The method of surgical treatment of chronic periodontitis

 

The invention relates to medicine, namely to oral surgery, and can be used in the surgical treatment of chronic periodontitis. They carry out the formation and mobilization of mucoperiosteal flap, removal of subgingival dental plaque, granulation, areas of necrotic bone, polishing of the tooth roots and the introduction bone defects sterile osteoplastic material. Before surgery and after 14-20 days he spend immunotherapy and correction of blood rheological properties in the form of 2-5 procedures centrifuge (CPC) or a single procedure hardware plasmapheresis (ACE). When this type of plasmapheresis is chosen based on the following indicators: the CPC do patients with intravascular platelet activation is the sum of active forms more than 30% and/or platelets more than 450 thousand/ál of blood and/or increasing populations of lymphocytes in 2 times and more the norm, and ACE is conducted in the presence of changes in other indicators of blood rheology and immunity, accompanied by an increase in circulating immune complexes (CIC) to 110 ME. In cases of need for immunosuppressive therapy process of immunofan. The method allows to reduce the number of complications and increase the efficiency of osteochondroplasty by improving blood microcirculation in the intervention area, elimination of immunological disorders in the patient's body, negatively affecting the regenerative processes in the bone wounds. 1 C.p. f-crystals, 4 Il., 3 table.

The invention relates to medicine, namely to oral surgery, and can be used for the surgical treatment of chronic periodontitis.

The closest technical solution is a method of surgical treatment of alveolar bone defect of periodontitis, in which before surgery by highly effective oral hygiene, careful removal of above - and subgingival deposits. Under anesthesia cut mucoperiosteal flap from the inner side of the flap deshevye scissors cut the pocket epithelium, then remove pathological periodontal tissues, Polish the roots of the teeth and injected into the formed bone defects sterile osteoplastic implant material [1].

The disadvantage of this method is not a complete restoration of tissue Paragon effect on the trophic status of the alveolar processes of the jaws, in mind what is broken reparative osteogenesis.

The task of the invention is to increase the effectiveness of surgical treatment of chronic periodontitis by optimization of reparative processes in the operated area.

This object is achieved in that in the method of surgical treatment of chronic periodontitis, including the formation and mobilization of mucoperiosteal flap, removal of subgingival dental plaque, granulation, areas of necrotic bone, polishing of the tooth roots and the introduction bone defects sterile osteoplastic material, it is new that before surgery and after 14-20 days he spend immunotherapy and correction of blood rheological properties in the form of 2-5 procedures centrifuge (CPC) or a single procedure hardware plasmapheresis (ACE), the appearance of a plasmapheresis is chosen based on the following indicators: CPC do patients with intravascular platelet activation is the sum of active forms of platelets is more than 30% and/or platelets more than 450 thousand/ál of blood and/or increasing populations of lymphocytes in 2 times and more the norm, and the enzyme is carried out at alicemoganika (CEC) to the ME 110 and above.

In cases of need for immunosuppressive therapy procedure the CPC before reinfusing complement the treatment of the suspension of erythrocytes 0.03 g of prednisolone, immunostimulatory 0.002 g of immunofan.

Holding plasmapheresis promotes detoxification of the body, normalizes the immune system, the rheological properties of blood of the patient, in mind which improves the blood flow in the thickness of the alveolar processes of the jaws, which, in turn, positively affects the trophic operated area. Due to the fact that in the immediate postoperative period in patients newly impaired blood rheology due to operational stress, after 14-20 days after the intervention plasmapheresis is performed again.

The proposed method is as follows.

For holding the ACE into the patient intravenously administered crystalloid, hemodynamic, detoxification and protein solutions depending on the initial blood counts (biochemical data and the peripheral portion) in the amount of 80% from 30% of the volume of circulating plasma in patients with excessive body weight, in other cases 95%. 10 minutes before blood sampling intravenous solution of heparin at a dose of 70 UNITS per 1 kg of body weight in patients with protrombinovogo blood sampling up to its full volume, then separate the plasma together with toxins and pathological components of blood from the formed elements and the remainder of the blood is re-infused. The cyclical nature of blood is 5-7, which directly depends on the volume of circulating plasma.

