a gelatin sponge to the wound with surgical sutures has also been proposed (Rossmann J.A., Rees T.D. A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding // Journal of Periodontology. - 1999. - Nov. - №70(11). -P. 1369-1375).

The disadvantages of this method are the duration of the surgical intervention associated with the need to fix the hemostatic material with surgical sutures, the need to purchase consumables and the sufficient complexity of fixing surgical sutures in the area of the hard palate.

There is a known method of stopping bleeding from the donor area with a fibrin membrane, which is made from the patient's venous blood by centrifugation (Semenov I.V., Peshko A.P., Goman M.Yu. Closing the donor site of the palatal autograft with a fibrin membrane. // Pacific Medical Journal. - 2020. - No. 2 (80). - P. 92-93).

The disadvantages of this method are: the need for preliminary collection of venous blood from the patient, the use of a certain amount of sterile gauze pads, the need to purchase consumables, the need for a device for centrifuging blood, the need for a device for producing fibrin membranes from venous blood after centrifugation, and the risk of bleeding in the long term.

A method is known for stopping bleeding from the donor area of the hard palate by applying cyanoacrylate medical glue to the wound surface (Ozcan M., Ucak O., Alkaya B., Keceli S., Seydaoglu G., Нау-tac M.C. Effects of platelet-rich fibrin on palatal wound healing after free gingival graft harvesting: a comparative randomized controlled clinical trial // The International Journal of Periodontics and Restorative Dentistry. - 2017. - V. 37. - e270-278).

The disadvantages of this method are: patients' dissatisfaction with the presence of a sharp chemical odor in the oral cavity, the high cost of consumables and a known risk of bleeding in the first 7 days of the postoperative period. The authors of this method themselves point out the low efficiency of hemostasis when using cyanoacrylate glue to stop bleeding from the donor area when taking a gum transplant.

Thus, the use of these or other materials does not exclude the possibility of bleeding from the donor wound in the near future and in the early postoperative period. Bleeding in the donor area, which was stopped during the operation, may occur after several hours and after several days under the action of fibrinolytic enzymes, which gradually decompose blood clots.

To stop bleeding from the donor area, medical devices are used: _CO2 laser, plasma coagulator, electrocoagulator, thermocoagulator.

A method is known for stopping bleeding in the area of the donor wound of the palate using a multifunctional contactless plasma high-voltage coagulator, in which the wound surface is treated with high-voltage plasma, and the distal end of the high-voltage contactless coagulator instrument during exposure to the donor site is located at a height of 2-3 mm from the area of exposure, and plasma sintering of the blood clot on the open scalped wound must be carried out two more times, while before suturing the wound is treated with a solution, after treatment with which a material promoting healing is applied, suturing the wound is performed with a continuous compression suture (Patent RU 2754062 C1, published on 08/25/2021).

The disadvantages of this method are: the need for a multifunctional contactless plasma high-voltage coagulator, the use of a certain amount of sterile gauze pads, the need to purchase consumables, the need for preliminary collection of the patient's venous blood, the need for a device for centrifuging blood, the need for a device for producing fibrin membranes from venous blood after centrifugation.

A method of stopping bleeding using diathermocoagulators is also known. However, the use of unipolar and monopolar coagulators in conditions of a scalped palatine wound is fraught with complications and an increase in the problem of bleeding from the donor wound. Since in cases of their use in the submucosal layer zone and in areas of fatty tissue, protein structures are fixed to the working part of the coagulator and are torn off from the thickness of the tissue, thereby increasing the area of injury to the blood vessel and increasing bleeding (Patent RU 2104041 C1, published 02.10.1998; Patent RU 2452440 C1, published 06.10.2012).

To stop bleeding from the donor area in the hard palate, a technique of bringing the edges of the wound together with catgut is also used (Patent RU 2754062 C1, published on 08/25/2021).

This method of stopping bleeding also has its drawbacks, which include the need to purchase surgical suture material, the need to use up dressing material, the long duration of the surgical intervention, and the risk of bleeding in the near future and in the long term.

