Method of applying a suture to fix a graft during soft tissue surgery

Abstract

The invention relates to methods of applying sutures in dentistry. During a vestibuloplasty, a free gingival graft is harvested from the oral cavity for placement on a bed. The bed is prepared for the application of the gingival graft, then the graft is fixed along its entire length using individual sutures. During application of the sutures, a first insertion is made in the area of the oral vestibule into the periosteum or into the deep mentalis muscle below the line of attachment of the graft, with the tail of the thread being left for subsequent knotting. The thread is drawn through the periosteum or the deep mentalis muscle parallel to the lower edge of the graft and extracted, thus forming a base of a triangle. A second insertion and extraction are made through the keratinized oral mucosa parallel to the upper edge of the graft, at a point between the first insertion and extraction, by drawing the thread across the surface of the graft toward the upper edge thereof, thus forming the apex of a triangle. A clamp is used to grasp the tail of the thread from the first insertion and extraction and a set of knots is tied in the area of the vestibule at the lower edge of the graft to complete the formation of a suture in the shape of a triangle. The knot is drawn to the region of the apex of the triangle. The invention enables low-trauma fixation of a graft using the proposed suture, which makes it possible to reduce the number of insertions and extractions and to minimize the number of sutures in the fixation area.

Description

METHOD OF SUTURE APPLICATION FOR FIXATION OF TRANSPLANT DURING SOFT TISSUE OPERATIONS AREA OF TECHNOLOGY

[0001] This technical solution generally relates to the field of dentistry, and in particular to methods of applying sutures, and is used in soft tissue operations to fix a transplant. LEVEL OF TECHNOLOGY

[0002] Often, in the course of clinical practice, a dentist has to deal with patients who have gum recession. This pathology is defined as exposure of the root surface in the area of ​​the gingival border, which, in essence, is an apical displacement of the soft tissue level after the loss of the corresponding periodontal attachment. Such clinical conditions compromise the patient's aesthetic profile, increase the risk of caries and provoke the development of hypersensitivity.

[0003] Despite the variety of soft tissue augmentation techniques that have been described over the past few years, the standard and most evidence-based protocol involves the steps of graft placement, suturing, and healing over a period of time.

[0004] Also, in the course of clinical practice, a dentist has to deal with patients who have a thin gum biotype in conditions of a deficit of vestibular bone grafting. This situation is a predisposing factor to the development of gum recessions and requires correction of the gum phenotype using vestibuloplasty with a transplant.

[0005] When applying a transplant, it is important to ensure its secure fixation using a suture and to ensure its low-traumatic fixation.

[0006] The prior art provides various categories of sutures for vestibuloplasty or apically displaced flap surgery.

[0007] For example, a nodal suture is often used (their number during vestibuloplasty is quite large - every 3 mm, and the transplant is constantly punctured, which worsens the blood supply). Nodal sutures are often placed along the vestibule to minimize the displacement of the transplant, but during the healing period they are technically difficult to remove and painful for the patient.

[0008] Also known from the prior art is a horizontal mattress U-shaped suture (A.I. Abelevich 2003, State Medical Academy, Nizhny Novgorod. Suturing skin wounds). A mattress suture (vertical or horizontal) allows the suture material to be placed away from the flap edge. Such a suture is often used to match the wound edges in interdental areas above the bone material when trying to achieve new attachment or when displacing flaps. A mattress U-shaped suture (horizontal) is used for very deep wounds when there are difficulties in matching the wound edges. A horizontal suture reduces the likelihood of postoperative complications in the form of a residual cavity. The puncture and puncture are performed symmetrically, at the same distance from the wound edge and from each other. This distance can be different (from 1 to 3 cm or more) and depends on the condition of the skin. As the distance between the sutures increases, the adaptation of the edges worsens, but microcirculation suffers less.

[0009] The disadvantages of the U-shaped suture include greater disruption of the blood supply to the edges of the wound and an unsatisfactory cosmetic result.

[0010] A common problem is the presence of sutures in the vestibule area, which bothers the patient due to the pain effect and complicates the removal of sutures (since they often heal and lead to trauma to the mucous membrane when removing the sutures).