When performing the CPC infusion program differs in that crystalloid, hemodynamic, detoxification and protein solution injected patients with overweight in the amount of 85% of 30% of the volume of circulating plasma, in other cases, 100%. The blood of the patient is taken in equal proportions in two sterile package in the amount of 25% of the circulating volume. The plasma together with the pathological components are removed using plasmacytoma, and the remaining portion of the blood after dilution in a ratio of 1: 1 with saline, is re-infused. In cases of need for immunosuppressive therapy procedure before reinfusing complement the treatment of the suspension of erythrocytes 0.03 g of prednisolone, immunostimulatory 0.002 g of immunofan.

CPC do patients with intravascular platelet activation (sum of active forms is more than 30% and/or platelets more than 450 thousand/µl blood) and/or increasing populations of lymphocytes in 2 times or more from Wirayuda immune complexes (CIC) to 110 ME cropped holding the ACE.

In addition to performing the above procedures in the preoperative period, according to the testimony, perform local therapeutic (treatment and dipolmacy teeth, anti-inflammatory therapy), orthopedic (electoral presledovanie teeth, making splinting devices and orthodontic measures. In patients with generalized chronic periodontitis in the projection of the alveolar ridge of the mandible spend a horizontal section along the interdental papilla and the edge of the free gingiva during dentition to the bone at an angle of 45° to the last partial excision of ingrown epithelium and granulation. Then the cuts are parallel to the top of the alveolar ridge on the posterior surface of the last tooth back up to 10 mm, further single incision continue downward, backward and outward, the other downwards, backwards, and inside for transitional fold. Form the vestibular and lingual mucoperiosteal flaps with dissection of the periosteum from the inner side at the base. Remove subgingival dental plaque, struck the cement of the tooth roots, excised granulation and vegetative cells, treated region of the alveolar bone, Polish the roots of the teeth, the wound is washed with antiseptic solution.in. Placed on top mucoperiosteal flaps, the wound is sutured in each mizunos the period of interrupted sutures without tension and in areas at the place of application of the lateral incisions. The wound is drained by a narrow rubber strips, established through additional incisions base vestibular flap length 2-3 mm, Stitches will be removed 8-10 days. On the upper jaw operation differs from the palatal side in the area of molars and premolars mucoperiosteal flaps form azkabanu form to supply the leg with the inclusion of the neurovascular bundle large palatal canal, in the area of the incisors and canines - triangular flap on the leg, the top of which is addressed to the median nebnom seam, the base - to the front teeth with the preservation of anatomic formations of the cutting channel. Additionally Palatine patches fixed with the help of iodoform Marley and the protective plate.

In patients with localized forms of chronic periodontitis intervention differs only in its size.

The rheology of blood and immune status are controlled by 10-12 days after surgery, revealed violations re-adjust ACE or the CPC.

Example 1. Patient M, 56 years old, complained of secondary Aden the years, when I first began to notice the bleeding gums and pathological tooth mobility occasionally lost teeth, therapeutic and orthopedic interventions did not produce a positive effect. Locally: determined abnormal mobility 11, 12, 13, 14, 21, 22, 23 - III degree, their roots exposed on2/3length. The mucous membrane of the alveolar process in the projection of the upper teeth swollen, hyperemic, after sensing bleeds. The depth of periodontal pockets 8-10 mm. and Lower teeth of the left upper jaw under bridges. On the orthopantomogram (OPG) is an irregular loss of bone tissue of the alveolar processes of the maxilla3/4lower - on2/3root length with clear contours, bridges, damaged roots 37 and 48. Examination by a physician revealed chronic gastritis, cholecystitis, and pancreatitis. From the rheological parameters of blood, an increase in the level of soluble hybridmonolith complexes; fibrin monomer complex) to 115 mcg/ml (normal less than 35 μg/ml), von Willebrand factor (PV) 182% (normal range 60-120%), fibrinogen-6.5 g/l (normal 2-4 g/l), PETIT to 114% (normal 80-100%), shortening of the activated partial thromboplastin time (APTT) up to 35 seconds (control of generalized periodontitis upper and lower jaw and severe chronic gastritis, cholecystitis, pancreatitis, chronic DIC in the stage of hypercoagulation, endothelin, secondary immunodeficiency with activation of humoral. Treatment: before operational intervention conducted the session ACE with the removal of 40% of the volume of circulating plasma and its hemodynamic compensation and protein solutions, and medications that improve the aggregation properties of erythrocytes. A course of therapy regarding the above pathology of internal organs. Removed dentures, 37 and 48, and then marked pathological mobility of the lower teeth of the first degree. Performed by a local anti-inflammatory activities. Surgery on the upper jaw according to the described technology. The postoperative period was uneventful, with no complications, wound healing primary. After 14 days; fibrin monomer complex was 65 μg/ml, fibrinogen 3.2 g/l, APTT 37 sec (control 38 sec), PETIT 95%, platelets 310 thousand/ál, the active form of platelets 43% (normal is 1.5-17.7%) and CEC 63 ME. Rheological data breach resolved holding 2 sessions of the CPC. Upon examination after 12 months from the intervention of pathological tooth mobility was not determined, periodontal pockets were absent, gums dense, nahodilsa and immunological parameters of blood were observed. Radiographically detected increase in height of the alveolar ridge of the upper jaw below the necks of the teeth 1-2 mm foci of osteoporosis, resorption of the roots of teeth and bone are not marked.