Currently, to prevent blood loss and reduce the risk of bleeding in the early postoperative period for hemostasis of the donor zone in the hard palate, it is advisable to use modern laser technologies. In the world dental practice, conduction lasers with a wavelength of infrared light are widely used. A modern innovative technology is a blue laser. The active medium of the blue laser is a semiconductor material consisting of a mixture of gallium nitride (GaN) and indium nitride (InN), denoted as InGaN (Burdukova O.A. Visible Dye Lasers with Semiconductor Pumping. Diss. ... Cand. of Physical and Mathematical Sciences. - Moscow, 2021: 122 p.). Blue light laser radiation corresponds to a wavelength of 445±40 nm and is absorbed by hemoglobin to a greater extent than laser technologies with a wavelength of infrared light, which is preferable for such manipulation as stopping bleeding from the donor area in the hard palate.

With non-contact exposure of the wound of the oral mucosa to laser radiation, a carbonized layer is formed in the area of its surface, referred to in scientific literature as a laser bandage (Convissar R.A. Lasers in Dentistry. Fundamental Principles and Clinical Practice / Translated from English under the scientific editorship of A.S. Kasparov. - Moscow: "TARKOMM", 2020. - 474 p.), which creates conditions for preventing microbial invasion into the surgical wound and promotes wound regeneration in a shorter time.

Disclosure of invention

However, the use of all known methods for stopping bleeding when taking a free gingival graft from the palate does not solve the problem of the risk of bleeding from the donor area and blood loss at the time of surgery, as well as in the early and late postoperative periods, which does not allow this widespread routine operation to be considered absolutely safe and not reducing the quality of human life.

The technical result of the invention is to increase the effectiveness of surgical intervention by ensuring hemostasis in the area of the surgical field, reducing blood loss in the patient, reducing the duration of the operation and preventing the risk of bleeding in the early postoperative period.

The technical result is achieved due to the fact that the method for stopping bleeding in the donor zone of the hard palate is characterized by the fact that after collecting a free gingival transplant in the hard palate area, carried out under application and infiltration anesthesia, the wound surface is exposed to a laser beam with a wavelength of 445 nm and a power of 1 W in a constant mode in a non-contact manner with a non-initiated fiber with a distance from the tip of the light guide to the wound surface of 4.5-5 mm using a dynamic technique for 3 minutes, after which a protective anti-inflammatory periodontal dressing COE PAK is fixed to the wound.

It is the laser radiation with a wavelength of 445±40 nm that has the highest degree of absorption by hemoglobin, which is manifested in the short time of hemostasis formation in the area of the surgical wound. The authors experimentally established that 3 minutes is the optimal and maximum time to stop bleeding in the donor zone of the hard palate of the upper jaw. Less time may not be enough to form a carbonized layer on the entire surface of the donor wound.

In this case, exposure to laser radiation with a wavelength of 445 nm at a power of less than 1 W will require an increase in the time for this procedure, which will extend the overall duration of the surgical intervention. Exposure to laser radiation with a wavelength of 445 nm at a power greater than 1 W will entail the risk of pronounced carbonization of tissues and an increase in temperature in the area of the surgical wound, which may manifest itself as pain syndrome in the early postoperative period.

Implementation of the invention

After taking a free gingival transplant from the palate, carried out under application and infiltration or application anesthesia, the laser radiation with a wavelength of 445 nm with a power of 1 W and in a constant mode in a contactless manner with a non-initiated fiber with a distance from the tip of the light guide to the wound surface of 4.5-5 mm using a dynamic technique for 3 minutes is applied. After the formation of a coagulation film on the wound surface and complete stopping of bleeding, a protective anti-inflammatory dressing made of medical polymer COE PAK manufactured by GC, Japan, is fixed to the wound. The ALTA BLUE semiconductor laser manufactured by NPO IRE-POLYUS, Russia, is used as a source of laser radiation with a wavelength of 445 nm.

The medical procedure of laser radiation exposure to the wound surface in the hard palate area in order to stop bleeding from a surgical wound is performed by a doctor. The wound surface in the hard palate area has individual architectonics. By placing the tip of the light guide at a distance of 5 mm from the wound surface and making lace-like movements over the wound surface (thus implementing a dynamic technique), the doctor's hand changes its spatial position, and the distance between the tip of the light guide and the wound surface can be reduced. It is important to maintain a distance of 4.5-5 mm from the tip of the light guide to the wound surface. Exposure to laser radiation with a wavelength of 445 nm at a power of 1 W and a constant mode at this distance is safe for biological tissues and at the same time effective in stopping bleeding.

