Method for dental orthopedic treatment of acquired defects of upper jaw

Abstract

FIELD: medicine.SUBSTANCE: invention relates to orthopedic dentistry, to maxillofacial prosthetics and is intended to optimize clinical stages of orthopedic treatment of patients with acquired defects of the upper jaw after operations for various diseases. Orthopedic treatment planning is carried out using cone beam computed tomography and cephalometric analysis. Moreover, in the case of a bilateral jaw defect with the presence of oronasal fenestration with a complete absence of the alveolar process and the anterior part of the hard palate, where the anterior border of the entrance opening of the acquired defect is formed by the soft tissues of the upper lip and anterior cheek sections, is mobile, and the posterior border of the entrance opening of the defect is formed by the structure of the hard palate and covered with a thinned traumatized mucous membrane, is immobile, while on the cephalometric image in the lateral projection, point A – the deepest point on the anterior contour of the base of the upper jaw and point Sna – the anterior nasal spine are absent, and it is impossible to determine the plane of the base of the upper jaw NL, an obturating prosthesis with a solid cast metal base is used. In case of a unilateral jaw defect with the presence of oronasal fenestration with a complete absence of the alveolar process and half of the hard palate on one side of the upper jaw, where the anterior, posterior and one of the lateral borders of the entrance opening of the acquired defect are formed by the soft tissues of the mucous membrane of the upper lip, cheek and posterior surface of the pharynx or the palatopharyngeal arch on one side, are mobile, and the lateral border of the entrance opening of the defect is formed by the structure of the palatine suture of the hard palate, covered with a thinned traumatized mucous membrane, is immobile, while on the cephalometric image in the direct projection the J point – the point of intersection of the tubercle of the upper jaw and the zygomatic buttress and the NC point – the most protruding edge of the nasal cavity are absent, a collapsible obturating prosthesis is used. In case of bilateral jaw defect within the hard palate with preservation of the alveolar process and the presence of oronasal fenestration, where the boundaries of the entrance opening of the acquired defect are formed in the area of the bony structure of the hard palate and covered with a thinned traumatized mucous membrane, are immobile, and the posterior border of the entrance opening of the defect is formed by the structure of the hard palate or soft tissues of the soft palate, can be either mobile or immobile, while on the cephalometric image in the lateral projection the plane of the base of the maxilla NL is interrupted, an obturating prosthesis with an elastic compensating lining is used.EFFECT: method, by determining the type of defect taking into account its topography and anatomy, allows for the optimization of the choice of the obturating design of the prosthesis, reducing the risk of damage to important anatomical structures and increasing the predictability of the orthopedic treatment plan.1 cl, 6 dwg, 3 ex

Description

[0001] The invention relates to medicine, in particular to orthopedic dentistry, to maxillofacial prosthetics and is intended to optimize the clinical stages of orthopedic treatment of patients with acquired defects of the upper jaw after operations for various diseases.

[0002] Improving the quality and quantity of treatment and diagnostic methods for patients with acquired defects of the maxillofacial region, which also includes, for example, the study of tumor markers, has increased the number of patients in this category who have the opportunity to receive high-quality rehabilitation [Development of reconstructive surgery of the maxillofacial region in Russia / S.V. Tereshchuk, D.A. Demin, I.I. Proposhin [et al.] / / Surgeon. - 2024. - No. 5-6 (201). - P. 16-27. - DOI 10.33920 / med-15-2403-02].

[0003] Despite this, the complex configuration of the defect, together with the severe mental state of the patient, often become a difficult obstacle to overcome for the orthopedist, preventing the successful completion of rehabilitation, but only delaying it. This once again confirms that one of the most important tasks of orthopedic treatment of acquired jaw defects remains the preservation of a sufficient volume of tissue for future prosthetics [Avanesov, A. M. Analysis of factors reducing the quality and effectiveness of dental concomitant therapy in cancer patients / A. M. Avanesov, E. N. Gvozdikova, E. F. Khalil [et al.] / / Tumors of the head and neck. - 2023. - Vol. 13, No. 3. - P. 63-71. - DOI 10.17650 / 2222-1468-2023-13-3-63-71].