Example 2. Patient H, 37 years old, came with complaints of gnetaceae from the periodontal pockets, putrid smell from the mouth. From the anamnesis: suffering for 12 years, conservative treatment did not give a positive effect. Locally: bite orthognathic, the eve of the oral cavity of sufficient depth, attachment of the frenulum of the upper and lower lips satisfactory. Cervical upper and lower teeth are bared. The mucous membrane of the alveolar process edematous, hyperemic. On the teeth of the upper and lower jaw were observed soft plaque, supragingival and subgingival dental plaque. The hygiene index on green-Vermilion - 2. The mobility of the upper and lower teeth I and II degree, the depth of periodontal pockets 6-7 mm. On OPG was determined non-uniform loss of bone tissue of the alveolar processes of the upper and lower jaws on1/2root length with sharp and uneven contours. Examination by a physician revealed chronic gastritis and neurocirculatory dystonia for cardiac and hypertensive type moderate with paroxys; fibrin monomer complex to 165 μg/ml, PV to 174%, fibrinogen up to 5 g/l, PETIT to 106%, shortening of the APTT to 35 sec (control 40 sec). From immunological blood parameters revealed an increase of the CEC to 143 ME. Diagnosis: chronic generalized periodontitis of upper and lower jaws moderate, chronic gastritis, neurocirculatory dystonia for cardiac and hypertensive type moderate with paroxysmal type of sympathoadrenal, chronic DIC in the stage of hypercoagulation, endothelin, secondary immunodeficiency with activation of humoral. Treatment: before operational intervention conducted the session ACE with the removal of 40% of the volume of circulating plasma and its hemodynamic compensation and protein solutions, and medications that improve the aggregation properties of erythrocytes. A course of therapy regarding the above pathology of internal organs. Local preoperative activities performed according to conventional methods. Surgical treatment was carried out in 2 stages with monthly intervals. The postoperative period was uneventful, with no complications, wound healing primary. After 14 days; fibrin monomer complex was 55 µg/ml, PE 145%, fibrinogen 3.75 g/l, APTT 36 sec (control 38 sec), PETIT 90%, platelets 475 thousand/ál, AK is the review after 2 months from the initial intervention abnormal mobility of the teeth of the first degree, periodontal pockets were absent, gums compact, and was at the level of the necks of the teeth, had a pale pink color. Radiographically in the projection of the former defects detected a faint shadow. Conducted orthopedic treatment. At survey 3 years later the patient had no complaints. The mucosa of the alveolar process without visible changes. Periodontal attachment level necks of the teeth. State dentures satisfactory. Deviations from hemostatic, immunological and biochemical blood parameters are not identified. Radiographically determined by the increase in height of the alveolar crest to the necks of the teeth, lesions of osteoporosis, resorption of the roots of the teeth and bones are not marked.