When performing the method of stopping bleeding in the donor zone of the hard palate using a semiconductor laser, an important condition is maintaining minor or surgical aspiration in the area of the surgical field in order to collect surgical smoke formed during blood coagulation.

In modern dental practice, the operation of transplanting a gingival flap from the palate is becoming widespread. However, the issue of a fast and effective method of stopping bleeding in the donor zone has not yet been resolved. The method of stopping bleeding that we claim is the fastest among the existing ones.

The invention is confirmed by clinical examples.

Example 1. Patient M., 26 years old, came to a dental clinic to see a dental surgeon with complaints of severe exposure of the roots of the teeth on the upper jaw on the right.

According to the patient, the process of exposure of the roots of the upper jaw teeth on the right began during the period of orthodontic treatment. Currently, the active period of orthodontic treatment is completely over. Over the past 9 months, the patient has been using an orthodontic retainer at night. Over the past 3 weeks, the patient has noted increased sensitivity in the area of the roots of the upper jaw teeth on the right when eating cold and sour food.

From the anamnesis: during orthodontic treatment, teeth 1.8, 1.4, 2.4, 2.8, 3.8, 4.8 were removed.

OBJECTIVE: General condition is satisfactory. Facial configuration is unchanged. Mouth opening is free. Regional lymph nodes are not enlarged. Increased tone of the masticatory muscle group. Cyanosis of the skin of the lower eyelid on the right. Cyanosis of the skin of the lower eyelid on the left. Dryness of the red border of the upper lip. Dryness of the red border of the lower lip. Decreased tone of the orbicularis oris muscle. Increased tone of the buccinator muscle on the left. Increased tone of the buccinator muscle on the right. Myofunctional disorders were revealed.

The oral mucosa is pale pink, moderately moist. Occlusion anomaly. The phenotype of the gingiva in the upper jaw is medium. The upper arch of the vestibule of the oral cavity is deep. The tongue occupies the lower floor of the oral cavity itself. The amplitude of tongue movements is reduced. Dysfunction of the tongue. Infantile type of swallowing. Landouzy test is positive (functional involvement of the neck muscles in the act of swallowing). Increased tone of the mental muscles. The "thimble symptom" is determined. Palpation of the mental muscle is painless for the patient.

Miller class II gingival recession in the area of teeth 1.7 - 1.6 - 1.5 on the vestibular side. Miller class I gingival recession in the area of tooth 1.3 on the vestibular side. Insufficient width of the zone of attached keratinized gingiva in the area of teeth 1.7 - 1.6 - 1.5, 1.3 on the vestibular side. Roll-shaped thickening of the gingiva in the area of teeth 1.7 - 1.6 - 1.5, 1.3-McCall'sfeston.

Indications were identified for performing gingivoplasty surgery in the area of teeth 1.7 - 1.6 - 1.5, 1.3 using the coronal flap transfer method with the use of a free de-epithelialized gingival graft from the palate in order to eliminate gingival recession of the teeth.

DIAGNOSIS: K07.5 - Maxillofacial anomalies of functional origin. K06.0 - Gum recession.

Somatic swallowing and normal tongue positioning in the oral cavity were taught. Myofunctional therapy exercises were recommended for a 21-day course. A procedure for occlusion correction using digital technologies was indicated. Surgery was scheduled for 21 days later.

There are no contraindications to the planned surgical intervention under local anesthesia. Currently, the patient has contacted a dental clinic to see a dental surgeon for a planned surgical intervention in the upper jaw on the right. Voluntary informed consent for gingivoplasty surgery has been issued.

Antiseptic treatment of the oral cavity using 0.05% chlorhexidine bigluconate solution (PERUO PLUS, «CURAPROX», Switzerland). Under application (benzocaine 20%) and infiltration anesthesia Solutio Articaini hydrochloridi 4% - 1.7 ml cum Solutio Adrenalini hydrochloridi 0.1% - 1:200000, a linear incision of the oral mucosa was made along the bottom of the gingival groove of teeth 1.7 - 1.6 - 1.5, 1.3 from the vestibular side. Surgical gingival papillae were formed in the area of teeth 1.7 - 1.6 - 1.5, 1.3. The mucoperiosteal flap was exfoliated to the level of the mucogingival line. The flap is split apically to the mucogingival line, preserving the integrity of the periosteum in the area of the roots of teeth 1.7-1.6-1.5, 1.3. The flap is mobilized. Mechanical treatment of the surface of the roots of teeth 1.7-1.6-1.5, 1.3 from the vestibular side is performed, demineralized root cementum of teeth 1.7-1.6-1.5, 1.3 is removed. The roots of teeth 1.7-1.6-1.5, 1.3 are treated with 24% EDTA gel ("PrefGel" by STRAUMANN). The exposure is 2 minutes. The anatomical gingival papillae of teeth 1.7-1.6-1.5, 1.3 are deepithelialized. Antiseptic treatment of the surgical field using PERIO PLUS (0.05% CHLOROHEXIDINE BIGLUCONATE solution). Hemostasis.