[0011] Compared to cross-shaped and U-shaped sutures, the proposed technical solution minimizes the number of injections from 4 to 3, improving the blood supply to the surgical area. ESSENCE OF THE TECHNICAL SOLUTION

[0012] A technical problem or technical task to be solved This technical solution is the implementation of a method for applying a suture to fix a transplant during soft tissue operations.

[0013] The technical result achieved by solving the above technical problem is an increase in reliability and the implementation of low-traumatic fixation of the transplant due to the use of the developed suture, which allows for a reduction in the number of punctures and, accordingly, a minimization of both the number of sutures in the fixation zone and the time of the surgical intervention itself, which contributes to the improvement of blood circulation in the operation zone and, consequently, accelerates healing.

[0014] Additionally, the method allows to eliminate the displacement of the transplant towards the keratinized mucosa and reduces the formation of a scar along the border of the transition due to the fact that the second injection is made at the junction of the transplant and the keratinized mucosa from the inside out, while the node itself is located on top in the zone of the keratinized gum outside the healing zone.

[0015] The shape of the suture itself in the form of a triangle (with modification, the puncture point) allows using fewer sutures without reducing the quality of tight fixation of the transplant.

[0016] The said technical result is achieved by implementing a method for applying a suture for fixing a graft during soft tissue operations, characterized by the fact that a free gingival graft is collected from the donor area on the palate for application to the bed; the bed is prepared for placing the free gingival graft; the free gingival graft is fixed along its entire length with separate sutures, each of which is applied as follows: the first puncture is made in the area of ​​the vestibule of the oral cavity into the periosteum below the line of attachment of the graft, while leaving the tail of the thread for subsequent tying of the knot, the thread is passed through the periosteum parallel to the lower border of the graft and a puncture is made, thereby forming the lower base of the triangle, the second puncture-puncture is made through the keratinized mucous membrane of the oral cavity parallel to the upper border of the transplant between the first puncture-puncture by passing the thread along the surface of the transplant in the direction of its upper border, thus forming the vertices of the triangle, grab the tail of the thread with a clamp from the first puncture-puncture and tie a set of knots in the area of ​​the vestibule along the lower border of the transplant, completing the formation of the suture in the form of a triangle, pull the knot to the area of ​​the vertex of the triangle.

[0017] In some embodiments, the first injection is made in the area of ​​the vestibule of the oral cavity into the periosteum 1 mm below the line of attachment of the transplant.

[0018] In some embodiments, a second injection-prick is performed through the keratinized mucous membrane of the oral cavity at the midpoint of the distance between the first injection-prick.

[0019] In some embodiments, a right triangle or an equilateral triangle or an acute triangle is obtained.

[0020] In some embodiments, after pulling the knot in the area of ​​the apex of the triangle, the remaining thread is cut off. DRAWINGS FOR DESCRIPTION

[0021] The method is illustrated by the following graphic materials, which are given below.

[0022] Fig. 1 shows a diagram of the application of a suture with puncture-extrusion points (positions 1-5), where 1 is the puncture site; 2 is the puncture site; 3 is the puncture; 4 is the keratinized gum; a; 5 is the transplant; dotted line is the thread passing through the tissue inside; straight line is the thread passing along the surface of the tissue.

[0023] Fig. 2 - Fig. 3 shows a general view of a free gingival graft for fixing it with sutures in accordance with the developed method of their application.

[0024] Fig. 4 - Fig. 5 shows a variant of the method for applying a suture to fix a transplant during soft tissue operations.

[0025] Fig. 6 shows an embodiment where a bed for fixing the transplant is formed.

[0026] Fig. 7 shows an embodiment where sutures are applied after fixation of the graft.

[0027] Fig. 8 shows an embodiment showing the 4th day after the operation. The sutures are sound. The tissues are covered with fibrin. There is no swelling.

[0028] Fig. 9 shows a variant of implementation, where the 7th day after the operation is shown. The sutures are sound. The transplant is in the epithelialization stage. There is no edema.

[0029] Fig. 10 shows an embodiment where the seams have been removed.