[0004] Domestic and foreign scientists have achieved good results in improving the quality of rehabilitation of patients with maxillofacial pathology. Today, with the help of modern treatment methods, it is possible to reduce tissue atrophy and improve functional and aesthetic indicators, as well as reduce the recovery period [Kochurova, E.V. Tumor marker CA 125 in assessing the effectiveness of treatment of malignant neoplasms of the maxillofacial region / Kochurova E.V., Kozlov S.V., Seryakov A.P. / / Medical Bulletin of the Ministry of Internal Affairs. - 2013. - No. 1. - P. 28-29. ISSN: 2073-8080.; Butterworth, C. The prosthodontic management of the maxillectomy patient / C. Butterworth / / British Dental Journal. - 2022. - No. 233 (9). - P. 744-748. - DOI 10.1038 / s41415-022-5106-9.]. However, the successful clinical outcome of orthopedic treatment of acquired defects of the upper jaw with oronasal communication depends on the type of preserved structures of the maxillofacial region adjacent to the acquired defect.The variety of existing obturating structures is often used empirically and does not have a system for using one or another structure depending on the location and type of defect in the oral cavity.

[0005] Currently, there is no system for using a specific orthopedic structure for a specific architecture of acquired maxillary defects. Years of experience treating patients in this category allow us to identify the most common types of postoperative maxillary defects and select appropriate methods of complex jaw prosthetics.

[0006] There are various analogues of the invention.

[0007] One of the most commonly used classifications currently is the one proposed by JS Brown et al. in 2000 [Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000; 22(1):17-26. PMID: 10585601], in which all maxillary defects were divided into 4 classes according to the vertical component and 3 subclasses according to the horizontal component. In addition to the classification, the authors proposed preferred reconstruction methods. The classification covers many variants of the location of acquired defects of the maxilla, but does not provide a clear algorithm for orthopedic treatment of each class, since it is focused primarily on maxillofacial surgeons. In addition, the classification has a large number of classes and subclasses, which are difficult to apply.

[0008] In 2013, Z. Durrani et al. [Durrani Z., Hussain SG, Alam SA A study of classification systems for maxillectomy defects. J Pak Prosthodont Assoc 2013;01(02):117-24.] proposed a classification based on the horizontal component and including division into alveolar ridge resection, subtotal, total, radical, and combined. This classification is based on the description of the defect in one plane, which does not allow for a complete representation of the defect, and there is no relationship between the type of orthopedic structure and the type of defect.

[0009] The prototype of this invention is the classification system of maxillectomy defects proposed in 2001 by DJ Okay et al. [Okay DJ, Genden E., Buchbinder D., Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86(4):352-63. DOI: 10.1067 / mpr.2001.119524. PMID: 11677528.] based on the assessment of the functional outcome and prosthetic methods. The advantage of this classification is its versatility and focus not only on surgical rehabilitation, but also on orthopedic. The disadvantages of this prototype include difficulty in adapting to clinical practice due to its bulkiness and the lack of clinical recommendations for orthopedic treatment of acquired defects of the upper jaw.

[0010] The technical result of the proposed method is to obtain an algorithm for the diagnosis and orthopedic treatment of patients with post-resection defects of the upper jaw, to optimize the clinical stages of orthopedic treatment by determining the type of defect taking into account its topography and anatomy, and to simplify the selection of the type of design of the obturating prosthesis.

[0011] Essence of the invention

[0012] The proposed method for diagnosing and treating acquired maxillary defects involves determining the type of defect, taking into account its topography and anatomy, and selecting the most appropriate obturating prosthesis. After collecting the patient's complaints and medical history and examining them, treatment planning is performed using radiographic diagnostics using CBCT and a computer-aided cephalometric analysis of the skull.

[0013] Depending on the topographic relationship of the entrance opening of the acquired defect of the upper jaw with other structures of the skull, the implementation of the developed method is classified by us into the following options.

[0014] Based on the data obtained, the defect is classified into one of the following classes:

[0015] MAA(maxilla-alveoiar anterior) - the entrance opening of the acquired defect of the upper jaw in the anterior section (Fig. 1).

[0016] MAL(maxilla-alveoiar lateralis) - the entrance opening of the acquired defect of the upper jaw in the lateral section (Fig. 2).

[0017] MAM(maxilla-alveoiar medianus) - the entrance opening of the acquired defect of the upper jaw in the middle section (Fig. 3).

[0018] This classification was compiled based on the known data on the anatomy of the alveolar process and hard palate of the maxilla, presented below.