Under application (BENZOCAINE 20%) and infiltration anesthesia Solutio Articaini hydrochloridi 4% - 1.0 ml cum Solutio Adrenalini hydrochloridi 0.1% - 1:200000 using a dental drill and a spherical bur with a diamond coating, deepithelialization of an area of the mucous membrane of the hard palate on the right in the projection of the roots of teeth 1.8-1.7-1.6-1.5, 1.3, 7 mm wide, was performed. Two parallel incisions were made in the mucous membrane on the palatal surface of the upper jaw on the right along the boundaries of the deepithelialization area in the projection of the roots of teeth 1.8-1.7-1.6-1.5, 1.3, without violating the integrity of the periosteum in order to form a free deepithelialized gingival flap. The edges of the incisions in the mucous membrane are connected to each other by linear incisions, forming a rectangle. Free gingival de-epithelialized graft is formed, designed, isolated. Manipulation is performed using a 15 s blade. Bleeding from the donor wound in the palate area is stopped using laser radiation with a wavelength of 445 nm for 3 minutes at a power of 1 W in a constant mode in a non-contact way using a dynamic technique with a non-initiated fiber (ALTA BLUE semiconductor laser manufactured by NPO IRE-POLUS, Russia). Distance from the tip of the light guide to the wound surface: 4.5-5 mm. Antiseptic treatment of the surgical wound using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, CURAPROX, Switzerland).

A free deepithelialized graft from the palate was placed and fixed onto the root cementum of teeth 1.7-1.6-1.5, 1.3 from the vestibular side to the enamel-cementum junction using PROLENE 6-0 synthetic thread. Antiseptic treatment of the surgical wound was performed using PERIO PLUS (0.05% CHLORHEXIDINE BIGLUCONATE solution). Hemostasis. A coronal flap advancement operation was performed to eliminate gingival recession of teeth 1.7-1.6-1.5, 1.3 from the vestibular side. The surgical gingival papillae were aligned with the deepithelialized anatomical gingival papillae of teeth 1.7-1.6-1.5, 1.3. The surgical wound was tightly sutured with 6-0 polypropylene synthetic thread. In the area of the upper vault of the vestibule of the oral cavity, horizontal mattress sutures are fixed on the right and left to immobilize the soft tissues of the vestibule of the oral cavity using 5-0 polypropylene thread.

In the area of the gums and teeth 1.8 - 1.7 - 1.6 - 1.5, 1.3 on the palatal side, a protective pressing anti-inflammatory periodontal dressing COE PAK made of polymer (manufactured by GC, Japan) is fixed.

The patient was given a Memo on the specifics of the early postoperative period and a Sheet of appointments. Recommendations were given. PER OS: IBUROFEN 400 mg. A follow-up examination is scheduled in 7 days.

CHECK-UP. The patient has no complaints. Follows recommendations. Does not take painkillers.

OBJECTIVE: General condition is satisfactory. Facial configuration is unchanged. Mouth opening is free. Regional lymph nodes are not enlarged.

When examining the oral cavity, no signs of inflammation in the area of the postoperative wound of the upper jaw on the right are noted. The sutures are fixed and consistent. The protective pressing anti-inflammatory periodontal dressing COE RAK made of polymer in the area of the palatal surface of the upper jaw on the right is preserved.

DS: Condition after major surgery. Z98.8 - Other specified post-surgical conditions.

TREATMENT: The dressing was removed from the area of the palatal surface of the upper jaw on the right. The wound surface is completely epithelialized. Probing the wound in the area of the palatal surface of the upper jaw on the right is painless for the patient.