[0030] Fig. 11 shows an embodiment showing the condition of the gums 3 weeks after the operation. DETAILED DESCRIPTION OF THE INVENTION

[0031] Below is a more detailed description of the claimed method, which does not limit the scope of the technical solution claims, but demonstrates the possibility of its implementation with the achievement of the claimed technical result.

[0032] A graft is an organ, tissue, or body part used for transplantation to replace a damaged body part.

[0033] A free gingival graft (FGG) is a soft tissue area that includes epithelial and connective tissue layers. Such a graft is transplanted from one part of the oral cavity to another.

[0034] Soft tissue plastic surgery is an operation aimed at changing the quality indicators of the gums and the volume of tissue in them.

[0035] Vestibuloplasty is a surgical procedure to deepen the vestibule of the mouth.

[0036] Apical advancement technique is a surgical procedure that allows increasing the area of ​​keratinized attached gingiva.

[0037] The keratinized part of the gums provides stabilization gingival margin, promotes the distribution of forces in muscle fibers during chewing, and also protects other tissues from any damage and traumatic effects.

[0038] Very often, with thin periosteum and deficiency of the outer bone plate, it is extremely difficult to fix the transplant due to the impossibility of injecting. The "KO-transformer" suture allows you to change the injection site to a suitable area with a change in the shape of the suture into various types of triangles. In some embodiments, when the periosteum is not visible, the deep mental muscles are used for injection.

[0039] In a specific embodiment, a free gingival graft is used, however, other types of grafts may be used without limitation.

[0040] In the first step, a free gingival graft is obtained by any methods known from the state of the art. The obtained graft is not the subject of the invention.

[0041] The patient's own tissues can be taken from many areas of the oral cavity. In most cases, the practice is to collect palatal autogenous gingival tissue (free gingival tissue) or autogenous connective tissue (subepithelial connective tissue). Either method is often combined with subepithelial connective tissue transplantation.

[0042] Free gingival grafts were the first to be used in dental practice, and they are still successfully used today. This technique produces thick bandages of keratinized gum. The traditional area for harvesting is the hard palate and sometimes the area of ​​the maxillary tubercle. The advantage of the method is the long-term stability of the keratinized area, the disadvantage is the frequent occurrence of pain during the healing stage and unsatisfactory aesthetics due to the mixing of shades.

[0043] Although the SDT is usually viewed in a simplified form, the hard palate is multilayered.

[0044] It contains epithelium, submucosa, adipose tissue, glandular tissue and periosteum. Each of these layers behaves differently during transplantation. Adipose tissue is absorbed and loses volume, glandular tissue can hinder revascularization or lead to the formation of retention cysts, and it is difficult to talk about the importance of the periosteum, since it is not always possible to guarantee its complete transfer to the transplant. Therefore, in SDT, it is preferable to have only two layers: the epithelium, which performs a protective function in the early postoperative period, and the proper plate, which carries the main regenerative potential and determines the degree of keratinization of the epithelium covering it.

[0045] The viability, subsequent engraftment of the transplant or flap, and therefore the success of the operation, directly depend on the availability of sufficient nutrition, so one of the key issues in transplantology is the trophic component. Nutrition can come from the donor site or the receiving zone, in connection with which two aspects can be noted - the donor trophic component and the recipient, which are closely interconnected. According to the nature of the blood supply to the donor tissue, it can be divided into two types: transplants and flaps.

[0046] The grafts are completely deprived of any blood supply and immediately after transplantation receive nutrition exclusively through plasma circulation from the tissues of the receiving bed.

[0047] The flaps receive blood supply from the donor area. They can be on a pedicle (one or more) or free, on a microvascular anastomosis formed after transplantation. An important parameter of the viability of all flaps is the total diameter of the feeding vessels, as well as the ratio of the length of the feeding base to its width. The advantage of flaps is the initial presence of a trophic component in the form of a central vessel or a sum of small vessels and capillaries. However, some features of flaps seriously limit their use in the oral cavity. The need to maintain the topography of the vascular bed to ensure the viability of the flap and the exit of some large vessels through bone openings do not allow for sufficient mobilization. The presence of a row of teeth and areas with pronounced curvature of the surface leads to the occurrence of kinks and tension of the flap base, which disrupts its nutrition and increases the risk of necrosis. In this regard, preference is given to the use of transplants or a combination of transplants and local flaps, such interventions are less traumatic and more predictable. Successful engraftment largely depends on the resistance of the flap or transplant tissue to the effects of hypoxia, on the area of ​​​​avascular zones in the receiving bed and, no less importantly, on the density of fixation of the donor tissue to the bed.