[0019] Classification (criteria) of the anatomy of the alveolar process and hard palate of the upper jaw for selecting optimal options for existing obturating prostheses (MAA, MAL, MAM - anatomical landmarks of missing structures of the upper jaw):

[0020] Type A: Obturating prosthesis with a solid metal base (optimal for MAA)

[0021] • bilateral jaw defect with oronasal communication with complete absence of the alveolar process and the anterior part of the hard palate.

[0022] • the anterior border of the entrance opening of the acquired defect is formed by the soft tissues of the upper lip and anterior cheek areas and is mobile.

[0023] • the posterior border of the entrance opening of the defect is formed by the rigid structure of the hard palate, covered with a thinned, easily injured mucous membrane, and is immobile.

[0024] • In the cephalometric image in the lateral projection, point A is missing—the deepest point on the anterior contour of the base of the upper jaw—as well as point Sna—the anterior nasal spine; it is impossible to determine the plane of the base of the upper jaw NL.

[0025] • Fixing part of the prosthesis: mechanical fixation using a system of supporting and retaining clasps on the teeth of the upper jaw, provides anti-tipping properties of the prosthesis.

[0026] • The obturating part of the prosthesis: acrylic, immersed into the defect, restores the lost volume of the upper lip.

[0027] Manufacturing technology: After obtaining anatomical impressions, plaster models of both jaws are cast and a custom-made tray is manufactured for the upper jaw. Models are made from the obtained functional impressions in accordance with the bite and facial bow registration data, and the models are fixed in the articulator. Using a parallelometer, the wax base of the future denture with a clasp support system is modeled on the upper jaw model. A sprue system is installed and a casting mold is made. The wax is replaced with metal. The assigned denture base is machined, polished, and tried in the oral cavity. The color of the artificial teeth is determined. The composition of the future obturating denture with artificial teeth is supplemented and modeled using the base wax. The wax composition of the denture, together with the plaster model, is plastered in a flask, and the wax is replaced with plastic.The finished structure is processed and polished with felts and polishing paste. The resulting prosthesis is then fitted into the patient's mouth.

[0028] Type B: Disassemblable obturating prosthesis (optimal for MAL)

[0029] • unilateral jaw defect with the presence of oronasal communication with complete absence of the alveolar process and half of the hard palate on one side of the upper jaw.

[0030] • the anterior, posterior and one of the lateral borders of the entrance opening of the acquired defect are formed by the soft tissues of the mucous membrane of the upper lip, cheek and posterior surface of the pharynx or palatopharyngeal arch on one side, and are mobile.

[0031] • the lateral border of the entrance opening of the defect is formed by the rigid structure of the palatine suture of the hard palate, covered with thinned, easily injured mucous membrane, and is immobile.

[0032] • In the cephalometric image in the direct projection, point J - the point of intersection of the maxillary tubercle and the zygomatic buttress, and point NC - the most protruding edge of the nasal cavity - are missing.

[0033] • Fixing part of the prosthesis: adhesive and mechanical fixation using a base and a clasp system made of elastic plastic on the teeth of the upper jaw, compensates for the force of chewing pressure.

[0034] • The obturating part of the prosthesis: acrylic, immersed into the defect, replenishes the lost volume of the upper lip, cheek, and ensures facial symmetry.

[0035] Manufacturing technology: After obtaining anatomical impressions, plaster models of both jaws are cast and a custom-made tray is manufactured for the upper jaw. A master model is created using the resulting functional impression. Based on the bite registration and facial bow data, the master model, along with the antagonist model, is fixed in the articulator. Base wax is used to complete and model the composition of the future obturating part, which is a separate element of the future denture. On the side facing the elastic replacement part of the denture, an additional element in the form of a thin border is created, which will align with the notch on the elastic replacement part to prevent displacement of the obturating part. Attention is paid to the complex architecture of the defect, undercuts are isolated, and the restoration is cast in rigid plastic (polymethyl methacrylate). The obturating part is fitted into the oral cavity and another impression is made together with the finished obturating part.The model obtained from the impression is duplicated, and the replacement portion of the denture is modeled in wax, complete with artificial teeth, clasps, and a recess for securing the obturating portion. After the wax composition is tried in, it is packed in a flask and embedded in elastic polyamide-based plastic (Vertex). After both portions of the denture are processed, the resulting denture is fitted into the patient's mouth.