Antiseptic treatment of the postoperative wound in the upper jaw area on the right from the vestibular and palatal sides using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, CURAPROX, Switzerland).

Recommendations were given. The stitches are scheduled to be removed in 7 days.

CHECK-UP EXAMINATION. Examination of the oral cavity does not reveal any signs of inflammation in the area of the postoperative wound of the upper jaw on the right. The sutures are fixed and consistent. The postoperative wound is completely epithelialized. The coronally displaced gingival flap in the area of teeth 1.8 - 1.7 - 1.6 - 1.5, 1.3 is fixed. Palpation of the mucous membrane of the alveolar process of the upper jaw in the area of teeth 1.8 - 1.7 - 1.6 -1.5, 1.3 from the vestibular side is painless for the patient. Palpation of the mucous membrane of the alveolar process of the upper jaw in the area of teeth 1.8 - 1.7 - 1.6 - 1.5, 1.3 from the palatal side is painless for the patient. Gum recession of teeth 1.8 - 1.7 - 1.6 - 1.5, 1.3 is eliminated. No tissue bleeding is observed. No signs of inflammation in the area of the postoperative wound of the palatal surface of the upper jaw on the right are observed. The postoperative wound on the palatal surface of the upper jaw on the right is completely epithelialized. Probing of the postoperative wound of the palatal surface of the upper jaw on the right is painless for the patient.

DS: Condition after major surgery. Z98.8 - Other specified post-surgical conditions.

The sutures were removed on the 14th day of the postoperative period under application (20% benzocaine) anesthesia. Antiseptic treatment of the postoperative wound in the upper jaw area was performed using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, CURAPROX, Switzerland).

The patient was given recommendations.

Example 2. Patient L., 32 years old, came to a dental clinic to see a dental surgeon with complaints about a change in the position of the gum contour in the area of the anterior group of teeth of the lower jaw.

According to the patient, she has been noticing changes in the position of the gum contour in the area of the anterior group of teeth of the lower jaw for the past three years. Currently, the patient has contacted a dental clinic to consult a dental surgeon to determine the periodontal status, identify the causes of changes in the position of the gum contour in the area of the anterior group of teeth of the lower jaw, inform about modern methods of rehabilitation of patients with this pathology and decide on the possibility and necessity of surgical periodontal treatment.

OBJECTIVE: General condition is satisfactory. Facial configuration is unchanged. Mouth opening is free. Regional lymph nodes are not enlarged. Increased tone of the masticatory muscle group. Cyanosis of the skin of the lower eyelid on the right. Cyanosis of the skin of the lower eyelid on the left. Dryness of the red border of the upper lip. Dryness of the red border of the lower lip. Decreased tone of the orbicularis oris muscle. Increased tone of the buccinator muscle on the left. Increased tone of the buccinator muscle on the right. Myofunctional disorders were revealed.

The oral mucosa is pale pink and moderately moist. Occlusion anomaly. The phenotype of the gums in the lower jaw area is medium. The lower arch of the oral vestibule in the area of the anterior group of teeth is shallow. The lower arch of the oral vestibule in the area of the lateral group of teeth on the left and right is deep. The tongue occupies the lower floor of the oral cavity itself. The amplitude of tongue movements is reduced. Dysfunction of the tongue. Infantile type of swallowing. Landouzy test is positive (functional involvement of the neck muscles in the act of swallowing). Increased tone of the mental muscles. The "thimble symptom" is determined. Palpation of the mental muscle is painless for the patient.

Orthodontic retainers are fixed in the area of the oral surface of the teeth of the anterior group of the upper and lower jaws.

Atrophy of the gingival papillae of teeth 3.3 - 3.2 - 3.1 - 4.1 - 4.2 - 4.3 class II according to Tornow. Gingival recession class III according to Miller in the area of teeth 3.3 -3.2-3.1 - 4.1 - 4.2 - 4.3 from the vestibular side. Gingival recession in the area of teeth 3.2-3.1 - 4.1 - 4.2 from the lingual side. Insufficiency of the width of the zone of attached keratinized gingiva in the area of teeth 3.7 - 3.6 -3.5 - 3.4 - 3.3 - 3.2 - 3.1 - 4.1 - 4.2 - 4.3 - 4.4 - 4.5 - 4.6 - 4.7 from the vestibular side. Roll-shaped thickening of the gums in the area of teeth 3.4 - 3.3 -3.2 - 3.1 - 4.1 - 4.2 - 4.3 - McCall's feston.