[0048] In some embodiments, artificial allogeneic and xenogeneic dermal materials are used to form keratinized gum. Their introduction into clinical practice is associated with the search for new solutions to simplify the Protocol of surgical intervention for expansion and thickening of the attached gum zone. MUCOGRAFT material can be used as an example. MUCOGRAFT material has a two-layer structure. The first layer consists of dense collagen, which serves as a barrier for cells and provides fixation to tissues, which is a condition for good wound healing. This layer has a soft consistency with sufficient elasticity. The second layer of the material consists of a thick porous, spongy collagen structure. This spongy surface is located next to the recipient tissue to facilitate the organization of a blood clot, as well as stimulate the formation of new blood vessels and tissue integration.

[0049] First, the surgical wound is treated with antiseptic saline solution.

[0050] Next, a bed is prepared for placing the transplant in a standard, generally accepted manner.

[0051] After this, the graft is fixed first along the edges with regular interrupted sutures. Then, the graft is fixed along its entire length with separate sutures in accordance with the proposed method of suturing for fixing a free gingival graft during vestibuloplasty.

[0052] The entire process of performing the operation according to the proposed technique is carried out as follows (see Fig. 1): the first puncture (5) is made in the area of ​​the vestibule of the oral cavity (4) into the periosteum 1 mm below the line of attachment of the graft, while leaving the tail of the thread for subsequent tying of the knot. Then the thread is passed through the periosteum parallel to the lower border of the graft (3) and a puncture is made (6), thereby forming the base of the triangle. Next, the second puncture-puncture is made (7), for which the thread is passed along the surface of the graft, in the direction of its upper border (2), and through the keratinized mucous membrane of the oral cavity (1) in the middle of the distance between the first puncture-puncture, the second puncture-puncture is made, thus forming the apex of the triangle, then the tail of the thread from the first puncture-puncture is grasped with a clamp and a surgical knot is tied - 2-1-2 in the area of ​​the vestibule along the lower border of the graft (3), completing the formation of the triangle.As a result, the knot is pulled to the area of ​​the apex of the triangle, and the remaining thread is cut off (Fig. 4 - Fig. 5).

[0053] First injection - the injection is made in the area of ​​the vestibule of the oral cavity through the periosteum at the level or below the area of ​​attachment of the transplant. The technique excludes a second injection.

[0054] The second puncture is made along the junction of the graft and keratinized mucosa from the inside out, which • eliminates the displacement of the transplant towards the keratinized mucosa; • improves the healing of the transplant, since the transplant itself is not injured by injections and the suture is located outside the transplant area; • reduces scar formation along the transition border.

[0055] The suture used in this technical solution under the brand name “KO-transformer” can be upgraded as a right triangle, equilateral triangle and acute triangle, changing the puncture zone and adapting the fixation of the graft. to the clinical situation.

[0056] The thread can be made from, for example, synthetic material prolene 6.0; 7.0 or monoquik 6.0, without limitation.

[0057] Then, in the early postoperative period, nonsteroidal anti-inflammatory drugs are prescribed at 400 mg strictly after meals 2 times a day for 4-5 days. For antiseptic treatment of the oral cavity, they can use, for example, the oxygen-containing drug Bluem in the form of mouth baths 2 times a day for 1 minute after individual oral hygiene for a course of 7-8 days and Argocol gel for home applications on a gauze swab for 15-20 minutes 3-4 times a day from the 2nd day of surgery.

[0058] Below is a clinical example to confirm the technical result obtained.

[0059] Fig. 6 - 11 shows an exemplary embodiment.

[0060] A 48-year-old female patient came from a third-party clinic at the stage of orthodontic treatment, upon referral from a doctor, to a periodontal surgeon regarding a change in the gum biotype for the safe continuation of orthodontic treatment and an increase in the efficiency zone.