[0036] Type C: Obturating prosthesis with elastic compensating lining (optimal for MAM)

[0037] • bilateral defect within the hard palate with preservation of the alveolar process and the presence of oronasal communication.

[0038] • the boundaries of the entrance opening of the acquired defect are formed in the area of ​​the bone structure of the hard palate and are covered with a thinned, easily injured mucous membrane, immobile.

[0039] • the posterior border of the entrance opening of the defect is formed by the rigid structure of the hard palate or the soft tissues of the soft palate, and can be either mobile or immobile.

[0040] • In the cephalometric image in the lateral projection, the plane of the base of the maxilla NL is interrupted.

[0041] • Fixing part of the prosthesis: mechanical and adhesive fixation using a clasp system on the teeth of the upper jaw and a base made of acrylic plastic with an elastic compensating lining located in the form of a ring in the area of ​​​​thinned mucosa covering the hard areas of the edge of the defect in the area of ​​​​the hard palate.

[0042] • The obturating part of the prosthesis: acrylic, immersed into the defect, replenishes the lost volume of the inferior nasal concha.

[0043] Manufacturing technology: After obtaining anatomical impressions, plaster models of both jaws are cast and a custom tray is made for the upper jaw. A functional impression is taken using a custom tray made of silicone impression material, and the centric relation of the jaws is determined using wax rims. The base wax is used to complement and model the composition of the future obturating denture with artificial teeth. The wax composition of the denture, along with the plaster model, is plastered in a flask. The base wax with artificial teeth is replaced with the prefabricated denture structure made of polymethyl methacrylate. Excess PMMA material is removed at a 45-degree angle from the defect entry opening (in the form of a ring) and along the rigid edge of the defect (in the form of a thin strip).A prepared elastic lining made of propenoic acid is placed in these areas, packed into a flask, and then polymerized under thermal influence. The finished structure is processed and polished with felts and polishing paste. The resulting prosthesis is then fitted into the patient's mouth.

[0044] Description of drawings

[0045] Figure 1 shows the Acquired defect of the upper jaw in the anterior section (AMD):

[0046] 1. Frontal plane;

[0047] 2. Sagittal plane;

[0048] 3. Transverse plane;

[0049] 4. Defect of the upper jaw in the anterior section.

[0050] Figure 2 shows the acquired defect of the upper jaw in the lateral region, unilateral (MAL):

[0051] 1. Frontal plane;

[0052] 2. Sagittal plane;

[0053] 3. Transverse plane;

[0054] 5. Unilateral defect of the upper jaw in the lateral region.

[0055] Figure 3 shows the Acquired defect of the median maxilla (AMD):

[0056] 1. Frontal plane;

[0057] 2. Sagittal plane;

[0058] 3. Transverse plane;

[0059] 6. Middle defect of the upper jaw.

[0060] Figure 4 shows the cephalometric analysis of a patient with acquired anterior maxillary defect (AMD).

[0061] Figure 5 shows the cephalometric analysis of a patient with acquired unilateral maxillary lateral defect (MAL).

[0062] Figure 6 shows the cephalometric analysis of a patient with acquired middle maxillary defect (MAD).

[0063] Implementation of the method

[0064] Based on preliminary planning, cone-beam computed tomography (CBCT) and cephalometric analysis, depending on the topography and anatomical features of the inlet of the acquired maxillary defect (the above-mentioned classes MAA, MAL, MAM), the type of obturating prosthesis is determined according to the above criteria (Type A, B, C). The type of fixing part of the obturating prosthesis is determined to ensure an anti-tipping effect and an optimal method of fixation. The type of obturating part of the prosthesis is determined to ensure optimal tightness of the oronasal communication with minimal trauma to the mucous membrane of the inlet of the defect.

[0065] After determining the type of prosthesis and taking anatomical impressions, plaster models of both jaws are cast and a custom tray is manufactured for the upper jaw. Models are made using the obtained functional impressions, in accordance with the bite registration and facebow data, and the models are fixed in an articulator. Modeling and polymerization of the prosthesis are carried out depending on the chosen generally accepted manufacturing technology.

[0066] Advantages of the proposed method

[0067] • Optimization of the choice of obturating prosthesis design depending on the anatomical and topographic features of the acquired defect of the upper jaw.