Indications for vestibuloplasty surgery in the area of teeth 3.4-3.3 - 3.2-3.1 -4.1 - 4.2 - 4.3 - 4.4 were identified using the technique of transplanting a free gingival flap from the palate in order to create a wide zone of attached keratinized gum and deepen the lower vault of the vestibule of the oral cavity.

DIAGNOSIS: K07.5 - Maxillofacial anomalies of functional origin. K06.0 - Gum recession.

Somatic swallowing and normal tongue positioning in the oral cavity were taught. Myofunctional therapy exercises were recommended for a 21-day course. A procedure for occlusion correction using digital technologies was indicated. Surgery was scheduled for 21 days later.

There are no contraindications to the planned surgical intervention under local anesthesia. Currently, the patient has contacted a dental clinic to see a dental surgeon for a planned surgical intervention in the lower jaw area. Voluntary informed consent for vestibuloplasty surgery has been issued.

Antiseptic treatment of the oral cavity using 0.05% chlorhexidine bigluconate solution (PERIO PLUS, «CURAPROX», Switzerland). Under application (20% benzocaine) and infiltration anesthesia Solutio Articaini hydrochloridi 4% - 1.7 ml cum Solutio Adrenalini hydrochloridi 0.1% - 1:200000, a linear incision of the mucous membrane was made to the periosteum parallel to and coronal to the mucogingival line by 0.5 mm in the area of the zone of teeth 3.4 - 3.3 - 3.2 - 3.1 - 4.1 - 4.2 - 4.3 - 4.4 from the vestibular side using a 15 s blade. Next, the tissues of the vestibule of the oral cavity were stretched, which allowed the edges of the surgical incision to be spread apart, and through the formed incision, the tissues of the submucosal layer were prepared without violating the integrity of the periosteum, and the mucomuscular flap was mobilized in the area of teeth 3.4 - 3.3 -3.2-3.1 -4.1 - 4.2 - 4.3 - 4.4. The edge of the mobilized flap was moved apically by 8 mm, and the mobilized flap was fixed to the periosteum with a continuous suture developed by the authors (Application No. 2023102349 dated 02.02.2023, with a synthetic polypropylene thread of 5-0 thickness. Antiseptic treatment of the surgical wound using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, "CURAPROX", Switzerland). Hemostasis. A deep vault of the vestibule of the oral cavity was created in the area of the anterior group of teeth of the lower jaw on the left and right.

Under application (BENZOCAINE 20%) and infiltration anesthesia Solutio Articaini hydrochloridi 4% - 1.0 ml cum Solutio Adrenalini hydrochloridi 0.1% - 1:200000, two parallel incisions of the mucous membrane were made on the palatal surface of the upper jaw on the left, without violating the integrity of the periosteum, in the projection of the roots of teeth 2.3 - 2.4 - 2.5 - 2.6 - 2.7 - 2.8, 7 mm wide, in order to form a free gingival flap.

The edges of the mucous membrane incisions are connected to each other by linear incisions, forming a rectangle. The free gingival graft is formed, shaped, and isolated. The manipulation is performed using a 15 s blade (Photo 1). Bleeding from the donor wound in the palate area is stopped using laser radiation with a wavelength of 445 nm for 3 minutes at a power of 1 W in a constant mode in a non-contact manner using a dynamic technique with a non-initiated fiber (ALTA BLUE semiconductor laser manufactured by NPO IRE-POLUS, Russia). The distance from the tip of the light guide to the wound surface: 4.5-5 mm (Photo 2). Antiseptic treatment of the surgical wound using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, CURAPROX, Switzerland). In the area of the gums and teeth 2.3 - 2.4 - 2.5 -2.6 - 2.7 - 2.8 on the palatal side, a protective, compressive, anti-inflammatory periodontal dressing COE PAK made of polymer (manufactured by GC, Japan) is fixed (Photo 3).

A free gingival graft from the palate is fixed to the wound surface - to the periosteum - in the area of teeth 3.3 - 3.2 -3.1 - 4.1 - 4.2 - 4.3 using interrupted and crossed horizontal mattress sutures using a synthetic polypropylene thread of 6-0 thickness. The area of the attached gum is expanded. Antiseptic treatment of the postoperative wound using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, "CURAPROX", Switzerland). Hemostasis.