Example 3. Patient D., 38 years old, came to the clinic with complaints of abnormal mobility of the teeth of the upper jaw, bleeding gums, considerable difficulty eating, putrid smell from the mouth. From the anamnesis: suffers from 26 years of age, was periodically treated by a dentist-therapist-rinse, periodontal dressings, subperiosteal injections. The effect is not there. Locally: bite orthognathic, the eve of the oral cavity of sufficient depth is s naked1/2-2/3length. The mucous membrane of the alveolar process edematous, cyanotic color, loose, when zondirovaniye bleeds. On the teeth of the upper and lower jaw were determined soft plaque, on the upper teeth supragingival and subgingival dental plaque. The hygiene index on green-Vermilion - 2,3. The mobility of the upper and lower teeth of the II degree, the depth of periodontal pockets 6-7 mm. On OPG noted the uneven loss of bone tissue of the alveolar processes of the maxilla half the length of the roots with sharp and uneven contours. Examination by a physician revealed a gastric ulcer in remission, chronic cholecystitis and pancreatitis. From the rheological parameters of blood were determined level; fibrin monomer complex 30 μg/ml, PE 148%, fibrinogen 4 g/l, PETIT 106%, shortening of the APTT to 35 sec (control 40 sec), the amount of active form of platelets was 75%, the total number of platelets 600 thousand/ál. From immunological blood parameters revealed an increase of the CEC to 160 ME. Diagnosis: chronic generalized periodontitis of the upper jaw and severe peptic ulcer in remission, chronic cholecystitis, pancreatitis, intravascular platelet activation, endothelin, the immunologic disorders eliminated by holding 2 sessions of the CPC with the removal of 20% of the volume of circulating plasma in the first and 25% in the second, each treatment was followed by treatment of the suspension of erythrocytes before reinfusing 0.05 g of prednisolone. In the infusion program consisted of crystalloid, protein and detoxification solutions, as well as hepatoprotectors. By local anti-inflammatory therapy, removed supragingival dental plaque, deportirovany teeth of the upper jaw, picked up a toothbrush and illustrates techniques of brushing. Made temporary nasonia tires. The operation is performed according to the developed technology. Sutures were removed on the 10th day. The postoperative period without complications. Wound healing primary. After 20 days; fibrin monomer complex 0 μg/ml, PE 100%, fibrinogen of 3.45 g/l, APTT 35 sec (control 38 sec), PETIT 100%, platelets 480 thousand/ál, the active form of platelets 38%, CEC 60 ME. Rheological data breach eliminated by carrying out 1 of the CPC session with the removal of 25% of the plasma. When viewed through 6 months of pathological tooth mobility was not determined, periodontal pockets were absent, gums dense, was at the level of the necks of the teeth, turned pale pink. Deviations from hemostatic and immunological parameters were not found. Radiographically - increase in height of the alveolar crest to the necks of the teeth, lesions of osteoporosis, is and 254 patients with chronic generalized periodontitis and 57 patients with chronic localized periodontitis. In all cases, the results are long-lasting positive effect. Complications were not observed. The method recommended for practical use. In tables 1-3 reflected violations of rheological properties of blood and immunity in patients with chronic generalized periodontitis before and after treatment.

The proposed method is illustrated with radiographs. In Fig.1 shows an x-ray picture of the patient M. before treatment, Fig.2 depicts the x-ray picture of the patient M. after treatment, Fig.3 shows the x-ray picture of the patient H. Before treatment, Fig.4 shows x-ray picture of the patient H. after the treatment.

The application of the proposed method of surgical treatment of chronic periodontitis reduces the number of complications and increases the efficiency of osteochondroplasty by improving blood microcirculation in the intervention area, elimination of immunological disorders in the patient's body, negatively affecting the regenerative processes in the bone wounds.

Literature

RF patent №2179417, M. class. And 61 In the 17/24, 2000.

Paramilitary mucoperiosteal flaps, removal of subgingival dental plaque, granulation, areas of necrotic bone, polishing of the tooth roots and the introduction bone defects sterile osteoplastic material, characterized in that before surgery and after 14-20 days he spend immunotherapy and correction of blood rheological properties in the form of 2-5 procedures centrifuge (CPC) or a single procedure hardware plasmapheresis (ACE), the appearance of a plasmapheresis is chosen based on the following indicators: the CPC do patients with intravascular platelet activation is the sum of active forms - more than 30% and/or platelets more than 450 thousand/ál of blood and/or increasing populations of lymphocytes in 2 times and more the norm, and ACE is conducted in the presence of changes in other indicators of blood rheology and immunity, accompanied by an increase in circulating immune complexes (CIC) to the ME 110 and above.

2. The method according to p. 1, characterized in that in the cases of the need for immunosuppressive therapy procedure before reinfusing complement the treatment of the suspension of erythrocytes 0.03 g of prednisolone, immunostimulating - 0,002 grams of immunofan.



 

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