[0068] • Reduction of the time of patient examination, and, as a consequence, the total time of orthopedic rehabilitation of patients with post-resection defects of the upper jaw.

[0069] • Reduces the risk of damage to important anatomical structures.

[0070] • Possibility of case classification and predictable orthopedic treatment plan.

[0071] • Possibility of monitoring the development of complications in the rehabilitation of patients with this pathology.

[0072] Clinical Cases

[0073] 1. Patient S., born in 1971, sought dental prosthetic rehabilitation after surgical treatment for maxillary cancer. After diagnosis, the acquired maxillary defect was classified as type A. Prosthetic rehabilitation was planned using a complex-jaw obturating prosthesis with a cast metal base made of cobalt-chromium alloy and a spherical concave obturating part. After application of the prosthesis, the patient had no complaints during a 6-month clinical follow-up. An objective examination of the oral cavity revealed no signs of inflammation in the mucous membrane under the prosthesis, functional tests were negative, and the hygienic condition of the prosthesis met clinical requirements.

[0074] 2. Patient N., born in 1965, sought dental prosthetic rehabilitation after surgical treatment for maxillary cancer. Based on diagnostic results, the acquired defect was classified as type B, and prosthetic rehabilitation was prescribed with a complex jaw detachable denture with an acrylic obturator and an elastic replacement part. After placement of the denture, the patient had no complaints during a 6-month clinical follow-up. An objective examination of the oral cavity revealed no signs of inflammation in the mucous membrane under the denture, functional tests were negative, and the hygienic condition of the denture met clinical requirements.

[0075] 3. Patient Ch., born in 1958, sought dental prosthetic rehabilitation after surgical treatment for maxillary cancer. Based on diagnostic tests, the defect was classified as type C, and a complex obturating jaw prosthesis with an elastic compensating lining was recommended as a rehabilitation method. Following prosthesis placement, the patient had no complaints during a 6-month clinical follow-up. An objective examination of the oral cavity revealed no signs of inflammation on the mucous membrane beneath the prosthesis, functional tests were negative, and the hygienic condition of the prosthesis met clinical requirements.

Claims

A method of dental orthopedic treatment of acquired defects of the upper jaw, including planning of orthopedic treatment with the performance of cone-beam computed tomography and cephalometric analysis, characterized in that in the case of a bilateral jaw defect with the presence of oronasal communication with a complete absence of the alveolar process and the anterior part of the hard palate, where the anterior border of the entrance opening of the acquired defect is formed by the soft tissues of the upper lip and anterior cheek sections, is mobile, and the posterior border of the entrance opening of the defect is formed by the structure of the hard palate and covered with a thinned traumatized mucous membrane, is immobile, while on the cephalometric image in the lateral projection, point A - the deepest point on the anterior contour of the base of the upper jaw and point Sna - the anterior nasal spine are absent, and it is impossible to determine the plane of the base of the upper jaw NL, an obturating prosthesis with a cast metal base is used,in case of a unilateral jaw defect with the presence of oronasal communication with a complete absence of the alveolar process and half of the hard palate on one side of the upper jaw, where the anterior, posterior and one of the lateral borders of the entrance opening of the acquired defect are formed by the soft tissues of the mucous membrane of the upper lip, cheek and posterior surface of the pharynx or palatopharyngeal arch on one side, are mobile, and the lateral border of the entrance opening of the defect is formed by the structure of the palatine suture of the hard palate, covered with a thinned traumatized mucous membrane, is immobile, while on the cephalometric image in the direct projection, the J point - the intersection point of the tubercle of the maxilla and the zygomatic buttress and the NC point - the most protruding edge of the nasal cavity are absent, a collapsible obturating prosthesis is used, in case of a bilateral jaw defect within the hard palate with preservation of the alveolar process and the presence of oronasal communication,where the boundaries of the entrance opening of the acquired defect are formed in the area of ​​the bony structure of the hard palate and covered with a thinned, traumatized mucous membrane, are immobile, and the posterior border of the entrance opening of the defect is formed by the structure of the hard palate or the soft tissues of the soft palate, can be either mobile or immobile, while on the cephalometric image in the lateral projection the plane of the base of the upper jaw NL is interrupted, an obturating prosthesis with an elastic compensating lining is used.

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