The patient was given a Memo on the specifics of the early postoperative period and a Sheet of appointments. Recommendations were given.

PER OS: IBUROFEN 400 mg.

A follow-up examination is scheduled in 7 days.

CHECK-UP. The patient has no complaints. Follows recommendations. Does not take painkillers.

OBJECTIVE: General condition is satisfactory. Facial configuration is unchanged. Mouth opening is free. Regional lymph nodes are not enlarged.

When examining the oral cavity, no signs of inflammation in the area of the postoperative wound of the lower jaw are noted. The sutures are fixed and consistent. The free gingival graft is actively integrated. Probing the mucous membrane in the area of the postoperative wound of the lower jaw is painless for the patient.

The protective, compressive, anti-inflammatory periodontal dressing COE RAK made of polymer in the area of the palatal surface of the upper jaw on the left is preserved.

DS: Condition after complex surgery. Z98.8 - Other specified post-surgical conditions.

TREATMENT: The dressing was removed from the area of the palatal surface of the upper jaw on the left. The wound surface is completely epithelialized. Probing the wound in the area of the palatal surface of the upper jaw on the left is painless for the patient.

Antiseptic treatment of the postoperative wound in the area of the lower jaw and in the area of the palatal surface of the upper jaw on the left using a 0.05% solution of chlorhexidine bigluconate (PERIO PLUS, CURAPROX, Switzerland).

Recommendations were given. The stitches were scheduled to be removed in 14 days.

CONTROL EXAMINATION. Upon examination of the oral cavity, no signs of inflammation in the area of the postoperative wound of the lower jaw are observed. The sutures fixing the free gingival graft are partially missing. The free gingival graft is fully integrated. The continuous suture developed by the authors (Application No. 2023102349 dated 02.02.2023) is fixed and consistent. A deep vault of the oral vestibule in the area of the anterior group of teeth of the lower jaw and a wide zone of attached keratinized gingiva in the area of teeth 3.4-3.3-3.2-3.1 -4.1 - 4.2 - 4.3 - 4.4 are created. The phenomenon of creeping attachment is noted.

DS: Condition after major surgery. Z98.8 - Other specified post-surgical conditions.

The sutures were removed on the 21st day of the postoperative period under application (20% benzocaine) anesthesia: for this purpose, the tip of the thread located in the projection of the root of tooth 3.4 was pulled with surgical tweezers, the knots were lifted and released from the surface of the oral mucosa, after which the knots were cut off from the underlying thread with sterile scissors. Next, one of the three ends of the thread located in the projection of the root of tooth 4.4 was pulled with surgical tweezers, the knots were lifted and released from the surface of the oral mucosa, after which the loop located at the base of the knots was dissected with sterile scissors. Using surgical tweezers, the knots located in the projection of the root of tooth 4.4 were captured, and along the direction of the continuous suture thread, a linear movement was made towards the lateral group of teeth of the lower jaw on the right in order to extract the thread from the thickness of the tissues of the vestibule of the oral cavity.

Antiseptic treatment of the postoperative wound in the lower jaw area using a 0.05% solution of chlorhexidine bigluconate (PERUO PLUS, CURAPROX, Switzerland).

The patient was given recommendations.

The use of the method for stopping bleeding in the area of the donor wound of the palatal surface of the upper jaw provides the following characteristics: prevention of blood loss, use of a low concentration of vasoconstrictor in the local anesthetic, the possibility of using a local anesthetic without a vasoconstrictor, no need to use dressings, reduction in the duration of surgical intervention, elimination of the difficulties of performing surgical manipulations, reduction in the risk of complications during surgery, reduction in the risk of complications in the late postoperative period, improvement in the quality of medical services provided to patients.

Claims (1)

A method for stopping bleeding in the donor zone of the hard palate, characterized by the fact that in the donor zone of the hard palate, after taking a free gingival graft in the hard palate, carried out under local anesthesia, the wound surface is exposed to a laser beam with a wavelength of 445 nm and a power of 1 W in a constant mode in a non-contact manner with a non-initiated fiber with a distance from the tip of the light guide to the wound surface of 4.5-5 mm using a dynamic technique for 3 minutes, after which a protective anti-inflammatory dressing made of medical polymer is fixed to the wound.