[0061] Fig. 6 shows how the bed for fixing the graft is preliminarily formed. Then the sutures are applied after fixing the graft using the proposed method (Fig. 7). Fig. 8 shows an embodiment showing the 4th day after the operation. The sutures are sound. The tissues are covered with fibrin. There is no edema. Fig. 9 shows an embodiment showing the 7th day after the operation. The sutures are sound. The graft is in the epithelialization stage. There is no edema. In Fig. 10 the sutures are removed and Fig. 11 shows the final result after 3 weeks.

[0062] It is obvious to a specialist in the state of the art that the developed technical solution allows achieving the stated technical result and ensuring increased reliability and low-traumatic fixation of the transplant due to the use of the developed suture, which allows reducing the number of injections. punctures, and, accordingly, minimize both the number of stitches in the fixation area and the time of the surgical intervention itself, which improves blood circulation in the surgical area and, therefore, accelerates healing.

[0063] Thus, the claimed method ensures reliable and low-traumatic fixation of a free gingival transplant due to the use of the suture developed by us.

[0064] The proposed suture is extremely convenient for use in fixing a free gingival graft during vestibuloplasties and operations to increase the area of ​​keratinized gum.

[0065] Compared to cross-shaped and U-shaped sutures, the number of injections is minimized from 4 to 3, improving the blood supply to the surgical area, which increases healing by 2 times.

Claims

FORMULA 1. A method of applying a suture to fix a graft during soft tissue operations, characterized by the fact that • prepare a bed for placing the transplant; • fixed along the entire length on the bed with separate sutures, each of which is applied as follows: a. make the first puncture in the area of ​​the vestibule of the oral cavity into the periosteum below the line of attachment of the graft, while leaving the tail of the thread for subsequent tying of a knot, b. pass the thread through the periosteum parallel to the lower border of the graft and make a puncture, thereby forming the lower base of the triangle, c. make a second puncture-puncture through the keratinized mucous membrane of the oral cavity parallel to the upper border of the graft between the first puncture-puncture by passing the thread along the surface of the graft in the direction of its upper border, thus forming the vertices of the triangle, d. grasp the tail of the thread with a clamp from the first puncture-puncture and tie a set of knots in the area of ​​the vestibule along the lower border of the graft, completing the formation of the suture in the form of a triangle, e. pull the knot to the area of ​​the apex of the triangle.

2. The method according to paragraph 1, characterized in that the first injection is carried out in the area of ​​the vestibule of the oral cavity into the periosteum 1 mm below the line of attachment of the transplant.

3. The method according to paragraph 1, characterized in that a second injection-prick is carried out through the keratinized mucous membrane of the oral cavity at the middle of the distance between the first injection-prick.

4. The method according to paragraph 1, characterized in that a right-angled triangle or an equilateral triangle, or an acute-angled triangle is obtained.

5. The method according to paragraph 1, characterized in that after pulling the knot in the area of ​​the apex of the triangle, the remaining thread is cut off.

6. The method according to paragraph 1, characterized in that a free gingival transplant is used as a graft.

7. The method according to claim 1, characterized in that the transplant is a modified material.

8. A method for applying a suture to fix a graft during soft tissue operations, characterized by the fact that • prepare a bed for placing the transplant; • fix the graft along its entire length on the bed with separate sutures, each of which is applied as follows: a. make the first puncture in the area of ​​the vestibule of the oral cavity into the deep mental muscles below the line of attachment of the graft, while leaving the tail of the thread for subsequent tying of a knot, b. pass the thread through the deep mental muscles parallel to the lower border of the graft and make a puncture, thereby forming the lower base of the triangle, c. make a second puncture-puncture through the keratinized mucous membrane of the oral cavity parallel to the upper border of the graft between the first puncture-puncture by passing the thread along the surface of the graft in the direction of its upper border, thus forming the vertices of the triangle, d. grasp the tail of the thread with a clamp from the first puncture-puncture and tie a set of knots in the area of ​​the vestibule along the lower border of the graft, completing the formation of the suture in the form of a triangle, e.drag the node to the area of ​​the triangle's apex.

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